The need for a model -- Currently available models in psychiatry -- Introduction to enactivism -- Body and mind - and world -- The existential dimension and its role in psychiatry -- Enriched enactivism : existential sense-making, values, and socio-cultural worlds -- Enactive psychiatry : psychiatric disorders are disorders of sense-making -- An enactive approach to causes, diagnosis and treatment of psychiatric disorders.

In clinical medicine, a diagnosis can offer an explanation of a patient's symptoms by specifying the pathology that is causing them. Diagnoses in psychiatry are also sometimes presented in clinical texts as if they pick out pathological processes that cause sets of symptoms. However, current evidence suggests the possibility that many diagnostic categories in psychiatry are highly causally heterogeneous. For example, major depressive disorder may not be associated with a single type of underlying pathological process, but with a (...) range of different causal pathways, each involving complex interactions of various biological, psychological, and social factors. This paper explores the implications of causal heterogeneity for whether psychiatric diagnoses can be said to serve causal explanatory roles in clinical practice. I argue that while they may fall short of picking out a specific cause of the patient's symptoms, they can nonetheless supply different sorts of clinically relevant causal information. In particular, I suggest that some psychiatric diagnoses provide negative information that rules out certain causes, some provide approximate or disjunctive information about the range of possible causal processes, and some provide causal information about the relations between the symptoms themselves. (shrink)

It is common for clinicians working in psychiatry and related clinical disciplines to be called on to make diagnostic clinical judgments concerning moral anxiety, which is a kind of anxiety that is closely bound up with decisions individuals face as moral agents. To make such a judgment, it is necessary to make a moral judgment. Although it has been common to acknowledge that there are ways in which moral and clinical judgment interact, this type of interaction has remained unacknowledged. (...) This raises questions as to the nature and limits of psychiatry—particularly concerning the extent to which psychiatric discourse ought to incorporate moral discourse, and the role of the clinician as an expert in identifying problematic anxiety. (shrink)

Researchers are studying how artificial intelligence (AI) can be used to better detect, prognosticate and subgroup diseases. The idea that AI might advance medicine’s understanding of biological categories of psychiatric disorders, as well as provide better treatments, is appealing given the historical challenges with prediction, diagnosis and treatment in psychiatry. Given the power of AI to analyse vast amounts of information, some clinicians may feel obligated to align their clinical judgements with the outputs of the AI system. However, a (...) potential epistemic privileging of AI in clinical judgements may lead to unintended consequences that could negatively affect patient treatment, well-being and rights. The implications are also relevant to precision medicine, digital twin technologies and predictive analytics generally. We propose that a commitment to epistemic humility can help promote judicious clinical decision-making at the interface of big data and AI in psychiatry. (shrink)

Battle Hall Davies' brother Nick ran away from home when she was in high school. Now he has found her and she is going to stay with him for the summer before starting college. Battle discovers that neither she nor her brother is the person she thought they were.

In this paper, my goal is to use an epistemic injustice framework to extend an existing normative analysis of over-medicalization to psychiatry and thus draw attention to overlooked injustices. Kaczmarek has developed a promising bioethical and pragmatic approach to over-medicalization, which consists of four guiding questions covering issues related to the harms and benefits of medicalization. In a nutshell, if we answer “yes” to all proposed questions, then it is a case of over-medicalization. Building on an epistemic injustice framework, (...) I will argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to answer the four questions, and I will import the conceptual resources of epistemic injustice to guide our thinking on these issues. This will lead me to defend more inclusive decision-making procedures regarding medicalization in the DSM. Kaczmarek’s account complemented with an epistemic injustice framework can help us achieve better forms of medicalization. I will then use a contested case of medicalization, the creation of Premenstrual Dysphoric Disorder in the DSM-5 to illustrate how the epistemic injustice framework can help to shed light on these issues and to show its relevance to distinguish good and bad forms of medicalization. (shrink)

This book presents a unique examination of mental illness. Though common to many mental disorders, delusions result in actions that, though perhaps rational to the individual, might seem entirely inappropriate or harmful to others. This book shows how we may better understand delusion by examining the nature of compulsion.

Recent years have seen the emergence of a new interdisciplinary field called embodied or enactive cognitive science. Whereas traditional representationalism rests on a fixed inside–outside distinction, the embodied cognition perspective views mind and brain as a biological system that is rooted in body experience and interaction with other individuals. Embodiment refers to both the embedding of cognitive processes in brain circuitry and to the origin of these processes in an organism’s sensory–motor experience. Thus, action and perception are no longer interpreted (...) in terms of the classic physical–mental dichotomy, but rather as closely interlinked. This paper describes the cycles of brain–organism interaction, of sensory–motor interaction with the environment and of embodied interaction with others. The brain is then interpreted as an organ of modulation and transformation that mediates the cycles of organism–environment interaction. Finally, consequences of the embodied and enactive approach for psychiatry are pointed out, in particular for a circular concept of mental illness. (shrink)

The three essays reprinted in this book were first published in 1963 as individual chapters of a psychiatric treatise entitled Psychiatrie der Gegen wart (Psychiatry of the Present Day). The editors, W. H. GRUHLE (Bonn), R. JUNG (Freiburg/Br. ), W. MAYER-GROSS (Birmingham, England), M. MUL LER (Bern, Switzerland), had not planned an encyclopedic presentation; they did not intend to present a "handbook" which would be as complete as possible in details and bibliographic reference. Their intention was to "raze the (...) walls" separating Continental and Anglo-Saxon psychiatries and to offer a synopsis of developments in psychiatry during the last decades on an international basis. The editors requested, therefore, cooperation of scholars from many foreign countries, large and small, on both sides of the Atlantic. A section entitled "Borderlands of Psychiatry", in which MARGARET MEAD (New York) discusses the relation of "Psychiatry and Ethnology", HANS HEIMAN (Bern), the relation of "Religion und Psychiatrie", and ROBERT VOLMER (Paris), "Art et Psychiatrie", is a good illustration of the trilingual character of the whole work. Two of the editors, GRUHLE and MAYER-GROSS, died before the publi cation had been completed. In a kind of posthumous eulogy, Professor JUNG and Professor MULLER praised the initiative and accomplishments of MAYER-GROSS, "who during the last five years of his life had given a great deal of his time to this work. He had set his mind on a synthesis of German and Anglo-Saxon psychiatry. (shrink)

The thesis that mental states extend beyond the skull, otherwise known as the extended mind thesis, has attracted considerable philosophical attention and support. It has also been accused of lacking practical import. At the same time, the field of psychiatry has remained largely unacquainted with ExM, tending to rely instead upon what ExM proponents would consider to be outdated models of the mind. ExM and psychiatry, therefore, have much to offer one another, but the connection between the two (...) has remained largely unexplored. Here, I consider what implications ExM may have for psychiatry and, in so doing, reveal how psychiatry may lend practical import to ExM. First, I detail the possibility of the extension of one mental state relevant to psychiatry. I augment this example by surveying other possibilities for extension in the context of psychiatric diagnoses. I then consider ways in which such extensions might alter psychiatric diagnosis and treatment. Overall, I argue that recognition of the truth of ExM could alter the diagnostic status of certain individuals by correcting both false positives and false negatives, re-conceptualize certain aspects of treatment, help us re-envision psychiatric research, and potentially increase empathy towards those individuals considered to be mentally disordered or mentally different. (shrink)

In a clinic-wide approach to establish liberal policies, a closed psychiatric ward was planned to be opened. The leaders of the multi-professional team of this ward requested continuous ethics support during the first few months after the transition from their previously closed ward into an open one. During the process of accompanying the team through this ethically sensitive period of institutional change, several variations of ethics consultation were developed: the ‘context-adjusted’ clinical ethics support. Some ethics consultations focused on a retrospective (...) evaluation of a patient case, in other ethics consultations consolidation of a previous case discussion was worked out, and/or reflections on fundamental ethical issues were included. Based on our experiences and the feedback of the team, we consider this context-adjusted clinical ethics support as feasible and effective. (shrink)

Advance Praise: "A distillation of the wisdom accumulated over a lifetime by one of our leading thinkers in psychiatry. . . .It should interest. . .anyone who has thought seriously about the brain, the mind and the meaning of illness." --Albert J. Stunkard, M.D., Professor of Psychiatry, University of Pennsylvania.

In this stunning reappraisal of the celebrated case of Daniel Paul Schreber, Lothane takes the reader on a richly documented tour of all the ingredients that made Schreber's illness a unique psychiatric event. Building outward from a close examination of Schreber's troubled relationship to his two psychiatrists, Flechsig and Weber, Lothane elaborates the personal, familial, and cultural contexts of Schreber's illness. Incorporating extensive new archival and bibliographic research, and providing extensive accounts of the personalities and theories of Schreber's two psychiatrists, (...) Paul Flechsig and Guido Weber, Zvi Lothane offers a stunning reappraisal of the Schreber case that overturns virtually all previous opinion. Lothane examines both the man and his milieu in a way that allows the reader fresh access not only to the tragedy of Schreber's illness but also to his heroic, if doomed, attempts to come to terms with his condition through writing. In the process, he persuasively demonstrates that important issues of both psychiatric diagnosis and psychoanalytic interpretation have heretofore been compromised by a failure to pay sufficient attention to Schreber's interpersonal, cultural, and historical contexts. (shrink)

The practice of coercive measures in psychiatry is controversial. Although some have suggested that it may be acceptable if patients are a danger to others or to themselves, others committed themselves to eliminate it. Ethical, legal and clinical considerations become more complex when the mental incapacity is temporary and when the coercive measures serve to restore autonomy. We discuss these issues, addressing the conflict between autonomy and beneficence/non-maleficence, human dignity, the experiences of patients and the effects of coercive measures. (...) We argue that an appeal to respect autonomy and/or human dignity cannot be a sufficient reason to reject coercive measures. All together, these ethical aspects can be used both to support and to reject a non-seclusion approach. The total lack of controlled trials about the beneficial effects of coercive measures in different populations however, argues against the use of coercive measures. (shrink)

Psychiatry widely assumes an internalist biomedical model of mental illness. I argue that many of psychiatry’s diagnostic categories involve an implicit commitment to constitutive externalism about mental illness. Some of these categories are socially externalist in nature.

A brief critical notice of Dan J Stein's new book _Problems of Living: Perspectives from Philosophy, Psychiatry, and Cognitive-Affective Science_.

The dominance of technological paradigms within psychiatry creates moral and ethical tensions over how to engage with the interpersonal narratives of those experiencing mental distress. This paper argues that such paradigms are poorly suited for fostering principled responses to human suffering, and proposes an alternative approach that considers a view of relationships based in feminist theories about the nature of caring. Four primary characteristics are presented which distinguish caring from technological paradigms: a concern with the particular nature of contexts, (...) embodied practice, the dialogical basis of caring and the existential basis of caring. From this we explore the role of the moral imagination and our ability, through narrative, to acknowledge, engage with and bear witness to the injustices that shape the lives of those who suffer. This, we argue, is at the heart of caring. Clinical implications are discussed, including an exposition of the importance of narrative in recovery from trauma and distress. Narrative Psychiatry, The Sanctuary Model of care, and Soteria, are outlined as examples of this type of practice. (shrink)

Psychiatry has long struggled with the nature of its diagnoses. This book brings together established experts in the wide range of disciplines that have an interest in psychiatric nosology. The contributors include philosophers, psychologists, psychiatrists, historians and representatives of the efforts of DSM-III, DSM-IV and DSM-V.

In lieu of an abstract, here is a brief excerpt of the content:The Nature of Proof in PsychiatryPaul Lieberman (bio)Keywordspsychotherapy process, knowledge and psychiatry, externalism, WittgensteinThis vivid clinical report illustrates recognizably, and provocatively, a number of routine, but often unexamined, clinical questions. In its few paragraphs, it depicts challenges that each practitioner confronts, and, in the flux of clinical work, addresses, however implicitly and imperfectly, every day: From what data, and by what processes, does a clinical formulation, or way (...) of understanding, come into being? How do we appraise its accuracy and adequacy? Of what value is even a well-substantiated understanding, in the mind of the therapist, to the patient? What is the power of empathy as a treatment tool? How do we assess someone's status as a “good candidate for therapy?” When, typically, only the outlines of a problem are visible, and its origins and implications are largely hidden, by what right do we recommend psychotherapy, and with what conception, at what level of detail, of what its outcome will be? These are among the questions that Dr. Bailey's story challenges us to address.They are clinical questions, of course, because they deal with empirical matters of fact—psychological processes, outcomes studies, and evidence. But they are also philosophical because, as Freud insisted and Dr. Bailey shows, information obtained in the clinical situation often has power and authority that lead us to believe we understand what is going on, understand the other person, even in the absence of scientifically tested hypotheses, or the clear application of research-based evidence. Interactions between people—including clinical interactions—have a life and ability to engage us. Their meanings can seem so transparent and convincing that no doubt or questioning may seem cogent. At their most powerful, such experiences can reawaken us to important realms of experience and feeling which we might, otherwise, forget, ignore, suppress, deny, or in other ways keep out of awareness; they have the potential to arouse us and reconnect us with truths that, once revived, can seem both valid and important—perhaps the kind of experience that we may derive from works of art or literature (in fact, Dr. Bailey's account could be seen as a clinical parable—meant to be neither true nor false, but instructive). But even less dramatic examples are commonplace: we do routinely claim to know and be able to interpret and understand the actions of other people from our everyday interactions with and observations of them.What is less clear is how to account for these convictions and how to appraise their value, because they do not derive from established scientific procedures. Clinical intuition has a role throughout medicine, but we usually expect it to be subjected later to more rigorous tests to establish the correct diagnosis. Yet, as Dr. Bailey's case illustrates, clinical intuition in the psychiatric encounter seems somehow different. When Colin [End Page 225] leads Dr. Bailey to the conclusion that a “painful lack of wounds” has made him depressed, we find this credible. It seems similarly credible that Dr. Bailey might be anxious about his own capacity to defend his young family, because he says he is, that he perceives Colin as testing his manhood or sincerity, because that seems to fit Colin's temperament, that being accurately understood is helpful, because most of us have had that experience and valued it, and that, most generally, an absence of challenge or of activity could be depressing. But suppose a patient believed that a painful lack of wounds produced diabetes instead of depression, or suppose he had developed epilepsy and attributed that to an absence of combat experience. We might see these as ‘pre-scientific’ or ‘hypothesis-generating’ (or worse). By contrast, it seems timid to consider psychiatric formulations to be always and only provisional or hypothetical.In what ways and to what extent should we expect psychiatry to be different, and why? Several considerations suggest that psychiatry's reasons are not, always and everywhere, the same as those of general medicine, nor are its objectives.In general medicine, we distinguish between signs and symptoms, on the one hand, and “underlying” disease processes, on the other. But in psychiatry, this distinction can be... (shrink)

We applaud Shen et al. (2024) for offering a framework to address how to return research results from digital phenotyping within the discipline of psychiatry. However, given the value-laden nature...

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending (...) their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons’ mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge. (shrink)

The problem of false accusations of child sexual abuse requires explanation. Investigators uncritically accepted theories and techniques from mental health authorities because of our society's traditional faith in such "experts." The history of this development is reviewed, illustrating the confusion resulting from a blending of investigative and therapeutic roles. Similarly hasty acceptance of unsupported medical interpretations are also reviewed. Recommendatons for reform stress a separation of investigators from mental health ideology, as well as more responsible investigative techniques.

ArgumentResearch into the biological markers of pathology has long been a feature of British psychiatry. Such somatic indicators and associated features of mental disorder often intertwine with discourse on psychological and behavioral correlates and causes of mental ill-health. Disorders of sociality – particularly psychopathy and antisocial personality disorder – are important instances where the search for markers of pathology has a long history; research in this area has played an important role in shaping how mental health professionals understand the (...) conditions. Here, I characterize the multiplicity of psychiatric praxis that has sought to define the mark of antisociality as a form of “ontological anarchy.” I regard this as an essential feature of the search for biological and other markers of an unstable referent, positing that uncertainties endure – in part – precisely because of attempts to build consensus regarding the ontology of antisociality through biomedical means. Such an account is suggestive of the co-production of biomarkers, mental disorder, and psychiatric institutions. (shrink)

This dissertation is a contribution to the contemporary field of phenomenological psychopathology, or the phenomenological study of psychiatric disorders. The work proceeds with two major aims. The first is to show how a phenomenological approach can clarify and illuminate the nature of psychopathology—specifically those conditions typically labeled as major depressive disorder and bipolar disorder. The second is to show how engaging with psychopathological conditions can challenge and undermine many phenomenological presuppositions, especially phenomenology’s status as a transcendental philosophy and its corresponding (...) anti-naturalistic outlook. In the opening chapter, I articulate the three layers of the subject matter of phenomenological research—what I refer to as “existentials,” “modes,” and “prejudices.” As I argue, while each layer contributes to what we might call the “structure” of human existence, they do not do so in the same way, or to the same degree. Because phenomenological psychopathology—and applied phenomenology in general—aims to characterize how the structure of human existence can change and alter, it is paramount that these layers be adequately delineated and defined before investigating these changes. In chapters two through five, I conduct hermeneutic and phenomenological investigations of psychopathological phenomena typically labeled as major depressive disorder or bipolar disorder. These investigations address the affective aspects of depression and mania, and the embodied aspects of depression. In addition to clearly articulating the nature of these phenomena, I show how certain psychopathological conditions involve changes in the deepest or most fundamental layer of human existence—what I refer to as existentials. As I argue, many of the classical phenomenologists (including Husserl and Heidegger) believed that these structural features were necessary, unchanging, and universal. However, this presupposition is challenged through the examination of psychopathological and neuropathological conditions, undermining the status of phenomenology as a transcendental philosophy. While this challenge to classical phenomenology is only sketched in the early chapters, in chapters six and seven I develop it in more detail in order to achieve two distinct ends. In chapter six I argue that psychopathology and neuropathology not only challenge phenomenology’s status as a transcendental philosophy, but also supply a key to developing a phenomenological naturalism (which I contrast with a naturalized phenomenology). Phenomenological naturalism, as I articulate it, is a position in which phenomenology is not subsumed by the metaphysical and methodological framework of the natural sciences, but nonetheless maintains the capacity to investigate how the natural world stands independent of human subjectivity (and how events in the natural world can bring about changes in the most fundamental structures of human existence). In the seventh chapter I argue that a phenomenology in which existentials are contingent and variable rather than necessary and unchanging allows phenomenologists to contribute to new dimensional approaches to psychiatric classification. Rather than begin from distinct categories of disorder, these approaches begin from distinct core features of human existence. These features, referred to as either dimensions or constructs, can vary in degree and are studied in both normal and pathological forms. (shrink)

The computational approach to psychiatric disorders, including delusions, promises explanation and treatment. Here, we argue that an information processing approach might be misleading to understand psychopathology and requires further refinement. We explore the claim of computational psychiatry being a bridge between phenomenology and physiology while focussing on the ontological commitments and corresponding methodology computational psychiatry is based on. Interconnecting ontological claims and methodological practices, the paper illustrates the structure of theory-building and testing in computational psychiatry.First, we will (...) explain the ontological commitments computational psychiatry is grounded in, theBayesian Brain hypothesis(BBH) of unconscious inference, paired with normative deontic approaches applied to gauge psychopathology. We then turn to the steps taken in empirical paradigms, from definitions, which are used as starting points, to the operationalisation and isolation of cognitive processes and hypothesis testing based on algorithmic models, to consecutive interpretations regarding the aetiology of psychiatric disorders. We outline how experimental paradigms in computational psychiatry are specifically designed to confirm aberrations in assumed inferential processes, which are thought of as being the underlyingcore invariant features.We will illustrate a gap between the ontological commitments of computational psychiatry and the operationalisation and testing of the cognition assumed to be relevant for psychopathology. This conceptual gap is of utmost importance when designing computational paradigms and may impede a crisp understanding of the approach. Lastly, in evaluating the conceptual gap, it becomes apparent that the information processing formalism used in computational psychiatry is still grounded in rational cognitive psychology. (shrink)