The latest edition of the Diagnostic and Statistical Manual of Mental Disorders included the Social Communication Disorder as a new mental disorder characterized by deficits in pragmatic abilities. Although the introduction of SPCD in the psychiatry nosography depended on a variety of reasons—including bridging a nosological gap in the macro-category of Communication Disorders—in the last few years researchers have identified major issues in such revision. For instance, the symptomatology of SPCD is notably close to that of Autism Spectrum Disorder. (...) This opens up the possibility that individuals with very similar symptoms can be diagnosed differently and receive different clinical treatments and social support. The aim of this paper is to review recent debates on SPCD, particularly as regards its independence from ASD. In the first part, we outline the major aspects of the DSM-5 nosological revision involving ASD and SPCD. In the second part, we focus on the validity and reliability of SPCD. First, we analyze literature on three potential validators of SPCD, i.e., etiology, response to treatment, and measurability. Then, we turn to reliability issues connected with the introduction of the grandfather clause and the use of the concepts of spectrum and threshold in the definition of ASD. In the conclusion, we evaluate whether SPCD could play any role in contemporary psychiatry other than that of an independent mental disorder and discuss the role that non-epistemic factors could play in the delineation of the future psychiatry nosography. (shrink)

The paper discusses an ethical analysis of three common cases involving the most popular requests in rhinoplasty. As the nose plays a fundamental role in the aesthetics and physiognomy of the human face, the request for rhinoplasty may be an expression of both subjective discomfort and objective dysfunction. The paper aims, therefore, to fill the gap between qualitative-subjective impressions related to bodily self-perception and its quantitative-objective assessment. Ethical evaluation should start with consideration of the formal object and circumstances of the (...) act, by posing the following question: Is this a real clinical case? Only after an undoubtedly positive answer to this question, should we consider specific case-related aspects; i.e., the best scientific evidence, available nosography and informed consent, before conducting an ethical evaluation of the case. DOI: 10.5294/pebi.2016.20.1.8. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:About and Beyond Comorbidity:Does the Crisis of the DSM Bring on a Radical Rethinking of Descriptive Psychopathology?Massimiliano Aragona (bio)Keywordscomorbidity, nosography, phenomenology, philosophy of scienceThe problem of psychiatric comorbidity is part of a series of difficulties of the current diagnostic system which at once were considered as a consequence of the way the system itself is organized (Aragona 2006). It was then believed that a Kuhnian reformulation of the (...) contemporary debate on the problems of the psychiatric diagnosis was very useful because it allowed clarification in a comprehensive picture of the many rivulets of conceptual research in that field.In their comments Zachar (2009) and Banzato (2009) seem to agree with my analysis of psychiatric comorbidity (Aragona 2009a) when it stresses that abnormally high frequencies of co-occurrence are to be explained, in important respects, as a consequence of the way mental disorders are operationalized in the Diagnostic and Statistical Manual of Mental Disorders (DSM; also showing the importance of conceptual clarification to deal with this sort of only apparently pure factual problems). On the contrary, they are both unconvinced of the appropriateness and/or fruitfulness of the use of the Kuhnian technical terms and theory in this context.It could be said that the major aim of the paper was to let clinicians understand the effect of conceptual decisions on what would otherwise seem as a simple empirical finding (in this case, high levels of comorbidity), and that this result seems to be achieved in any case, thus minimizing the importance of a disagreement about the philosophical terms as a pure terminological dispute. Nevertheless, in my work the Kuhnian model had a significant role in the clarification of this matter and it also suggests to the reader a range of possible consequences that are not trivial (Zachar, for example, says to be skeptical about the possibility of a crisis and also about the possibility that a new paradigm could eliminate what I call the [End Page 29] comorbidity anomaly). As a consequence, some of the Kuhnian concepts that seemed to be at odds in this context have to be considered in detail to justify my analysis and its consequences. For reasons of space, I avoid a point-by-point reply to all the comments and I concentrate my discussion on three main points. First, I discuss the background of Kuhn's definition of terms such as anomaly and paradigm, as well as my own reasons for using them. In doing so the details of the psychiatric items under study that I wanted to highlight through the use of these philosophical concepts should emerge more clearly. Second, I discuss the problem of having distinguished between artifactual and real comorbidity. Third, I reconsider some of these problems, looking for their implications for future psychopathological research.Anomalies and ParadigmsBanzato (2009) stresses that comorbidity cannot be a truly Kuhnian anomaly because it is an anticipated side effect of the initial setup of the DSM, and not some unexpected discovery that violates the paradigm-induced expectation. This is a basically correct account of the most known version of Kuhnian anomalies; that is, the tale of some evident nature's failure to conform to clear paradigm expectations, which immediately forces researchers to recognize its importance as a possible source of crisis. However, as is the case for many other Kuhnian terms, he discussed anomalies in several scripts and there are other possible versions of its meaning. In particular, Kuhn (1977, XVII) highlighted that only in very rare cases are anomalies completely unexpected and come out of blue to announce an imminent crisis that leads to a large revolution. More frequently, scientific revolutions are much more smaller, like the discovery of oxygen, and in these cases the process is so gradual that historians find it difficult to say exactly when a discovery was made and who did it. Even in these much smaller cases the usual prelude to changes of this sort is the awareness of anomaly, but here anomalies are not extraordinary events; rather, they are "countless discrepancies between theory and experiment [that] during the course of his career, every natural scientist again and again notices and passes by" (Kuhn... (shrink)

Reading the vast panorama of the history of Western medicine in general and psychiatry in particular sheds an interesting light not only on social constructions and representations but also on the perception of the Other by the medical institution. Colonial medicine in its struggle - praiseworthy, moreover - against epidemics, presents an interesting case here. We read in the Colonial Medical Archives at Berlin, that a certain Dr Roesener was sent to Kamerun (Cameroon), a German protectorate, to take charge of (...) the eradication of malaria, hookworm (anchylostoma), filariosa and sleeping sickness. But he also found himself faced with mental illnesses and, in his report of October 1909, reported the case of a sick man of the Dwala tribe claiming to be a friend of the Kaiser and presenting all the symptoms of mental illness. A problem of nosography arose - stemming from the cultural perception of an illness and above all of the Other: did this Dwala merit being mad? To understand the meaning of this question, we must return to the German anthropology of the last century, which made a clear distinction between ‘natural people’ (Naturmenschen) and those that were civilized, who were part of Kultur. Moreover, in this report Roesener used the word Naturmenschen to signify the Dwala. In this perspective, as the doctor notes, mental illness was, in the medical teaching of that time, a disturbance of the mind, a malaise of civilization. The prerequisite for being mentally ill was being implicitly part of a civilization. Mental illness was, moreover, translated in German by Geisteskrankheit, in other words, literally, illness of the mind. Now, the ‘natural person’ (the Dwala) has no civilization and in consequence cannot be sick in his mind. And yet he presented all the symptoms which made him a classic mental patient. Could one apply the nosography proper to illnesses stemming from civilization to ‘natural peoples’? Without resolving the problem which his terminological usage posed, Roesener insistently demanded that Berlin send the logistical means to Cameroon to build a lunatic asylum (Irrenhaus). To the problem of mental fragility that was posed came the answer of incarceration in a society that knew nothing of confinement of its ‘mental patients’, the latter often not being considered as inferior. (shrink)

A Kuhnian reformulation of the recent debate in psychiatric nosography suggested that the current psychiatric classification system (the DSM) is in crisis and that a sort of paradigm shift is awaited (Aragona, 2009). Among possible revolutionary alternatives, the proposed fi ve-axes etiopathogenetic taxonomy (Charney et al., 2002) emphasizes the primacy of the genotype over the phenomenological level as the relevant basis for psychiatric nosography. Such a position is along the lines of the micro-reductionist perspective of E. Kandel (1998, (...) 1999), which sees mental disorders reducible to explanations at a fundamental epistemic level of genes and neurotransmitters. This form of micro-reductionism has been criticized as a form of genetic-molecular fundamentalism (e.g. Murphy, 2006) and a multi-level approach, in the form of the burgeoning Cognitive Neuropsychiatry, was proposed. This article focuses on multi-level mechanistic explanations, coming from Cognitive Science, as a possible alternative etiopathogenetic basis for psychiatric classification. The idea of a mechanistic approach to psychiatric taxonomy is here defended on the basis of a better conception of levels and causality. Nevertheless some critical remarks of Mechanism as a psychiatric general view are also offered. (shrink)

The reorganization of psychiatric knowledge at the turn of the twentieth century derived from Emil Kraepelin’s clinical classification of psychoses. Surprisingly, within just few years, Kraepelin’s simple dichotomy between dementia praecox (schizophrenias) and manic-depressive psychosis (bipolar disorders) succeeded in giving psychiatry a new framework that is still used until the present day. Unexpectedly, Kraepelin’s simple clinical scheme based on the dichotomy replaced the significantly more differentiated nosography that dominated psychiatric research in the last three decades of the nineteenth century (...) (Janzarik in Themen und Tendenzen der deutschsprachigen Psychiatrie. Springer, Berlin, 1974 ). Moreover, although all the components of the future development were already available shortly after 1868, the real course, which led to Kraepelin’s dichotomy, was unpredictable then. This paper explores the ways in which the unpredictability of psychiatric knowledge and the postulate of a rationality underlying psychopathological phenomena interacted in the debates regarding the classification of psychoses. It examines the “natural antagonism” between the practical aspirations of an increasingly specialized medical nosology and unitary conceptions, which, in a psychopathological countermovement, emphasized that no somatic criteria can be specified for the majority of psychic abnormalities and that all nosological distinctions are not binding (Janzarik 1974, 20). In this context, this paper investigates the revival of unitary theories of psychosis in postwar German psychiatry and seeks to understand why the forms of thinking that dominated nineteenth-century psychiatry have proved to be very lasting. Furthermore, this paper emphasizes the perspectivity underlying psychiatric research on psychoses and explores the ways in which writing the history of the schizophrenia concept involves inevitably writing the history of the entire psychiatry. (shrink)

The psychopathological analysis of hysteria is a victim of narrow conceptualizations. Among these is the inscription of hysteria in the feminine sphere, about body and sexuality, which incentivized conceptual reductionism. Hysteria has been mainly considered a gendered pathology, almost exclusively female, and it has been associated with cultural and/or religious features over time rather than treated as a psychopathological world. Further, hysteria has been dominated by conceptual inaccuracies and indecision, not only in terms of clinical features but also in terms (...) of its definition. For this reason, it seems necessary to “undress” hysteria from this feminization, sexualization, and corporealization with which it has been abundantly clothed over the years. “Undressing” hysteria will make possible a reconfiguring and deconstructing of the explanatory-causal model of Charcot and Freud. However, if we take out this cultural heritage, the stigma accompanying this diagnosis, and the weight of the enormous historical tradition that hysteria carries, the world of hysteria continues to constitute a domain full of complexity and nosographic challenges. Hysteria has been considered a sum of psychological behaviors and states illustrated by drama, mystery, or falsity. The difficulty in understanding the multiple somatic manifestations which characterize this clinical condition created several controversies and much confusion. In the current nosography, the personological component of hysteria has been separated from its symptomatic manifestation, in the Histrionic Personality Disorder and Conversion Disorder categories, respectively. This segmentation by descriptive nosography does contribute to a unitary understanding of the phenomenon and, consequently, of daily clinical practice. Clinical complexity can be grasped and deciphered only if the symptom is inscribed in the patient’s lifeworld and his/her subjective life history. Clinical practice is thus thought of in terms of a structural aggregation of a homogeneous set of phenomena, together constituting a specific way of being in the world. The starting point of this article is the evident modalities characterizing this life-world, taking care not to confuse the point of origin with the point of expression. (shrink)

Depue & Morrone-Strupinsky's (D&M-S's) model of affiliation meets the criteria advanced for the definition of behavior systems and endophenotypes. We argue that its application in psychiatry could be useful for identifying a biological pathophysiology common to a variety of conditions that are currently classified in very different categories of psychiatric nosography, including autism, schizoid personality, primary psychopathy, and dismissing attachment.

In this paper, my aim is to understand the origin of experimental and scientific models of pathogeny of the diseases of the nervous system in the Salpêtrière (Paris). I will analyse the role of the contexts of cell theory, microscopy and the advances in histological techniques in the creation of various pathogenic models, based on the concept of the cell, the Wallerian degeneration and the neurone concept. I argue that, as medicine and pathology remain autonomous in their methods and goals, (...) because of the evident degree of complexity of diseases, close and reciprocal interactions with sciences, their practices and theories, make it possible to establish convergences between clinical observations, pathological data and those from the experimental models of pathologies. The search for pathogenic models behaves like an engine, which is efficient in assembling facts, in testing pathogeneses and reforming nosologies, combined with the breakthroughs in biology. This paper is a case study showing the emergence of such interactions in the last decades of the nineteenth-century in Paris. (shrink)

The reorganization of psychiatric knowledge at the turn of the twentieth century derived from Emil Kraepelin’s clinical classification of psychoses. Surprisingly, within just few years, Kraepelin’s simple dichotomy between dementia praecox (schizophrenias) and manic-depressive psychosis (bipolar disorders) succeeded in giving psychiatry a new framework that is still used until the present day. Unexpectedly, Kraepelin’s simple clinical scheme based on the dichotomy replaced the significantly more differentiated nosography that dominated psychiatric research in the last three decades of the nineteenth century (...) (Janzarik in Themen und Tendenzen der deutschsprachigen Psychiatrie. Springer, Berlin, 1974 ). Moreover, although all the components of the future development were already available shortly after 1868, the real course, which led to Kraepelin’s dichotomy, was unpredictable then. This paper explores the ways in which the unpredictability of psychiatric knowledge and the postulate of a rationality underlying psychopathological phenomena interacted in the debates regarding the classification of psychoses. It examines the “natural antagonism” between the practical aspirations of an increasingly specialized medical nosology and unitary conceptions, which, in a psychopathological countermovement, emphasized that no somatic criteria can be specified for the majority of psychic abnormalities and that all nosological distinctions are not binding (Janzarik 1974, 20). In this context, this paper investigates the revival of unitary theories of psychosis in postwar German psychiatry and seeks to understand why the forms of thinking that dominated nineteenth-century psychiatry have proved to be very lasting. Furthermore, this paper emphasizes the perspectivity underlying psychiatric research on psychoses and explores the ways in which writing the history of the schizophrenia concept involves inevitably writing the history of the entire psychiatry. (shrink)