In lieu of an abstract, here is a brief excerpt of the content:The Future Is Political and TransdisciplinaryAwais Aftab (bio)Philosophy, psychiatry, & psychology (PPP) is a transdisciplinary oasis, one of the few journals in mental health care that facilitate a meaningful dialogue between philosophers, psychiatrists, psychologists, and scholars from related disciplines. The fact that PPP successfully provides such a space is of no small importance, especially from my perspective as a psychiatrist. The multidisciplinary nature of the undertaking has been a (...) central aspect of the identity of the journal from the very beginning. PPP has maintained this transdisciplinary inclusive spirit over the years, and its editorial and advisory boards remain richly representative, but the challenge of ensuring continued participation of clinicians is not insubstantial. After all, the point is not token participation, but a robust and transformative interdisciplinary engagement. Clinicians have much to contribute to philosophical debates, however, such capacity for dialogue requires sustained cultivation (Aftab & Waterman, 2021), and forces in medical education have led to a situation where comparatively fewer psychiatrists have the interest or the ability to engage in such rigorous dialogue with philosophers. Philosophy of mental health has grown and specialized exponentially since the mid-90s. Keeping up with this literature is difficult even for philosophers, it is no small feat for full-time clinicians.This means that PPP and its affiliate organizations have a responsibility to take a more active role in supporting educational initiatives to ensure that future generations of psychiatric clinicians are able to contribute to philosophical debates, and that philosophy of psychiatry does not become divorced from clinical and practical concerns. My advice to clinicians based on my experience would be two-fold: first, it is essential to acquire a basic familiarity with the philosophy of psychiatry literature. Aftab and Waterman (2021) offer a sample list of reading recommendations. At the time of this writing, the International Network for Philosophy and Psychiatry is also undertaking efforts to develop curricula aimed at clinicians. Second, it is important to find ways to interact with others in the philosophy of psychiatry community. Formal avenues to do so include the annual meetings of the Association for the Advancement of Philosophy and Psychiatry and the Philosophy Special Interest Group of the Royal College of Psychiatrists, among others. There are also various online communities active on social media that many find helpful.In recent years, we have seen an unprecedented enthusiasm and support for inclusion of lived experience in mental health care. This is a welcome and much needed development, but we are only just beginning to scratch the surface of [End Page 5] how to philosophically navigate this inclusion. Frameworks such as standpoint epistemology and epistemic justice offer us starting points (Knox, 2022), but much remains to be worked out (Aftab, 2022). There are notable philosophical challenges, such as ascertaining the limits of lived experience, and the biases and errors to which it is vulnerable; the application of scientific method and philosophical criticism to lived experience; methods to resolve disagreements when different forms of lived experience contradict each other; handling discrepancies between knowledge from lived experience and knowledge from other sources be handled; and analyzing the intersection of politics of lived experience with other differentials of power. I anticipate that these topics will be of central importance to the field and to the journal in the coming years.It is also vital that philosophy of psychiatry engage with the sociopolitical dimensions of madness (Kalathil & Jones, 2016). The failure of philosophy to do so in a meaningful way has already been articulated powerfully by commentators such as Nev Jones (2022). An important aspect of acknowledging philosophy's failures in this regard comes from the notion of "elite capture," recently popularized by Olúfẹ́mi O. Táíwò (2022). It refers to how progressive philosophical ideas such as standpoint epistemology are co-opted by the "elite" to serve their own ends. Discussions on social media have already begun to point out that concepts in philosophy of psychiatry such as "epistemic injustice" show signs of elite capture by the psychiatric establishment, resulting in token participation but no systemic changes. Philosophy of psychiatry needs to tackle its own vulnerability to co-option. This will require creative forms of philosophizing and engagement with... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Can The Psychopathologized Speak?Notes on Social Objectivity and Psychiatric ScienceAwais Aftab*, MD (bio)In "Exclusion of Psychopathologized Standpoints Due to Hermeneutical Ignorance Undermines Psychiatric Objectivity" (2022), Bennett Knox offers a compelling argument that failure of psychiatric community to engage with the "psychopathologized" in processes such as the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) constitutes a form of epistemic injustice and threatens the social objectivity of (...) psychiatric science. I find myself in agreement with the central thesis and I am glad to see it articulated so well by Knox. While it is clear that the exclusion of psychopathologized standpoints in psychiatric science cannot be justified, there are issues that arise that require further clarification, and may generate disagreements, when we consider the complexities of how this inclusion is to take place, what requirements can be imposed on this process of inclusion, and the relationship between the DSM and psychiatric science broadly when it comes to social objectivity.The Methodological Objectivity of the DSM Does Not Exhaust the Methodological Objectivity of Psychiatric ScienceThe DSM is a nosological project within a particular historical context, operating with a certain set of assumptions (Aftab & Ryznar, 2021). The DSM has limitations in terms of what sorts of perspectives it can meaningfully incorporate, but the limitations of the DSM are not the limitations of psychiatric science. This is because psychiatric science is a pluralistic domain and includes many different methodologies and perspectives (Jerotic & Aftab, 2021). As one example, the DSM is poorly equipped to capture the phenomenology of psychiatric conditions. It is not something that it sets out to do. This, however, only becomes a serious problem if we adopt the attitude "if it's not in the DSM then it doesn't really count." Unfortunately, many in the psychiatric community have [End Page 267] adopted this sort of attitude, at least implicitly, resulting in a serious neglect of phenomenology (and various other perspectives, including those of the psychopathologized), leading Nancy Andreasen to bemoan the "death of phenomenology." (Andreasen, 2007) The DSM is methodologically limited by design; there are things that it will fail to do. The appropriate response is to acknowledge these inherent limitations. Other perspectives such as neurodiversity or Hearing Voices Movement also bring their own sets of assumptions and limitations. The DSM is simply one element, one perspective, one methodology in a scientific field that is capable of and ought to adopt a plurality of perspectives and methodologies. This is worth pointing out because Knox appears to assume that if it proves difficult or impossible for the DSM to include radically diverse perspectives, then "all the worse for psychiatry's objectivity." If it is impossible for the DSM, that does not mean that it is also impossible for psychiatric science.1In Determining What Counts as Inappropriate Exclusion, What Is the Role of Scientific Expertise?Longino herself brings up this question: "in determining what counts as inappropriate exclusion of dissenting perspectives, does it matter what kind of issue is involved? Are the duties of inclusion different when the question is, Should we be trying to learn about such and such, for example, atomic fission? than when it is, Is atomic fission a controllable or uncontrollable process?" (Longino, 2002, p. 133) The danger that needs to be averted here is that of trivializing expertise and placing experts on an equal footing with non-experts, a danger that is strikingly illustrated by our social response to the coronavirus disease 2019 pandemic.Take an example from medicine. Individuals with lung cancer have a lot to offer when it comes to the treatment of lung cancer, including their experiences of care, and choice of, say, aggressive chemotherapy vs palliative comfort care, etc. but how much do they have to contribute on the matter of the histopathological classification of lung cancer? Consider the Hierarchical Taxonomy of Psychopathology (HiTOP) (Kotov et al., 2021). This quantitative nosological project has a very specific aim: to determine the patterns of covariation among psychiatric symptoms using statistical techniques such as factor analysis. This... (shrink)

In this commentary on Anneli Jefferson’s book “Are Mental Disorders Brain Disorders?,” I offer an overview of her central thesis, and then propose my own modified account of when we are justified in calling mental disorders as “brain disorders.” In doing so, I draw on recent work in neuroscience that understands the relationship between brain and behavior in complex, dynamic, and computational terms. In particular, I disagree with Jefferson’s criterion of sufficiency, that a particular brain process should always realize a (...) psychological dysfunction. I propose that a psychiatric disorder can be said to be a brain disorder if there are empirically identifiable systematic brain differences associated with it and if these associations are contextualized within a scientifically robust theoretical understanding of the relationship between brain and behavior. I conclude by preliminary reflections on whether the issue of “mental disorder” versus “brain disorder” comes down to “the language of psychology” versus “the language of neuroscience,” and the degree to which the former can be expressed in the latter. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Two Different “Religious Experience vs Psychopathology” DistinctionsAwais Aftab, MD (bio)Mohammed Rashed’s analysis of the distinction between “religious experience” and “psychopathology” challenges the assumptions that underlie traditional efforts to make such a distinction and he arrives at a provocative and memorable conclusion: “The distinction between religious experience and mental disorder can only be invoked from a secular standpoint but can only be clarified from a religious standpoint. In other words: (...) if you have the grounds to invoke it, you cannot have the tools to clarify it; and if you have the tools to clarify it, you do not have the grounds to invoke it” (Rashed, 2024). (For another recent discussion that challenges underlying assumptions of this dichotomy, see Gipps and Clark (2024) on the distinction between religious delusion and religious belief.)There is great merit in Rashed’s analysis, and I am in agreement with many aspects of the discussion. In particular, I admire Rashed’s ability here, as well as elsewhere (Rashed, 2021), to break the impasse of definitional debates by deconstructing and destabilizing the distinctions involved. In this commentary I’d like to note some points of disagreement and qualification that I hope can move Rashed’s analysis forward in a constructive way.The first thing I want to bring up is that Rashed defines religious experience very broadly: “Psychological distress or anomalous experience that has a religious origin, content, or end (purpose).” This effectively turns the distinction between religious experience and psychopathology into an instance of the general distinction between the religious worldview and the secular worldview. “Mental disorder” is understood by Rashed to be an exclusively secular concept. I am not sure this way of framing the dichotomy is entirely correct. If our notion of “religious experience” include any anomalous experiences believed to serve a religious purpose, then Rashed is correct that for the religious no anomalous experience would be excluded. And if “mental disorder” requires giving up on the idea of a divine purpose for our [End Page 211] suffering, then indeed the religious do not have the grounds to invoke it.I’d suggest that a better approach may be to think of two different “religious experience vs psychopathology” distinctions, one within the context of the religious worldview and one within the context of the secular worldview. Both are fuzzy and present demarcation problems of their own; both can be and ought to be destabilized.Rashed recognizes that the religious worldview does make space for illness and disease; it’s just that he says even these concepts are understood within a broader religious view of suffering:the proposal is not that religious traditions have no category of distress that is somatic in nature—of course they do—but that even with those categories, religion is never far off the horizon and will make an appearance at some point, if not in the origin or content of distress, then in terms of its broader purpose and so the recommended interventions.(Rashed, 2024, pp. 201)A vital implication of this is that the distinction between religious experience and a secular view of somatic illness would pose the same problem as the distinction between religious experience and mental illness; the religious would not have grounds to invoke it, for no illness is devoid of religious significance. And yet, the religious do meaningfully talk of “illnesses” and “diseases,” and they do meaningfully talk of “madness” (if not mental illness), and many often do meaningfully differentiate between madness and mysticism. This shows that the religious worldview has its own notions of disease and psychopathology, which differ from their secular counterparts in the sense that suffering involved is imbued with a divine purpose. The religious scholars interested in differentiating between the anomalous nature of the mystical experience and the anomalous nature of madness are interested, in part, in marking out abnormalities of thought and behavior so severe that they come to resemble the effects of somatic illness. Madness is where the internal coherence of the mystical experience breaks down, and becomes an instance of suffering at par with somatic illness.The secular worldview recognizes the phenomenology of religious experience—there is religious or mystical content—but... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:On the Importance of Conceptual ContrastsMadness, Reason, and Mad PrideAwais Aftab, MD (bio)Garson (2023) offers an engaging historical and philosophical discussion around the importance Late Modern thinkers assigned to the task of differentiating madness from idiocy (or more specifically, to the tripartite distinction of sanity, madness, and idiocy). Based on this analysis, Garson’s identifies the need to offer a positive account of mental illness—one that does not define the (...) essence of mental illness exclusively as the absence, lack, or failure of the power of reasoning. Following the Late Modern thinkers (Locke, Kant, Wigan, and Heinroth), Garson concludes that madness is infused with reason, and what characterizes madness is the presence of reason in an altered and mutated form. This is all worth taking seriously. My own assessment of this historical and philosophical material nonetheless differs from that of Garson. To recognize madness as possessing reason within it in an altered form may be of less profound significance than he thinks it is. Garson’s discussion commendably highlights the importance of making conceptual contrasts explicit in definitional debates, and this should indeed lead us to search for contrasts that are more philosophically illuminating (what is better will depend on the context of inquiry). However, in my view, the recognition of madness as altered reason neither reframes the project of defining “mental disorder” nor does it provide an intellectual scaffolding for mad activism.The significance of “madness contains reason within in but in an altered or perverse form” is difficult to translate into contemporary scientific terms, and the fuzziness and historical baggage around the terms “madness,” “reason,” and “perversion” does not make it easy. “Mental disorder” or “psychopathology” means to us something quite different than what madness meant to Late Modern thinkers, and while “madness” remains a popular term in philosophical literature, there is no clarity on the nature of overlap between the domain of madness and the domain of conditions currently classified by the diagnostic manuals. Mental disorders, as currently conceptualized, include a motley of conditions that were previously characterized using terms such as idiocy, madness, neuroses, and psychopathic personalities. [End Page 297]From our contemporary vantage point, to compare idiocy and madness is to make a distinction within the domain of psychopathology. We are comparing two groups of psychiatric conditions. The lessons we derive from this comparison do not necessarily extrapolate well to a comparison of mental disorders with something outside the domain of psychopathology. To the extent that psychopathology is inclusive of both idiocy and madness, psychiatric disorders both contain and do not contain “reason” within them. The domain is heterogenous in this regard, and broad generalizations about the nature of reason in the mental disorders would be simplistic at best and inaccurate at worst. Other distinctions that we have made within the domain of psychopathology have included organic versus functional, neurosis versus psychosis, categories versus continua, and distinctions used within nosology have included operationalized criteria versus phenomenology, idiographic versus nomothetic, medical versus non-medical, description versus explanation, and so on (Aftab & Ryznar, 2021; Zachar, Banicki, & Aftab, 2023), all of which have the potential to offer a positive account of some aspect of psychopathology.It is worth nothing that the distinction between “absence of reason” versus “perversion of reason” is analogous to the common distinction between absence of function and altered function in patho-physiology. Such a distinction exists for almost every function that exists. Consider vision: absence of vision (blindness) and altered vision (illusions, distortions, hallucinations). Consider hypoesthesia (reduced sense of touch) and paraesthesia (altered sense of touch—tingling, pricking, burning, etc.). Garson alludes to diminished sexual capacity versus paraphilia as an analogy, but he does not seem to appreciate that the analogy applies much more broadly. Is the distinction between absence of reason versus perversion of reason of any greater significance than the distinction between blindness and hallucination? If we were to say, “What distinguishes hallucination from blindness is not the failure, absence, or lack of sight, but its presence—albeit in a perverse and mutated form,” how profound would it really be for our notions of disorder? Or imagine some Late Modern physician saying that a disturbance of speech and... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Dialectical Tension Between Gloomy and Rosy Prospects of Behavioral GeneticsAwais Aftab, MD (bio)Turkheimer and Greer’s article “Spit for Science and the Limits of Applied Psychiatric Genetics” (2024) offers a devastating critique of the state of psychiatric genetics, using Spit for Science (S4S) as a case study. I have read the paper many times in the process of writing this commentary, and each time I am left inarticulate. Nonetheless, I (...) hope that my comments, from the point of view of a practitioner who operates at the intersection of clinical psychiatry, psychiatric science, and philosophy of psychiatry, will be of some value to the discussion. I have no substantial disagreements with Turkheimer and Greer. The main point I wish to convey is that there is reason to hope that findings from genetic research will contribute to clinical progress in psychiatry in an incremental and iterative manner, but because psychiatric genetics has overpromised and underdelivered, we find ourselves vacillating between bullish and bearish moods.Some critics may say that the choice to selectively focus on S4S is unfair, or that it gives a misleading impression of the current state of psychiatric genetics. The launch and implementation of S4S captures a particular moment in the history of psychiatric genetics when it was known that individual associations will be small and that large samples will be needed for significant associations, but it was not appreciated exactly how small and how large respectively. Initial estimates of sample sizes needed for successful genetic associations turned out to be wildly inadequate. Progress occurred only with unprecedented international collaboration and extremely large sample sizes. For example, a 2022 genome-wide association study (GWAS) of schizophrenia included more than 76,000 people with schizophrenia and 240,000 controls (Trubetskoy et al., 2022)! S4S is one project from one institution. It is understandable in retrospect that a sample of 10,000 freshmen could only have delivered so much. It may be argued that whatever the promise of psychiatric genetics as a field, it is not constrained by the success or failure of S4S.On the one hand, it is true that S4S did not have the requisite sample size. On the other hand, the contemporary understanding of the genetics of alcohol use has not improved on insights from S4S by that much (Deak et al., 2019). SNP-based heritability estimate of problematic alcohol use [End Page 451] is close to 10% based on a GWAS of 435,000 individuals (Zhou et al., 2020), consistent with statistically non-significant estimates from S4S. The same GWAS has identified 29 risk variants, and genetic correlations with more than a hundred other phenotypes. Transcriptomic analysis has revealed that implicated genes are expressed in the brain but also in gastrointestinal, adipose, and liver tissue, pointing toward pathways of protection and vulnerability. A polygenic risk score (PRS) derived from associated variants is consistently and significantly associated with alcohol dependence, with variance explained ranging from 0.77% to 2.12% in different samples (Zhou et al., 2020).At present, PRS for problematic alcohol use has little predictive value at the individual level and is practically worthless from the standpoint of clinical practice. There are hints that genetic associations can point toward brain mechanisms involved in alcohol use disorder, but we have little to show for it yet. That PRS will achieve clinical utility is not guaranteed but neither is it impossible. A PRS for externalizing behavior explains approximately 10% of the variance, which is on par with factors such as socioeconomic status and neighborhood disadvantage (Karlsson Linnér et al., 2021). And even if PRS does not become a common part of clinical practice, it can still be a useful tool in clinical research. With regard to understanding mechanisms, the trivial effect size of the genetic association is by itself irrelevant. This point is made eloquently by Steven HymanWhen used as a tool to associate a trait with biology, the effect size of the allele on the ultimate phenotype does not matter… what makes a gene product a good drug target is not the effect size of the associated allele, but its overall role in biology… Once a pathway is shown to... (shrink)

This article comments on the following previously published article: Moncrieff, J., “ It Was the Brain Tumor That Done It!” Szasz and Wittgenstein on the Importance of Distinguishing Disease from Behavior and Implications for the Nature of Mental Disorder. Philosophy, Psychiatry, & Psychology, 27, 169–181.Joanna Moncrieff’s philosophical views on the nature of mental illness represent in many ways the enduring legacy of Thomas Szasz in philosophy of psychiatry. She articulates a defense of Szaszian thinking about disease, with connections to Wittgenstein’s (...) philosophy, that is probably as compelling a defense as a contemporary student of philosophy is likely to find. However, Moncrieff’s... (shrink)