This short contribution questions the ethics of basing the way we think and act in relation to mental disorder on beliefs and assumptions that are in the view of the author at best, unhelpful and at worst, simply incorrect.

Recently clinicians have become more reliant on technologies such as artificial intelligence (AI) and machine learning (ML) for effective and accurate diagnosis and prognosis of diseases, especially mental health disorders. These remarks, however, apply primarily to Europe, the USA, China and other technologically developed nations. Africa is yet to leverage the potential applications of AI and ML within the medical space. Sub-Saharan African countries are currently disadvantaged economically and infrastructure-wise. Yet precisely, these circumstances create significant opportunities for (...) the deployment of medical AI, which has already been deployed in some places in the continent. However, while AI and ML have come with enormous promises in Africa, there are still challenges when it comes to successfully applying AI and ML designed elsewhere within the African context, especially in diagnosing mental health disorders. We argue, in this paper, that there ought not to be a homogeneous/generic design of AI and ML used in diagnosing mental health disorders. Our claim is grounded on the premise that mental health disorders cannot be diagnosed solely on ‘factual evidence’ but on both factual evidence and value-laden judgements of what constitutes mental health disorders in sub-Saharan Africa. For ML to play a successful role in diagnosing mental health disorders in sub-Saharan African medical spaces, with a precise focus on South Africa, we allude that it ought to understand what sub-Saharan Africans consider as mental health disorders, that is, the value-laden judgements of some conditions. (shrink)

The effects of mental disorder are apparent and pervasive, in suffering, loss of freedom and life opportunities, negative impacts on education, work satisfaction and productivity, complications in law, institutions of healthcare, and more. With a new edition of the 'bible' of psychiatric diagnosis - the DSM - under developmental, it is timely to take a step back and re-evalutate exactly how we diagnose and define mental disorder. This new book by Derek Bolton tackles the problems involved in (...) the definition and boundaries of mental disorder. It addresses two main questions regarding mental illness. Firstly, what is the basis of the standards or norms by which we judge that a person has a mental disorder - that the person's mind is not working as it should, that their mental functioning is abnormal? Controversies about these questions have been dominated by the contrast between norms that are medical, scientific or natural, on the one hand, and social norms on the other. The norms that define mental disorder seem to belong to psychiatry, to be medical and scientific, but are they really social norms, hijacked and disguised by the medical profession? Secondly, what is the validity of the distinction between mental disorder and order, between abnormal and normal mental functioning? To what extent, notwithstanding appearances, does mental disorder involve meaningful reactions and problem-solving? These responses may be to normal problems of living, or to not so normal problems - to severe psycho-social challenges. Is there after all order in mental disorder? With the closing of asylums and the appearance of care in the community, mental disorder is now in our midst. While attempts have been made to define clearly a concept of mental disorder that is truly medical as opposed to social, there is increasing evidence that such a distinction is unviable - there is no clear line between what is normal in the population and what is abnormal. 'What is Mental Disorder?' reviews these various crucial developments and their profound impact for the concept and its boundaries in a provocative and timely book. (shrink)

"Grapples with the legacy of Jerome Wakefield, one of the most influential critics of modern psychiatry and the use of the DSM for psychiatric diagnosis"--.

In this dissertation, I examine our mental health concepts to see what work they are currently doing as well as what work they could be doing. In 1976, Christopher Boorse stated that the mental health literature is a “web of obscurities” (p. 51). To resolve some of this confusion, I argue that we need to consider the goals we should have for our mental health concepts and then give accounts of those concepts that meet our stated goals. (...) I argue that our goals for our mental health concepts should be twofold: first, we need concepts that will work to alleviate the stigmatization of mental disorder as this stigmatization gets in the way of providing and receiving medical help, and second, we need concepts that will be useful tools for medical practitioners to use in their diagnosis and treatment practices. -/- I begin by arguing that our mental disorder concept is not currently a useful tool for medical practitioners. Moreover, I argue that our mental disorder concept is confused in such a way that it is unlikely that it could ever be a useful tool for medical practitioners. If we cannot give an account of the mental disorder concept that is a useful tool for medical practitioners, then perhaps we can give an account of the mental disorder concept that can be used toward our goal of alleviating the stigmatization of mental disorder. Before we can do that, however, we need an account of the stigmatization concept so that we can understand what our mental disorder concept needs to be alleviating. -/- I argue that stigmatization is a process whereby some entity becomes marked as disgraceful or shameful. This stigmatization process includes (1) an attitude against the entity for reasons found in the social ideology, and (2) acts against the entity. I then argue that acts of stigmatization take two forms: direct stigmatization (where stigmatizors take acts against the stigmatized entity) and indirect stigmatization (where potential victims of stigmatization take acts to avoid becoming victims of stigmatization). With that in mind, we learn that if we are to alleviate the stigmatization of mental disorder, we need to work on alleviating both direct and indirect stigmatization. It is at this point that I argue for a new account of our mental disorder concept that can be utilized to alleviate the direct and indirect stigmatization of mental disorder. With our mental disorder concept redesigned to achieve that goal, I turn to the goal of providing medical help for persons that need that help. I argue that we need to reconceptualize what it means to be a ‘diagnosable condition’ so that we can develop a new framework for diagnosis and treatment that will be more efficacious than our current system. In conclusion, I suggest that we can untangle the current confusion that is the mental health literature by imbuing our mental health concepts with specific purposes and then utilizing them to achieve those purposes as I outline in this dissertation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Moral Responsibility:Disorders of Personhood as Harmful Dysfunctions, With Special Reference to AlcoholismJerome C. Wakefield (bio)Keywordsalcohol dependence, philosophy of psychiatry, mental disorder, harmful dysfunction, psychiatric diagnosis, person, moral responsibilityIn his paper, Ethical Decisions in the Classification of Mental Conditions as Mental Illness, Craig Edwards grapples with a profound problem: why is it that when we classify a mental condition as (...) a mental disorder, that tends to take the condition out of the sphere of moral responsibility or virtuousness of character? For example, it is not uncommon when someone commits suicide and the question is raised as to why he or she did it, that instead of a reason or character trait that would place the act within a moral calculus, one is offered the explanation "she was clinically depressed" or "he was bipolar," and this tends to terminate discussion and make reasons and moral evaluation superfluous. Why does such a comment have that effect?As Edwards notes, this can get complicated as the moral and the disordered interact. Certainly people are sometimes morally responsible for acting on their disordered impulses (as in pedophilia), and they are responsible for putting themselves in the way of disorder, as when someone imbibes in a way likely to lead to alcoholism. But at the normal/disorder divide, there seems to be a consistent lifting of some responsibility, reflecting the application of the sick role. For example, the rough equivalent of our current category of post-traumatic stress disorder (PTSD) was recognized as a disorder in earlier wars ("shell shock," "war neurosis"), but often considered an expression of cowardice; the cowardice was morally evaluable as a failure of virtue (even if, like many personality traits, being a coward is not within the person's direct voluntary control) and led to contempt for those with PTSD, but nonetheless—except in cases thought to be malingering—the PTSD that resulted constituted a disorder for which the individual was [End Page 91] not in the same direct sense blameworthy. This moral shift requires explanation.This topic also has important social ramifications. Relief from responsibility may sound like a good thing, and it is trumpeted by mental health advocates as a reason for supporting the classification of many conditions as disorders. But as Edwards is aware, it is a two-edged sword. Disordered status may allow escape from censure and offer the protections of the sick role, but it also changes the relationship of the agent to his or her own actions and imposes the responsibility of the sick role on the individual to attempt to change ("get better"). The sick role allows for no defense of an idiosyncrasy based on normal variation ("It takes all kinds…") or the individual's eccentric vision or steadfast integrity, for that vision or sense of integrity are now seen as pathological and not morally legitimate. The individual is subjected to endless entreaties to seek help and it is implied that not to do so is irresponsible, so that a decision to embrace one's nature and remain as one is becomes illegitimate. Moreover, the sick role allows for no explanation in terms of the individual's normal defensive response to unjust, deprived, or challenging social or environmental circumstances, thus weakening the motives for social change rather than individual intervention.In sum, there is an inevitable sense in which being placed in the sick role inherently stigmatizes the "sick" condition in virtue of the special moral attitudes extended to the disordered. Cultures can thus easily exploit the sick role and its much-touted relief from responsibility to extend the reach of social control processes. This is one reason why the distinction between disorder and non-disorder is so important, and why it is crucial to identify when non-disordered conditions are mislabeled as disorders—as when, for example, psychiatry gets it wrong about the distinction between normal and disordered sadness (Horwitz and Wakefield, 2007). Such overpathologization can redefine the boundaries of our moral universe on mistaken grounds.Edwards offers two provocative answers—not entirely at ease with each other—to the question of why mental disorders relieve the patient from moral responsibility: (1) mental disorders are... (shrink)

As it emerged from philosophical analyses and cognitive research, most concepts exhibit typicality effects, and resist to the efforts of defining them in terms of necessary and sufficient conditions. This holds also in the case of many medical concepts. This is a problem for the design of computer science ontologies, since knowledge representation formalisms commonly adopted in this field do not allow for the representation of concepts in terms of typical traits. However, the need of representing concepts in terms of (...) typical traits concerns almost every domain of real world knowledge, including medical domains. In particular, in this article we take into account the domain of mental disorders, starting from the DSM-5 descriptions of some specific mental disorders. On this respect, we favor a hybrid approach to the representation of psychiatric concepts, in which ontology oriented formalisms are combined to a geometric representation of knowledge based on conceptual spaces. (shrink)

A new diagnostic system for organic psychiatry is presented. We first define "organic psychiatry", and then give the theoretical basis for conceiving organic psychiatric disorders in terms of hypothetical psychopathogenetic processes, HPP:s. Such hypothetical disorders are not strictly identical to the clusters of symptoms in which they typically manifest themselves, since the symptoms may be concealed or modified by intervening factors in non typical circumstances and/or in the simultaneous presence of several disorders. The six basic disorders (...) in our system are Astheno Emotional Disorder (AED), Somnolence Sopor Coma Disorder (SSCD), Hallucination Coenestopathy Depersonalisation Disorder (HCDD), Confusional Disorder (CD), Emotional Motivational Blunting Disorder (EMD) and Korsakoff's Amnestic Disorder (KAD). We describe their usual etiologies, their typical symptoms and course, and some forms of interaction between them. (shrink)

This paper explores how the diagnosis of mental disorder may affect the diagnosed subject’s self-concept by supplying an account that emphasizes the influence of autobiographical and social narratives on self-understanding. It focuses primarily on the diagnoses made according to the criteria provided by the Diagnostic Statistical Manual of Mental Disorders (DSM), and suggests that the DSM diagnosis may function as a source of narrative that affects the subject’s self-concept. Engaging in this analysis by appealing to (...) autobiographies and memoirs written by people diagnosed with mental disorder, the paper concludes that a DSM diagnosis is a double-edged sword for self- concept. On the one hand, it sets the subject’s experience in an established classificatory system which can facilitate self-understanding by providing insight into subject’s condition and guiding her personal growth, as well as treatment and recovery. In this sense, the DSM diagnosis may have positive repercussions on self-development. On the other hand, however, given the DSM’s symptom-based approach and its adoption of the Biomedical Disease model, a diagnosis may force the subject to make sense of her condition divorced from other elements in her life that may be affecting her mental- health. It may lead her frame her experience only as an irreversible imbalance. This form of self-understanding may set limits on the subject’s hopes of recovery and may create impediments to her flourishing. (shrink)

_Psychopathology at School_ provides a timely response to concerns about the rising numbers of children whose behaviour is recognised and understood as a medicalised condition, rather than simply as poor behaviour caused by other factors. It is the first scholarly analysis of psychopathology which draws on the philosophers Foucault, Deleuze, Guattari and Arendt to examine the processes whereby children’s behaviour is pathologised. The heightened attention to mental disorders is contrasted with education practices in the early and mid-to-late twentieth (...) century, and the emergence of a new conceptualization of childhood is explored. Taking education as a central component to the contemporary experience of growing up, the book charts the ways in which mental disorders have become commonplace in childhood and youth, from birth through to college and university, but also offers examples of where professionals have refused to pathologise children’s behaviour. The book examines the extent of the influence of psychopathology on the lives of children and young people, as well as the practices that infiltrate education and the possibilities for alternative educational responses that negate the diagnosis of mental disorder. Psychopathology at School is a must read for anyone concerned about the growing influence of psychopathology in education and will be of particular interest to educated readers and to scholars, students and professionals in education, psychiatry, psychology, child studies, youth studies, nursing, social work and sociology. (shrink)

This paper employs the methodological framework of linguistic analytic philosophy to explore the conceptual issues arising from a study of the different models of disorder implicit in five groups of stakeholders concerned in the community care of people with a diagnosis of long-term schizophrenia. Linguistic analysis, gives a precise fix on the nature of the practical difficulties presented by such models, suggests a powerful heuristic for displaying and comparing models, is the basis of a methodology which is neutral as (...) between users and providers of services, provides an intuitively powerful way of understanding the results of work of this kind, and facilitates the translation of research into practice. (shrink)

Psychiatry's relation to the rest of medicine is ambivalent. Its legitimacy as a specialty is often conceived as being closely linked to its fidelity to the fundamental paradigms of medicine, especially the centrality of diagnosis and the association of diagnosis with treatment indications. However, as Gagné-Julien notes, a major impetus behind the quest for a solution to the demarcation problem in psychiatry is "growing concerns regarding over-medicalization". Although it could appear that these two considerations point in opposite directions, (...) both arguably would be served by what Gagné-Julien labels "a satisfying definition" of mental disorder. Such a... (shrink)

At present, psychiatric disorders are characterized descriptively, as the standard within the scientific community for communication and, to a certain extent, for diagnosis, is the DSM, now at its fifth edition. The main reasons for descriptivism are the aim of achieving reliability of diagnosis and improving communication in a situation of theoretical disagreement, and the Ignorance argument, which starts with acknowledgment of the relative failure of the project of finding biomarkers for most mental disorders. Descriptivism (...) has also the advantage of capturing the phenomenology of mental disorders, which appears to be essential for diagnosis, though not exhaustive of the nature of the disease. I argue that if we rely on the distinction between conceptions (procedures of identification) and concepts (reference-fixing representations), which was introduced in the philosophical debate on the nature of concepts, we may understand a limited but valid role for descriptive characterizations, and reply to common objections addressed by those who advocate a theoretically informed approach to nosology. (shrink)

Abstract: At present, psychiatric disorders are characterized descriptively, as the standard within the scientific community for communication and, to a cer- tain extent, for diagnosis, is the DSM, now at its fifth edition. The main rea- sons for descriptivism are the aim of achieving reliability of diagnosis and improving communication in a situation of theoretical disagreement, and the Ignorance argument, which starts with acknowledgment of the relative fail- ure of the project of finding biomarkers for most (...) class='Hi'>mental disorders. Descrip- tivism has also the advantage of capturing the phenomenology of mental dis- orders, which appears to be essential for diagnosis, though not exhaustive of the nature of the disease. I argue that if we rely on the distinction between conceptions (procedures of identification) and concepts (reference-fixing representations), which was introduced in the philosophical debate on the nature of concepts, we may understand a limited but valid role for descrip- tive characterizations, and reply to common objections addressed by those who advocate a theoretically informed approach to nosology. (shrink)

The main thesis of this paper is that mental health practitioners can legitimately infer that a patient's given condition is a case of mental disorder without having diagnosed any specific mental disorder. The article shows how this is justifiable by relying either on psychopathological reasoning, on 'intentional' analysis or possibly on other modes of reasoning. In the end, it highlights the clinical and philosophical consequences of the plurality of modes of 'inferences to mental disorder'.

Although the “Introduction” to the DSM makes it clear that the presence of “clinical” distress or impairment is insufficient for a diagnosis of “mental disorder” , in practice the clinician is completely unshackled from the conceptual definition and is free to decide on a case-by-case basis if “enough” distress or impairment is present, regardless of circumstances, to judge that “mental disorder” can be diagnosed. It is argued that reference to a biological or psychological dysfunction cannot raise “ (...) class='Hi'>mental disorder” from a judgment quite like “This is pornography, not literature” to a technical–scientific term because “biological dysfunction” must be tied to an outcome that is itself less ambiguous than “mental disorder,” and “psychological dysfunction” erroneously assumes that how people are supposed to think, feel, and act, regardless of circumstances, can be as uncontentious as ideas about physical well being, and in addition erroneously assumes that human behavior can be causally explained. (shrink)

Following a Canadian Supreme Court ruling invalidating an absolute prohibition on physician assisted dying, two reports and several commentators have recommended that the Canadian criminal law allow medical assistance in dying (MAID) for persons with a diagnosis of mental disorder. A key element in this process is that the person requesting MAID be deemed to have the ‘mental capacity’ or ‘mental competence’ to consent to that option. In this context, mental capacity and mental competence (...) refer to ‘decision-making capacity’, which is a distinct area of clinical study and research in the theory of informed consent. The purpose of this discussion is to bring several controversial but insufficiently acknowledged problems associated with decision-making capacity to the forefront of the proposed extension of MAID to persons diagnosed with mental disorders. Open-ended access to MAID by persons who suffer from mental health conditions already exists in Belgium and the Netherlands, where the issues raised here are equally relevant. In this paper, we highlight the serious limitations of relying on capacity assessments to allow access to MAID/Euthanasia. (shrink)

The stated purpose of the Diagnostic and Statistical Manual of Mental Disorders is to classify mental disorders. However, no tenable operational definition of mental disorder is offered in the manual. This leaves the possibility open that the behaviors labeled as disordered in the DSM are not members of a valid category. Attempts to define mental illness fall into the category of essentialist or relativist based, respectively, on the acceptance or denial of the existence of (...) a defining biological attribute that all mental disorders possess. However, the disorders in the DSM cannot be accounted for by either of these approaches making it unlikely that they represent a single valid concept. Simultaneous inclusion of brain illnesses and normal behaviors in the DSM are a likely explanation for the disparate nature of DSM disorders. (shrink)

The notion of harm is frequently used in the discussion of the nature of mental disorder. Harm also plays important roles in the prominent diagnostic manuals such as DSM and ICD. Recently, however, Cristina Amoretti and Elisabetta Lalumera have questioned the idea that harm should be a necessary constituent of mental disorders. They argue that the notion of harm is underspecified and potentially leads to false negatives in diagnosing mental disorders. Given that harm plays significant (...) roles in medical diagnosis and treatment indicates that we should be reluctant to remove it as a criterion for deciding whether some condition is a mental disorder. Instead, we argue that harm should be understood in the prudential sense and harm in this sense provides a way of responding to worries raised by Amoretti and Lalumera, while staying true to the conception of harm that is relevant for psychiatric practice. (shrink)

In the Netherlands and Belgium, it is lawful for voluntary euthanasia to be offered on the grounds of psychiatric suffering. A recent case that has sparked much debate is that of Aurelia Brouwers, who was helped to die in the Netherlands on account of her suffering from borderline personality disorder. It is sometimes claimed that whether or not a mentally ill person’s wish to die is valid hinges on whether or not that wish is a symptom of the person’s (...) class='Hi'>mental disorder. This article addresses the philosophical problems raised by this claim, with a specific focus on the diagnosis of borderline personality disorder. After considering descriptivist and causal conceptualizations of mental disorder, I argue that the current approach to borderline personality disorder in psychiatry precludes the possibility of dissociating the wish to die from the disorder. I then examine the implications of this analysis for the question of whether or not the request for voluntary euthanasia in the case of borderline personality disorder can be considered valid. Ultimately, I conclude that the inability to dissociate the wish to die from the disorder does not invalidate the wish in the case of borderline personality disorder. (shrink)

Background: There has for some time now been recognition that there was a relationship between exceptional creative talent and mental disorder. The works of Andreasen (2008) and others in this area have been very significant. However, most of the research has been carried out in USA and Europe. Very little has come out of Africa on the subject. Aim : To survey the beliefs of different groups within an African society, concerning the possibility of a relationship between creative talent (...) and mental disorder. To assess creativity within a community of people with a formal diagnosis of mental disorder. Materials and Methods: Some of the mythology of the Yoruba was examined for content, concerning the behaviour of certain notable individuals and the existence of psychopathology based on modern-day criteria. The beliefs of members of the general public and mental health professionals concerning the existence of a relationship between creative talent and psychopathology were surveyed using a questionnaire designed for the project. A sample of patients with formal diagnoses of affective disorder or schizophrenia drawn from two units, the Lagos State University Teaching Hospital and the Federal Neuropsychiatric Hospital Yaba, were assessed for 'Creativity.' Results : Although there are notable 'eccentric' figures in local mythology, the overwhelming majority of the people surveyed do not believe there is any relationship between creativity and mental illness. They however believe that engaging in creative activities helps the mentally ill to recover from illness. The mental health professionals, who were clinical psychologists and psychiatrists, had a significant minority who believed that a relationship does exist, and they also strongly assert that creative activity has a therapeutic effect for the mentally ill. A survey of in-patients diagnosed with schizophrenia and affective disorder failed to show a significant difference in the creativity of the two populations, as measured by the originality score of the Rorschach scale. The survey of patients is inconclusive, based on small sample size (ten patients with a diagnosis of schizophrenia, ten with bipolar affective disorder.). The linkage between formal mental disorder is only recognised by a significant minority of mental health professionals. A significant proportion of the population believe that creative activity aids recovery from mental illness. More research is required into this important subject in Africa. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Close Enemies: The Relationship of Psychiatry and Psychology in the Assessment of Mental DisordersPhilippe Le Moigne, PhDAs Peter Zachar rightly points out in his comment, the assessment of mental disorders underwent new developments with the release of the Diagnostic and Statistical Manual of Mental Disorders-V in 2013 (American Psychiatric Association, 2013). Whereas in 1980, the manual had been thought of in a rigorously categorical (...) way, on the basis of distinct and closed syndromic entities, this new version advocated the development of a radically dimensionalist approach, with the diagnosis aiming this time to restore the whole symptomatological picture of the patient on a spectrum of ratings are supposed to cover the entirety of psychiatric semiology (American Psychiatric Association, 2013).For its part, my article aimed to show how standardized assessment, guided by the return of psychiatry’s authority and the assertion of its legitimacy in the diagnostic field, gave the ascendancy in the 1980s to the classificatory tradition and thus to the categorical model, to the detriment of personality approach and test psychology which offered a competing solution here. This perspective, historically dated, may have led the reader to think that there is an antagonism that cannot be overcome here. Rather, it should be seen as a form of structuring opposition, or even a “complementarity inscribed in rivalry,” between psychiatry and psychology, which is naturally susceptible to change over time.Indeed, the reversal operated by the Diagnostic and Statistical Manual of Mental Disorders-V is not total because it cannot be total. The defense of the dimensionalist approach, dear to the psychological testing tradition, was intended here to allow the identification of co-morbidities, present in most patients but poorly apprehended by the categorical approach, and to open up diagnosis to prevention by screening for minor manifestations of psychopathology when they suggest the [End Page 259] development of a manifest episode of the disease in the more or less long term. The risk here is that we end up with overdiagnosis and thus an over-representation of false positives (Wakefield, 2015). In other words, this type of approach does not escape the obligation to determine threshold scores, likely to indicate the lower limit of the disorder, and thus to resort to a categorical approach. There is a first affinity between the two perspectives which obeys, beyond the divergences in principle, a technical requirement.But the two approaches have even more in common when we look at their epistemological background: they share the idea that the representation and the intervention on mental disorder, to use Ian Hacking’s expression (1983), must be based on the model proposed by the physical and natural sciences. And as Greta Kaluzeviciute aptly points out in her comment, this orientation leads to the idea of measuring mental disorder in particular to conduct elaborate quantification operations to determine, for example, whether two entities are statistically distinct or whether a drug has a significant effect on the evolution of a pathology.This is in fact an old question that can be formulated as follows, to use the expression of the psychometrician Joel Michell (1999): are psychological dimensions metric? In other words, if we want to apply the language of numbers to mental disorders, they must share its properties, two of which seem essential: it must be possible to establish that each mental disorder, in the same way as qualities attributable to length for example, has a zero and can be divided by means of gradients (or degrees of intensity) whose interval is constant (Le Moigne, 2018; Michell, 1999). For lack of space, let us only address the second condition. This one has already been denied by many, starting with Bergson at the end of the nineteenth century (1889). He does not believe in the quantification of psychological expressions, starting with sensations. What is the common point, he wrote, between the feeling of a mild pain, as one feels a stiffness, and the sensation of a needle being hammered into your flesh? For him, one and the other of these intensities are incomparable, so that they do not belong to a similar register of sensations that one could stage from a 0 toward a... (shrink)

Following a Canadian Supreme Court ruling invalidating an absolute prohibition on physician assisted dying, two reports and several commentators have recommended that the Canadian criminal law allow medical assistance in dying (MAID) for persons with a diagnosis of mental disorder. A key element in this process is that the person requesting MAID be deemed to have the ‘mental capacity’ or ‘mental competence’ to consent to that option. In this context, mental capacity and mental competence (...) refer to ‘decision-making capacity’, which is a distinct area of clinical study and research in the theory of informed consent. The purpose of this discussion is to bring several controversial but insufficiently acknowledged problems associated with decision-making capacity to the forefront of the proposed extension of MAID to persons diagnosed with mental disorders. Open-ended access to MAID by persons who suffer from mental health conditions already exists in Belgium and the Netherlands, where the issues raised here are equally relevant. In this paper, we highlight the serious limitations of relying on capacity assessments to allow access to MAID/Euthanasia. (shrink)

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, currently in its fourth edition and considered the reference for the characterization and diagnosis of mental disorders, has undergone various developments since its inception in the mid-twentieth century. With the fifth edition of the DSM presently in field trials for release in 2013, there is renewed discussion and debate over the extent of its relative successes - and shortcomings - at iteratively incorporating scientific evidence on the (...) often ambiguous nature and etiology of mental illness. Given the power that the DSM has exerted both within psychiatry and society at large, this essay seeks to analyze variations in content and context of various editions of the DSM, address contributory influences and repercussion of such variations on the evolving landscape of psychiatry as discipline and practice over the past sixty years. Specifically, we document major modifications in the definition, characterization, and classification of mental disorders throughout successive editions of the DSM, in light of shifting trends in the conceptualization of psychopathology within evolving schools of thought in psychiatry, and in the context of progress in behavioral and psychopharmacological therapeutics over time. We touch upon the social, political, and financial environments in which these changes took places, address the significance of these changes with respect to the legitimacy (and legitimization) of what constitutes mental illness and health, and examine the impact and implications of these changes on psychiatric practice, research, and teaching. We argue that problematic issues in psychiatry, arguably reflecting the large-scale adoption of the DSM, may be linked to difficulties in formulating a standardized nosology of psychopathology. In this light, we highlight 1) issues relating to attempts to align the DSM with the medical model, with regard to increasing specificity in the characterization of discrete mental disease entities and the incorporation of neurogenetic, neurochemical and neuroimaging data in its nosological framework; 2) controversies surrounding the medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture; and 3) what constitutes treatment, enablement, or enhancement - and what metrics, guidelines, and policies may need to be established to clarify such criteria. (shrink)

Stoic conception of mental disorders is still interesting and could be fruitful used in the current debate on psychiatric classification.

In lieu of an abstract, here is a brief excerpt of the content:Clarifying the Relationship Between Vice and Mental Disorder: Vice as Manifestation of a Psychological DysfunctionMichael B. First (bio)KeywordsDSM-IV, psychiatric diagnosis, impulse control disorders, sexually violent predator commitmentIndividuals generally present for psychiatric evaluation for one of two reasons: either because they themselves are suffering from a psychiatric symptom that causes distress (e.g., severe panic) or impairs their ability to function effectively (e.g., memory loss), or else they (...) are brought to clinical attention because their behavior or attitudes are considered by others to be problematic. There are a wide range of behaviors that fall into this second category. In some cases, the individual is pressured to seek treatment because of the negative impact that a behavior has on a relationship partner (e.g., sexual dysfunction, anger outbursts) or an employer (e.g., excessive alcohol use). Often, however, the external trigger for a clinical evaluation falls under Sadler’s definition of vice, that is, criminal (illegal) behaviors or attitudes that could be considered “wrongful” or “immoral” in the social arena because the behavior violates the law or an important social more.Given that one of the most important goals of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is to facilitate clinical practice (First et al. 2004) and in doing so provide a diagnostic code to cover any patient that might present himself or herself to a mental health professional, the DSM has evolved over its various editions to become a veritable laundry list of psychological and behavioral ills, some of which may constitute a violation of the rights of others or society. The DSM-III (and its successors) have adopted a descriptive approach wherein disorders are defined in terms of their presenting surface symptomatology, which was necessitated by the field’s lack of knowledge about the underlying etiology of mental disorders. Given this reliance on presenting symptoms, it is therefore inevitable that some disorders are defined in terms of behaviors that can be considered vices. For example, impaired impulse [End Page 35] control often leads to acting out behavior that, at its mildest is inappropriate, and at its most severe is destructive to self and others. Many of the disorders cited by Sadler as being vice-laden fall into this category, namely, pyromania (failure to resist impulses to set fires), kleptomania (failure to resist impulses to steal), intermittent explosive disorder (failure to resist aggressive impulses), certain forms of substance abuse (i.e., those involving possession and use of illegal substances) and paraphilias (i.e., those involving nonconsenting victims).It is important to clarify from the outset that the criteria for determining whether a behavior is a “vice” (i.e., whether it is illegal or immoral) is not equivalent to the criteria for determining whether a behavior is indicative of a mental disorder. According to the DSM-IV-TR definition, a mental disorder is conceptualized as a “clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (American Psychiatric Association [APA] 2000, xxxi). The definition warns against considering “deviant behavior[s] (e.g., political, religious, or sexual)” and “conflicts that are primarily between the individual and society” to be evidence of mental disorder except in those cases in which the “deviance or conflict is a symptom of a dysfunction in the individual.” Thus, when considering whether a particular “vice” behavior is a component of a mental disorder, it is crucial to determine whether the behavior is a manifestation of an underlying psychological dysfunction, such as a dysfunction in impulse control. If so, it may potentially be appropriate for that individual to be treated as “medically ill” in addition to, or instead of, being treated simply as a criminal.Let us examine some illustrative examples of cases that demonstrate the relationship between vice and mental disorders and the different ways in which the legal and mental health systems might deal with such cases. Consider the case of an individual who breaks... (shrink)

: This contribution aims to address epistemological issues at the crossroads of philosophy of science and psychiatry by reflecting on the notions of organization and resilience. Referring to the debate on the notion of “organization” and its explanatory relevance in philosophical neo-mechanistic theories, I consider how such positions hold up when tentatively applied to the mental health context. More specifically, I show how reflections on psychiatric resilience, cognitive reserve, and accommodation strategies challenge attempts to embrace a mechanistic perspective on (...) mental disorders. A deeper focus on these aspects of mental health is relevant to theoretical discussions on explanatory models as well as for clinical practice, diagnosis, and treatment. Keywords: Psychiatric resilience; Cognitive Reserve; Organization; Mechanism Il ruolo esplicativo dell’organizzazione e la resilienza psichiatrica: sfide ad un approccio meccanicistico alla malattia mentale Riassunto: Questo articolo intende discutere alcuni temi epistemologici all’incrocio tra la filosofia della scienza e la psichiatria, riflettendo sulle nozioni di organizzazione e resilienza. Muovendo dalle riflessioni sulla nozione di “organizzazione” sviluppate nell’ambito delle teorie neo-meccaniciste, e dalla difesa del suo ruolo esplicativo, il lavoro analizza la possibilità di estendere alcune posizioni relative alla spiegazione scientifica al contesto delle scienze della salute mentale. Più nello specifico, si illustra come le indagini sulla resilienza psichiatrica, la riserva cognitiva e le strategie di compensazione possano mettere in discussione i tentativi di abbracciare una prospettiva meccanicistica quando si affronta il tema del disturbo psichiatrico. Una maggiore attenzione ai suddetti filoni di ricerca può avere un impatto significativo sia sulla discussione relativa ai modelli teorici di spiegazione della malattia mentale sia sui processi clinici di diagnosi e terapia. Parole chiave: Resilienza psichiatrica; Riserva cognitiva; Organizzazione; Meccanicismo. (shrink)

The field of mental health continues to struggle with the question of how best to structure its diagnostic systems. This issue is of considerable ethical importance, but the implications for public health approaches to mental health have yet to be explored in any detail. In this article I offer a preliminary treatment, drawing out several core issues while sounding a note of caution. A central strand of the debates over diagnosis has been the contrast between categorical and (...) dimensional models, with renewed attention due to recent publication of the DSM-5, launch of the RDoC, and ongoing work on the ICD-11. This dispute involves an interesting assortment of ethical and empirical considerations, many with direct relevance for public health. It has been proposed, for example, that dimensional diagnosis may be morally preferable because it can help reduce the stigma associated with mental disorder. This is a pressing concern, as preventive strategies are expanded in mental health, often operating under dimensional assumptions that target various risk factors. But this type of proposal relies upon an empirical claim and the scientific status of dimensionality remains unresolved, including its relation to stigma. I suggest, then, that the current state of the evidence does not yet warrant clear adjudication between competing frameworks, and thus any implications for public mental health remain highly provisional. More research is needed to help resolve these issues, including ethical analysis. (shrink)

Psychiatric diagnoses are increasingly seen as viable categories around which self and social identities might be drawn. This introduces a new pressure on the “boundary problem” for psychiatry: when members of the public request diagnoses to affirm their self-identities how should we draw the line between mental disorder and normality? If psychiatrists have the authority to recognize and diagnose mental disorder, how can roles as diagnosers and gate-keepers be balanced in a post-stigma era of mental health care? (...) Focusing on the disorder identified would-be patient who would not attract the diagnosis they seek were they not to seek it, this essay explores what it means to have an identity bound to a psychiatric diagnosis and considers a framework for psychiatrists to negotiate clinical encounters that involve the seeking of identity affirming diagnoses. (shrink)

An important international discussion began because of some pioneer studies carried out by Young (1996a) on the internet addiction disorder (IAD). In the fifth and most recent version of the Diagnostic, and Statistical Manual of Mental Disorders (DSM) there is no mention of this disorder and among researchers there are basically two opposite positions. Those who are in favor of a specific diagnosis and those who are claiming the importance of specific criteria characterizing this behavior and the (...) precise role it has in the patient’s life. The aim of the present paper is to answer the question whether it is possible or not to formulate diagnoses of internet-related disorders. We revised literature on the history of diagnostic criteria, on neurocognitive evidence, on the topic debate and on IAD instrumental measures. We found that the disorder was not univocally defined and that the construct was somehow too broad and generic to be explicative for a diagnosis. Indeed, the models are borrowed from other addiction pathologies and they are often formulated before the development of internet as intended in current society. In conclusion, we think we need a more innovative, integrated and comprehensive model for an IAD diagnosis. (shrink)

Medical professionals, including mental health professionals, largely agree that moral judgment should be kept out of clinical settings. The rationale is simple: moral judgment has the capacity to impair clinical judgment in ways that could harm the patient. However, when the patient is suffering from a "Cluster B" personality disorder, keeping moral judgment out of the clinic might appear impossible, not only in practice but also in theory. For the diagnostic criteria associated with these particular disorders (Antisocial, Borderline, (...) Histrionic, Narcissistic) are expressed in overtly moral language. I consider three proposals for dealing with this problem. The first is to eliminate the Cluster B disorders from the DSM on the grounds that they are moral, rather than mental, disorders. The second is to replace the morally laden language of the diagnostic criteria with morally neutral language. The third is to disambiguate the notion of moral judgment so as to respect the distinction between having morally disvalued traits and having moral responsibility for those traits. Sensitivity to this distinction enables the clinician, at least in theory, to employ morally laden diagnostic criteria without adopting the sort of morally judgmental (and potentially harmful) attitude that results from the tacit presumption of moral responsibility. I argue against the first two proposals and in favor of the third. In doing so, I appeal to Grice's distinction between conventional and conversational implicature. I close with a few brief remarks on the irony of retaining overtly moral language in an ostensibly medical manual for the diagnosis of mental disorders. (shrink)

Background: Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in several mental disorders. Some studies have suggested that eating disorders may also be associated with impairments in mentalizing. The aim of this work is to investigate the possible presence of mentalizing subtypes in a sample of patients with EDs.Method: A sample of patients with eating disorders completed a battery of measures assessing mentalization (...) and related variables, including the Reflective Functioning Questionnaire, the Difficulties in Emotion Regulation Strategies, the Interpersonal Reactivity Index. Clinicians rated patients in relation to imbalances in different dimensions of mentalization to prementalizing modes and attachment style by using the Mentalization Imbalances Scale, the Modes of Mentalization Scale, and the Adult Attachment Questionnaire. A latent profile analysis was conducted to test the possible presence of different subgroups. MANOVA was used to test the possible differences between the four mentalizing profiles in relation to emotion dysregulation, empathy, and adequate and impairments in mentalizing.Results: The latent profile analysis suggested the presence of four different profiles in relation to impairments in the dimensions of mentalization: affective/self/automatic imbalances, external imbalance, cognitive/self/automatic imbalances, and cognitive/other/automatic imbalances. Patients belonging to profile 1 are characterized by the prevalence of affective mentalization that overwhelms the capacity to reflect on mental states with an imbalance on the self-dimension; profile 2 patients are excessively focused on the external cues of mentalization; profile 3 patients are characterized by an over-involvement on the cognitive and self-facets of mentalization, with an impairment in adopting the other mind perspective; and profile 4 patients have similar impairments compared to profile 3 patients but with an excessive focus on others and deficits in self-reflection. These profiles were heterogeneous in terms of EDs represented in each group and presented significant differences on various variables such as attachment style, emotion dysregulation, empathy, interpersonal reactivity, and reflective function. This study represents, so far, the first work that confirms the presence of different mentalizing patterns in ED patients.Conclusions: ED patients can be classified in relation to impairments in different dimensions of mentalization above and beyond ED diagnosis. (shrink)

e understanding of the etiology and pathogenesis of these psyc hiatric disorders such as schizophrenia and depression is still n ot completely clear. At present, there is a lack of objective ne urobiological markers that can be used in clinical routine work such as clinical diagnosis, curative effect evaluation and progn osis evaluation of psychiatric disorders. Therefore, it is of great clinical significance to find biomarkers to improve the diagnos is level and evaluate the curative effect. Electroencephalogram (...) (EEG) is a non-invasive technique to record the potential activi ty of biological brain, through which researchers can analyze th e mechanisms underlying psychiatric disorders. In addition, mac hine learning can be used to further verify the role of these el ectrophysiological indicators in clinical diagnosis and curative e ffect evaluation of psychiatric disorders. The goal of this resear ch topic is to advance research on neurobiomarkers and EEG/ MEG-based diagnostic methods for mental disorders. We hope to conduct in-depth research on the pathogenesis and diagnostic measures of mental diseases such as schizophrenia and depressi ve disorder through EEG/MEG, in order to improve the perfor mance of artificial intelligence for mental diseases diagnosing.Under this research theme, the following is a brief overview of nine published articles, which respectively studied the diagnosis, The work in this special issue may fall into three categories of research: 1) method... (shrink)

The public, mental health consumers, as well as mental health practitioners wonder about what kinds of values mental health professionals hold, and what kinds of values influence psychiatric diagnosis. Are mental disorders socio-political, practical, or scientific concepts? Is psychiatric diagnosis value-neutral? What role does the fundamental philosophical question "How should I live?" play in mental health care? In his carefully nuanced and exhaustively referenced monograph, psychiatrist and philosopher of psychiatry John Z. Sadler (...) describes the manifold kinds of values and value judgements involved in psychiatric diagnosis and classification systems like the DSM. Professor Sadler takes the reader on a fascinating conceptual tour of the inner workings of psychiatric diagnosis, considering the role of science, culture, sexuality, politics, gender, technology, human nature, patienthood, and professions in building his vision of a more humane psychiatric diagnostic process. (shrink)

This paper explores the factors that contribute to the degree of a mood disorder patient’s self- insight, defined here as her understanding of the particular contingencies of her life that are responsive to her personal identity, interpersonal relationships, illness symptoms, and the relationship between these three necessary components of her lived experience. I consider three factors: (i) the Diagnostic Statistical Manual of Mental Disorders (DSM), (ii) the DSM culture, and (iii) the cognitive architecture of the self. I argue (...) that the symptom-based descriptions of mood disorders which eliminate the subjective features of the patient’s illness experience, in conjunction with the features of the DSM-culture and the cognitive biases that guide the patient, contribute to the impoverishment of her self-insight. The resulting impoverished self-insight would prevent her from developing resourceful responses to her interpersonal problems. In analyzing how these factors combine to influence the patient’s self-insight, I distinguish the therapeutic impact of receiving a psychiatric diagnosis, which facilitates patient’s clinical treatment, from its reflective impact, how the diagnosis informs the patient’s reflection on who she is, how her mental disorder is expressed, and how her interpersonal relationships proceed. I substantiate my argument by considering a patient’s memoir of psychopathology. (shrink)

Gender Identity Disorder is classified as a mental illness and included in the DSM-IV and ICD-10. It will also be included in the DSM-V. The psychiatric diagnosis, in spite of some apparent advantages, has significant psychological and social adverse implications. This paper discusses some of the main epistemological reasons to consider gender variance as a mental disorder. It will also evaluate whether reasons of other kinds may justify the inclusion of gender variance amongst mental illnesses.

The Disordered Mind, Third Edition is a wide-ranging introduction to the philosophy of mental disorder or illness. It examines and explains, from a philosophical standpoint, what mental disorder is: its reality, causes, consequences, compassionate treatment, and more. Revised and updated throughout, the third edition includes enhanced discussions of the distinction between mental health and illness, selfhood and delusions about the self, impairments of basic psychological capacities in mental disorder and the distinct roles that mental causation (...) and neural mechanisms play in mental illness. The book is organized around four questions: What is a mental disorder or illness? What makes mental disorder something bad? What are various mental disorders and what do they tell us about the mind? What is mental health and how may it be restored? Numerous disorders are discussed including: addiction, agoraphobia, delusion, depression, dissociative identity disorder, obsession-compulsion, schizophrenia, and religious scrupulosity, among others. Several neurological disorders are examined. Various problems associated with DSM-5 and with psychiatric diagnosis are explored. Including chapter summaries and suggestions for further reading at the end of each chapter, The Disordered Mind presupposes no special background in philosophy, and as such will be of interest to those in related disciplines such as psychology, psychiatry and mental health, and professions such as nursing and social work. (shrink)

In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity (...) as an alternative justification. However, this approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis. (shrink)

Sometime ago, I found myself using the diagnosis of a student’s depression as a critical tool of interpretation, searching for signs of mental illness in her essay that explored order and disorder in T. S. Eliot’s The Waste Land. I realised that my reading had become a creative act, combining poem, poet, student essay and author to create, in a sense, one readable text. The present paper is a reflection upon the processes of order and disorder located in (...) a diagnosis of “madness” and the readings of writer and text this diagnosis initiated. I look to deconstruct acts of reading and diagnosis. (shrink)

The author analyses how debate over the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has tended to privilege certain conceptions of psychiatric diagnosis over others, as well as to polarise positions regarding psychiatric diagnosis. The article aims to muddy the black and white tenor of many discussions regarding psychiatric diagnosis by moving away from the preoccupation with diagnosis as classification and refocusing attention on diagnosis as a temporally and spatially (...) complex, as well as highly mediated process. The article draws on historical, sociological and first-person perspectives regarding psychiatric diagnosis in order to emphasise the conceptual—and potentially ethical—benefits of ambivalence vis-à-vis the achievements and problems of psychiatric diagnosis. (shrink)

In this volume, leading philosophers of psychiatry examine psychiatric classification systems, including the Diagnostic and Statistical Manual of Mental Disorders, asking whether current systems are sufficient for effective diagnosis, treatment, and research. Doing so, they take up the question of whether mental disorders are natural kinds, grounded in something in the outside world. Psychiatric categories based on natural kinds should group phenomena in such a way that they are subject to the same type of causal (...) explanations and respond similarly to the same type of causal interventions. When these categories do not evince such groupings, there is reason to revise existing classifications. The contributors all question current psychiatric classifications systems and the assumptions on which they are based. They differ, however, as to why and to what extent the categories are inadequate and how to address the problem. Topics discussed include taxometric methods for identifying natural kinds, the error and bias inherent in DSM categories, and the complexities involved in classifying such specific mental disorders as "oppositional defiance disorder" and pathological gambling. -/- Contributors George Graham, Nick Haslam, Allan Horwitz, Harold Kincaid, Dominic Murphy, Jeffrey Poland, Nancy Nyquist Potter, Don Ross, Dan Stein, Jacqueline Sullivan, Serife Tekin, Peter Zachar. (shrink)

Dissociative Identity Disorder is an uncommon disorder that has long been associated with exposure to traumatic stressors exceeding manageable levels commonly encompassing physical, psychological and sexual abuse in childhood that is prolonged and severe in nature. In DID, dissociation continues after the traumatic experience and produces a disruption in identity where distinct personality states develop. These personalities are accompanied by variations in behaviour, emotions, memory, perception and cognition. The use of literature in psychiatry can enrich comprehension over the subjective experience (...) of a disorder, and the utilisation of 'illness narratives' in nursing research have been considered a way of improving knowledge about nursing care and theory development. This research explores experiences of DID through close textual reading and thematic analysis of five biographical and autobiographical texts, discussing the lived experience of the disorder. This narrative approach aims to inform empathetic understanding and support the facilitation of therapeutic alliances in mental healthcare for those experiencing the potentially debilitating and distressing symptoms of DID. Although controversies surrounding the biomedical diagnosis of DID are important to consider, the lived experiences of those who mental health nurses encounter should be priority. (shrink)

Premenstrual dysphoric disorder was recently moved to a full category in the DSM-5 . It also appears set for inclusion as a separate disorder in the ICD-11 . This paper argues that PMDD should not be listed in the DSM or the ICD at all, adding to the call to recognise PMDD as a socially constructed disorder. I first present the argument that PMDD pathologises understandable anger/distress and that to do so is potentially dangerous. I then present evidence that PMDD (...) is a culture-bound phenomenon, not a universal one. I also argue that even if medication produces a desired effect, there are biological correlates with premenstrual anger/distress, such anger/distress seems to occur monthly, and women are more likely than men to be diagnosed with affective disorders, none of these factors substantiates that premenstrual anger/distress is caused by a mental disorder. I argue that to assume they do is to ignore the now accepted role that one’s environment and psychology play in illness development, as well as arguments concerning the social construction of mental illness. In doing so, I do not claim that there are no women who experience premenstrual distress or that their distress is not a lived experience. My point is that such distress can be recognised and considered significant without being pathologised and that it is unethical to describe premenstrual anger/distress as a mental disorder. Further, if the credibility of women’s suffering is subject to doubt without a clinical diagnosis, then the way to address this problem is to change societal attitudes towards women’s suffering, not to label women as mentally ill. The paper concludes with some broader implications for women and society of the change in status of PMDD in the DSM-5 as well as a sketch of critical policy suggestions to address these implications. (shrink)

This essay argues that making a diagnosis in medicine is essentially a hermeneutic enterprise, one in which interpretation skills play a major part in understanding a disease. The clinical encounter is an event comprised of two voices; one is the voice of science which is grounded in empiricism, the other is that of human experience, which is grounded in story-telling and the interpretation of those stories.Using two voices, one from the Diagnostic and Statistical Manual of Mental Disorders-III-Revised, (...) which describes alcohol abuse and alcohol dependence, and the other, that of Claire, a character in Edward Albee's play, A Delicate Balance, who is conversing with her brother-in-law, Tobias, I apply principles from Hans-Georg Gadamer's hermeneutics to the clinical diagnostic process. The essay will demonstrate that we overlook an enormous amount of information about alcoholism by an overreliance on objective data and that our hope for understanding alcoholics is in listening to their voices, and sharing the interpretation of their experiences with them. (shrink)

The development of the fifth edition of the American Psychiatric Association9s _Diagnostic and Statistical Manual of Mental Disorders_—the DSM-5—has reenergised and driven further forward critical discourse about the place and role of diagnosis in mental health. The DSM-5 has attracted considerable criticism, not least about its role in processes of medicalisation. This paper suggests the need for a sociology of psychiatric critique. Sociological analysis can help map fields of contention, and cast fresh light on the assumptions and (...) nuances of debate around the DSM-5; it underscores the importance of diagnosis to the governance of social and clinical life, as well as the wider discourses critical commentaries connect with and are activated by. More normatively, a sociology of critique can indicate which interests and values are structuring the dialogues being articulated, and just how diverse clinical opinion regarding the DSM can actually be. This has implications for the considerations of health services and policy decision-makers who might look to such debates for guidance. (shrink)

This chapter argues that a successful plea of legal insanity ought to rest upon proof that a criminal act is causally related to symptoms of a mental disorder. Diagnosis of a mental disorder can signal to the court that the defendant had very little control over relevant moral ignorance or incompetence. Must we draw the same conclusion for defendants who lack moral knowledge due to miseducation or other extreme environmental conditions, unrelated to a mental disorder? Adults (...) who were brainwashed as children, for example, might seem “insane” due to their lack of moral knowledge. However, since legal culpability rests on the capacity to understand the criminal law’s moral demands, to reflect on these demands across time, and to control one’s behavior in light of them, simple ignorance of morality's demands does not excuse. (shrink)