This chapter examines philosophical issues surrounding the classification of mental disorders by the Diagnostic and Statistical Manual of Mental Disorders (DSM). In particular, the chapter focuses on issues concerning the relative merits of descriptive versus theoretical approaches to psychiatric classification and whether the DSM should classify natural kinds. These issues are presented with reference to the history of the DSM, which has been published regularly by the American Psychiatric Association since 1952 and is currently in (...) its fifth edition. While the first two editions of the DSM adopted a theoretical (psychoanalytic) and etiological approach to classification, subsequent editions of the DSM have adopted an atheoretical and purely descriptive (“neo-Kraepelinian”) approach. It is argued that largest problem with the DSM at present—viz., its failure to provide valid diagnostic categories—is directly related to the purely descriptive methodology championed by the DSM since the third edition of the DSM. In light of this problem, the chapter discusses the prospects of a theoretical and causal approach to psychiatric classification and critically examines the assumption that the DSM should classify natural kinds. (shrink)

This paper addresses philosophical issues concerning whether mental disorders are natural kinds and how the DSM should classify mental disorders. I argue that some mental disorders (e.g., schizophrenia, depression) are natural kinds in the sense that they are natural classes constituted by a set of stable biological mechanisms. I subsequently argue that a theoretical and causal approach to classification would provide a superior method for classifying natural kinds than the purely descriptive approach adopted by the DSM since DSM-III. My (...) argument suggests that the DSM should classify natural kinds in order to provide predictively useful (i.e., projectable) diagnostic categories and that a causal approach to classification would provide a more promising method for formulating valid diagnostic categories. (shrink)

In this chapter, I provide an overview of phenomenological approaches to psychiatric classification. My aim is to encourage and facilitate philosophical debate over the best ways to classify psychiatric disorders. First, I articulate phenomenological critiques of the dominant approach to classification and diagnosis—i.e., the operational approach employed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-10). Second, I describe the type or typification approach to psychiatric (...) classification, which I distinguish into three different versions: ideal types, essential types, and prototypes. I argue that despite their occasional conflation in the contemporary literature, there are important distinctions among these approaches. Third, I outline a new phenomenological-dimensional approach. I show how this approach, which starts from basic dimensions of human existence, allows us to investigate the full range of psychopathological conditions without accepting the validity of current diagnostic categories. (shrink)

A large part of the controversy surrounding the publication of DSM-5 stems from the possibility of replacing the purely descriptive approach to classification favored by the DSM since 1980. This paper examines the question of how mental disorders should be classified, focusing on the issue of whether the DSM should adopt a purely descriptive or theoretical approach. I argue that the DSM should replace its purely descriptive approach with a theoretical approach that integrates causal information into the DSM’s descriptive (...) diagnostic categories. The paper proceeds in three sections. In the first section, I examine the goals (viz., guiding treatment, facilitating research, and improving communication) associated with the DSM’s purely descriptive approach. In the second section, I suggest that the DSM’s purely descriptive approach is best suited for improving communication among mental health professionals; however, theoretical approaches would be superior for purposes of treatment and research. In the third section, I outline steps required to move the DSM towards a hybrid system of classification that can accommodate the benefits of descriptive and theoretical approaches, and I discuss how the DSM’s descriptive categories could be revised to incorporate theoretical information regarding the causes of disorders. I argue that the DSM should reconceive of its goals more narrowly such that it functions primarily as an epistemic hub that mediates among various contexts of use in which definitions of mental disorders appear. My analysis emphasizes the importance of pluralism as a methodological means for avoiding theoretical dogmatism and ensuring that the DSM is a reflexive and self-correcting manual. (shrink)

Contemporary psychiatry finds itself in the midst of a crisis of classification. The developments begun in the 1980s—with the third edition of the Diagnostic and Statistical Manual of Mental Disorders —successfully increased inter-rater reliability. However, these developments have done little to increase the predictive validity of our categories of disorder. A diagnosis based on DSM categories and criteria often fails to accurately anticipate course of illness or treatment response. In addition, there is little evidence that the DSM (...) categories link up with genetic findings, and even less evidence that they... (shrink)

In psychiatry some disorders of cognition are distinguished from instances of normal cognitive functioning and from other disorders in virtue of their surface features rather than in virtue of the underlying mechanisms responsible for their occurrence. Aetiological considerations often cannot play a significant classificatory and diagnostic role, because there is no sufficient knowledge or consensus about the causal history of many psychiatric disorders. Moreover, it is not always possible to uniquely identify a pathological behaviour as the symptom of (...) a certain disorder, as disorders that are likely to differ both in their causal histories and in their overall manifestations may give rise to very similar patterns of behaviour. -/- Consider delusions as an example. It wouldn’t be correct to define delusions as those beliefs people form as a result of a neurobiological deficit and a hypothesis-evaluation deficit (as some versions of the two-factor theory of delusions suggest), because for some delusions no neurobiological deficit may be found, and reasoning biases and motivational factors may be contributors to the formation of the delusion (e.g. McKay et al., 2005). Moreover, it would be a mistake to define delusions as symptoms of schizophrenia alone, because they occur also in other disorders, including dementia, amnesia, and delusional disorders. Thus, aetiological considerations may appear in the description and analysis of delusions, but do not feature prominently in their definition. -/- In this paper I argue that the surface features used as criteria for the classification and diagnosis of disorders of cognition are often epistemic in character. I shall offer two examples: confabulations and delusions are defined as beliefs or narratives that fail to meet standards of accuracy and justification. Although classifications and diagnoses based on features of people’s observable behaviour are necessary at these early stages of neuropsychiatric research, given the variety of conditions in which certain phenomena appear, I shall attempt to show that current epistemic accounts of confabulations and delusions have limitations. Epistemic criteria can guide both research and clinical practice, but fail to provide sufficient conditions for the identification of delusions and confabulations, and fail to demarcate pathological from non-pathological narratives or beliefs. -/- Another limitation of current epistemic accounts – which I shall not address here – is the excessive focus on epistemic faults of confabulations and delusions at the expense of their epistemically neutral or advantageous features (see Bortolotti and Cox, 2009). This may lead to a misconception of delusions and confabulations, and to an oversimplification in the assessment of the needs of people who require clinical treatment for their psychotic symptoms. (shrink)

Jonathan Y. Tsou examines and defends positions on central issues in philosophy of psychiatry. The positions defended assume a naturalistic and realist perspective and are framed against skeptical perspectives on biological psychiatry. Issues addressed include the reality of mental disorders; mechanistic and disease explanations of abnormal behavior; definitions of mental disorder; natural and artificial kinds in psychiatry; biological essentialism and the projectability of psychiatric categories; looping effects and the stability of mental disorders; psychiatric classification; and the (...) class='Hi'>validity of the DSM's diagnostic categories. The main argument defended by Tsou is that genuine mental disorders are biological kinds with harmful effects. This argument opposes the dogma that mental disorders are necessarily diseases that result from biological dysfunction. Tsou contends that the broader ideal of biological kinds offers a more promising and empirically ascertainable naturalistic standard for assessing the reality of mental disorders and the validity of psychiatric categories. (shrink)

This thesis investigates the nature of psychiatric disorders, and to what extent they can form a basis for classification, explanation, and treatment interventions. These questions are important in the light of the “crisis of validity” in psychiatry, according to which current diagnostic categories do not pick out real disorders. I address the questions by defending an account of psychiatric disorders that can better accommodate social aspects and non-epistemic values than the symptom-based model of the (...) class='Hi'>Diagnostic and Statistical Manual of Mental Disorders (DSM) and the brain disease model of the biomedical approach, including the Research Domain Criteria (RDoC). I concentrate on three ways that psychiatric disorders can differ from prototypical natural kinds, such as biological species and chemical elements. First, the concept of psychiatric disorder or mental disorder is partly value-laden and cannot be defined based only on scientific facts. Second, the objects of psychiatric classifications are interactive human kinds because people with disorders respond to their classifications through looping effects. Third, sociocultural factors can shape disorders in complex ways, which is indicated by their cross-cultural variation. I argue that these challenges can be overcome with a pluralistic explanatory account that grants an explicit role to value-sensitive considerations and social scientific research. Based on this, I argue that particular disorders can in principle support inductive inferences. ------------------------------------------------------------------------------------------ My key argument is that although whether a condition is considered pathological is partly a value-laden question, this does not rule out a realist account of particular psychiatric disorders as homeostatic property cluster kinds (HPC). I assert that causal mechanisms responsible for psychiatric kinds can be understood non-metaphysically based on the contrastive-counterfactual and interventionist theories of explanation. An advantage of this account is that it can address the concern that psychiatric explanations require one to relate heterogeneous causal factors on different levels, such as genetic, neurological, psychological, and social. My novel argument is that mechanistic explanations of scientific kinds have applicability domains over which they account for specific aspects of kinds and warrant inductive inferences. That is, identifying the applicability domain of an explanation spells out the conditions under which the explanation is expected to be reliable and when it can break down. This helps to understand how different discipline approaches, including social and cultural ones, can be complementary and make an explanation of a psychiatric kind more reliable. On the other hand, the account also shows how the complex nature of psychiatric kinds can license re-classifications for different epistemic and non-epistemic purposes. Finally, in the light of the social implications of psychiatric classifications, I suggest a value-sensitive or ameliorative approach to engineering the concept of psychiatric disorder. In conclusion, my account shows that research on the social and cultural factors that shape psychiatric disorders, and weighing the non-epistemic values that influence classificatory practices, can and should inform classificatory choices as well as policy and treatment interventions. (shrink)

The failure of psychiatry to validate its diagnostic constructs is often attributed to the prioritizing of reliability over validity in the structure and content of the Diagnostic and Statistical Manual of Mental Disorders. Here I argue that in fact what has retarded biomedical approaches to psychopathology is unwarranted optimism about diagnostic discrimination: the assumption that our diagnostic tests group patients together in ways that allow for relevant facts about mental disorder to be discovered. I consider (...) the Research Domain Criteria framework as a new paradigm for classifying objects of psychiatric research that solves some of the challenges brought on by this assumption. (shrink)

This article supports calls for an increased integration of patients into taxonomic decision making in psychiatry by arguing that their exclusion constitutes a special kind of epistemic injustice: preemptive testimonial injustice, which precludes the opportunity for testimony due to a wrongly presumed irrelevance or lack of expertise. Here, this presumption is misguided for two reasons: the role of values in psychiatric classification and the potential function of first-person knowledge as a corrective means against implicitly value-laden, inaccurate, or incomplete (...) diagnostic criteria sets. This kind of epistemic injustice leads to preventable epistemic losses in psychiatric classification, diagnosis, and treatment. (shrink)

KEYWORDS: Validity, reliability, values, taxonomy, clas- sification, McDowell.

Psychiatric classification, as exemplified by the Diagnostic and Statistical Manual of Mental Disorders, is dealing with a lack of trust and credibility—in the scientific, but also in the public realm. Regarding the latter in particular, one possible remedial measure for this crisis in trust lies in an increased integration of patients into the DSM revision process. The DSM, as a manual for clinical practice, is forced to make decisions that exceed available data and involve value-judgments. Regarding such (...) decisions, public epistemic trustworthiness requires that these value-judgments should be representative of those of the affected public, and that the public has a reason to believe such a representation to be realized. Due to the long tradition of distrust in psychiatry, such a reason can in this case best be provided by an actual integration of patients into the decision-making process, rather than by their representation through scientific experts. (shrink)

Abstract Recently, some philosophers of psychiatry (viz., Rachel Cooper and Dominic Murphy) have analyzed the issue of psychiatric classification. This paper expands upon these analyses and seeks to demonstrate that a consideration of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) can provide a rich and informative philosophical perspective for critically examining the issue of psychiatric classification. This case is intended to demonstrate the importance of history for philosophy of psychiatry, and (...) more generally, the potential benefits of historically-informed approaches to philosophy of science. (shrink)

Classificatory realism is the view that nature divides herself up into classes, or “natural kinds”, and claims that it is the goal of scientific classification systems to correctly identify, name, and describe these classes. On this view, the legitimacy of a classification is independent of us and our needs, and instead depends entirely on how well the structure of the classification “matches” the natural kind structure of reality. Progress with respect to classification consists in finding classifications (...) that better match reality. Ultimately, classifications are seen as representations of reality, and it is the world itself that dictates what is to count as a good or correct classification of a given domain. In this thesis I argue against classificatory realism. In the course of this argument, I develop and defend an alternative view of our diagnostic and classificatory practices in psychiatry. This alternative view takes seriously the fact that psychiatric classifications and diagnostic concepts are technical extensions of natural language — tools that are introduced by particular humans, at a particular point in time, for particular human purposes. Viewed from this alternative perspective, some of the most vexing problems in the philosophy of psychopathology suddenly become tractable. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Deflating Psychiatric ClassificationClaudio E. M. Banzato (bio)Keywordsnosography, comorbidity, utility, pragmatismSystems of classification bring order into the world. They are a key part of the informational working infrastructure of the world we inhabit (Bowker and Star 1999). Thus, much of the human interaction hinges on these ordering—pattern identifying and creating—systems. Formal or informal, standardized or ad hoc, visible or invisible, enforced or optional, there are a myriad of (...) classifications we necessarily live by.Typically, classifications convey representations of states of affairs to make interventions on them feasible and, to some extent, predictable. In other words, classificatory systems and schemes try to confer intelligibility to the world. By succeeding in such task, they may provide rational grounds to human operation on reality (toward the most diverse ends). This account fully applies to medical classifications, which struggle to sort out all kinds of diseases, ailments, complaints, and sufferings that can possibly be targeted by medical interventions. This means classifications are instrumental to the ends pursued by medicine, quintessential modificatory activity. In sum, classifications are cognitive tools devised to build up knowledge by making relevant distinctions, which may prove helpful to guide human action.By working well, classifications eventually tend to become invisible. They end up looking just natural, as if they were carved by nature itself. But indeed purpose is the touchstone here. Even if a given class of objects fully qualifies as a 'natural kind' and necessary and sufficient criteria for class membership can be definitely established, it does not entail that it constitutes the best way to classify these objects irrespective of the context. Peter Zachar (2002) offers a compelling example from natural sciences, the utmost practical importance of distinguishing between hydrogen and its isotopes (hydrogen, deuterium, and tritium). In this case, the classificatory thrust stretches beyond the shared atomic number. In his words, "A crucial factor in recognizing them as distinct is that they are used in distinct activities and practices. We get a better neutron bounce with heavy water or D2O. Deciding what aspects of internal structure are important therefore cannot be isolated from external factors." (p. 220)In contemporary psychiatry, diagnostic classification has been center stage for several reasons. But before addressing them, however, a brief historical detour is necessary. Back in the nineteenth century, putting forward a new classification of mental diseases was taken somewhat as a token of psychiatric proficiency according to the witty remark by the French physician and publicist Philippe Buchez: "Upon believing that they have [End Page 23] completed their studies, rhetoricians will compose a tragedy and alienists a classification" (Berrios 1999, 152). By the middle of the twentieth century, many psychiatric classifications (based on diverse principles and underlying theoretical orientations) were still used across the world. The British psychiatrist Erwin Stengel (1959), in his influential report on classification of mental disorders, pointed out that the issue of difficulty of communication was then the order of the day for psychiatry, because it was widely perceived as one of the most serious obstacles to the progress in the field.The broad, worldwide survey carried out by Stengel made it clear that classifications of all shapes were used in different contexts, but they were seldom appealing outside the boundaries of the respective centers that generated them. Such diversity of classifications reflected not only different functions or purposes they were meant to serve, but also the role played by the history of a given problem within a particular medical tradition and cultural background. Thus, Stengel's aims for an acceptable statistical international classification were relatively modest: it should simply ground epidemiological work.Stengel's stance on classification was frankly pragmatic and utilitarian. He understood well the difficulties posed by the 'disease entity' assumption in psychiatry and asked the straight question: "Firstly, what do we classify in this field? Are we classifying diseases or people?", to which he offered a compromised answer: "It may be said that the material the psychiatrist has to classify consists neither of diseases nor of people but of a variety of disorders or reactions, a material which does not readily lend itself to classification" (Stengel 1959, 612). For him, the pursued agreement on the... (shrink)

Discussions of psychiatric nosology focus on a few popular examples of disorders, and on the validity of diagnostic criteria. Looking at Anorexia Nervosa, an example rarely mentioned in this literature, reveals a new problem: the DSM has a strict taxonomic structure, which assumes that disorders can only be located on one branch. This taxonomic assumption fails to fit the domain of psychopathology, resulting in obfuscation of cross-category connections. Poor outcomes for treatment of Anorexia may be due to (...) it being pigeonholed as an Eating Disorder, when a disturbance of body perception may be a more central symptom than food restriction. This paper explores the possibility of restructuring the DSM taxonomy to allow for a pluralist classification of disorders. This change could improve treatment and research without requiring any changes to diagnostic criteria. (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)

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 main article for a Philosophy, Psychiatry, & Psychology philosophical case conference is intended to raise philosophical, psychiatric, and public policy issues concerning the relationship between concepts of criminality, mental disorder, and the classification of mental disorders. After introducing the basic problem of the confounding of “vice” and mental disorder concepts in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition—Text Revision, the author summarizes three different cases from the literature that illustrate the problem of the (...) vice–mental disorder relationship. Four general aspects of the conceptual issues are presented to frame the discussion, and general questions in a range of domains are posed for commentators. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Anthropological Perspectives in Psychiatric NosologyJuan J. López-Ibor Jr. (bio) and María-Inés López-Ibor (bio)KeywordsDSM, etiology, Aristotelian causes, social dramasPsychiatry and clinical psychology, as we learn in this paper, are disciplines in need of an ontological perspective. Very few branches of contemporary learning share this characteristic. Probably only theoretical physic and theology—as the rest have long ago given up trying to define and understand the essence of their object, for (...) example, life in the case of biology or mind in psychology. Consequently, the paper by Pérez-Álvarez, Sass and García-Montes, “The Ontology of Mental Disorders in Constructivist Perspective,” (2008) should be welcomed and indeed included in the reading lists for trainees in psychiatry and clinical psychology.The authors propose an approach to the understanding of mental disorders that is extremely attractive and well articulated, and which also has practical implications for clinicians. It is not just another “philosophical divertimento” devoid of scientific and practical importance. Let us analyze the article in an orderly way.Less DsmThe authors of the target paper disapprove of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III/IV approach to defining illnesses by starting from the symptoms that are present—on the grounds that this may lead clinicians to assume that their sole role is to identify, fight, and suppress the symptoms by whichever procedure. They propose an alternative that is dear to myself because it follows the path of the so-called “anthropological” psychiatry of Binswanger, von Gebsattel, Erwin Strauss, Zutt, López-Ibor, Sr., and others. In essence, this is a phenomenological approach to the meaning of mental diseases, one that emphasizes how the illness is revealed to the patient him- or herself.The target article’s criticism of DSM should be considered in the context of the abuses committed on its behalf. The DSM is not a textbook of psychiatric disorders, nor does it contain a definition of the diseases. The DSM does not tell what a disease is (Klerman et al. 1984)—something that is impossible with a classification system based on the manifestations of the diseases, the signs and symptoms. The DSM, as its title states, is just a diagnostic and statistical manual, which does not contain anything about the origin of [End Page 259] any disease nor an explanation of why it exists or what it means. The DSM is, in fact, just a tool to determine whether a disease is present, and therefore to facilitate communication between professionals and with other individuals, without saying anything about the disease’s aitia—a key term (associated with notions of essence as well as cause) to be discussed below. In theory, most clinicians should understand these limitations; it may be, however, that this is not really the case for many who read or use the DSM. In the world there are around 200,000 psychiatrists; since 1980 the number of DSM copies sold is in the order of several hundred thousand.The misuse of a classification system is even more noticeable in the International Classification of Diseases (ICD)-10 Research Version. The instructions for the use of this version recommend that the first step is to make an inventory of all the symptoms present, and then to construct a diagnosis based on them. This how all computer-assisted systems work. This procedure can, however, only be valid if the clinician has already reached a diagnostic conclusion by other means—a diagnosis then to be confirmed for research purposes. It may be that this is one of the reasons why the ICD-10 Research Version has almost never actually been used for research.Furthermore, the concept of symptoms in psychiatry applies only to organic mental disorders (Schneider 1959), conditions in which the patient’s attitude and way of experiencing the symptoms do not play the kind of role that they play in schizophrenia and other mental disorders. The quotation from the important paper by Sass and Parnas in this context is most appropriate. It is indeed that case that “subjective experience can play an important causal role in the progressive experiential transformations of a developing schizophrenic illness... (shrink)

Cognitive diagnostic assessment has been developed rapidly to provide fine-grained diagnostic feedback on students’ subskills and to provide insights on remedial instructions in specific domains. To date, most cognitive diagnostic studies on reading tests have focused on retrofitting a single booklet from a large-scale assessment. Critical issues in CDA involve the scarcity of research to develop diagnostic tests and the lack of reliability and validity evidence. This study explored the development and validation of the (...) class='Hi'>Diagnostic Chinese Reading Comprehension Assessment for primary students under the CDA framework. Reading attributes were synthesized based on a literature review, the national curriculum criteria, the results of expert panel judgments, and student think-aloud protocols. Then, the tentative attributes were used to construct three booklets of reading comprehension items for 2–6 graders at three key stages. The assessment was administered to a large population of students in grades 2–6 from 20 schools in a district of Changchun City, China. Q-matrices were compared and refined using the model-data fit and an empirical validation procedure, and five representative cognitive diagnostic models were compared for optimal performance. The fit indices suggested that a six-attribute structure and the G-DINA model were best fitted for the reading comprehension assessment. In addition, diagnostic reliability, construct, internal and external validity results were provided, supporting CDM classifications as reliable, accurate, and useful. Such diagnostic information could be utilized by students, teachers, and administrators of reading programs and instructions. (shrink)

En este artículo, nos proponemos analizar el horizonte epistemológico sobre el que se construye la psiquiatría de Kraepelin, particularmente su posición frente al problema de los criterios de clasificación de las enfermedades mentales, que fue un tema ampliamente discutido por la psiquiatría mundial a fines del siglo XIX. Analizamos de qué modo Kraepelin se vinculaba con el debate de su época sobre la definición de criterios científicos, válidos y objetivos de clasificación de las enfermedades psiquiátricas, para, posteriormente, analizar las consecuencias (...) implícitas en una elección de criterios diagnósticos que significó el abandono de las narrativas de los pacientes frente a la fantasmagoría de las categorías diagnósticas. In this paper we analyze the epistemological framework on which Kraepelin's psychiatry was built. We are particularly interested in Kraepelin's position relating to the criteria of classification of mental illnesses; a topic that was widely discussed by in psychiatry throughout the world at the end of the XIX century. We analyze his contributions to the discussion concerning the definition of scientific and objectively valid criteria for the classification of psychiatric illnesses. Then, we show how settling upon certain diagnostic criteria led to paying little attention to patients narratives, and giving major weight to the paraphernalia of diagnostic categories. (shrink)

The concept of a “validator” as a unit of evidence for the validity of a psychiatric category has been important for more than fifty years. Validator evidence is aggregated by expert committees (for the Diagnostic and Statistical Manual of Mental Disorders (DSM), these are referred to as “workgroups”), which use the results to make nosological decisions. Through an examination of the recent history of psychiatric research, this paper argues that it is time to reassess this traditional (...) practice. It concludes with specific suggestions for going forward. (shrink)

This article does not directly consider the feelings and emotions that occur in mental illness. Rather, it concerns a higher level methodological question: To what extent is an analysis of feelings and felt emotions of importance for psychiatric classification? Some claim that producing a phenomenologically informed descriptive psychopathology is a prerequisite for serious taxonomic endeavor. Others think that classifications of mental disorders may ignore subjective experience. A middle view holds that classification should at least map the contours (...) of the phenomenology of mental illness. This article examines these options. I conclude that it is not true that phenomenology is a logical prerequisite for classification, nor even that classification should necessarily respect phenomenological boundaries, but that detailed phenomenological examination can sometimes inform classification. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Impact of Clinicians on the Diagnostic ManualThomas A. Widiger (bio)Keywordsdiagnosis, classification, DSM, taxonomy, clinical judgmentSurveys of clinicians’ opinions can be very informative. There is a long tradition within medicine that new disorders are discovered within clinical practice. The original edition of the American Psychiatric Association’s (APA) diagnostic manual (DSM) was based in large part on clinical experience. The recent editions have been governed more (...) heavily by more systematic research (Widiger and Clark 2000), but many of the new additions are still said to come from clinical practice. As described for the development of DSM-III (APA 1980), “if there is general agreement among clinicians, who would be expected to encounter the condition, that there are a significant number of patients who have it and that its identification is important in their clinical work, it is included in the classification” (Spitzer, Sheehy, and Endicott 1977, 3).Clinicians can also be surveyed with regard to their opinions concerning a proposed revision. The ultimate consumers of a diagnostic manual are practicing clinicians and any effort to develop an official nomenclature should consider the opinions of the persons who must use the classification within their clinical practice (First et al. 2004; Sadler 2005). Clinicians can also be surveyed (or studied) with respect to how the diagnostic manual is being implemented. Much of this research has demonstrated that clinicians might be failing to apply the diagnostic manual in a reliable or valid manner (Garb 2005; Kutchins and Kirk 1997).It is perhaps obvious, however, that a diagnostic manual should not be governed primarily by clinical opinion or current clinical practice. The authors of DSM-III (APA 1980) and DSM-III-R (APA 1987) indicated that they would include a new diagnosis within the official nomenclature if a group of clinicians indicated that it was important to their clinical practice (Spitzer et al. 1977). This liberal threshold led to the decision of the DSM-III-R Task Force to include such diagnoses as paraphiliac rapism, self-defeating personality disorder, and sadistic personality disorder despite the lack of systematic research supporting their validity and the likelihood that these new diagnoses would have harmful social and forensic applications (Widiger 1995). These diagnoses no longer even appear within the appendix of DSM-IV-TR (APA 2000) for proposed diagnoses needing further study.The authors of DSM-III avoided opinion surveys because “no one wanted to repeat the scene of the general membership voting on a presumably ‘scientific’ issue, as was done in 1973 on the [End Page 277] issue of the elimination of homosexuality from the DSM-II classification” (Spitzer, Williams, and Skodol 1980, 152). Matters of construct validity should probably be addressed through systematic research rather than through opinion polls. Decisions should be informed by a fair hearing of the diversity of perspectives, and these viewpoints and perspectives should be systematically and enthusiastically solicited. Nevertheless, the most scientifically valid decision may at times be “politically incorrect.” The authors of the diagnostic manual should have the authority to make innovative decisions that are scientifically justified even when they are contrary to general clinical consensus (Widiger and Clark 2000).Some persons, though, do suggest that the diagnostic manual should be modeled on how disorders are being diagnosed within clinical practice. This is perhaps most readily evident in the proposals of Westen and Shedler (2000) to diagnose mental disorders via prototypal matching. They eschew the provision of specific and explicit criterion sets in favor of simply matching the patient to a global (e.g., paragraph description) of a prototypic case. A purported strength of this approach is that it is said to “conform to the way clinicians think about psychiatric diagnoses” (First and Westen 2007, 473).There are, however, concerns with respect to prototypal matching. First, it is not really clear that clinicians actually provide diagnoses in this manner. There are data to suggest that clinicians instead reach a diagnostic decision on the basis of just one or two individual diagnostic criteria rather than matching to a global prototype (Herkov and Blashfield 1995).More important, it is unclear whether the diagnostic manual should in fact emulate what is occurring within clinical practice. There is a... (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)

The main objective in this chapter is to examine the role of judgments of rationality in the current understanding of psychiatric disorders. To what extent are the criteria for classification and diagnosis independent of judgments of rationality? The typical symptoms of many psychiatric disorders are described as instances of epistemic, procedural, or emotional irrationality, and references to such forms of irrationality are frequently made in the current classificatory and diagnostic criteria for schizophrenia, dementia, depression, and personality (...) disorders. That said, the chapter defend the view that irrationality is neither necessary nor sufficient for a behavior to be characterized as symptomatic of a psychiatric disorder. (shrink)

Current psychiatric classification adopts a disorder-focused diagnostic approach, as exemplified within ICD-11 and DSM-V. Although this approach has improved reliability of categorization, its validity and utility has been questioned. Limitations include high comorbidity between supposedly distinct disorders; heterogeneity within diagnoses; limited treatment efficacy; and similarities across disorders in aetiology, latent symptom structure, and underlying biology. There is also evidence of transdiagnostic cognitive-behavioural processes. An alternative approach is therefore to focus on fundamental underlying mechanisms of psychopathology rather (...) than observed symptom clusters. This article considers the possible benefits, hurdles, and steps towards implementation of this transdiagnostic mechanistic approach, using the example of repetitive negative thought. (shrink)

After the introduction of the fifth Diagnostic and Statistical Manual of Mental Disorders, familiar voices were raised in protest. The voices stem from ideas of which, among others, and in different ways, Michel Foucault and Thomas Szasz were influential proponents: The movement was referred to as 'antipsychiatry.' This movement reacted, among other things, to the system of categorization of mental disorders. Diagnoses, in a system of classification, were thought to be vague, arbitrary, labelling, stigmatizing, and scientifically and clinically (...) poorly validated. In contemporary debates on DSM-5, similar critiques can be heard, expressed by a movement now referred to as 'critical psychiatry'... (shrink)

Classifying Madness (Springer, 2005) concerns philosophical problems with the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the D.S.M. The D.S.M. is published by the American Psychiatric Association and aims to list and describe all mental disorders. The first half of Classifying Madness asks whether the project of constructing a classification of mental disorders that reflects natural distinctions makes sense. Chapters examine the nature of mental illness, and also consider whether mental disorders fall into (...) natural kinds. The second half of the book addresses epistemic worries. Even supposing a natural classification system to be possible in principle, there may be reasons to be suspicious of the categories included in the D.S.M. I examine the extent to which the D.S.M. depends on psychiatric theory, and look at how it has been shaped by social and financial factors. I aim to be critical of the D.S.M. without being antagonistic towards it. Ultimately, however, I am forced to conclude that although the D.S.M. is of immense practical importance, it is unlikely to come to reflect the natural structure of mental disorders. (shrink)

The scientific investigation of mental disorders is an invigorating area of inquiry for philosophers of mind and science who are interested in exploring the nature of typical and atypical cognition as well as the overarching scientific project of ‘carving nature at its joints’. It is also important for philosophers of medicine and bioethicists who are concerned with concepts of disease and with the development of effective and ethical treatments of mental disorders and the just distribution of mental health services. Philosophical (...) worries surrounding mental health and its care have recently extended beyond the bounds of academia, becoming a vigorous topic of debate in a variety of public domains in the wake of the publication of the most recent revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , the psychiatric classification system used by mental health professionals in the USA, and increasingly, by those around the world.The DSM-5 lists mental disorders according to the observable symptoms presented by patients. It is designed for pragmatic use across a variety of settings to accomplish several tasks: to facilitate clinical treatment, to provide clear criteria of eligibility for various administrative and policy related purposes ), and primarily, to further scientific research into mental disorder aetiology. Although designed to meet the needs and interests of various stakeholders , the recently revised manual has not fully satisfied any of them. This failure challenges the assumption that a single manual …. (shrink)

The increasing integration of Machine Learning (ML) techniques into clinical care, driven in particular by Deep Learning (DL) using Artificial Neural Nets (ANNs), promises to reshape medical practice on various levels and across multiple medical fields. Much recent literature examines the ethical consequences of employing ML within medical and psychiatric practice but the potential impact on psychiatric diagnostic systems has so far not been well-developed. In this article, we aim to explore the challenges that arise from the (...) recent use of ANNs for the old problems of psychiatric nosology. To enable an empirically supported critical reflection on the topic, we conducted semi-structured qualitative interviews with Swiss and German experts in computational psychiatry. Here, we report our findings structured around two themes, namely (1) the possibility of using ML for defining or refining of psychiatric classification, and (2) the desirability of employing ML for psychiatric nosology. We discuss these themes by relating them to recent debates about network theory for psychiatric nosology and show why empirical research in the field should critically reflect on its contribution to psychopathology research. In sum, we argue that beyond technical, regulatory, and ethical challenges, philosophical reflection is crucial to harness the potential of ML in psychiatry. (shrink)

Aims: The Research Diagnostic Criteria for Temporomandi¬bular Disorders (RDC/TMD) Axis I diagnostic algorithms were demonstrated to be reliable but below target sensitivity and specificity. Empirical data supported Axis I algorithm revisions that were valid. Axis II instruments were shown to be both reliable and valid. An international consensus workshop was convened to obtain recommendations and finalization of new Axis I diagnostic algorithms and new Axis II instruments. Methods: A comprehensive search of published TMD diagnostic literature was (...) followed by review and consensus via a formal structured process by a panel of experts for revision of the RDC/TMD. Results: The recommended Diagnostic Criteria for TMD (DC/TMD) Axis I protocol includes both a valid screener for pain diagnoses and valid criteria for the most common pain-related TMDs and for one intra-articular disorder. The Axis II protocol retains selected RDC/TMD screening instruments augmented with new instruments to better assess the interactions between pain and psychosocial functioning. A comprehensive classification system is also presented. Conclusion: The recommended evidence-based DC/TMD protocol is appropriate for use in both the clinical and research settings. Simple Axis I and II screening tests augmented by validated Axis I and Axis II instruments allow for identification of simple to complex TMD patients. (shrink)

Normality Does Not Equal Mental Health: The Need to Look Elsewhere for Standards of Good Mental Health is the first book to question the equation of psychological normality and mental health. It is also the first book to take contemporary psychiatry and clinical psychology to task for deeply flawed thinking when they accept the diagnostic system propounded by the DSM, which reifies syndromes into alleged “mental disorders.” Where Thomas Szasz argued that “mental disorders” are myths, Bartlett makes the much (...) more damaging charge that reifying mental disorders involves a provable form of fallacious thinking, producing a variety of epistemological nonsense. /// -/- -/- The author weighs the evidence, and with strict logic, compelling evidence, and careful analysis, challenges the current paradigm of mental health theorists and practitioners. Never has the case against the standard of psychological normality and against the non-scientific creation of “mental disorders” been made with such boldness, multidisciplinary knowledge, solid scholarship, and clarity of language. /// -/- -/- Normality Does Not Equal Mental HealthAlthough the need to question psychological normality as a satisfactory standard of good mental health has been staring us in the face for a long time, no one, clinical professional or scholar, has had the courage or the intellectual willingness to face with unflinching honesty the shortcomings and disappointments of psychological normality and to propose that we should look elsewhere for standards of good psychological health. /// -/- -/- Contemporary psychiatry and clinical psychology, on the contrary, base their conception of mental health on the standard of psychological normality. This supposition has come to be accepted uncritically and without question, and yet it has become fundamental to current clinical theory and practice, and forms the core of the psychiatric classification system of the DSM, which has become today’s diagnostic authority. /// -/- -/- While touting today’s scientific gold standard of “evidence-based” research, DSM’s authoritative classification of “mental disorders” is itself hardly “evidence-based,” for it is recognized, but seldom emphasized, that the majority of DSM’s “mental disorders” have no known empirical, organic basis. /// -/- -/- Normality Does Not Equal Mental Health takes DSM to task not only for its failure to adhere to today’s evidence-based standard, but for its failure to rein in its highly speculative diagnostic labeling, in accordance with the modern paradigm of rigorous science, which repudiates metaphorical reifications whose alleged validity rests only on the voting preferences of a professional membership. /// -/- -/- The book is a carefully argued critique of the dominant assumption in current psychiatry and clinical psychology that psychological normality is fundamental to mental health and therefore good. In place of this unsatisfactory presumption, Normality Does Not Equal Mental Health proposes a positive and constructive revision in our understanding of mental health and of our conception of mental disorders. (shrink)

BackgroundThe aim of this study was to explore the construct validity and diagnostic properties of the Reading the Mind in the Eyes Test in non-demented patients with amyotrophic lateral sclerosis.MaterialsA total of 61 consecutive patients and 50 healthy controls were administered the 36-item RMET. Additionally, patients underwent a comprehensive assessment of social cognition via the Story-Based Empathy Task, which encompasses three subtests targeting Causal Inference, Emotion Attribution, and Intention Attribution, as well as global cognitive [the Edinburgh Cognitive and (...) Behavioral ALS Screen ] and behavioral screening [the Frontal Behavioral Inventory ; the Dimensional Apathy Scale ; the Beck Depression Inventory ; and the State and Trait Anxiety Inventory-Y]. The construct validity of the RMET was tested by regressing it within a stepwise model that encompassed as predictors the abovementioned cognitive and behavioral measures, covarying for demographic and motor confounders. Receiver-operating characteristics analyses allowed exploring intrinsic and post-test properties of the RMET both in discriminating patients from HCs and in identifying patients with a defective SET-EA performance.ResultsThe RMET was solely predicted by the SET-EA and SET-IA. RMET scores showed high accuracy both in discriminating patients from HCs and in identifying patients with a defective SET-EA score, with adequate-to-optimal both intrinsic and post-test properties.DiscussionThe RMET is a convergently and divergently valid measure of affective social cognition in non-demented ALS patients, also featuring optimal intrinsic and post-test diagnostic properties in both case-control and case-finding scenarios. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.3 (2003) 265-266 [Access article in PDF] Definition Is Limited and Values Inescapable Richard Mullen THIS IS A welcome paper that lays bare some of the presumptions of those who seek to determine the status of psychiatric disorder. At different times debate on the subject reflects stigma, prejudice, needs for coherent categorization, and occasionally just antipsychiatric resentment. As Pickering hints, much philosophical argument may (...) be selected to support a position already chosen.The article illustrates that the likeness argument is insufficient to demonstrate that mental disorders are or are not disorders in any other more profound sense. Similarly perhaps, if a debate were conducted about whether or not a bony fracture, hypertension, obesity, or bacterial infection were real illnesses, the likeness argument might be unfruitful. This is perhaps unsurprising; notions of health and illness, mental or physical, are largely abstractions. In psychiatry, so-called symptoms are themselves abstract classifications of incompletely articulated mental phenomena far more diverse than the definitions and criteria to be found in a diagnostic manual.Argument by analogy is always limited. If my car has a flat tire, the car will be dysfunctional or disordered. Its loss of performance will be the symptoms of the flat tire, which is the lesion. It is a problem quickly diagnosed and treated. If convenient, I suppose my car could have been said to be ill, but this would not lead to any particular insights into the nature of cars, mechanics, health, or anything else.A variety of concepts can be contained within terms such as illness,disease, and disorder. They include the clinicopathological approach (the disease is the organic lesion), the disease is deviance approach, disease as distress, and approaches that consider disease—particularly mental disorder—as largely socially constructed. None may resolve the questions that Pickering raises, but recognizing that our terms are not always precise or used consistently is part of formulating the problem more clearly. For the most part clinical psychiatry (and the rest of medicine) has no difficulty in properly identifying most of our patients as disordered or ill. The fact that there are some borderline instances, difficult to classify either way, does not invalidate the classification.Consideration of whether or not the features of a disorder can in themselves determine whether or not a person is disordered is timely for two reasons. As stigma about (some) psychiatric disorder lessens, and opportunities for complaint and compensation expand, an era of self-definition as mentally disordered has arrived. How are mental health practitioners to respond to someone whose mental distress appears not to be clinically significant, but who demands access to the sick role? Also of current concern for clinical psychiatry is widespread pressure to define as disordered those persons whose antisocial behavior brings them into conflict with society. Professional recognition that definitions of mental disorder are inadequate, or rather incomplete, [End Page 265] may be valid. Worryingly, there are others who are willing to define it for us.Both major international systems of classification of mental disorder offer definitions of mental disorder that turn on what is to be meant by clinical significance or clinically recognizable. In the current Diagnostic and Statistical Manual, mental disorder implies "clinically significant impairment or distress," and criteria for specific disorders mostly including a comment about "clinically significant distress or impairment in social, occupational, or other important areas of functioning" (APA 2000, 8). In the International Classification of Disease, disorder is used to imply "existence of a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal function" (WHO 1992, 5). It seems that no definition of mental disorder is adequate for all purposes. Seeking to improve existing definitions by further defining the terms used quickly becomes an exercise in pedantry, far removed from practical utility.Pickering mentions as an example the "symptom" of delusions. Available definitions are widely recognized as incomplete or otherwise unsatisfactory (David 1999). This leads to debate about what the individual elements within the definition precisely mean. However in practice delusions are identified with remarkably high reliability (WHO 1973... (shrink)

The network approach to psychiatric phenomena has the potential to clarify and enhance psychiatric diagnosis and classification. However, its generally well-justified anti-essentialism views psychiatric disorders as invariably fuzzy and arbitrary, and overlooks the likelihood that the domain includes some latent categories. Network models misrepresent these categories, and fail to recognize that some comorbidity may represent valid co-occurrence of discrete conditions.

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)

This dissertation examines psychiatry from a philosophy of science perspective, focusing on issues of realism and classification. Questions addressed in the dissertation include: What evidence is there for the reality of mental disorders? Are any mental disorders natural kinds? When are disease explanations of abnormality warranted? How should mental disorders be classified? -/- In addressing issues concerning the reality of mental disorders, I draw on the accounts of realism defended by Ian Hacking and William Wimsatt, arguing that biological research (...) on mental disorders supports the inference that some mental disorders (e.g., schizophrenia, mood disorders, and anxiety disorders) are real theoretical entities, and that the evidence supporting this inference is causal and abductive. In explicating the nature of such entities, I argue that real mental disorders are natural kinds insofar as they are natural classes of abnormal behavior whose members share the same causal structure. I present this position in terms of Richard Boyd’s homeostatic cluster property theory of natural kinds, and argue that this perspective reveals limitations of Hacking’s account on the looping effects of human kinds, which suggests that the objects classified by psychiatrists are unstable entities. I subsequently argue that a subset of mental disorders (e.g., schizophrenia and Down syndrome) are mental illnesses insofar as they are disorders caused by a dysfunctional biological process that leads to harmful consequences for individuals. I present this analysis against Thomas Szasz’s argument that mental illness is a myth. -/- In addressing issues of psychiatric classification, my analysis focuses on the Diagnostic and Statistical Manual of Mental Disorders (DSM), which has been published regularly by the American Psychiatric Association since 1952, and is currently in its fourth edition. After examining the history of DSM in the twentieth century, and in particular, DSM’s shift to an atheoretical and purely descriptive system in the 1980s, I consider the relative merits of descriptive versus causal systems of classification. Drawing on Carl Hempel’s analysis of taxonomic systems in psychiatry, I argue that a causal classification system would provide a superior approach to psychiatric classification than the descriptive system currently favored by DSM. (shrink)

The purpose of cognitive diagnostic modeling is to classify students' latent attribute profiles using their responses to the diagnostic assessment. In recent years, each diagnostic classification model makes different assumptions about the relationship between a student's response pattern and attribute profile. The previous research studies showed that the inappropriate DCMs and inaccurate Q-matrix impact diagnostic classification accuracy. Artificial Neural Networks have been proposed as a promising approach to convert a pattern of item responses into (...) a diagnostic classification in some research studies. However, the ANNs methods produced very unstable and unappreciated estimation unless a great deal of care was taken. In this research, we combined ANNs with two typical DCMs, the deterministic-input, noisy, “and” gate model and the deterministic-inputs, noisy, “or” gate model, within a semi-supervised learning framework to achieve a robust and accurate classification. In both simulated study and real data study, the experimental results showed that the proposed method could achieve appreciated performance across different test conditions, especially when the diagnostic quality of assessment was not high and the Q-matrix contained misspecified elements. This research study is the first time of applying the thinking of semi-supervised learning into CDM. Also, we used the validating test to choose the appropriate parameters for the ANNs instead of using typical statistical criteria. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Underplayed Ethics and the Dilemmas of Psychiatric CareChong Siow Ann and Tamra LysaghtThe practice of psychiatry is fraught with uncertainty. The exact causes and the biological substrates underlying mental disorders remain to be elucidated; even the diagnosis of these disorders is descriptive and not based on an etiological understanding and no biological diagnostic markers have been validated. The manifestation of almost all mental disorders results from a (...) complex interaction of biological and environmental factors which encompasses the patient’s unique life history, experiences and relationship with others and the community. In the face of such uncertainties — at times extending to the types of treatment (psychiatry is generally acknowledged not be an exact science) — it has been argued that adopting a pragmatic approach is necessary.1 Accordingly, this approach necessitates high ethical standards among mental health practitioners.Some mental illnesses are associated with varying degrees and types of cognitive impairments. Others have certain symptoms like auditory hallucinations and delusions that might severely compromise the patients’ autonomy, distort their sense of reality, increase the risk of harm to themselves or others and render them incapable of making informed decisions in their treatment and participation in research.Consequently, there are issues that are particular to the provision of mental healthcare. These include the need for enforced involuntary treatment with the corollary of depriving a patient of his personal liberty even [End Page 173] though it is often justified on the grounds that it is in the patient’s best interests. However, at times, it is the legal and societal obligation of mental health practitioners to protect those who might be harmed from the patient’s action that might seem to be more pressing. In this situation of double agency, lies the tension of providing confidential care for patients and acting as “an agent of the state” where that patient’s confidentiality might be breached and his liberty infringed upon. This situation is further aggravated by the stigma that clings ever so tenaciously to those who suffer from mental disorders and where it is the norm to stereotype them as dangerous and unpredictable.Consideration of a patient’s autonomy is also challenged by characteristics that are unique to the practice of psychiatry. The prescription of certain psychotropic medications can alter how people think and feel, while psychotherapy works towards changing the patient’s views and values. The philosopher, Jennifer Radden, describes this process as “re-forming the patient’s whole self or character … akin to the responsibilities of raising children”.2 The psychotherapeutic relationship is thus particularly personal and intimate because patients are asked to provide information that often reveals their innermost feelings, fears and fantasies. This information is provided on the basis of trust and assurance of confidentiality, and with expectation of being helped.Jeremy Holmes and Gwen Adshead have elaborated on the vulnerability of patients seeking psychotherapy: they might be particularly susceptible to exploitation because their past experiences of being exploited have led to their distress and help seeking — their dependency and the extreme privacy of the therapeutic relationship make any transgression difficult to be uncovered.3 There is a calamitous combination of the “unconscious wish in the patient to be used” with the complicity of an unethical therapist seeking to fulfil his own interests.4As in any other doctor-patient relationship, the relationship between the mental healthcare practitioner and the patient is one of unequal power where the former is ascendant. While that power should be exercised to heal and to relieve suffering, it also gives the practitioner tremendous power “to harm, reject, misunderstand, or exploit patients who struggle with the experience of mental illness, which itself may generate helplessness, despair, distress, and exceptional dependence on the clinician”.5 Given the potential of doing good and harm coupled with the likelihood of being so significant in the life of the patient,6 providing care for those with mental disorders and distress is necessarily ethically exacting — arguably more so than in other medical practice settings. [End Page 174]This precariousness has led to the suggestion that ethics in psychiatry should have a special status and that the more general principles of biomedical ethics are too limited in scope to... (shrink)

Effective and specifically targeted social and therapeutic responses for antisocial personality disorders and psychopathy are scarce. Some authors maintain that this scarcity should be overcome by revising current syndrome - based classifications of these conditions and devising better biocognitive classifications of antisocial individuals. The inspiration for the latter classifications has been embedded in the Research domain criteria approach (RDoC). RDoC - type approaches to psychiatric research aim at transforming diagnosis, provide valid measures of disorders, aid clinical practice, and improve (...) health outcomes by integrating the data on the genetic, neural, cognitive, and affective systems underlying psychiatric conditions. In the first part of the paper, we discuss the benefits of such approaches in comparison to the dominant syndrome-based ones and review recent attempts at building biocognitive classifications of antisocial individuals. Other researchers, how ever, have objected that biocognitive approaches in psychiatry are committed to an untenable form of explanatory. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinicians’ “Folk” Taxonomies and the DSM: Pick Your PoisonG. Scott Waterman (bio)Keywordsnosology, classification, diagnosis, psychopathologyWith attention turning to the process of formulating the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V; e.g., Kendler et al. 2008), the study by Flanagan and Blashfield (2007) of the similarities and differences between clinicians’ “folk” taxonomies and psychiatry’s official one is timely, and its lessons are in (...) need of analysis. In this commentary I first address questions raised by the existence of multiple de facto taxonomies, and by the characteristics of those taxonomies themselves, before focusing attention on the DSM diagnostic system and its attributes that make acceptance by its constituencies far less than complete. Although the aim of Flanagan’s and Blashfield’s study is explicitly descriptive rather than normative, it provides an important opportunity to examine the extent to which our taxonomies serve the purposes for which they were constructed—whether by experts or by clinicians.There are certainly reasons to expect significant deviations between clinicians’ everyday taxonomies and the official one. Perhaps the most glaring reason is the fact that—even if it were desirable—no one can be familiar with the enormous number of categories codified by the DSM. On the other hand, the remarkable hegemony of the DSM—in the education and training of physicians and clinical psychologists, in clinical communication, and in the ubiquitous administrative functions of billing and coding—makes such deviations at least somewhat surprising and in need of scrutiny and explanation. The first question, however, is whether one should be concerned by the existence (surprising or otherwise) of multiple taxonomies. Flanagan and Blashfield make the compelling case that, given the high rate at which Americans seek clinical attention for psychiatric problems, the stakes are commensurately high for our efforts at categorizing those problems in valid and useful ways. And the extent to which a gulf exists between the way psychiatry and clinical psychology are written about and taught on the one hand, and conceptualized and practiced by clinicians on the other, invites a multitude of problems—among which cynicism about our disciplines may be one of the most pernicious.At least as important as their finding of only moderate correlations between clinicians’ taxonomies [End Page 271] and that of the DSM are the characteristics of clinicians’ diagnostic systems themselves. One potentially major artifact of their methodology, however, must be borne in mind: the instruction to the clinicians in their study to “[p]ut together the diagnoses that have similar treatments…” (emphasis mine). Although they cite previous work (Flanagan and Blashfield 2006) in defense of the proposition that such instruction did not unduly influence their findings, it was certainly an avoidable potential problem, which itself likely reflects the history of our clinical disciplines in which the treatment cart frequently pulled the diagnosis horse. It is, therefore, not unlikely that clinicians’ taxonomies might emphasize treatment considerations even if they had not been directed to do so. The fallacious reasoning behind such intuitively appealing practice, however, must be exposed. The implicit assumption that treatment response is a proxy for other important characteristics of illnesses is predicated on the false proposition that our treatments exert their effects via similar mechanisms across the various indications for their uses, thus allowing us to infer from such responses that what was awry in the first place among the conditions for which a given treatment is effective must be closely related. Categorizing mania and trigeminal neuralgia together by virtue of their shared responses to anticonvulsant therapy, or considering autoimmune platelet deficiencies to be closely related to abdominal trauma due to the fact that each sometimes requires splenectomy, are examples of the potential results of acting on that false premise.Another parameter on which the clinicians in the current study based their nosologies—most explicitly by the “dimensional experts”—is the “environmental” versus “biological” one. Given that a coherent dichotomy would either distinguish environmental from genetic etiological factors, or would contrast psychological (i.e., subjective or first-person) from biological (i.e., objective or third-person) manifestations of illness, a taxonomy one of whose axes purports to represent an environmental/biological continuum cannot... (shrink)

In this article I discuss the emergence of Female Sexual Dysfunction within American psychiatry and beyond in the postwar period, setting out what I believe to be important and suggestive questions neglected in existing scholarship. Tracing the nomenclature within successive editions of the American Psychiatric Association’s Diagnostic and Statistical Manual, I consider the reification of the term ‘FSD’, and the activism and scholarship that the rise of the category has occasioned. I suggest that analysis of FSD benefits from (...) scrutiny of a wider range of sources. I explore the multiplicity of FSD that emerges when one examines this wider range, but I also underscore a reinscribing of anxieties about psychogenic aetiologies. I then argue that what makes the FSD case additionally interesting, over and above other conditions with a contested status, is the historically complex relationship between psychiatry and feminism that is at work in contemporary debates. I suggest that existing literature on FSD has not yet posed some of the most important and salient questions at stake in writing about women’s sexual problems in this period, and can only do this when the relationship between ‘second-wave’ feminism, ‘post-feminism’, psychiatry and psychoanalysis becomes part of the terrain to be analysed, rather than the medium through which analysis is conducted. (shrink)