In this article I discuss the emergence of Female Sexual Dysfunction (FSD) 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 ( DSM), 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 (especially since the popular and scientific cross-pollinate). 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)

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)

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has for decades been a locus of dispute between ardent defenders of its scientific validity and vociferous critics who charge that it covertly cloaks disputed moral and political judgments in scientific language. This essay explores Alasdair MacIntyre's tripartite typology of moral reasoning—"encyclopedia," "genealogy," and "tradition"—as an analytic lens for appreciation and critique of these debates. The DSM opens itself to corrosive neo-Nietzschean "genealogical" critique, such an (...) analysis holds, only insofar as it is interpreted as a presumptively objective and context-independent encyclopedia free of the contingencies of its originating communities. A MacIntyrean tradition-constituted understanding of the DSM, on the other hand, helpfully allows psychiatric nosology to be understood both as "scientific" and, simultaneously, as inextricable from the political and moral interests—and therefore the moral successes and moral failures—of the psychiatric guild from which it arises. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Minding Psychiatric PracticePaul B. Lieberman, MD (bio)In recent discussions of what makes or should make something 'a psychiatric disorder' (if anything does; Lange, 2007), attention and contention have mostly involved problems distinguishing disorder from normal life, expectable suffering, neurological disease, criminality, prejudice, error, religious experience and effects of injustice, but the question of what makes or should make something psychiatric is also important and difficult to (...) answer. It's important because general conceptions of what kinds of things we treat (e.g., disorders of the heart, brain, or mind) guide practice by specifying what constitutes, nurtures or poisons them, ways they may break apart or be repaired and processes that produce change, as well as by helping to draw appropriate boundaries between psychiatry and other fields. It's difficult because psychiatry comprises many kinds of objects, theories and forms of practice (primarily biomedical, psychodynamic and cognitive behavioral), and we don't know which, if any, are 'natural' or valid. It's also not established whether or why all or any should be called, 'psychiatric,' what explains their being so-called (if it is correct to do so), or which may be fundamental or constitutive and which derivative and potentially eliminable.One appealing answer (the Diagnostic and Statistical Manual of Mental Disorders [DSM] an swer; American Psychiatric Association, 2013) to the question of what makes something psychiatric is that it is mental in some essential way. But few psychiatrists could explain what that might mean, nor would many be able to say what a mental disorder is or defend the idea that the conditions they work with are (always?) such things (though many probably wouldn't deny it either; they wouldn't know what to say and most wouldn't think it mattered). But if the idea that 'psychiatric disorders are essentially mental' seems obvious yet unclear to psychiatrists, what's the alternative? And if no alternative leaps to mind, then are psychiatrists practicing without knowing what they're treating?In "What makes a disorder 'mental'? A practical treatment of psychiatric disorder," Joseph Gough (2023) addresses these problems with two bold proposals: first, that we abandon altogether using 'mental' (assuming we understand its meaning) in the definition of 'psychiatric disorder,' and, second, that we, instead, define psychiatric disorders as those conditions best treated by psychiatrists (including psychologists, social workers, nurses and other practitioners).To a psychiatrist, these proposals seem, both, a welcome validation of our work ("At last, someone appreciates us!"), but also a troubling destabilization of how we understand that work ("That can't be right: it's backwards!") In Gough's [End Page 37] wide-ranging and carefully reasoned defense of his two proposals, he offers many novel and provocative insights relevant to problems defining psychiatric disorders. I will consider only a few of the issues he raises, which I think are especially worth emphasis and further thought.Gough initially rejects mentality in the definition of psychiatric disorder by reminding us that it is neither sufficient nor necessary for inclusion in the DSM. Vision is mental but blindness is not in the manual; caffeinism and erectile dysfunction are not mental but are included. Later, he offers two additional reasons for abandoning mentality: it promotes stigma and encourages dualism. I think all these arguments are correct. (Although blindness is not the best example because DSM defines mental disorders as disturbances of "thought, feeling and behavior" and blindness is none of these. But many other examples (e.g., encephalopathies) could make the point.)But Gough passes over this issue too quickly: we should pause and consider more carefully possible reasons to keep or even privilege the mental in psychiatry as well as the losses we might suffer if we gave it up. The examples and arguments he offers for abandoning the mental could be contested if one were motivated to do so. For example, one could argue, as Gough does elsewhere, that the DSM is just wrong sometimes and should be revised. Perhaps, as Gough briefly considers, there is a subset of 'mental' disorders that are properly psychiatric (where, e.g., certain favored features such as meaning, agency, narrative, or connection of 'self and world' are preserved, and... (shrink)

Failings of a categorical systemFor decades, standardized classification systems have attempted to define psychiatric disorders in our mental health care system, with the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association (APA), 2013) and International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10; World Health Organization, 2010) being internationally best-known. One of the major advantages of the DSM must be that it has seriously diminished the international linguistic confusion (...) regarding psychiatric disorders. Since its introduction, it contributed extensively towards one common international language for defining and conceptualizing psychiatric disorders. Strikingly, within the field of psychological testing a similar step forward seems to have not yet been taken. At present, there exists no international standard for the use of psychological tests that takes the definition of a specific symptom as listed in DSM-5 as its starting point, and reliably and validly measures this symptom. Rather, the majority of tests are measuring constructs consisting of a multitude of symptoms. For example, the Beck’s Depression Inventory (Beck et al., 1996) measures core symptoms of depression summing up to a depression score. Accordingly, we believe it is time for a change. The diagnostics of psychiatric disorders, where disorders are defined as nosological units with a single cause, a single organic substrate, and a single time course, has been problematic for centuries. The field of psychiatry has always been ambivalent about its desire to follow a medical model (Blaney, 2015), but afflicted due to its definitions of pathology. The definition of a psychiatric disorder in DSM-5 offers little room for a clear cut pathogenesis and harsh demarcation of syndromes. This is reflected in the DSM-5, where it states: “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013, p.20). An unfortunate and recognized consequence of this definition within the current system is that many symptoms overlap within categories of psychiatric disorders and patients end up diagnosed with many co-morbid disorders.Two fundamental problemsRegardless of new attempts to improve the diagnostics of psychiatric disorders, the DSM-5 represents the status quo. Consequently, the distinction between diagnosis and classification remains substantial and more than a discussion on semantics. We identify two fundamental problems within the current framework. Generally, a psychiatric diagnosis is considered to be descriptive (Hengeveld and Schudel, 2003). The clinician will describe a syndrome (its nature, timespan, and severity) within the framework of a disorder, and often include a differential diagnosis, predisposing protective or vulnerability factors, and provoking or maintaining factors. Within the DSM-5 framework, a similar ‘approach to clinical case formulation’ is taken (APA, 2013, p. 19). Evidently, a descriptive diagnosis has a hypothetical character. It consists of the clinician’s hypothesis and is based on his or hers professional considerations according to the abovementioned factors. Once the clinician has formulated a descriptive diagnosis, it is then complementary ‘translated’ into a DSM-5 classification. Herein lies the problem. For the layman, the existence of this distinction between diagnosis and classification is usually unknown. Preceding treatment, the clinician will give the client a classification of the existing psychiatric problems and the client may attribute more meaning to it than appropriate, thereby fostering the risk of reification. Second, the DSM-5 is a categorical system. Thus, individual disorders are regarded as discrete units – ‘you either have it, or you don’t’. DSM-5 states about this: “(…) scientific evidence places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors (…)”. And “(…) we have come to recognize that the boundaries between disorders are more porous than originally perceived.” (APA, 2013, p. 6). This leads to a fundamental problem. Because the overwhelming majority of psychiatric disorders examined thus far using taxometric methods appear to be dimensional in nature (Haslam, 2003; Widiger and Samuel, 2005), consequently all of their categorizations become artificial and debatable. Even though DSM-5 took a modest step towards a more dimensional approach, its core remains categorical. To illustrate, consider the Borderline Personality Disorder (BPD). This classification consists of nine diagnostic criteria of which a minimum of five need to be present for the diagnosis of BPD. A simple numerical combination algorithm leads to a staggering number of 256 distinct presentations of BPD (Albion et al., 2013). Due to this chameleon-like nature, the disorder’s diagnostic validity becomes questionable. Strikingly, this number is relatively small when compared to other conditions, e.g., there are 636,120 ways to have posttraumatic stress disorder (Galatzer-Levy and Bryant, 2013).DSM-5 does propose an alternative model for personality disorders based on personality functioning and traits (APA, 2013, p. 761), as a possible answer to the problem that most patients fit with multiple co-morbid personality disorders or to the category of personality disorder not otherwise specified. In November 2012, the chair committee of APA decided to move this alternative model to section III of DSM-5 and to sustain the categorical system in section II. A potential solutionDSM-5 and its predecessors have brought about an invaluable improvement regarding the formulation of a common international language for psychiatric disorders. However, the individual disorders fit poorly with its starting point of discrete units and strict boundaries. Van Os (2014) has argued for a better balance between the categorical and personalized aspects of psychiatric disorders. We argue for a two-step approach.Particularly due to the ‘weak boundaries’ between disorders, it might be beneficial to limit ourselves by merely categorizing clients into the main categories of the DSM-5 according to their most prominent symptoms (Van Os, 2014), i.e. their main complaint. In other words, clinicians could first ask themselves whether the symptomatology is concerning a neurodevelopmental disorder, or a bipolar and related disorder, or a depressive disorder, and so on. It will drastically reduce the over 400 classifications in DSM-5 down to 20 categories. Van Os (2014) even argues to combine some of the main categories, reducing this number even further to 15 categories. The advantages of reducing the over 400 classifications are fivefold: 1) a syndrome, being an aggregation of symptoms, creates a false relation between symptoms that are that are already heterogeneous themselves; 2) 15 broad categories are functional: it results into a very heterogeneous group of clients within a category and thus prevents stereotypes and invites further personalizing of complaints; and 3) a dimensional measure of a symptom rather than a syndrome will correspond better with the client regardless of it not providing the complete picture. Focusing on the main complaint will indicate where there is an immediate need for care (Van Os, 2014); 4) it will allow clinicians to recognise subthreshold conditions more easily (Magruder and Calderone, 2000); and 5) it might facilitate the development of clear demarcations between normal and abnormal functioning (Kessler, 2002; Widiger and Samuel, 2005). Please, see also Table 1.This also fits well within scientific advances, as thus far strongest evidence has been found for a distinction between internalizing and externalizing disorders, even superseding these 15 main categories (DSM-5; APA, 2013, p.13, but see Weiss et al., 1998). The second step would concern the personalized aspect, which we argue to define on a level of core symptoms of the specific main category, to be agreed upon later. To assess these core symptoms, the field of psychological testing could develop an internationally applicable instrument to reliably and validly measure each (core) symptom on a dimensional scale. Many of these instruments are readily available and have proven its psychometric properties within scientific research. Elements from these instruments could be easily transformed to work within the new system. Within the field of psychology, this approach could aid development of a common international language to define symptoms, analogous to the field of psychiatry. Importantly, current psychological testing mainly implies the use of self-report measures. This leads to an abundance of auto-amnestic information. To increase the reliability and validity of psychological tests to assess DSM-5 symptoms, it may be important to add two additional information resources. This would entail psychological tests where a next of kin answers questions about the symptom of the client, and psychological tests that include the clinicians’ judgment, such as structured clinician-based interviews. Conversely, we also need to acknowledge the well-known limitations of clinical judgment (e.g., Faust, 1986; Garb, 1998). Advantages of a new frameworkThe changes we suggest have big implications and are not easily implemented in the current framework. Clients may prefer the comfort of a single clear label, similar to what they are used to in other areas of medicine. Health insurance providers and policy makers may argue for single labels as well. Therefore, it would require a lot of explanation from our clinicians to promote a change. Our suggestions for broader categories may not disambiguate the current situation better than the existing approach, but it will promote personalisation of health care. Difficulties in diagnostic reliability will remain in disorders that fall on the boundaries of the taxons, e.g., schizoaffective disorder versus bipolar disorder with psychotic characteristics, which may benefit from further study. There are also some politically tinged questions to keep in mind: How will we finance our health care, and how will we ensure a gradual transition from the current financing system, including clients who already have their labels? What about visitations from insurers and health inspection? How can they control for a good standard of quality in health care when considering the increasing heterogeneity? Nevertheless, we argue that the benefits outweigh the disadvantages. We will see a shift from a categorical to a personalized approach, which will lead to less (self) stigmatizing, less estrangement, and it will challenge reification thinking. DSM-V states that “a reformulation of research goals should also keep DSM-5 central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches to diagnosis in coming years” (APA, 2013, p. 13). Our proposition for psychological testing on symptom level could contribute to this development. Furthermore, this new approach will do more justice to the heterogeneity of symptoms within and outside of classification categories, see also Table 1. Moreover, in this new approach we join forces of expert knowledge from the fields of psychiatry and psychological science. Finally, it offers new and potentially better opportunities to map health care needs. This in turn will lead to a better interface for allocation of appropriate treatment. It will present a clearer picture of when preventative care is preferred over treatment and vice versa. Importantly, health care needs will be more closely attuned to the ‘own story’ of the client.We argue for the national and international psychological associations in Europe and the United States of America to support the idea of a collective approach to develop an internationally standardized psychological testing battery to reliably assess all the core symptoms of the main categories in DSM-5. (shrink)

Realizing the benefits of translating psychiatric genomics research into mental health care is not straightforward. The translation process gives rise to ethical challenges that are distinctive from challenges posed within psychiatric genomics research itself, or that form part of the delivery of clinical psychiatric genetics services. This article outlines and considers three distinct ethical concerns posed by the process of translating genomic research into frontline psychiatric practice and policy making. First, the genetic essentialism that is commonly (...) associated with the genomics revolution in health care might inadvertently exacerbate stigma towards people with mental disorders. Secondly, the promises of genomic medicine advance a narrative of individual empowerment. This narrative could promote a fatalism towards patients' biology in ways that function in practice to undermine patients' agency and autonomy, or, alternatively, a heightened sense of subjective genetic responsibility could become embedded within mental health services that leads to psychosocial therapeutic approaches and the clinician-patient therapeutic alliance being undermined. Finally, adopting a genomics-focused approach to public mental health risks shifting attention away from the complex causal relationships between inequitable socio-economic, political, and cultural structures and negative mental health outcomes. The article concludes by outlining a number of potential pathways for future ethics research that emphasizes the importance of examining appropriate translation mechanisms, the complementarity between genetic and psychosocial models of mental disorder, the implications of genomic information for the clinician-patient relationship, and funding priorities and resource allocation decision making in mental health. (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)

In the May, 1960, issue of the American Bar Association Journal (vol. 499), Morton Birnbaum, a lawyer and physician, argued for a legal right to psychiatric treatment of the involuntarily committed mentally ill person. In the 18 years since his article appeared,, there have been several key court cases in which this concept of a right to psychiatric treatment has figured prominently and decisively. It is important to note that the language of the decisions have had (...) at least an indirect effect in the recently enacted mental Hygiene Law of the State of New York. While I shall not seek to establish the historical thesis that Birnbaum’s article has been efficacious in bringing about both these court decisions and changes in statutory laws, I do want to examine Birnbaum’s article and some of the opinions for three cases: Wyatt v. Stickney (1972), Wyatt v. Aderholt (1974), and O’Connor v. Donaldson (422 US 563, 1975), in an effort to understand both the significance of these changes in our laws and the underlying philosophical and ethical notions of which they are an expression. Birnbaum observed that the notable feature of the legal situation at the time was that there had not been recognized a constitutional requirement that one who had been institutionalized for mental illness according to due process must receive treatment. Birnbaum argued that the effects of an omission of such a requirement to treat were that mental institutions typically offered only custodial care, that patients who were held only under custodial care typically did not improve, and that the result was that involuntary incarceration in a mental institution was, at least from the point of view of the patient, functionally no different than would be imprisonment for an unspecified period of time. Birnbaum argued for a recognition and enforcement in the courts of the right to treatment “...as a necessary and overdue development of our present concept of due process of law,” i.e., as required by the 14th Amendment to the U.S.. (shrink)

The DSM-IV-TR (American Psychiatric Association 1994, 689) defines personality disorder (PD) as: An enduring pattern of experience and behavior that deviates markedly from the expectations of an individual’s culture. This pattern is manifested in two (or more) of the following areas: 1 Cognition (i.e., ways of perceiving and interpreting self, other people, and events); 2 Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response); 3 Interpersonal functioning; and 4 Impulse control. B The enduring ..

In February 2010, the American Psychiatric Association (APA) launched their DSM-5 website with details about the development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The APA invited “the general public” to review the draft diagnostic criteria and provide written comments and suggestions. This revision marks the first time the APA has solicited public review of their diagnostic manual. This article analyzes reported speech on the DSM-5 draft diagnostic criteria for the (...) classification Posttraumatic Stress Disorder. It demonstrates how textual standardization facilitates the cultural portability of the DSM-5 diagnostic criteria such that a community of speakers beyond the borders of the APA come to be seen as exemplary speakers, writers, and revisers of the professional style. Furthermore, analysis shows how co-authoring practices recontextualize the “voice” and persona of putative patient reported speech on Criterion D2. As a consequence of textual standardization, spoken discourse becomes recontextualized as the product of scientific inquiry and the organization of psychiatric knowledge. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Religious Perspectives on Bioethics, Part ILaura Jane Bishop (bio) and Mary Carrington Coutts (bio)This is Part One of a two part Scope Note on Religious Perspectives on Bioethics. Part Two will be published in the December 1994 issue of this Journal. This Scope Note has been organized in alphabetical order by the name of the religious tradition.Contents for Parts 1 and 2Part 1Part 2I.GeneralI.Native AmericanII.African Religious TraditionsReligious TraditionsIII.Bahá'í FaithII.Protestantism—willIV.Buddhism (...) and Confucianisminclude a general sectionV.Eastern Orthodoxyand sections focused onVI.Hinduismspecific denominations.VII.IslamIII.Roman CatholicismVIII.JainismIX.JudaismIntroductionThe many religions of the world bring diverse, and occasionally divergent, attitudes to bioethical issues. These beliefs may guide patients and health care professionals as they seek or provide health care. In an attempt to facilitate understanding of and access to information about these beliefs in our pluralistic and global society, this Scope Note identifies literature by the world's major religious groups on topics relating to bioethics.Topics covered by this Scope Note include general attitudes to health and [End Page 155] health care, the physician-patient relationship, treatment refusal, abortion, contraception, sterilization, reproductive technologies, genetics, mental health, human experimentation, organ transplantation and donation, death, euthanasia, suicide, and prolongation of life. Material was not available on all of these topics for each religion.The literature gathered here represents only a small portion of the available writing on religion and medicine, and is limited to that which comments explicitly on bioethical issues. Some faiths have a rich tradition of writing in bioethics; for others the literature is more limited. Variation in coverage is not intended to indicate the relative importance of a faith, but reflects accessibility and space constraints. Individuals interested in obtaining additional information are encouraged to contact the National Reference Center for Bioethics Literature.Specific citations about a region or country were chosen because of the predominance of a religious tradition within the population. In all cases, variation in spelling represents author usage. This Scope Note treats only the literature published in English, and every attempt has been made to identify English language sources for these faiths.It is important to remember that doctrinal and theological differences exist even within the same denomination and that views of individual patients, family members, and health care providers should be sought.Dictionaries and EncyclopediasMelton, J. Gordon, ed. Encyclopedia of American Religions. Fourth edition. Detroit: Gale Research, 1993. 1217 p. Basic information about the history, sacred texts, membership, educational facilities, publications, and North American addresses are provided for 1,730 churches, denominations, sects, and cults. Bibliographies for many faiths supplement this extensive resource.Reich, Warren T., ed. Encyclopedia of Bioethics. New York: Free Press, Macmillan, 1978. 4 volumes. Articles on all the major religions as they relate to bioethics are included in this highly-regarded encyclopedia. In addition, many of the topical essays feature a section on the views of various faiths on the topic under discussion. For the best use of the Encyclopedia, see the subject index in volume 4. (Note: a revised, second edition is due to be published by Macmillan in late 1994.)GeneralAmerican Psychiatric Association. Committee on Religion and Psychiatry. Guidelines Regarding Possible Conflict Between Psychiatrists' Religious Commitment and Psychiatric Practice. American Journal of Psychiatry 147 (4): 542, April 1990. The American Psychiatric Association recommends that psychiatrists respect their patients' religious beliefs and that they not impose their own [End Page 156] beliefs on their patients.Bankowski, Z., and Bryant, J. H. Health Policy, Ethics and Human Values: Proceedings of the XVIIth CIOMS Round Table Conference, Athens Greece. Geneva: Council for International Organizations of Medical Sciences, 1985. 336 p. Many sections of this volume address issues where religion impacts health policymaking. Africa, the Middle East, Europe, Latin America, and Asia are highlighted for the varied ways in which their religions and cultures are integrated into the provision of health care.Batchelor, Edward, ed. Abortion: The Moral Issues. New York: Pilgrim Press, 1982. 246 p. Batchelor compiles a collection of essays by experts on religious ethics as they relate to abortion. Includes... (shrink)

Many symptoms of possession described by exorcists correspond to the symptoms of psychiatric disorders. Before helping a person who feels that they are possessed by an evil spirit, one should answer this question: when is therapy necessary, and when is an exorcism required? The article points out that psychiatrists have different attitudes to theological explanations of possession and exorcism. According to the author, it is best to adopt a complementary attitude, such as leaves room for the thought that there (...) exist two causes for the symptoms of possession - the natural and the supernatural one. This may then furnish a common approach for medicine, psychology and religion. The article presents the theological criteria for determining possession by an evil spirit, and the psychological criteria for diagnosing pathological possession, as given by the World Health Organisation and the American Psychiatric Association. The author discusses similarities and differences between the theological criteria for diagnosing demonic possession and the criteria involved in a medical diagnosis. On the basis of both psychological and theological criteria, it is possible to recognize psychopathological states and demonic possession in multidimensional terms. This allows the author to distinguish four situations: health, psychopathological possession, demonic possession of a mentally healthy person, and coexistence of demonic possession with psychiatric disorders. Practical experience shows that the largest number of patients seeking help in health centres belongs to the fourth group, which is why there is a need for close cooperation between exorcists and psychologists or psychiatrists. (shrink)

After revelations of participation by psychiatrists and psychologists in interrogation of prisoners at Guantánamo Bay and Central Intelligence Agency secret detention centers, the American Psychiatric Association and the American Psychological Association adopted Position Statements absolutely prohibiting their members from participating in torture under any and all circumstances, and, to a limited degree, forbidding involvement in interrogations. Some interrogations utilize very aggressive techniques determined to be torture by many nations and organizations throughout the world. This paper (...) explains why psychiatrists and psychologists involved in coercive interrogations violate the Geneva Conventions and the laws of the United States. Whether done with ignorance of professional ethical obligations or not, these psychiatrists and psychologists have crossed an ethical barrier that may best be averted from re-occurring by teaching medical students and residents in all medical specialties about the ethics principles stemming from the 1946–1947 Nuremberg trials and the Geneva Conventions, together with the Ethics Codes of the World Medical Association and the American Medical Association; and, with regard to psychiatric residents and psychological trainees, by the teaching about The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry and the Ethical Principles of Psychologists and Code of Conduct, respectively. In this way, all physicians and psychologists will clearly understand that they have an absolute moral obligation to "First, do no harm" to the human beings they professionally encounter. (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)

Transgender issues and transgender rights have become increasingly a matter of media attention and public policy debates. Reflecting changes in psychiatric perspectives, the diagnosis of “trans‐sexualism” first appeared in the International Statistical Classification of Diseases and Related Health Problems in 1975 and shortly thereafter, in 1980, in the Diagnostic and Statistical Manual of Mental Disorders. Since that time, international standards of care have been developed, and today those standards are followed by clinicians across diverse cultures. In many instances, treatment (...) of older adolescents and adults is covered by national health care systems and, in some cases, by private health insurance. Most recently, the Medicare ban on coverage for gender reassignment surgery was lifted in 2014.In contrast to the relative lack of controversy about treating adolescents and adults, there is no expert clinical consensus regarding the treatment of prepubescent children who meet diagnostic criteria for what was referred to in both DSM‐IV‐TR and ICD‐10 as gender identity disorder in children and now in DSM‐5 as gender dysphoria. One reason for the differing attitudes has to do with the pervasive nature of gender dysphoria in older adolescents and adults: it rarely desists, and so the treatment of choice is gender or sex reassignment. On the subject of treating children, however, as the World Professional Association for Transgender Health notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue into adulthood, and only 6 to 23 percent of boys and 12 to 27 percent of girls treated in gender clinics showed persistence of their gender dysphoria into adulthood. Further, most of the boys’ gender dysphoria desisted, and in adulthood, they identified as gay rather than as transgender.In an effort to clarify best treatment practices for transgender individuals, a recent American Psychiatric Association Task Force on the Treatment of Gender Identity outlined three differing approaches to treating prepubescent gender dysphoric children. (shrink)

This paper challenges the exclusion of patients from epistemic practices in psychiatry by examining the creation and revision processes of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a document produced by the American Psychiatric Association that identifies the properties of mental disorders and thereby guides research, diagnosis, treatment, and various administrative tasks. It argues there are epistemic—rather than exclusively social/political—reasons for including patients in the DSM revision process. Individuals with mental disorders are indispensable resources to (...) enhance psychiatric epistemology, especially in the context of the crisis, controversy, and uncertainty surrounding mental health research and treatment. (shrink)

This article begins with arguments evident at the time of writing about the 5th revision of the Diagnostic and Statistical Manual of the American Psychiatric Association. The historical lineages of those arguments are international and not limited to the USA (the current focus in the DSM-5 controversy). The concern with psychiatric diagnosis both internationally and in the USA came to the fore at the end of the Second World War with the construction of the American (...) Psychiatric Association’s Diagnostic and Statistical Manual ( DSM-I) and the World Health Organization’s classification of ‘Diseases, Injuries and Causes of Death’ (ICD-6). However, the linkage between categories of morbidity, assumptions about natural biological categories and treatment specificity with ‘magic bullets’ emerged in the middle of the 19th century in physical medicine. This article explores the legitimacy of current psychiatric diagnoses in the light of that international, not national, history of medical knowledge. In conclusion it explores judgements about current cultural imperialism (at times made about US psychiatry) and an older picture of Eurocentrism, which is now being refracted in more recent globalizing knowledge-claims about mental disorder. (shrink)

Borderline personality disorder is a complex psychopathological phenomenon. It is usually thought to consist in a vast instability of different aspects that are central to our experience of the world, and to manifest as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity” [American Psychiatric Association, 2013, p. 663]. Typically, of the instability triad—instability in self, affect and emotion, and interpersonal relationships—only the first two are described, examined, and conceptualized from an experiential (...) point of view. In this context, disorders of self have often motivated analyses of self-experience and the sense of self, affective disorders have been frequently considered in the light of emotional experience and its phenomenological structure. Patterns in the phenomenology of social experience have found comparatively little traction when it comes to the conceptualization of the interpersonal disturbances in borderline. In this paper, I argue that interpersonal instability in borderline consists in much more than fragile and shifting relationships but, most importantly, also involves certain styles in experiencing others. These styles, I suggest, may play an explanatory role for the borderline-typical patterns of interpersonal turmoil and so deserve more attention. To better describe and understand these styles, I explore the phenomenological structure of borderline affective instability and discuss the implications it might have for how a person experiences and relates to other people. Considering core aspects of borderline affective instability, such as alexithymia, emotional contagion, emotion dysregulation, and chronic emptiness, I propose borderline can be interpreted as a disturbance of interaffective exchange, which gives rise to certain ways of experiencing others that imply a social impairment. (shrink)

Source [1] Andrew E. P. Mitchell, Federica Galli, Sondra Butterworth. (2023). Editorial: Equality, diversity and inclusive research for diverse rare disease communities. Front. Psychol., vol. 14. doi:10.3389/fpsyg.2023.1285774. "It is also important to recognize that certain mental health disorders are classified as rare conditions and have their own cultural concepts of distress, as defined in the DSM-5 (American Psychiatric Association, 2013)" and require “equal attention and support for individuals and their families, both physically and emotionally”. [1].

This paper presents the foundation upon which the contemporary knowledge of body integrity dysphoria (BID) is built. According to the World Health Organisation’s International Classification of Diseases, 11th edition (ICD-11), the main feature of BID is an intense and persistent desire to become physically disabled in a significant way. Three putative aetiologies that are considered to explain the insurgence of the condition are discussed: neurological, psychological and postmodern theories. The concept of bodily representation within the medical context is highlighted, with (...) the concept of dysphoria, which was brought to the fore with the introduction of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and the ICD-11. Contemporary issues of “justice” are addressed to identify ethically relevant distinctions between BID and sex reassignment surgery. It is argued that there is no ethically relevant difference between the BID actor’s desire for invasive surgical intervention and the wish of gender dysphoric individuals to undergo sex reassignment surgery procedures. Some BID actors self-mutilate, and this presents medical professionals with difficult choices regarding whether or not to intervene in order to satisfy the BID patient’s desire. Both abstention and intervention may lead to severe ethical complications for doctors and patients despite the positive outcomes in terms of quality of life for BID individuals who manage to undergo such procedures. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narcissism, Empathy and Moral ResponsibilityRonald W. Pies, MD (bio)Professor Fatic’s timely and wide-ranging essay demonstrates how the topic of narcissism has undergone a resurgence of interest in recent decades. This may owe, in part, to the controversial claim that narcissism is on the rise in the United States, at least among American college students (Twenge & Foster, 2010). As I discuss presently, the term “narcissism” is open to (...) many interpretations, and differs somewhat from the specific designation, Narcissistic Personality Disorder (NPD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013). As Fatic rightly notes,Narcissism as a personality structure may or may not be diagnosed as NPD, depending on various criteria, perhaps most importantly on whether the narcissistic person actually encounters functional and emotional difficulties and shows up for diagnosis and evaluation.As Professor Fatic’s essay clearly shows, narcissism (variously defined) has important “ethical ramifications.” Fatic is primarily interested in exploring the relationship between what he calls the narcissist’s “emotional incompetence” and that person’s degree of moral responsibility. To oversimplify Fatic’s complex set of interlinked arguments, Fatic concludes that “emotional incompetence does not in fact reduce the moral responsibility of a narcissist person, whether diagnosed with Narcissistic Personality Disorder or not.” Drawing on the moral theories of Philip Pettit and Michael Slote—in particular, Slote’s “sentimentalist ethics” with its emphasis on empathy (Slote, 2004)—Fatic argues that narcissism is both “a moral failure and a psychopathology.” Nevertheless, for Fatic, narcissists remain “fully morally responsible for their insensitivity and interpersonal emotional incompetence.” Why? Because they have the moral duty “to acquire the moral and emotional competence required for the making of moral choices.”Some Philosophical ConcernsAs I understand Fatic’s argument, he is asserting that the narcissist ought to be held responsible for a kind of self-education process that will ameliorate his or her emotional incompetence. Fatic writes,[W]e develop our morality through constant moral education and testing, which we receive both through socialization and through our own efforts later in life, as autonomous human beings. [End Page 173]We are thus responsible for what kind of moral actors we are and are becoming based on our way of life, and have a moral duty to improve our own moral senses and sensibilities by constantly working on the development of virtues.It seems to me that this line of reasoning assumes that all, or most, narcissists possess the capacity to seek and acquire this “moral education.” Perhaps so—but I am not sure Fatic has demonstrated this. It seems at least plausible that, in virtue of the adverse developmental and perhaps even neurological factors that may generate the narcissistic personality (Fan et al., 2011), some narcissists may lack the capacity to modify their psychopathology by means of “moral education.” This leads me to wonder whether Professor Fatic has adequately explored the very heterogeneous nature of narcissism. Indeed, Fatic’s thesis seems to point toward a kind of Platonic “essence” of narcissism, conveyed by his frequent allusion to “the narcissist”—one of whose defining or essential features is said to be a lack of empathy.But, as I will suggest presently, this is at best an oversimplification of narcissism as psychiatrists understand the term. Indeed, there are degrees and varieties of narcissism, differing in their capacity for empathy—which is itself a psychologically complex term. Recent research suggests that “narcissistic personality disorder symptomatology does not reflect a “narcissist” category but rather a continuum of narcissistic pathology” (Aslinger, Manuck, S. Pilkonis, Simms, & Wright, 2018).Furthermore, Professor Fatic’s thesis seems to view “moral responsibility” as a binary construct; i.e., either one possesses, or does not possess, full moral responsibility. But as I have argued elsewhere, moral responsibility may be viewed as lying along a continuum that reflects varying degrees of voluntariness for any given individual (Pies, 2007).Consequently, in my view, any valid assessment of the “the narcissist’s” moral responsibility must consider both the heterogeneity of narcissism and the non-binary (i.e., continuous) nature of moral responsibility.One way of conceptualizing this “two-track” model is... (shrink)

There are a number of considerations, including ethical and clinical or diagnostic factors, in utilizing the diagnosis of posttraumatic stress disorder in criminal proceedings. The reliability and validity of the diagnosis may be questioned. Legal precedent may consider extant diagnostic criteria for PTSD and comorbid diagnoses. However, these diagnostic criteria are often in flux considering new research findings. For example, the introduction of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American (...) class='Hi'>Psychiatric Association, includes some changes in the PTSD diagnostic criteria. How will this affect interpretation of past legal judgments? Moreover, PTSD has significant psychiatric comorbidity, e.g., substance abuse, which in itself may influence violent behavior and its consequences. Some of these comorbid diagnoses also have changes in their diagnostic criteria. The introduction of biological tests in the assessment of PTSD will likely facilitate more objective diagnosis. (shrink)

Obsessive-compulsive disorder (OCD) is considered to be one of the more common serious mental disorders, with a prevalence rate of about 1% (Heyman et al. 2006). It is characterized by obsessions, or compulsions, or both. According to the DSM-IV (American Psychiatric Association 1994), obsessions are “recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.” Compulsions, on the other hand, are (...) repetitive behaviors (e.g., hand washing, ordering, checking) or “mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied .. (shrink)

Although it is not yet officially recognized as a clinical entity which is diagnosable, Internet Gaming Disorder (IGD) has been included in section III for further study in the DSM-5 by the American Psychiatric Association (APA, 2013). This is important because there is increasing evidence that people of all ages, in particular teens and young adults, are facing very real and sometimes very severe consequences in daily life resulting from an addictive use of online games. This article (...) summarizes general aspects of IGD including diagnostic criteria and arguments for the classification as an addictive disorder including evidence from neurobiological studies. Based on previous theoretical considerations and empirical findings, this paper examines the use of one recently proposed model, the Interaction of Person-Affect-Cognition-Execution (I-PACE) model, for inspiring future research and for developing new treatment protocols for IGD. The I-PACE model is a theoretical framework that explains symptoms of Internet addiction by looking at interactions between predisposing factors, moderators, and mediators in combination with reduced executive functioning and diminished decision making. Finally, the paper discusses how current treatment protocols focusing on Cognitive-Behavioral Therapy for Internet addiction (CBT-IA) fit with the processes hypothesized in the I-PACE model. (shrink)

Delusions, a key feature of psychosis, are usually thought of as a type of belief, as in the definition of the American Psychiatric Association: A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (e.g. it is not an (...) article of religious faith). This characterization is often criticized, but other definitions typically comprise similar elements. For some, delusions are only loosely considered as beliefs (Jaspers 1963; Moor and Tucker .. (shrink)

A core symptom of depression, anhedonia, involves deficits in the ability to experience positive emotion (American Psychiatric Association, 2000). Positive emotional disturbances play a central rol...

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.2 (2003) 161-167 [Access article in PDF] Social, Cognitive, and Neural Constraints on Subjectivity and Agency:Implications for Dissociative Identity Disorder Peter Q. Deeley In this commentary, I consider Matthew's argument after making some general observations about dissociative identity disorder (DID). In contrast to Matthew's statement that "cases of DID, although not science fiction, are extraordinary" (p. 148), I believe that there are natural analogs of (...) the disorder that, when considered, make it seem less puzzling and exotic. After discussing these examples, I examine the relations between social, cognitive, and neural processes supporting subjectivity and agency, to identify sources of personal identity in cases of DID that can be used as a basis for assessing Matthew's points against Behnke and Sinnott-Armstrong. I am not proposing a comprehensive theory, but rather identifying what I believe are components of such a theory. I then outline an approach to determining criminal responsibility in DID, drawing on analogies with other psychiatric disorders. Dissociative Identity Disorder DID is a disorder described in DSM-IV, which "is characterised by the presence of two or more distinct identities or personality states that recurrently take control of the individual's behaviour accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness" (American Psychiatric Association, p. 519). Recognizing Personal Identity How is personal identity recognized in normal cognition? If we take personhood to involve recognition of continuity of social, psychological, and physical identity for a given individual, then such judgments are routinely made rapidly and automatically as an aspect of what has come to be termed social cognition (Adolphs 2003). There is likely to be considerable redundancy in [End Page 161] the types of information used to make judgments about whether a person is the same as one who was previously encountered, or perhaps heard about—for example, facial features, movement patterns, speech prosody, dress, speech content, gender, ethnicity, social role, among other features, all provide information about individual identity, and hence personhood. When uncertainty exists, it is likely to reflect a loss or alteration of cues that would ordinarily be used in a rapid, automatic, unexamined way (Adolphs 2003). In such extreme cases (for example, severe mental illness or disfigurement), the problem of identification becomes the subject of explicit reasoning (and hence of potential disagreement, because we then engage in post hoc rationalizations to establish criteria for determining personhood, whereas normally we rely on essentially automatic, implicit abilities that work in most circumstances, some of which make little use of linguistic representations and formal reasoning—for example, individual facial identity recognition, which may occur as quickly as 170 ms after stimulus onset [Adolphs 2003]). Nevertheless, examining our judgments and intuitions in cases that force us to explicitly consider whether personal identity is preserved may provide analogies and clues for how we should proceed with DID. Let us consider, then, some natural analogs of DID. Natural Analogs of DID Method Acting I suggest that method acting is an analog of DID (Manderino 1985). Method acting refers to an approach to acting training and performance in which emphasis is placed on intensely imagining and identifying with the mental life of the character being portrayed. Training courses and manuals list many techniques and practices that can be used to facilitate absorption in a role, drawing on different kinds of memory—for example, experiential memories, memories of others, general knowledge (semantic memory), and memories of sensations and feelings, to creative a vivid sense of the subjective experience and actions of the character. Manderino, a method acting teacher, comments: "it is important to investigate the way in which your own mental makeup can improperly influence a character. Insecurities, self-consciousness, shyness or self-doubts can maintain a strong hold, and permitting any of these feelings to enter a performance is to remain the actor and not enter into the mental life of the character. For some, acting allows personal problems to be left behind, and they are thankful for the complete escape that... (shrink)

Recent conceptual developments in psychiatric diagnosis have the potential for catastrophic results, particularly for Christians in the mental health field, but also for all persons who have a vested interest in the identification and treatment of mental disorder. I explore these theoretical developments by focusing on the manner in which dysphoria has been situated in the dominant contemporary system of psychiatric nosology, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. I target for discussion, primarily, two specific (...) consequences of dysphoria’s new place in contemporary psychiatry, namely, the explicit depathologizing of Pedophilia and the introduction of “Gender Dysphoria” as a new diagnostic category. Although Pedophilia and Gender Dysphoria share the characteristic of not being designated as mental disorders by the American Psychiatric Association (APA), they interestingly differ insofar as a sufficient degree of dysphoria is believed to have the ability to transform Pedophilia from a “condition” to a psychiatric disorder (namely, “Pedophilic Disorder”), while no amount of dysphoria, it is believed, is capable of transforming the diagnosis of Gender Dysphoria into an explicit psychiatric disorder. I trace some of the likely motivations for the APA’s having made these changes, discuss some of these changes’ untoward theoretical and practical consequences, and attempt to forge a coherent path to a more general theory of psychopathology. (shrink)

In the current climate of dramatic advances in the neurosciences, it has been widely assumed that the diagnosis of mental disorder is a matter exclusively for value-free science. Starting from a detailed case history, this paper describes how, to the contrary, values come into the diagnosis of mental disorders, directly through the criteria at the heart of psychiatry's most scientifically grounded classification, the American Psychiatric Association's DSM (Diagnostic and Statistical Manual). Various possible interpretations of the prominence of (...) values in psychiatric diagnosis are outlined. Drawing on work in the Oxford analytic tradition of philosophy, it is shown that, properly understood, the prominence of psychiatric diagnostic values reflects the necessary engagement of psychiatry with the diversity of individual human values. This interpretation opens up psychiatric diagnostic assessment to the resources of a new skills-based approach to working with complex and conflicting values (also derived from analytic philosophy) called 'values-based practice.' Developments in values-based practice in training, policy and research in mental health are briefly outlined. The paper concludes with an indication of how the integration of values-based with evidence-based approaches provides the basis for psychiatric practice in the twenty-first century that is both science-based and person-centred. (shrink)

Recent neuroscience studies have reported that neurofeedback training with the use of functional magnetic resonance imaging enables the regulation of an individual’s cognitive, emotion-related, and behavioral states through a real-time representation of her brain activities. Since this technique has been applied not only to clinical research to, for example, mitigate mental or psychiatric symptoms but also to non-clinical research to, for example, change the cognition or preferences of a so-called healthy participant, neurofeedback-based cognitive and/or moral enhancements may be realized (...) in the future. However, neurofeedback-based human enhancement is not the only issue that requires neuroethical consideration. I examine why and to what extent the dual application of neurofeedback technique will blur the lines between the mental, the social, and the moral, threatening some social norms, such as individual freedom and diversity. First, I consider the link between the mental and the social in psychiatry. Examining the definition of “mental disorder” provided by the American Psychiatric Association, I show that the mental is partly defined through social performance. Second, I make explicit the link between the social and the moral and argue that moral evaluation of an activity is gently but positively correlated with its social evaluation. Third, I demonstrate the links between the mental, the social, and the moral. In spite of a great deal of effort to distinguish these notions, the possibility of the dual application of this technique blurs the lines between them. Fourth, I examine whether such blurred lines signal sociocultural evolution or dystopia and argue that it can be understood as a beginning of the second advent of ethical virtue. I conclude that further cautious consideration of neuroethics is required because the establishment of this technique may have unique influences on our society. (shrink)

Although the Historical concept of melancholia has undergone numerous metamorphoses, it has maintained a place in psychiatric classification and currently refers to a specific melancholic subtype of major depression (American Psychiatric Association 2000, 419). Although melancholia—as a description of pathological states—constitutes the focus of this paper, it must be pointed out that the range of states encompassed by melancholia cover a far wider spectrum than that covered by the term ‘disease.’ As Jennifer Radden notes, melancholia (and (...) melancholy) referred to “both a normal disposition and a sign of mental disturbance” (Radden 2000, ix), thus covering a wide range of emotional variations that cannot be reduced .. (shrink)

In this essay, the author describes how he faced institutionalized homophobia during his psychiatric training, and how he later wrote a play inspired by the life of a gay psychiatrist. Despite Freud’s supportive stance, homosexuality aroused the antipathy of American organized psychiatry and psychoanalysis and came to be listed as an illness in the Diagnostic and Statistical Manual. Dr. John E. Fryer outed himself as “Dr. H Anonymous” at a 1972 meeting of the American Psychiatric (...) class='Hi'>Association, and the next year homosexuality was removed from the DSM. The 2014 play Doctor Anonymous offers a fictionalized account of this watershed moment in the history of the gay rights movement. The author discusses his own psychotherapeutic work with gay male patients, including those who had previously been treated with conversion therapy, and explores how the play mirrors his own life experience and the experience of his patients. (shrink)

ArgumentIn 1980, when the diagnosis of Posttraumatic Stress Disorder was introduced into the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, survivor guilt – a symptom long associated with trauma of the Holocaust and other extreme experiences – was included in the list of symptom criteria. But in the revised edition of the manual of 1987, survivor guilt was demoted to the status of merely an “associated feature” of the condition. Now that survivor guilt has (...) disappeared from the official lexicon of trauma, shame has come to take its place as the emotion that most defines the traumatic state. This paper examines the rationale for the shift from survivor guilt to shame in the context of the American Psychiatric Association's revisions. It argues that the shift can be understood as yet another manifestation of the oscillation between mimetic and antimimetic theories of trauma that, I have argued in my book Trauma: A Genealogy, has structured the understanding of trauma from the start. (shrink)

A striking feature of post-modernism is its distrust of the subject. If the modern period, beginning with Descartes, sought in the subject a source of certainty, an Archimedian point from which all else could be derived, post- modernism has taken the opposite tack. Rather than taking the self as a foundation, it has seen it as founded, as dependent on the accidents which situate consciousness in the world. The same holds for the unity of the subject. Modernity, in its search (...) for a single foundation, held the subject to be an indissoluble unity. Post-modernism’s position, by contrast, is announced by Nietzsche: “The assumption of one single subject is perhaps unnecessary; perhaps it is just as permissible to assume a multiplicity of subjects, whose interaction and struggle is the basis of our thought and our consciousness in general? ...My hypotheses: The subject as multiplicity.” Given this, there is a natural correspondence between the success of post- modernism and the current interest in multiple personality disorder. In the latter, we actually have the experience of a “multiplicity of subjects” in their interaction and struggle. The subject stands there before us “as multiplicity.” It gives us a concrete case, one which raises some of the pressing questions associated with the post-modern denial of the subject. Confronting it, we ask: how real are the personalities composing the multiplicity of this disordered self? What, in fact, does this multiplicity tell us about the self? about its genesis and status? What does it reveal about “our thought and consciousness in general”? I plan, in the short compass of this paper, to sketch some answers to these questions. §1. A brief description of MPD. The American Psychiatric Association gives two criteria for (MPD) multiple personality disorder. First, and most obviously, there is “the existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring pattern. (shrink)

This article addresses the precarious place of transgender and gender non-cis persons in relation to their discrimination-protections in recent legal, medical, and ethical policies in the United States. At present, there exists a contradiction such that trans persons are considered "pathological" enough that they are included in the latest iteration of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-V) as "gender dysphoric," but they are not included in the category of "disabled" under the Americans with Disabilities (...) Act (ADA). As such, trans persons in America are subject to the stigma of pathology (albeit with medical treatment) without the full protections of the ADA. By contrast, transgender and non-cis-gender Americans find their queer cohorts who are HIV-positive to be fully protected by the ADA. We ask whether transgender and non-cis-gender persons should embrace their (already pathologized) personhood as a disability. Sometimes "choosing disability" affords more rights than it deploys stigma. (shrink)

The aim of this paper is to explore a new framework for personality assessment that may function as sanity nosology of personality traits: the Positive Personality Model. The recent publication of DSM-5 created the opportunity to assess personality traits as dimensional constructs (American Psychiatric Association, 2013). In Section III, five maladaptive personality traits are proposed as the maladaptive versions of Five Factor Model (FFM) traits (Costa and McCrae, 1985). This approach draws on the existing idea of conceptualizing (...) pathological and typical personality traits as part of a continuum. It places DSM-5’s maladaptive traits in a sickness pole and FFM’s traits in a “typical” pole. This spectrum, however, does not include a positive perspective that represents healthy behavior: a sanity nosology. The Positive Traits Inventory-5 (PTI-5; de la Iglesia and Castro Solano, 2018) is a measure designed to assess the positive reverse of the Personality Inventory for DSM-5-Adult (PID-5; Krueger, Derringer, Markon, Watson and Skodol, 2013). The 220 positive personality criteria were studied psychometrically using a sample of 1902 Argentinean adults from the general population (Mage = 39.10, SD = 13.81, Min = 18, Max = 83; 50.1% females, 49.9% males). Exploratory and confirmatory factor analyses resulted in a five-factor solution. The dimensions were labeled Sprightliness, Integrity, Serenity, Moderation, and Humanity and subsumed under the denomination of Positive Personality Model (PPM). Analyses of convergent validity provided some grounds for interpreting the five positive traits as positive versions of the pathological traits and the typical traits. When tested for its predictive capability on mental health, the PPM outperformed the variance explained by the FFM. It is concluded that the PPM may constitute a positive pole in the continuum of personality traits –possibly functioning as a sanity nosology– and that it is somewhat more related to optimal functioning than to typical trait models. The PPM should be confirmed in other populations, its predictive capability ought to be tested with other relevant variables, and longitudinal studies should be done to analyze the stability of the traits over time. (shrink)

Previous research (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004; Pomerantz & Segrist, 2006) indicates that when psychologists consider a client with symptoms of depression or anxiety, payment method significantly influences diagnostic decisions. This study extends the scope of the previous research to consider clients with symptoms of social phobia and attention deficit hyperactivity disorder (ADHD). Psychologists in independent practice responded to vignettes of clients whose descriptions deliberately included subclinical impairment. Half of the participants were told that the clients would pay via (...) managed care; the other half were told that the clients would pay out-of-pocket. Confirming previous studies, payment method had a highly significant impact on diagnosis such that compared to out-of-pocket clients, managed care clients were much more likely to be assigned Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) diagnoses. Ethical implications relate to informed consent, accuracy and truthfulness in diagnosis, and psychologists' integrity. (shrink)

This book is the second volume of an interdisciplinary study, chiefly one of philosophy and psychology, which concerns personality, especially the abnormal in terms of states of aloneness, primarily that of the negative emotional isolation customarily known as loneliness. Other states of aloneness investigated include solitude, reclusiveness, seclusion, desolation, isolation, and what the author terms “aloneliness,” “alonism,” “lonism,” and “lonerism.”Insofar as this study most explicitly focuses on abnormal personalities, it employs the general and specific definitions of personality aberrations as formulated (...) by the American Psychiatric Association in its latest edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-IV). The author views personality as preeminently comprised of the individual's interpersonal relationships. Unlike theDSM-IV, he proposes that people with personality disorders not only possibly but necessarily manifest deviancy regarding interpersonal functioning via serious shortcomings in shared inwardness, paramountly reciprocated intimacy.This work also engages in an analysis of five social factors that are conducive to predisposing, precipitating, and maintaining negative kinds of personality and aloneness. The author has formed these factors into an acronym titledSCRAM since when they are present, intimacy scurries away and in its absence, loneliness and other sorts of unwanted aloneness scamper in and fill the person with unhappiness via, for instance, sadness and self-worthlessness. The constituents of SCRAM are the following social illnesses: Successitis (for example, the fixation on fame and fortune),Capitalitis (greed-driven, unfettered capitalism), Rivalitis (competitivitis),Atomitis (hyper-individualism), and Materialitis (for example, the anti-spirituality of consumeritis).In sum, this book provides a different perspective on personality via the lenses of various types of aloneness and their lack of public and private intimacy, especially love. (shrink)

Background Delusions are a significant feature of mental illnesses and can occur in many clinical conditions (Maher, 2001) yet the standard clinical definition (American Psychiatric Association. DSM-5 Task Force, 2013) is highly contentious. Much of the literature holds elements such as bizarreness of content and incorrigibility of belief as defining factors of delusion. However, on closer inspection, delusions are not so easy to pin down. The difficulty in defining delusion is not a new one as “…we are (...) all capable of having convictions and it is a universal human characteristic to hold on to our own mistaken judgements.” (Jaspers, 1963, p.63). Objective I intend to highlight some of the difficulties associated with the definition of delusion and perhaps clarify the phenomenology. Methodology I examine some of the philosophical, psychological and psychiatric literature with regard to the definition of delusion. I also consider my experience of my own mental activity and experiences from my therapeutic work. Results/Conclusion I identify that delusions are a heterogeneous group and that there may be more than one ‘class’ of delusion. I also show that delusions are multi-dimensional with characteristics on a continuum with normal beliefs and that further research is needed to clarify the phenomenology. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 4.1 (1997) 91-93 Concurrent Contents: Recent and Classic References at the Interface of Philosophy, Psychiatry, and Psychology Articles Allen, J. F., J. Hallperin, and R. Friend. 1985. Removal and diversion tactics and the control of auditory hallucinations. Behavior Research and Therapy 23:601-605.Baker, H. D. 1995. Psychoanalysis and ideology: Bakhtin, Lacan, and Zizek. History of European Ideas 20:499-504.Bernet, R. 1994. Derrida-Husserl-Freud: The trace of transference. Southern (...) Journal of Philosophy 32 suppl.:141-158.Boden, M. A. 1996. Commentary on "Towards a design-based analysis of emotional episodes." Philosophy, Psychiatry, & Psychology 3, no. 2:135-136.Castelfranchi, C., and M. Miceli. 1996. Commentary on "Towards a design-based analysis of emotional episodes." Philosophy, Psychiatry, & Psychology, no. 2:129-133.Fowes, B. J., and F. C. Richardson. 1996. Why is multiculturalism good? American Psychologist 51, no. 6:609-621.Frith, C. 1996. Commentary on "Free will in the light of neuropsychiatry." Philosophy, Psychiatry, & Psychology 3, no. 2:91-93.Forde, R. 1996. Inclusion of psychosocial conditions in clinical practice and the problem of medicalization. Theoretical Medicine 17, no. 2:151-161.Gaylin, W., and D. Doukas. 1995. The second-hand suicide threat. Hastings Center Report 25:20-22.Gillet, G. 1995. Consciousness, thought, and neurological integrity. Journal of Mind and Behavior 16, no. 3:215-233.Haskell, R. E. 1993. Realpolitik in the addictions field: Treatment-professional, popular-culture ideology, and scientific research. Journal of Mind and Behavior 14, no. 3:257-276.Kuys, T. 1995. The tally argument again. Methodological Science 28, nos. 2-3:43-55.Lear, J. 1995. The heterogeneity of the mental: Sebastian Gardner's irrationality and the philosophy of psychoanalysis. Mind: A Quarterly Review of Psychology and Philosophy 104:863-879.Libet, B. 1996. Commentary on "Free will in the light of neuropsychiatry." Philosophy, Psychiatry, & Psychology 2, no. 3:95-96.Lloyd, D. 1996. Commentary on "Toward a design-based analysis of emotional episodes." Philosophy, Psychiatry, & Psychology 3, no. 2:127-128.Pepper-Smith, R., W. R. C. Harvey, and M. Silberfeld. 1996. Competency and practical judgment. Theoretical Medicine 17, no. 2:135-150. [End Page 91]Spence, S. A. 1996a. Free will in the light of neuropsychiatry. Philosophy, Psychiatry, & Psychology 3, no. 2:75-90.------. 1996b. Response to the commentaries. Philosophy, Psychiatry, & Psychology 3, no. 2:99-100.Stein, D. J. 1996. The philosophy of psychopathy. Perspectives in Biology and Medicine 39:569-580.Stephens, G. L. 1996. Commentary on "Free will in the light of neuropsychiatry." Philosophy, Psychiatry, & Psychology 3, no. 2:97-98.Varela, C. R. 1995. Ethnogenic theory and psychoanalysis: The unconscious as a social construction and a failed explanatory concept. Journal for the Theory of Social Behavior 25:4.Weisberger, A. M. 1995. The ethics of the broader usage of Prozac: Social choice or social bias? International Journal of Applied Philosophy 10, no. 1:69-74.Wright, I., A. Sloman, and L. Beaudoin. 1996a. Response to the commentaries. Philosophy, Psychiatry, & Psychology 3, no. 2:137.------. 1996b. Towards a design-based analysis of emotional episodes. Philosophy, Psychiatry, & Psychology 3, no. 2:101-126. Books American Psychiatric Association. Task Force on Consent to Voluntary Hospitalization. 1993. Consent to voluntary hospitalization. Washington, DC: American Psychiatric Association.Christiansen, H. D. 1972. Ethics in counseling: Problem situations. Tucson: University of Arizona Press.Clark, P., and C. Wright, eds. 1988. Mind, psychoanalysis and science. New York: Blackwell.Comerchero, V., ed. 1970. Values in conflict: Christianity, marxism, psychoanalysis, existentialism. New York: Appleton-Century-Crofts.Epstein, R. S. 1994. Keeping boundaries: Maintaining safety and integrity in the psychotherapeutic process. Washington, DC: American Psychiatric Press.Fairbairn, G. J. 1995. Contemplating suicide: The language and ethics of self harm. New York: Routledge.Grubb, A., ed. 1991. Decision-making and problems of incompetence. New York: John Wiley & Sons.Haas, L. J., and J. L. Malouf. 1995. Keeping up the good work: A practitioner's guide to mental health ethics. 2nd ed. Sarasota: Professional Resource Exchange.Hacking, I. 1995. Rewriting the soul: Multiple personality and the sciences of memory. Princeton: Princeton University... (shrink)

Are psychotherapy clients who pay via health insurance more likely to receive Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994) diagnoses than identical clients who pay out of pocket? Previous research (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004) indicates that when psychologists consider a mildly depressed or anxious client, payment method significantly influences diagnostic decisions. This study extends the scope of the previous study to include clients whose symptoms are even less severe. (...) Independent practitioners responded to vignettes of clients whose profiles deliberately included subclinical impairment and a high level of functioning. Half of the participants were told that the clients would pay via managed care; the other half were told that the clients would pay out of pocket. As in the earlier study, payment method had a highly significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to be assigned DSM-IV diagnoses. In addition, a noteworthy percentage of participants assigned diagnoses regardless of payment method. Ethical implications are discussed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Postmodern Assumptions of Philosophy of PsychiatryThe author reports no conflicts of interest.This paper makes claims for relevance of philosophy to psychopathology, as inspired in part by the work of Karl Jaspers. Yet there is no such thing as philosophy, in a general sense; there are philosophies, or as Jaspers would prefer, there is philosophizing (Ehrlich & George, 1994; Jaspers, 1951). Jaspers' approach to philosophy was akin to Freud's approach (...) to psychology: the goal was to make unconscious assumptions conscious. The unconscious assumption in the present paper is that there is such a thing as philosophy, which could then be useful for psychopathology. In effect, the author is probably meaning academic philosophy, or mainstream thinking in current philosophy of psychiatry. If that is the meaning, then Jaspers' question would be: What are the unconscious underlying assumptions of modern academic philosophy of psychiatry? The author's paper does not ask that question. But if we do, my answer would be that current mainstream philosophy of psychiatry has a basic worldview, another concept very central to Jaspers' thinking (Rindermann, 2021). Its worldview is postmodernist relativism about truth and skepticism about science, especially biology as applied to psychiatry. This unconscious assumption in modern philosophy of psychiatry is a major impediment in any benefits it might provide to psychiatry and psychopathology, as will be explained in the rest of this commentary.The paper refers to major depressive disorder (MDD) without appreciating that the term itself makes assumptions which the paper wishes to argue should be in the province of philosophy to analyze. The term MDD is not the same as depression, although the paper synonymizes the two. This synonym is an unanalyzed assumption, namely, that the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system validly defines psychopathology. It clearly does not, for reasons that modern philosophy of psychiatry has not accurately analyzed (Ghaemi, 2014).About a decade ago, when DSM-5 was being developed, colleagues in the field of philosophy of psychiatry had worked for decades on psychiatric diagnosis, and there was initial hope that the time had come for an impact (Kendler et al., 2008). The leader of the prior edition of DSM was unhappy [End Page 17] with the fifth revision. A set of essays were published where philosophers and psychiatrists engaged the former DSM leader about psychiatric diagnosis (Frances, 2013). His response, with a somewhat derisive reference to "philosophyland," was eye opening to me. He explicitly stated that DSM revisions were not based on science or facts, but on "pragmatism," on the beliefs of DSM leaders about what was best for the profession or society. In short, it was admitted that DSM was a social construction, just as postmodern thinking had said about psychiatric diagnosis since Foucault. Yet this admission was made unconsciously; DSM leadership does not use that phrase, nor does it understand its conceptual foundations. Surprisingly to me, colleagues in the world of philosophy and psychiatry also failed to make the obvious connection, or if they did, they seemed to have little problem with it (Phillips et al., 2012). Social constructionism was their worldview too.In effect, philosophy of psychiatry had nothing to provide; it did not analyze or critique the philosophical worldview of DSM leadership; it shared that worldview and participated in it (Kendler, 2013).The result, in my view, is that mainstream philosophy of psychiatry has failed in the role which it could have played, the role of making the unconscious postmodern assumptions of psychiatry conscious, and criticizing those assumptions. Instead, it applauded them.My broader critique of mainstream philosophy of psychiatry gets played out in papers such as this one in relation to the DSM term MDD, which should be dropped because it is not a scientifically sound term; it has many conceptual and scientific falsehoods within it, which both a philosophical analysis and a scientific analysis would demonstrate.The term MDD was invented in the DSM-III process in the late 1970s to get votes for passage of that third revision by the American Psychiatric Association in 1980 (Decker, 2013). It literally was a social construction. To the extent that it had any scientific basis, it had its roots in the... (shrink)

Philosophy of psychiatry is a philosophical discipline focused on fundamental theoretical and conceptual issues in contemporary psychiatry. One of such issues is the so-called demarcation problem, which can be understood as the question about the difference between mental illness and psychological functioning which is normal, or healthy. After a brief account of the standard criteria for such differentiation the dominant naturalistic understanding of psychiatry as well as the notion of mental illness proper to the latter are subjected to scrutiny. Then, (...) in turn, critical currents are investigated with their concept of psychiatry as a discipline of humanistic and normative character. Some of these currents, such as the antipsychiatry of Szasz, are of historical importance today. Still, however, many threads are discussed, especially in the context of the notion of mental disorder developed by the American Psychiatric Association. One may expect that such discussions will be fruitfully carried on, especially in those cases when particular disorders are philosophically investigated. (shrink)

Psychiatric disorders usually do not have characteristic physical exam findings, imaging, or lab values. Psychiatrists therefore diagnose and treat patients largely based on reported or observed behavior, which makes collateral information from a patient’s close contacts especially pertinent to an accurate diagnosis. The American Psychiatric Association considers communication with patients’ supports a best practice when the patient provides informed consent or does not object to the communication. However, situations arise in which a patient’s objection to such (...) communication is the product of impaired decision-making and the benefits of obtaining collateral information represent best practice. In this article a framework for addressing these situations is proposed using a full decisional capacity evaluation, followed by an alternate decision-making process by concurrence from a second physician. It is recommended that a patient’s refusal to allow the gathering of collateral information should be addressed exactly like refusals for other diagnostic or treatment interventions. (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)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumWhat’s Psychiatry Got to do With It?Paul B. Lieberman, MDIf in life we are surrounded by death, so too in the health of our intellect by madness.—WittgensteinDelirium is a medical syndrome defined as “a relatively acute decline in cognition that fluctuates over hours or days” whose primary manifestation is a deficit of attention. It is common, estimated to occur in 10% to more than 50% of hospitalized patients, (...) with higher prevalence rates among people in nursing homes and at the end of life. It is often fatal, with a mortality rate in the hospital estimated to be 25% to 33%. Caused by a wide variety of conditions and frequently difficult to diagnose, it lacks characteristic postmortem pathology (Josephson & Miller 2018)‘Excited delirium,’ as Byju and Friesen forcefully argue (Byju & Friesen, 2023), is, if nothing else, an excuse. The ‘diagnosis’ has not been empirically validated and remains controversial (American Psychiatric Association, 2020). And while delirium is usually treated by internists and emergency medicine physicians, psychiatrists should also be concerned about the misuse of a putative medical diagnosis and join actively in discussion about it. For one thing, patients mis-diagnosed with this condition, as Byju and Friesen’s examples suggest, may actually have another psychiatric condition and, so, be people for whose safety we should advocate. Moreover, the kinds of police interventions which Byju and Friesen document as involving excited delirium also befall patients with other psychiatric problems in whom the issue of delirium does not arise.There are at least two broad ways in which psychiatrists are qualified and obligated to engage with this issue. As physicians, we should join our medical colleagues in carefully but persistently telling the scientific, medical truth. As psychiatrists, we should bring psychiatric knowledge into the discussion, for example, by explaining what can happen when people who do not, apparently, have a diagnosable mental disorder interact under stress with other people who, apparently, do.Delirium is a clinical diagnosis, made when characteristic signs and symptoms are present which should not be made ‘by exclusion’ when, as may happen, other causes are not found. There is no evidence of delirium in any of the three clinical descriptions Byju and Friesen provide. Perhaps such evidence exists which is not in their brief reports, but these three people appear to have had, either, another psychiatric condition, such as psychosis or drug intoxication, or perhaps no [End Page 353] diagnosis at all. Psychiatrists are particularly wellpositioned to make this point since patients with mental health problems are often misdiagnosed when they seek medical attention and are told, and treated as if, “it’s all (“just”!) psychological.”Excited delirium, if it exists, is fatal in 10% of cases (Gonin, Beysard, Hersin, & Carron, 2018) and, although this is lower than the rate for delirium in general, it is still high. Medical personnel must be available to evaluate and ensure the safety of patients in custody.The potential conflict between protecting the patient and protecting the public should not be overstated. Although physical trauma and excessive administration of medications, including ketamine 500 mg IV (Orhurhu, Vashicht, Claus, & Cohen, 2023) can be lethal, mechanical restraint by itself is not (Chieze et al., 2019; Gleerup et al., 2019): something else is necessary, such as asphyxiation (Evans, Wood, & Lambert, 2003). Nor is restraint necessary in many cases in which ‘de-escalation’ techniques can be equally effective (Garriga et al., 2016; Fernández-Costa, 2020). Perhaps these points are best made by law enforcement leaders—and they have been—but psychiatrists can add that safe management of potential violence can be provided for agitated people with psychiatric conditions.Although it is not clear what kind of strength ‘superhuman’ strength might be (certainly not medical), relative imperviousness to pain is clinically described. Its locus classicus is Beecher’s observation, during World War II, that injured soldiers awaiting return home from the front, required lower than usual doses of analgesics (Beecher, 1946). And it’s a common experience, scientifically confirmed, that physical trauma may not become painful until sometime after the injury (Melzack, Wall, & Ty, 1982). But pain is a warning. Its absence is not a license, but a caution... (shrink)

This paper aims to show that the classification by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders of a distinct listing of disorders known as Culture-Bound Syndromes is misguided. I argue that the list of CBS comprises either genuine disorders that should be included within the main body of the DSM; or ersatz-disorders that serve a practical role for psychiatrists dealing with patients from certain cultures but will one day be eliminated or (...) assimilated by bona fide DSM classifications. In support of these views I draw on claims from two key themes in the philosophy of science: the claim that all folk explanations for phenomena are thoroughly theoretical and therefore fallible; and the occurrence of theoretical elimination in the history of science. I contend that any ersatz-disorders located in the DSM that are judged to be radically false do not differ in kind from eliminated theories in the history of pre-science. (shrink)

According to the DSM IV, a person with GID is a male or female that feels a strong identification with the opposite sex and experiences considerable stress because of their actual sex (Task Force on DSM-IV and American Psychiatric Association, 2000). The way GID is characterized by health professionals, patients, and lay people belies certain assumptions about gender that are strongly held, yet nevertheless questionable. The phenomena of transsexuality and sex-reassignment surgery puts into stark relief the following (...) question: “What does it mean to be male or female?” But while the answer to that question may be informed by contemplation of GID, we should also be aware that the answer to the question “what does it mean to have GID?” is shaped by our concepts of male and female. First, I consider the concept of transsexuality, and explain how it forces us to clarify our concepts of sex and gender, and leads to the development of what I will call the “standard view.” I then explain GID from a mental-health standpoint, question the concept of gender identity, and try to uncover some fundamental assumptions of the standard view. I argue that these assumptions are at odds with the plausible view that gender supervenes on physical, psychological, and/or social properties. I go on to argue, contra the standard view, that gender has no essence. I suggest an anti-essentialist account of gender according to which “man” and “woman” are cluster concepts. This undermines the dualistic conception of gender that grounds the standard view. An anti-essentialist view of gender cannot make sense of the concept of “gender identity” and hence sees so-called “GID” as primarily conflict between the individual and her society, and only derivatively a conflict between the individual and her body. (shrink)