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 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: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)

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)