Diagnosing the Diagnostic and Statistical Manual of Mental Disorders (Karnac, 2014) evaluates the latest edition of the D.S.M.The publication of D.S.M-5 in 2013 brought many changes. Diagnosing the Diagnostic and Statistical Manual of Mental Disorders asks whether the D.S.M.-5 classifies the right people in the right way. It is aimed at patients, mental health professionals, and academics with an interest in mental health. Issues addressed include: How is the D.S.M. affected by financial links with (...) the pharmaceutical industry? To what extent were and should patients involved in revising the classification? How are diagnoses added to the D.S.M.? Does medicalization threaten the idea that anyone is normal? What happens when changes to diagnostic criteria mean that people lose their diagnoses? How important will the D.S.M. be in the future? (shrink)

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

The 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)

이 연구는 정신질환에 대한 기존의 정의를 개괄적으로 검토하고 DSM-5의 정신질환 정의를 고찰함으로써, DSM의 정의가 정상과 이상 사이의 경계 세우기라는 목적을 제대로 구현하지 못함을 보여주고, 정신질환의 정의에 관한 논의의 함의를 제시한다. 프랜시스와 필립스의 연구는 정신질환의 정의에 관련된 논의가 다양한 존재론적, 인식론적 기반 위에서 개진되었음을 알려준다. 기존의 논의는 크게 실재론적 태도와 정신질환 개념이 자의적이라는 구성주의적 태도로 나뉜다. DSM-5는 실재론적 입장을 견지하고 있으나, 진단에 가치적 개념을 포함하고 있고 실질적인 객관적 지표가 없다는 문제점이 있다. DSM-III편집의 책임자인 스피처의 정신질환 정의 또한 같은 문제를 내포한다. DSM-5는 (...) 통일된 판단만을 보장할 뿐 정상과 이상 사이의 경계 세우기라는 기능을 제대로 수행하지 못한다. (shrink)

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

The Diagnostic and Statistical Manual of Mental Disorders contains the official diagnostic criteria for recognized mental illnesses. Some have asserted that DSM revisions have caused the boundaries of specific disorders to expand to include more behaviors, but no previous research has examined if such expansion is isolated or endemic. The current research consisted of an exploration of revisions to diagnostic criteria for 81 disorders. Each change between editions of the DSM was conceptually analyzed as making (...) the disorder more exclusive or more inclusive in terms of the number of people who could theoretically meet the criteria. Results indicated that 63% of disorders moved toward inclusivity, that each edition of the DSM moved toward inclusivity, and that most types of revisions increase inclusivity. (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)

The introduction of the Diagnostic and statistical manual of mental disorders in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual: Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview . Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of “construct (...) validity” and “conceptual validity” and a failure to distinguish between “disorder” and “non disordered conditions for which we help people.” The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. Categorisation nosology to spectrum nosology: The move to “degrees of severity” of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication. (shrink)

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

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

In lieu of an abstract, here is a brief excerpt of the content:Diagnostic Criteria, Psychological Tests, and Ratings Scales: Extending the HistoryPeter Zachar, PhD (bio)Le moigne narrates a history of the development of psychiatric ratings scales as hybrids between psychological tests and diagnostic categories. In his telling, psychological tests seek to quantify population-based traits on which every person has a position and which tend to be conceptualized as being stable. Personality traits are often conceptualized as dispositions. Diagnostic (...) categories represent not trait-like properties of populations but episodic states consisting of clusters of symptoms experienced by individuals with disorders. Ratings, scales, he notes, are hybrids between the two. They are used to quantify psychiatric symptom clusters so that change over time can be measured. Le Moigne argues that these distinctions were initially suggested during the development of measures that could assess outcomes in psychopharmacological treatment studies.With respect to depression, Le Moigne writes that in the 1970s and 1980s something akin to depressive personality was reconceptualized as a temperament. A key move, somewhat reflective of Kraepelin’s notion of a depressive temperament, was to view a dysthymic temperament as both a predisposing factor and an attenuated form of depression. Thus, an episodic state commandeered the predisposing–dispositional role that was assigned to stable personality traits.This conceptual shift allowed test-like ratings scales to be seen as useful for quantifying not just stable traits, but salient features of episodic states that are potentially subject to change in response to interventions. To put it another way, in the development of a psychological test, one goal is to have high test-retest reliability (i.e., stability of measurement). With rating scales used to measure change, one wants the scores to not be as stable; ideally the scores on the later assessments will be lower. According to Le Moigne, when dysthymia was subsequently placed on axis I of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III (as a syndrome) and segregated from personality disorders which were placed on axis II, personality traits were evicted from the conceptualization of depressive disorders.One perennial feature of psychiatry and psychology is that even if an older idea is superseded [End Page 253] in the view of some thinkers, it can still attract adherents. Indeed, interest in understanding a relationship between personality and attenuated states did not fully disappear. For example, based on research in genetics, the schizophrenia spectrum concept included not only schizophrenia, but also milder conditions such that were conceptualized as personality disorders; that is, schizotypal personality disorder and paranoid personality disorder (Kety, Rosenthal, Wender, & Schulsinger, 1971).During the development of the DSM-IV, some people wanted to add depressive personality disorder to the manual (Phillips, Hirschfeld, Shea, & Gunderson, 1995). It seems to have become a territorial dispute between mood disorder specialists and personality disorder specialists The mood disorders specialists challenged the personality disorder specialists to differentiate depressive personality disorder from early onset, chronic dysthymia. They were able to do so by using criteria such as critical, blaming, and derogatory toward self. After the mood disorders work group proposed incorporating some of those criteria into a revised criteria set for dysthymia, the two sets overlapped. The result was the old criteria for dysthymia were printed in DSM-IV and criteria for depressive personality disorder and the revised criteria for dysthymia were both placed in the appendix.In the DSM-5, Axis II was eliminated and personality disorders were placed alongside all the syndromic symptom clusters at the same level. Even so, interest in attenuated presentations as personality-related lingered still. During the development of the DSM-5 there was some thought to using diagnostic spectra as a meta-structure for organizing the manual (Andrews et al., 2009). One idea was to move some personality disorders into a best fitting spectrum, akin to attenuated forms. This did occur with schizotypal personality disorder which is both in the DSM-5 chapter on schizophrenia and in the chapter on personality disorder. In the schizophrenia chapter it is positioned as the earliest emerging disorder on the spectrum. There was also some interest in grouping avoidant personality disorder with the anxiety disorders, but the evidence supporting such a change was not available.These issues may... (shrink)

The Diagnostic and Statistical Manual of Mental Disorders classifies “anorexia nervosa” as a mental disorder, yet individuals with anorexia often characterize it as an identity. The author describes the identity of being an anorectic and compares it with what it takes to have anorexia in the diagnostic sense. This furthers the existing scholarship on anorexia and identity, most notably by revealing a disconnect between being an anorectic and having anorexia: Some individuals inhabit the identity of being (...) an anorectic but do not have anorexia because they do not have a significantly low body weight. The author explores whether expanding the diagnostic criteria for anorexia would be beneficial for anorectics by examining the implications of classifying the identitive phenomenon of being an anorectic in terms of a medical concept of mental disorder. In the short term, the answer depends on whether being an anorectic calls for interventions that require a diagnosis. Either way, it would be beneficial to develop nonmedical frameworks for understanding anorexia that facilitate interventions that do not require a diagnosis. Understanding being an anorectic as an identity lays the scaffolding for a nonmedical way of conceptualizing anorexia that illuminates innovative approaches to assisting anorectics. (shrink)

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

Machine learning (ML) has emerged as a promising tool in psychiatry, revolutionising diagnostic processes and patient outcomes. In this paper, I argue that while ML studies show promising initial results, their application in mimicking clinician-based judgements presents inherent limitations (Shatte et al. in Psychol Med 49:1426–1448. https://doi.org/10.1017/S0033291719000151, 2019). Most models still rely on DSM (the Diagnostic and Statistical Manual of Mental Disorders) categories, known for their heterogeneity and low predictive value. DSM's descriptive nature limits the validity (...) of psychiatric diagnoses, which leads to overdiagnosis, comorbidity, and low remission rates. The application in psychiatry highlights the limitations of supervised ML techniques. Supervised ML models inherit the validity issues of their training data set. When the model's outcome is a DSM classification, this can never be more valid or predictive than the clinician’s judgement. Therefore, I argue that these models have little added value to the patient. Moreover, the lack of known underlying causal pathways in psychiatric disorders prevents validating ML models based on such classifications. As such, I argue that high accuracy in these models is misleading when it is understood as validating the classification. In conclusion, these models will not will not offer any real benefit to patient outcomes. I propose a shift in focus, advocating for ML models to prioritise improving the predictability of prognosis, treatment selection, and prevention. Therefore, data selection and outcome variables should be geared towards this transdiagnostic goal. This way, ML can be leveraged to better support clinicians in personalised treatment strategies for mental health patients. (shrink)

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, emphasizes diagnosis and statistically significant commonalities in mental disorders. As stated in the Introduction, “[i]t must be admitted that no definition adequately specifies precise boundaries for the concept of ‘mental disorder’ ” (DSM-IV, 1994, xxi). Further, “[t]he clinician using DSM-IV should ... consider that individuals sharing a diagnosis are likely to be heterogeneous, even in regard to the defining features of the diagnosis, and that boundary cases will (...) be difficult to diagnose in any but a probabilistic fashion” (DSM-IV, 1994, xxii). This article proposes that it may be helpful for clinicians to study narratives of illness which emphasize this heterogeneity over statistically significant symptoms.This paper examines the recorded experiences of unusually articulate sufferers of the disorder classified as Major Depression. Although sharing a diagnosis, Hemingway, Fitzgerald, and Styron demonstrated different understandings of their illness and its symptoms and experienced different resolutions, which may have had something to do with the differing meanings they made of it.I have proposed a word, autopathography, to describe a type of literature in which the author's illness is the primary lens through which the narrative is filtered. This word is an augmentation of an existing word, pathography, which The Oxford English Dictionary, Second Edition, defines as “a) [t]he, or a, description of a disease,” and “b) [t]he, or a, study of the life and character of an individual or community as influenced by a disease.” The second definition is the one that I find relevant and which I feel may be helpful to clinicians in broadening their understanding of the patient's experience. (shrink)

The general concept of mental disorder specified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is definitional in character: a mental disorder might be identified with a harmful dysfunction. The manual also contains the explicit claim that each individual mental disorder should meet the requirements posed by the definition. The aim of this article is two-fold. First, we shall analyze the definition of the superordinate concept of mental disorder to better understand (...) what necessary criteria actually characterize such a concept. Second, we shall consider the concepts of some individual mental disorders and show that they are in tension with the definition of the superordinate concept, taking pyromania and narcissistic personality disorder as case studies. Our main point is that an unexplained and not-operationalized dysfunction requirement that is included in the general definition, while being systematically violated by the diagnostic criteria of specific mental disorders, is a logical error. Then, either we unpack and operationalize the dysfunction requirement, and include explicit diagnostic criteria that can actually meet it, or we simply drop it. (shrink)

The development and publication of Diagnostic and Statistical Manual of Mental Disorders, fifth edition produced a peak in mainstream media interest in psychiatry, and a large and generally critical set of scientific commentaries. The coverage has focused mainly on the expansion of some categories, and loosening of some criteria, which together may lead to more people receiving diagnoses, and accompanying accusations of the medicalisation of normal living. Instructions given to members of DSM-5 work groups appear to have (...) encouraged this.1 This has not been the only source of disquiet. The influence of the pharmaceutical industry on the members of the appointees to DSM diagnostic work groups, which constructed the new rubrics, has caused concern,2 as remuneration and insurance coverage in the USA depends partly on DSM diagnosis, and the pharmaceutical industry has been accused of encouraging the development of new diagnoses as a way to increase profitability.3 Societal impact has been an explicit part of the development of DSM-5, as outlined in the article in this issue.4 Reasons for decisions by DSM-5 workgroups have included enabling sufferers to receive treatment which would not be available without a DSM diagnosis , or …. (shrink)

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association [APA], 2013) defines melancholia as “A mental state characterized by very severe depressi...

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

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) uses the conceptualization of psychopathology to make psychiatric diagnoses operational. The use of explicit operational criteria appears to be based on an implicit neo-positivist epistemology. Operationalism involves an excessive focus on quantitative descriptions of behavior manifestations, contesting that psychopathology is understood as a deviation from the normal or the average in a given population. Consequently, the normal and the psychopathological become homogeneous. Our analysis investigates if this (...) neo-positivist epistemology narrows psychopathology conceptualization and endanger integration with the hybrid biopsychosocial model of psychiatry. Based on Georges Canguilhem’s theorization of a qualitative approach to the individual organism who is in a state of morbidity, we show that the (psychiatric) pathology also contains differences in quality. Moreover, that humans are norm-producing organisms that actively respond to changes in their internal and external environment. In this regard, the operationalization of mental disorders could include the normativity in humans, i.e., the ability to produce norms. We argue this will mitigate the one-sided psychopathology conceptualization and strengthen the relationship between psychiatric nosology and psychiatry’s hybrid biopsychosocial model. (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)

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

The last two decades have seen a dramatic increase in scientific publications on Tourette syndrome, but the etiology of this common neurodevelopmental condition is still unknown. Many questions remain—about the unitary nature of the syndrome, and the criteria used to define it in such internationally accepted manuals as the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Disorders. Meanwhile, individuals and families affected by TS remain underserviced, as pharmacological and behavioral therapies provide relief (...) for some but not all who need support. We urgently need new... (shrink)

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

As a text in use by mental health practitioners, policy makers, and ordinary individuals, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) categorizes a variety of mental, psychological, and emotional experiences on a wide spectrum of disorders. Many common experiences are described there as symptoms, chiefly for the purposes of identifying, diagnosing, and treating disorders. “Disorientations” are not (yet) categorized as a stand-alone disorder in the DSM, but involve a cluster of experiences that border on and (...) overlap with experiences already categorized as symptoms of other disorders. Where experiences of disorientation appear in the DSM, they are, for the most part, still understood as.. (shrink)

Murphy (2006) criticizes psychiatric nosology from the perspective of the philosophy of science, arguing that the model of pathology as encapsulated in the Diagnostic and Statistical Manual of Mental Disorders reflects a folk conception of the mental, and of malfunctioning, that is inadequately integrated with cognitive and behavioral neuroscience. The present paper supports this view through a case study of research on pathological gambling. It argues that recent modeling based on fMRI studies and behavioral genetics suggests a (...) stipulative, non-seamless reduction of pathological gambling to a specific disorder of the mesolimbic dopamine system. This argument is agnostic as between prior philosophical commitments to realism or empiricism. (shrink)

This article examines the revision of the Diagnostic and Statistical Manual of Mental Disorders and its claim of incorporating a “greater cultural sensitivity.” The analysis reveals that the manual conveys mixed messages as it explicitly addresses the critique of being ethnocentric and having a static notion of culture yet continues in a similar fashion when culture is applied in diagnostic criteria. The analysis also relates to current trends in psychiatric nosology that emphasize neurobiology and decontextualize (...) distress and points to how the DSM-5 risks serving as an ethnic dividing line in psychiatry by making sociocultural context relevant only for some patients. (shrink)

Clinical delusions are commonly thought of and characterized as beliefs, both by psychiatrists and by the general population. That fact is encoded in the definition of delusion in the Glossary of Technical Terms of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders :A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to (...) the contrary.Although almost every aspect of this definition is debatable, describing delusion as a type of aberrant belief has engendered a specialized discussion in itself, engaging philosophers... (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)

Depression is an affective disorder involving a significant change in an individual’s emotional and affective experiences. While the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition mentions that social impairment may occur in depression, first-person reports of depression consistently name isolation from others as a key feature of depression. I present a phenomenological analysis of how certain interpersonal relations are experienced in depression. In particular, I consider whether depressed individuals are able to enter into “we-experiences” with (...) other people. We-experiences are experiences had with two or more people as a we, experiences that allow one to enter into robustly shared experiences with others. I claim that the ability to enter into we-experiences is eroded in depression due to an overwhelming feeling of being different to and misunderstood by others. As such, I suggest that depression should be conceived of as fixing an individual in their first-person singular perspective, thus inhibiting their ability to experience in the first-person plural and to feel a sense of connectedness or togetherness with others as part of a we. By attending to on-going impacts of a diminished ability to enter into we-experiences, we can provide a situated and more nuanced account of the changes of interpersonal relations in depression that captures the progressive nature of the disorder. In turn, this analysis furthers our understanding of the emergence, frustration, and erosion of actual and habitual we-experiences. (shrink)

To what extent does payment method (managed care vs. out of pocket) influence the likelihood that an independent practitioner will assign a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnosis to a client? When a practitioner does diagnose, how does payment method influence the specific choice of a diagnostic category? Independent practitioners responded to a vignette describing a fictitious client with symptoms of depression or anxiety. In half of the vignettes, the fictitious (...) client intended to pay via managed care; in the other half, the fictitious client intended to pay out of pocket. Payment method had a very significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to receive diagnoses and more likely to receive adjustment disorder diagnoses in particular. We discuss implications involving informed consent and other ethical issues. (shrink)

This paper notes the re-ignited controversy surrounding the publication of a new edition of the Diagnostic and Statistical Manual of Mental Disorders, suggesting that the early work of Michel Foucault can explain why the mere diagnosis of or criteria for mental illness remains a heated flashpoint. In particular, it argues that Foucault articulates a common issue within the philosophical foundations of psychiatry and psychology that the paper terms the ‘subjectivity problem.’ It observes, using Foucault’s work, that these (...) disciplines treat not just simple objects but complex subjects that are capable of interacting with that labelling and who are shaped by it. Drawing on the related work of Ian Hacking on kind-making as world-making, the article fleshes out why the subjectivity problem remains persistent within psychiatry and psychology as forms of knowledge, preventing them from operating as many commentators might desire them to – as pure and objective sciences. Finally, the paper reflects on the relationship of psychiatry and psychology as forms of knowledge, the manner in which they constitute their objects, and how this might shape the biopolitical episteme in which we find ourselves today. (shrink)

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

A revival of the dialogue between phenomenology and psychiatry currently takes place in the best international journals of psychiatry. In this article, we analyse this revival and the role given to phenomenology in this context. Although this dialogue seems at first sight interesting, we show that it is problematic. It leads indeed to use phenomenology in a special way, transforming it into a discipline dealing with empirical facts, so that what is called “phenomenology” has finally nothing to do with phenomenology. (...) This so-called phenomenology tallies however with what we have always called semiology. We try to explain the reasons why phenomenology is misused in that way. In our view, this transformation of phenomenology into an empirical and objectifying discipline is explained by the role attributed to phenomenology by contemporary authors, which is to solve the problems raised by the Diagnostic and Statistical Manual of Mental Disorders. (shrink)

In the United States, the National Institute of Mental Health is seeking to encourage researchers to move away from diagnostic tools like the Diagnostic and Statistical Manual of Mental Disorders. A key mechanism for this is the “Research Domain Criteria” initiative, closely associated with former NIMH Director Thomas Insel. This article examines how key figures in US psychiatry construct the purpose, nature, and implications of the ambiguous RDoC project; that is, how its novelty is constituted through (...) discourse. In this paper, I explore and analyze these actors’ accounts of what is new, important, or desirable about RDoC, demonstrating how they are constituted through institutional context and personal affects. In my interviews with mental health opinion leaders, RDoC is presented as overly reliant on neurobiological epistemologies, distant from clinical imaginaries and imperatives, and introduced in a top-down manner inconsistent with the professional norms of scientific research. Ultimately, the article aims to add empirical depth to current understandings about the epistemological and ontological politics of contemporary psychiatry and to contribute to science and technology studies debates about “the new” in technoscience. Accordingly, I use discussions about RDoC as a case study in the sociology of novelty. (shrink)

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is universally acknowledged as the prominent reference textbook for the diagnosis and assessment of psychiatric diseases. However, since the publication of its first version in 1952, controversies have been raised concerning its reliability and validity and the need for other novel clinical tools has emerged. Currently the DSM is in its fourth edition and a new fifth edition is expected for release in 2013, in an intense intellectual debate (...) and in a call for new proposals. (shrink)

This paper aims at considering the conceptual status of feeding and eating disorders (FEDs). Now that the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has changed the classification and some relevant criteria of FEDs, it is particularly relevant to evaluate their psychiatric framework and their status as mental disorders. I focus my efforts on addressing only one specific question: Do FEDs fit the DSM-5 general definition of mental disorder? In DSM-5 a mental disorder is defined as (...) a syndrome that reflects adysfunctionand is usually associated with significantdistress or disability. More importantly, there is an explicit statement saying thatallmental disorders listed in the manual must meet the requirements highlighted by the general definition. Thus, I evaluate whether or not FEDs are really meant to reflect a dysfunction and are usually associated with significant distress or disability. (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)

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

In 1952, the Diagnostic and Statistical Manual of Mental Disorders (DSM) system of creating, validating, studying and employing a diagnostic system in clinical psychiatric practice was introduced. There have been several updates and revisions to this manual and, regardless of its a theoretical framework, it actually does have a framework and presupposition. Essentially the DSM dictates that all psychiatric disorders are syndromes, or a collection of symptoms that commonly occur together and impair psychosocial functioning. These (...) syndromes allow for homogenous groups of patients to be studied and psychotherapies and pharmacotherapies to be developed. This editorial will examine the DSM system with regards to its applicability to central nervous system dysfunction where psychiatric disorders are concerned. Specifically, the brain does not follow categorical, or syndromal, constructs. In fact, the psychiatric patient likely inherits several risk genes that promote abnormal proteins along several neuropathways in the brain. These abnormalities create dysfunctional neurocircuits which create individual psychiatric symptoms, but not a categorical syndrome or diagnosis. The concept that the DSM may be excellent for clinical diagnostic purposes, but less correct in its assumptions for a psychopharmacologist's treatment approaches will be discussed. (shrink)

Selective mutism (SM) is a developmental disorder characterized by a child’s inability to speak in certain contexts and/or in the presence of unfamiliar interlocutors. This work proposes a critical discussion of the most recent studies on SM, with respect to clinical and diagnostic features, as well as the etiology and treatment of this disorder. At present, all research work supports the hypothesis that SM is a complex anxiety disorder with multifactorial etiology (interaction among biological and environmental causes). The latest (...) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) places SM mutism among “Anxiety Disorders”, and no longer among “Other Childhood, Infant and Adolescent Disorders” (as in DSM-IV). Other important aspects relate to cognitive biases and emotional states at the base of SM, which partly explain the disorder’s persistence and represent an important objective of intervention work. No data in the literature point to a total remission of SM, but good results are achieved with cognitive behavior intervention and multimodal therapy (MMT) involving a variety of child interaction contexts. (shrink)

In light of the recent calls for integrating phenomenology and psychiatry, I will address the problem of heterogeneity in major depressive disorder (MDD) using the phenomenological account of depression put forth by Fernandez (Fernandez, 2014). I will first go over the distinction between two of the major specifiers of major depressive disorder, namely melancholic and atypical depression. Then, I review the account of depression developed by Fernandez, which considers some of the people diagnosed with MDD to have an erosion of (...) the capacity for the category of moods as opposed to a particular kind of mood. I will apply this conception to the diagnostic and statistical manual criteria for melancholic and atypical depression, and consider how reactive and unreactive depressed moods can be clarified using this conception. I argue that we can help our understanding of MDD by viewing melancholic depression as primarily characterized by structural erosion of the person’s situatedness (observed as a lack of mood reactivity) and atypical depression as a state in which the capacity for moods in general has not been eroded (hence, the retention of mood reactivity), with the psychopathology rooted only in the content of experience (the moods themselves). I discuss how this conception related to other phenomenological accounts of depression and why it can be useful in making sense of some clinical observations between the two specifiers, namely the differences in illness severity and symptoms of depersonalization and derealization, before concluding the work by considering its relationship with the operationalized approach of the DSM. (shrink)

Guidelines for revisions to Diagnostic and Statistical Manual of Mental Disorders, 5th edition asked those proposing certain types of revision to consider potential harms to patients. Specifically, those proposing new diagnoses were to consider whether ‘the harm that arises from the adoption of the proposed diagnosis exceed[s] the benefit that would accrue to affected individuals’, and potential for harm was cited as a possible reason for keeping a diagnosis in the appendix rather than promoting it to the (...) main classification. The ‘do no harm’ criterion was referred to in... (shrink)

Using a densely constructed ethnographic subject, Josephine, the “ugly duckling,” I use Foucault’s complex notion of an Apparatus to examine how Josephine’s decision to have weight-loss surgery is understandable even though it permanently destroys her normally functioning digestive system. I try to illuminate how the decision is deeply embedded in extraordinarily complex neoliberal biopolitical structures and dynamics of fat hatred camouflaged by liberatory discourses that promise “empowerment,” becoming “normal,” and discovery of her “real self.” I argue that in contemporary America, (...) Fat Hatred must be understood as a powerful systemic structure of racialized gendered oppression, that one tactic to normalize weight-loss surgery involves assimilating it to “normal” cosmetic surgery, and that Josephine must be seen, simultaneously, as legitimizing dominant obesity discourses and practices, enacting genuinely liberating personal choices, demonstrating her status as a “good American bio-citizen,” and contributing to the collective physical health and mental health of the nation since “obesity” is soon to be included in the fifth edition of the canonical Diagnostic and Statistical Manual of Mental Disorders as a mental disorder. (shrink)

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

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)