The very idea of mental illness is contested. Given its differences from physical illnesses, is it right to count it, and particular mental illnesses, as genuinely medical as opposed to moral matters? One debate concerns its value-ladenness, which has been used by anti-psychiatrists to argue that it does not exist. Recent attempts to define mental illness divide both on the presence of values and on their consequences. Philosophers and psychiatrists have explored the nature of the (...) general kinds that mental illnesses might comprise, influenced by psychiatric taxonomies such as the Diagnostic and Statistical Manual and the International Classification of Diseases, and the rise of a rival biological ‘meta-taxonomy’: the Research Domain Criteria (RDoC). The assumption that the concept of mental illness has a culturally invariant core has also been questioned. This book serves as a guide to these contested debates. (shrink)

In ?Some Myths about ?Mental Illness'? (Inquiry, Vol. 18 [1975], No. 3), Michael Moore attempts to clarify and refute what he takes to be the radical (existential) position concerning the nature and diagnosis of mental illness. Moore's dissatisfaction with certain formulations and conceptualizations of the radical position is endorsed; as also the need to introduce greater rigor and precision into the discussion of mental illness. But Moore's clarifications are really misunderstandings and, in consequence, his (...) refutations do not succeed. Moore's five?fold interpretative classification of the radical thesis is retained. (shrink)

This paper argues for psychological realism in the conception of psychiatric disorders. We review the following contemporary ways of understanding the future of psychiatry: (1) psychiatric classification cannot be successfully reduced to neurobiology, and thus psychiatric disorders should not be conceived of as biological kinds; (2) psychiatric classification can be successfully reduced to neurobiology, and thus psychiatric disorders should be conceived of as biological kinds. Position (1) can lead either to instrumentalism or to eliminativism about psychiatry, depending on (...) whether psychiatric classification is regarded as useful. Position (2), which is inspired by the growing interest in neuroscience within scientific psychiatry, leads to biological realism or essentialism. In this paper we endorse a different realist position, which we label psychological realism. Psychiatric disorders are identified and addressed on the basis of their psychological manifestations which are often described as violations of epistemic, moral or social norms. A couple of examples are proposed by reference to the pathological aspects of delusions, and the factors contributing to their formation. (shrink)

In recent years there has been considerable discussion and controversy concerning the concepts of mental health and mental illness. The controversy has centered around the problem of providing criteria for an adequate conception of mental health and illness, as well as difficulties in specifying a clear and workable system for the classification, understanding, and treatment of psychological and emotional disorders. In this paper I shall examine a cluster of these complex and important issues, focusing (...) on attempts to define ‘mental health’ and ‘mental illness’; diverse factors influencing the ascription of the predicates ‘is mentally ill’ and ‘is mentally healthy’; and some specific problems concerning these concepts as they appear in various theories of psychopathology. The approach here will be in the nature of a survey, directed at the specification of a number of problems—conceptual, methodological, and pragmatic—as they arise in various attempts to define and to provide criteria for applying the concepts of mental health and mental illness. (shrink)

We argue that dominant research approaches concerning mental illness, which are centered on traditional categories of psychiatric classification as codified in the DSM-IV, have serious empirical, conceptual, and foundational problems. These problems have led to a classification scheme and body of research findings that provide a very poor map of the domain of mental illness, a map that, in turn, undermines clinical and research pursuits. We discuss some current efforts to respond to these problems (...) and argue that the DSM-5 revision process is not very promising, whereas the NIMH Research Domain Criteria initiative and some recent research in cognitive neuroscience fares better, although the latter remains potentially compromised by residual influences of the DSM-based approach. We conclude with some lessons and suggestions for the pursuit of alternative research pathways. (shrink)

B a c k g r o u n d. The article demonstrates the development and influence of the main diagnostic systems in psychiatry, such as the DSM and the ICD, on the concept of psychiatric diseases. The problem of classification of psychiatric disorders is one of the main topics that is the field of study of the philosophy of psychiatry. The correct diagnosis within a particular diagnostic system directly affects the choice of appropriate drug treatment, psychotherapy and social (...) support for people suffering from mental disorders. Misdiagnosis has not only negative medical but also social consequences, leading to stigmatization and avoidance of people suffering from mental disorders. M e t h o d s. The research uses an integrated approach to the analysis of psychiatric diagnostic systems, including historical, comparative and interdisciplinary methods. The application of the historical method contributed to a detailed study of the evolution of psychiatric diagnostic systems and changes in approaches to the classification of mental disorders. A comparative analysis of the main diagnostic systems was carried out, considering their structure, diagnostic criteria and interaction. The interdisciplinary method involves the integration of knowledge from psychiatry, philosophy, medical history, cultural studies, and psychology, providing a deep understanding of the medical, philosophical, social, and cultural aspects of mental disorders. R e s u l t s. The article analyzes the historical development of ideas and methodology for the classification of mental disorders from ancient Greece to the present. From Hippocrates and Plato to Sydenham, Kabanis, Pinel, and Eskierol, the authors trace the evolution of understanding of mental disorders, emphasizing the shift in emphasis from etiological theories to more descriptive and categorical models. The authors describe the current state of the DSM and ICD classification systems, which play a dominant role in psychiatric science and subsequent social support and welfare for people suffering from mental disorders. Changes that have occurred in these systems and their impact on psychiatric practice and research are discussed. Considerable emphasis is placed on the history of the diagnosis of post-traumatic stress disorder (PTSD), which becomes a symbolic indicator of the complexities and challenges associated with the modern classification of mental illness. The authors consider the phenomenological method as a tool for a deeper understanding of PTSD, especially in the context of the constant psychotraumatic factors of war, the consequences of which generate new challenges for Ukrainian psychiatric practice. The authors present a case study using the phenomenological approach to diagnose PTSD, which demonstrates the need for a detailed analysis of patients' internal experience for accurate diagnosis and effective treatment. C o n c l u s i o n s. The conclusions emphasize the importance of integrating philosophical methods into the diagnosis and analysis of mental illness in clinical practice. The authors call for the development of interdisciplinary research involving both philosophers and mental health professionals to develop more detailed and person-centered approaches to the diagnosis and treatment of mental disorders. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Should Clinicians’ Views of Mental Illness Influence the DSM?Elizabeth H. Flanagan (bio) and Roger K. Blashfield (bio)Keywordsclinicians, DSM, values, psychopathology, scienceThe relationship between clinicians and the DSM is complex. Clinicians are the primary intended audience of the DSM. However, as Widiger (2007) pointed out in his commentary, there is a tension associated with trying to meet the clinical goals of the DSM and also trying to optimize (...) the scientific goals of the DSM. Most commentators would agree that the recent editions of the DSM (from the DSM-III onward) have favored scientific values (e.g., Sadler 2005). Some commentators have taken sides and aligned themselves with either clinicians or with the science of classification. For instance, Garb (2005) has argued that clinicians should receive incentives to align themselves more closely with the science of the DSM. In contrast, Westen and Shedler (1999) have favored a clinician-based approach to the DSM and have argued that an ideal classification should be based on the prototypes that clinicians use to conceptualize diagnostic categories. Perhaps an extreme suggestion on how to deal with this tension between the values of clinicians and the values of scientists is to adopt the ICD-10 solution and create two versions of the next DSM. One version would be written for clinicians and another for researchers (Phillips et al. 2003).Widiger (2007) wondered whether the two of us as authors are on the fence about how the views of clinicians should affect the DSM. As clinical psychologists who are both clinicians and researchers, we understand his comment, especially in light of our attempt in our article not to overgeneralize from the time-consuming, labor-intensive, yet methodologically limited study we reported in our major paper.Nonetheless, our answer to the question asked in the title of this response, “Should clinicians’ views of mental illness influence the diagnostic manual?” is a clear and unequivocal yes. In our view, too much of the research literature stimulated by the recent DSMs has primarily used the diagnostic criteria in these DSMs to specify patient samples and then perform various experiments to study the DSM categories. We favor a different approach to research which is consistent with a comment once made by the philosopher of science, Karl Popper: “scientific theories originate from myths, and... a myth may contain important anticipations of scientific theories” (1963, 39). We believe that clinicians, with their years [End Page 285] of experience dealing with the ambiguities, the emotionality, and the chaos of psychopathology, have formed complex conceptual systems to try to understand the mysteries of abnormal behavior. We strongly support increased research attempts that will use clinicians as subjects and that will attempt to understand how clinicians use diagnostic concepts to understand patients.Although research on clinicians has not attracted a large amount of attention in the field, there is a long history of such research studies. For instance, in the 1970s, Overall used multivariate techniques to create graphical maps of how clinicians represented relationships among diagnoses (Overall et al. 1977). Widiger has used a similar strategy in some of his research (Widiger et al. 1987). In the early 1980s, a view of concept formation from cognitive psychology was used by Cantor et al. (1980) to look at psychiatric diagnoses as representing prototypes. Horowitz and colleagues extended this research. Blashfield and his colleagues had a grant to use the prototype model to study personality disorders and performed research investigating both case histories (Blashfield et al. 1985) and analyses of diagnostic criteria (Blashfield and Breen 1989; Davis, Blashfield, and McElroy 1993). Westen and colleagues have attempted to reconceptualize DSM personality disorder categories using the prototype model (Westen and Shedler 1999). Ahn and her colleagues (Ahn et al. 2006; Kim and Ahn 2002) have taken more recent applications of ideas from cognitive psychology to study how clinicians use and understand diagnostic categories. Finally, Flanagan and colleagues (Flanagan and Blashfield 2006; Flanagan, Keeley, and Blashfield, in press; Flanagan, Miller, and Davidson, submitted) have used qualitative and quantitative data analysis techniques to try to understand the diagnostic concepts held by experienced clinicians.Besides empirical studies of how clinicians use diagnostic concepts, we also support the increased interest in... (shrink)

Kant’s conception of mental illness is unlikely to satisfy contemporary readers. His classifications of mental illness are often fluid and ambiguous, and he seems to attribute to human beings at least some responsibility for preventing mental illness. In spite of these apparent disadvantages, I argue that Kant’s account of mental illness can be illuminating to his views about the normative dimensions of human cognition. In contrast to current understandings of mental (...) class='Hi'>illness, Kant’s account is what I refer to as “non-pathological.” That is, most mental illnesses are for Kant continuous with normally functioning cognition. Someone with a healthy reason can easily fall into mental illness and someone with mental illness can (perhaps not as easily) re-establish healthy reason. By accepting a non-pathological definition of mental illness, it follows for Kant that humans have more agency and responsibility regarding their mental health than current views allow, which explains why several of his writings aim to prescribe a “diet of the mind” (2:271). Contrary to popular readings of Kant as a champion of reason’s power, Kant’s conception of mental illness shows that he recognizes how fragile human reason can be. (shrink)

Our philosophical understanding of mental illness is being shaped by neuroscience. However, it has the paradoxical effect of igniting two radically opposed groups of philosophical views. On one side, skepticism and denialism assume that, lacking clear biological mechanisms and etiologies for most mental illnesses, we should infer they are constructions best explained by means of social factors. This is strongly associated with medical nihilism: it considers psychiatry more harmful than benign. On the other side of the divide, (...) naturalism and reductionism are on the look for failures in the biological functioning of the organism whenever a genuine mental illness occurs. Psychiatry as currently practiced, accordingly, exhibits the gaps of an ongoing research programme; a yet to be completed neuroscience would link mental illnesses with identifiable biological mechanisms. Both sides of this divide claim to be fostered by scientific discoveries and advances in neuroscience, when taken at face value. Against this background, we argue instead for a modest view. To that end, we draw attention to some nuances in the scientific realism debate. While contending that neuroscientific theories and models aim to provide true representations of their target systems, and can justifiably claim to have attained some, we argue that our confidence should not be placed beforehand in specific features of these scientific representations. Hence, it would be unwarranted to extract morals for psychiatry from posits (or their absence) in neuroscientific explanations of mental illnesses. To illustrate our position, we examine some recent discoveries in neuroscience concerning bipolar disorder. We conclude by linking our topic to a broader issue in the philosophy of medicine: insofar as psychiatry is a biomedical specialty, its classifications of health and disease are guided by pragmatic concerns, as well as by scientific discoveries. (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)

Mental disorder (earlier entitled “illness” or “disease”) is ascribed to deviations from normal thoughts, reasoning, feelings, attitudes, and actions that are considered socially or personally dysfunctional and apt for treatment. Schizophrenia, depression, and bipolar disorder are core examples. The concept of mental disorder plays a role in many domains, including medicine, social sciences such as psychology and anthropology, and the humanities, including literature and philosophy. Philosophical discussions are the primary focus of the present entry, which differs from (...) the entry on Philosophy of Psychiatry in noting several different approaches—not only those of the philosophy of science and mind, but also those arising from phenomenology and social theory. -/- Mental disorder is a widely contested concept and there are longstanding debates on whether disorders are biological or social in nature. Even uncontroversial disorders, such as those listed above, were not always regarded as disorders in the past (Porter 2002). Moreover, the status of mental disorder has frequently indicated ethical, as much as other deficiency (Irwin 2013). Such reminders direct our attention to contemporary medical psychiatry’s sometimes uncompromisingly neurobiological, and avowedly value-free “medical model”, with its incumbent analogies and assumptions, and to the general question of how the taxa of psychiatric classifications are to be viewed as objects of natural science. This model has received intensive philosophical scrutiny, including arguments that deny these conditions are deficiencies at all. Along with issues arising from cognitive psychology and the neurosciences, such foundational matters make up much of the following entry. Because of their focus on issues central to the philosophy of mind and ethics (e.g., the mind-body problem, moral responsibility, agency and identity), analyses of mental disorder have extensive implications for those fields. As clinical phenomena, they also reflect an inescapable, everyday, social reality, giving theoretical inquiries additionally urgent practical, moral, and legal implications. (shrink)

Mental disorder (earlier entitled “illness” or “disease”) is ascribed to deviations from normal thoughts, reasoning, feelings, attitudes, and actions that are considered socially or personally dysfunctional and apt for treatment. Schizophrenia, depression, and bipolar disorder are core examples. The concept of mental disorder plays a role in many domains, including medicine, social sciences such as psychology and anthropology, and the humanities, including literature and philosophy. Philosophical discussions are the primary focus of the present entry, which differs from (...) the entry on Philosophy of Psychiatry in noting several different approaches—not only those of the philosophy of science and mind, but also those arising from phenomenology and social theory. -/- Mental disorder is a widely contested concept and there are longstanding debates on whether disorders are biological or social in nature. Even uncontroversial disorders, such as those listed above, were not always regarded as disorders in the past (Porter 2002). Moreover, the status of mental disorder has frequently indicated ethical, as much as other deficiency (Irwin 2013). Such reminders direct our attention to contemporary medical psychiatry’s sometimes uncompromisingly neurobiological, and avowedly value-free “medical model”, with its incumbent analogies and assumptions, and to the general question of how the taxa of psychiatric classifications are to be viewed as objects of natural science. This model has received intensive philosophical scrutiny, including arguments that deny these conditions are deficiencies at all. Along with issues arising from cognitive psychology and the neurosciences, such foundational matters make up much of the following entry. Because of their focus on issues central to the philosophy of mind and ethics (e.g., the mind-body problem, moral responsibility, agency and identity), analyses of mental disorder have extensive implications for those fields. As clinical phenomena, they also reflect an inescapable, everyday, social reality, giving theoretical inquiries additionally urgent practical, moral, and legal implications. (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)

"Grapples with the legacy of Jerome Wakefield, one of the most influential critics of modern psychiatry and the use of the DSM for psychiatric diagnosis"--.

Labeling theory as ideology and as science: Scheff, T. J. Schizophrenia as ideology. Scheff, T. J. On reason and sanity. Scheff, T. J. The labeling theory of mental illness. Greenley, J. R. Alternate views of the psychiatrist's role. Temerlin, M. K. Suggestion effects in psychiatric diagnosis. Rosenhan, D. L. On being sane in insane places.--Changing the system: Scheff, T. J. Labeling, emotion, and individual change. Schatzman, M. Paranoia or persecution: the case of Schreber. Sidel, R. Mental diseases (...) in China and their treatment. Obeysekere, G. The idiom of demonic possession. (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 lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 57-62 [Access article in PDF] Listening to People Or Listening to Prozac?Another Consideration of Causal Classifications Jennifer Hansen Keywords causal classification, descriptivism, melancholia, neurasthenia, depression, cultural relativism. The shape and detail of depression have gone through a thousand cartwheels, and the treatment of depression has alternated between the ridiculous and the sublime, but the excessive sleeping, inadequate eating, suicidiality, withdrawal from social (...) interaction, and relentless despair are all as old as the hill tribes, if not as old as the hills. In the years since man achieved the capacity for self-reference, shame has come and gone; treatments for bodily complaints have alternated and crossed with treatments for spiritual ones; pleas to external gods have echoed pleas to internal demons. To understand the history of depression is to understand the invention of human being as we now know and are him. Our Prozac-popping, cognitively focused, semi-alienated postmodernity is only a stage in the ongoing understanding and control of mood and character. (Solomon 2001, 286) ALTHOUGH ANDREW SOLOMON clearly believes that "the shape and detail of depression have gone through a thousand cartwheels," Jennifer Radden gives us pause before assuming that depression is just another name for Dame Melancholy. Solomon's claim depends on a deeper metaphysical claim about the nature of depression and its causes. The current method of psychiatric nosology, descriptivism, does not necessarily support equating melancholia and depression. Furthermore, it appears that adopting descriptivism as the sole method of classifying mental disorders commits us to cultural relativist psychiatry. Below I reconsider whether we want to rule out causal classifications and suggest that embracing both descriptivism and causal classifications offer us greater possibilities in understanding human illness and culture.Although the occasion for Jennifer Radden's essay is to investigate whether or not melancholia and depression refer to the same thing, her essay detours into a consideration of extra-descriptivist models of psychiatric illness versus the descriptivism of current psychiatric nosology. This detour turns out to be warranted; her purely academic question yields to a timelier question concerning the proper methodology for classifying mental disorders. Whereas debates about psychiatric nosology are perennial, the recent success of the new generation of antidepressants [End Page 57] is reviving biological psychiatry and its search for the neurochemical origins of depression. Hence, embedded in Radden's question concerning whether or not melancholia is the same thing as clinical depression, is another important question concerning the causes of mental illness, particularly depression.Currently, with its descriptivist approach, the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not classify mental illness, such as clinical depression, based on underlying causes. The cluster of symptoms and behavioral signs that lead a clinician to diagnose one as depressed that are contained in either the DSM or the International Classification of Diseases (ICD) may be too fuzzy or elusive to give any clear distinction between major depression, mild depression, and the blues. For example, one group of epidemiologists points out that [t]he DSM-III, DSM-III-R, and DSM-IV acknowledge that depression, like many mental disorders, has no currently obvious natural classes... If natural classes of depression exist, then their nosology awaits the discovery of distinct and reliable genetic, biological, clinical, or other predictors of risk, severity, or clinical course. Clinicians have a tradition of separating depressions into subtypes; however, this subtyping has not yet led to clear-cut delineations of syndromes in populations. (Kaelber 1995, 4) The evidence is still insufficient to establish the biological or psychological origins of depression. Although many theories exist that explain why people become depressed, scientifically we are not yet in a position to determine which is the right theory. From a pragmatic perspective, however, whether or not we know what causes depression, we can nonetheless attempt to alleviate suffering from depression. And it is with this goal in mind that the DSM-IV and ICD-10 classify mental disorders.Now, given that our current methodology for psychiatric nosology does not establish causes, it is also insufficient for determining what... (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 (...) class='Hi'>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)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Moral Responsibility:Disorders of Personhood as Harmful Dysfunctions, With Special Reference to AlcoholismJerome C. Wakefield (bio)Keywordsalcohol dependence, philosophy of psychiatry, mental disorder, harmful dysfunction, psychiatric diagnosis, person, moral responsibilityIn his paper, Ethical Decisions in the Classification of Mental Conditions as Mental Illness, Craig Edwards grapples with a profound problem: why is it that when we classify a mental condition as (...) a mental disorder, that tends to take the condition out of the sphere of moral responsibility or virtuousness of character? For example, it is not uncommon when someone commits suicide and the question is raised as to why he or she did it, that instead of a reason or character trait that would place the act within a moral calculus, one is offered the explanation "she was clinically depressed" or "he was bipolar," and this tends to terminate discussion and make reasons and moral evaluation superfluous. Why does such a comment have that effect?As Edwards notes, this can get complicated as the moral and the disordered interact. Certainly people are sometimes morally responsible for acting on their disordered impulses (as in pedophilia), and they are responsible for putting themselves in the way of disorder, as when someone imbibes in a way likely to lead to alcoholism. But at the normal/disorder divide, there seems to be a consistent lifting of some responsibility, reflecting the application of the sick role. For example, the rough equivalent of our current category of post-traumatic stress disorder (PTSD) was recognized as a disorder in earlier wars ("shell shock," "war neurosis"), but often considered an expression of cowardice; the cowardice was morally evaluable as a failure of virtue (even if, like many personality traits, being a coward is not within the person's direct voluntary control) and led to contempt for those with PTSD, but nonetheless—except in cases thought to be malingering—the PTSD that resulted constituted a disorder for which the individual was [End Page 91] not in the same direct sense blameworthy. This moral shift requires explanation.This topic also has important social ramifications. Relief from responsibility may sound like a good thing, and it is trumpeted by mental health advocates as a reason for supporting the classification of many conditions as disorders. But as Edwards is aware, it is a two-edged sword. Disordered status may allow escape from censure and offer the protections of the sick role, but it also changes the relationship of the agent to his or her own actions and imposes the responsibility of the sick role on the individual to attempt to change ("get better"). The sick role allows for no defense of an idiosyncrasy based on normal variation ("It takes all kinds…") or the individual's eccentric vision or steadfast integrity, for that vision or sense of integrity are now seen as pathological and not morally legitimate. The individual is subjected to endless entreaties to seek help and it is implied that not to do so is irresponsible, so that a decision to embrace one's nature and remain as one is becomes illegitimate. Moreover, the sick role allows for no explanation in terms of the individual's normal defensive response to unjust, deprived, or challenging social or environmental circumstances, thus weakening the motives for social change rather than individual intervention.In sum, there is an inevitable sense in which being placed in the sick role inherently stigmatizes the "sick" condition in virtue of the special moral attitudes extended to the disordered. Cultures can thus easily exploit the sick role and its much-touted relief from responsibility to extend the reach of social control processes. This is one reason why the distinction between disorder and non-disorder is so important, and why it is crucial to identify when non-disordered conditions are mislabeled as disorders—as when, for example, psychiatry gets it wrong about the distinction between normal and disordered sadness (Horwitz and Wakefield, 2007). Such overpathologization can redefine the boundaries of our moral universe on mistaken grounds.Edwards offers two provocative answers—not entirely at ease with each other—to the question of why mental disorders relieve the patient from moral responsibility: (1) mental disorders are... (shrink)

The ability to (re)classify populations is a key component of state power, but not all new state classifications actually succeed in changing how people are categorized and governed. This article examines the French state’s partly unsuccessful project in 2005 to use a new classification—“psychic handicap”—to ensure that people with severe mental disorders received services and benefits from separate agencies based on a designation of being both “mentally ill” and “disabled.” Previous research has identified how new classifications can be (...) impeded by cultural and cognitive barriers to their adoption and struggles between professionals or administrators over their implementation. Drawing on 186 interviews, archival sources, and 13 months of observations across different French bureaucracies, I expand on this literature in two ways. First, I use the case of psychic handicap to argue that a new classification can also fail to achieve its intended effect when it constitutes a bureaucratically split personality—a combination of classifications that imply that individuals belong to two, mutually exclusive kinds of people. I show how psychic handicap embodied contradictory expectations about the behavior, characteristics, and institutional trajectory of people with mental disorders. Second, I identify how bureaucrats resolved these contradictions through mechanisms of refractory looping, outsourcing expertise, and classification by default, which in this case led to the reclassification of this population as simply “mentally ill.” This framework calls attention to how practical inconsistencies can limit the impact of new classifications, even absent overt resistance to their elaboration or implementation. (shrink)

Transcultural comparisons taking the differences and commonalities into consideration in the fields of mental health and ill mental health have always been a focus of scientific interest. The ‘East’ and ‘West’ comparisons in this regard, could be the one most widely deliberated. ‘East and West’, as a human-made conceptual construct, has evolved to signify many social, cultural, political, economic and psychological realities and meanings, beyond its geographical references. Such conceptualizations both reflect and re-construct our realities. -/- Beyond the (...) inequalities and discrepancies in resources, the ‘East and West’ dualism has an impact on mental health theory and praxis in a many different ways. The range, content, patterns and expression of psychopathology and psychiatric symptomatology; the explanatory models of mental disorders; the diagnostic and classification systems; the psychopharmacological and psychotherapeutical interventions; the role of family and psychosocial support systems; basic conceptualizations of mental health and disease are some of the main areas of diversity. -/- This chapter, after briefly discussing the historical roots of the conceptualization of ‘East and West’, will be focused on the relations of mental health and ill mental health with this and related conceptualizations. It is concluded that, in this day of globalization, to improve the quality of psychiatric theory and praxis within a framework of high ethical standards, a paradigm focusing on the unity in diversity and embracing a non-dualistic, non-categorical, and non-hierarchical humanistic approach to cultural differences would bring all the colours of humanity and therefore psychiatry onto the canvas. (shrink)

Without a better understanding of mental disease, patients diagnosed with a mental disease may be mistreated clinically and/or socially, and caregivers and families may be wrongfully blamed for causing the disease and/or for not effectively helping and developing meaningful relationships with the patient as person. In trying to understand mental disease and why its various dimensions raise difficulties for our systems of classification and our medical models of diagnosis and treatment, a framework is required. This framework (...) will connect metaphysical, epistemological, and ethical considerations in ways that are mutually supportive and illuminating. This, in turn, will benefit those who are diseased and those persons who study, classify, diagnose, and treat disease. (shrink)

This paper examines the representation of mental illness and mental disorder in the Washington Community Protection Act of 1990 (WCPA), the first package of sexual predator legislation passed in the United States. I focus on the public outcry over a violent crime committed by a repeat sexual offender, Earl Shriner, and show how the act was drafted in direct response to this outcry. Following his arrest, there was a public discussion of a) whether the state had a (...) responsibility to cure individuals like Shriner before releasing them, and b) whether sex offenders could be cured at all. The WCPA was a landmark law because it shifted forensic psychology in the use of sexual criminals from an intervention model to a containment model, from a model that sought to separate out those sexual criminals who could be treated to a model that separated out sexual criminals because they could not be treated. I demonstrate here that this shift was made in response to the representation of Earl Shriner as a member of a group classified by legislators as having a coherent, recognizable and untreatable mental disorder that caused them to commit acts of sexual violence. (shrink)

In psychiatry there is no sharp boundary between the normal and the pathological. Although clear cases abound, it is often indeterminate whether a particular condition does or does not qualify as a mental disorder. For example, definitions of ‘subthreshold disorders’ and of the ‘prodromal stages’ of diseases are notoriously contentious. -/- Philosophers and linguists call concepts that lack sharp boundaries, and thus admit of borderline cases, ‘vague’. Although blurred boundaries between the normal and the pathological are a recurrent theme (...) in many publications concerned with the classification of mental disorders, systematic approaches that take into account philosophical reflections on vagueness are rare. This book provides interdisciplinary discussions about vagueness in psychiatry by bringing together scholars from psychiatry, psychology, philosophy, history, and law. It draws together various lines of inquiry into the nature of gradations between mental health and disease and discusses the individual and societal consequences of dealing with blurred boundaries in medical practice, forensic psychiatry, and beyond. -/- Part I starts with an overview chapter that helps readers to navigate through the philosophy of vagueness and through the various debates surrounding demarcation problems in the classification and diagnosis of mental illness. Part II encompasses historical and recent philosophical positions on gradualist approaches to health and disease. Part III approaches the vagueness of present psychiatric classification systems, and the debates concerning their revisions by scrutinizing controversial categories, such as posttraumatic stress disorder, and the difficulties of day-to-day diagnostic and therapeutic practice. Part IV finally focuses on social, moral, and legal implications that arise when being mentally ill is a matter of degree. (shrink)

While classifications of mental disorders have existed for over one hundred years, it still remains unspecified what terms such as 'mental disorder', 'disease' and 'illness' might actually denote. While ontologies have been called in aid to address this shortfall since the GALEN project of the early 1990s, most attempts thus far have sought to provide a formal description of the structure of some pre-existing terminology or classification, rather than of the corresponding structures and processes on the (...) side of the patient. We here present a view of mental disease that is based on ontological realism and which follows the principles embodied in Basic Formal Ontology and in the application of BFO in the Ontology of General Medical Science. We analyzed statements about what counts as a mental disease provided in the research agenda for the DSM-V, and in Pies' model. The results were used to assess whether the representational units of BFO and OGMS were adequate as foundations for a formal representation of the entities in reality that these statements attempt to describe. We then analyzed the representational units specific to mental disease and provided corresponding definitions. Our key contributions lie in the identification of confusions and conflations in the existing terminology of mental disease and in providing what we believe is a framework for the sort of clear and unambiguous reference to entities on the side of the patient that is needed in order to avoid these confusions in the future. (shrink)

The philosophy of medicine and psychiatry has considered the defining of disease, illness, and disorder an important project for over three decades. Within this literature, accounts based on adaptive "functions" have been prominent, particularly in the DSM nosology. In response to this trend, Jerome Wakefield has presented a view of mental disorder as "harmful dysfunction." In this view, "harm" contributes the value-element to disorder concepts, while "dysfunction" implies a value-free foundation as long as the latter is grounded in (...) evolutionary biology. In a critical review of Wakefield's and others' functionalist arguments for disorder concepts, we make four major points. We recommend a shift away from the definition of value-free disorder concepts, instead emphasizing the analysis of the logical features and the value commitments in nosological categories. (shrink)

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

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

This paper argues that specific phobia is an ideal kind of psychiatric disorder because it bears the marks of a mature medical diagnosis and is amenable to causal explanation. A new and ambitious program of ‘causal revolution’ has recently emerged in psychiatry that hopes to refurnish our taxonomies by discovering the underlying biological and psychological causes that create and maintain mental illness. I show that the sort of causal story envisioned by the program is a mechanistic property cluster (...) (MPC) structure, which involves a causal mechanism that explains the co-occurrence of a disorder’s signs and symptoms (Kendler, Zachar & Craver, 2011). I then build a model of fear in humans and sketch a novel account of specific phobia as a configuration of the fear system in thrall to deregulated network dynamics such as hysteresis, tipping points, and feedback loops. Specific phobia has an MPC structure. I close by reflecting on whether we can reasonably expect other mental disorders to fit an MPC mold, and thus lend themselves to future causal validation. This paper shows that specific phobia holds a unique place in our picture of mental disorder that has so far been missed. It is an ideal kind of psychopathology. (shrink)

In _ Psychiatry in the Scientific Image, _Dominic Murphy looks at psychiatry from the viewpoint of analytic philosophy of science, considering three issues: how we should conceive of, classify, and explain mental illness. If someone is said to have a mental illness, what about it is mental? What makes it an illness? How might we explain and classify it? A system of psychiatric classification settles these questions by distinguishing the mental illnesses and (...) showing how they stand in relation to one another. This book explores the philosophical issues raised by the project of explaining and classifying mental illness. Murphy argues that the current literature on mental illness -- exemplified by the Diagnostic and Statistical Manual of Mental Disorders -- is an impediment to research; it lacks a coherent concept of the mental and a satisfactory account of disorder, and yields too much authority to commonsense thought about the mind. He argues that the explanation of mental illness should meet the standards of good explanatory practice in the cognitive neurosciences, and that the classification of mental disorders should group symptoms into conditions based on the causal structure of the normal mind. (shrink)

Mental health research and care in the twenty first century faces a series of conceptual and ethical challenges arising from unprecedented advances in the neurosciences, combined with radical cultural and organisational change. The Oxford Textbook of Philosophy of Psychiatry is aimed at all those responding to these challenges, from professionals in health and social care, managers, lawyers and policy makers; service users, informal carers and others in the voluntary sector; through to philosophers, neuroscientists and clinical researchers. Organised around a (...) series of case studies in five key topic areas - concepts of disorder, the philosophical history of psychopathology, philosophy of science, ethics and philosophical value theory, and philosophy of mind - the book provides a detailed introduction to the field and a framework for study and skill development. Each case study is supported by selected readings from both philosophy and mental health, thinking skills exercises, self-test questions, key learning points and detailed guides to further reading. There is an introduction for philosophers to classification and descriptive psychopathology, and for practitioners to philosophical methods (including logic). The philosophical topics covered include philosophical methods (analytic and Continental); phenomenology, hermeneutics and existentialism, logical empiricism and its successors; idealism and realism; reasons and causes; and modern theories of mind and brain, free will and personal identity. Topics from mental health include psychiatry and 'anti-psychiatry'; Jaspers' psychopathology and the new neurosciences; the future of psychiatric classifications; strengths-based approaches, recovery practice, social inclusion and diversity; and key topics in psychopathology, such as delusion, autism, disorders of volition, thought insertion and other experiences in schizophrenia. The Oxford Textbook of Philosophy of Psychiatry aims to secure the skills-base of the discipline by bringing philosophers closer to the realities of practice in mental health, and mental health practitioners closer to the resources of philosophy as a partner to the sciences in responding to the challenges of twenty-first century mental health and social care. (shrink)

Schizophrenia is a serious mental illness characterized by a disconnection between brain regions. Transcranial magnetic stimulation is a non-invasive brain intervention technique that can be used as a new and safe treatment option for patients with schizophrenia with drug-refractory symptoms, such as negative symptoms and cognitive impairment. However, the therapeutic effects of transcranial magnetic stimulation remain unclear and would be investigated using non-invasive tools, such as functional connectivity. A longitudinal design was adopted to investigate the alteration in FC (...) dynamics using a dynamic functional connectivity approach in patients with schizophrenia following high-frequency repeated transcranial magnetic stimulation with the target at the left dorsolateral prefrontal cortex. Two groups of schizophrenia inpatients were recruited. One group received a 4-week high-frequency rTMS together with antipsychotic drugs, while the other group only received antipsychotic drugs. Resting-state functional magnetic resonance imaging and psychiatric symptoms were obtained from the patients with schizophrenia twice at baseline and after 4-week treatment. The dynamics was evaluated using voxel- and region-wise FC temporal variability resulting from fMRI data. The pattern classification technique was used to verify the clinical application value of FC temporal variability. For the voxel-wise FC temporary variability, the repeated measures ANCOVA analysis showed significant treatment × time interaction effects on the FC temporary variability between the left DLPFC and several regions, including the thalamus, cerebellum, precuneus, and precentral gyrus, which are mainly located within the cortico-thalamo-cerebellar circuit. For the ROI-wise FC temporary variability, our results found a significant interaction effect on the FC among CTCC. rTMS intervention led to a reduced FC temporary variability. In addition, higher alteration in FC temporal variability between left DLPFC and right posterior parietal thalamus predicted a higher remission ratio of negative symptom scores, indicating that the decrease of FC temporal variability between the brain regions was associated with the remission of schizophrenia severity. The support vector regression results suggested that the baseline pattern of FC temporary variability between the regions in CTCC could predict the efficacy of high-frequency rTMS intervention on negative symptoms in schizophrenia. These findings confirm the potential relationship between the reduction in whole-brain functional dynamics induced by high-frequency rTMS and the improvement in psychiatric scores, suggesting that high-frequency rTMS affects psychiatric symptoms by coordinating the heterogeneity of activity between the brain regions. Future studies would examine the clinical utility of using functional dynamics patterns between specific brain regions as a biomarker to predict the treatment response of high-frequency rTMS. (shrink)

The well-replicated observation that many people maintain mental health despite exposure to severe psychological or physical adversity has ignited interest in the mechanisms that protect against stress-related mental illness. Focusing on resilience rather than pathophysiology in many ways represents a paradigm shift in clinical-psychological and psychiatric research that has great potential for the development of new prevention and treatment strategies. More recently, research into resilience also arrived in the neurobiological community, posing nontrivial questions about ecological validity and (...) translatability. Drawing on concepts and findings from transdiagnostic psychiatry, emotion research, and behavioral and cognitive neuroscience, we propose a unified theoretical framework for the neuroscientific study of general resilience mechanisms. The framework is applicable to both animal and human research and supports the design and interpretation of translational studies. The theory emphasizes the causal role of stimulus appraisal (evaluation) processes in the generation of emotional responses, including responses to potential stressors. On this basis, it posits that a positive (non-negative) appraisal style is the key mechanism that protects against the detrimental effects of stress and mediates the effects of other known resilience factors. Appraisal style is shaped by three classes of cognitive processes – positive situation classification, reappraisal, and interference inhibition – that can be investigated at the neural level. Prospects for the future development of resilience research are discussed. (shrink)

Evidence suggests that participation in plaza dancing may affect mental health. This study for the first time quantified the relationships between plaza dancing and psychological well-being and ill-being. We systematically searched PubMed, Web of Science, CNKI, Wanfang, and VIP to identify relevant studies published from the databases since their inception to July 25, 2021. The standardized mean differences of pre-to-post intervention data were calculated in the meta-analysis. Subgroup and meta-regression analyses were performed to test the potential moderating effects of (...) age, outcome classification, measurement instruments, district, publication year, total sample size, and the duration, frequency, and length of the square dance intervention. A total of 25 original articles met all the eligibility criteria and were included in the review, and 17 studies were included in the meta-analysis. The meta-analysis revealed that plaza dancing improved psychological well-being and reduced psychological ill-being. The study participants’ age and district did not seem to affect the effectiveness of the plaza dancing intervention. The duration and frequency of plaza dancing affected the association between square dance and psychological well-being and psychological ill-being. Plaza dancing has a significant positive effect on psychological well-being and psychological ill-being, and the effects are moderated by intervention modality. Generalizing plaza dancing interventions to promote psychological well-being and prevent or treat psychological ill-being is needed.Systematic Review Registration[www.crd.york.ac.uk/prospero], identifier [CRD42021272016]. (shrink)

The study of mental illness by the methods of molecular genetics is still in its infancy, but the use of genetic markers in psychiatry may potentially lead to a Virchowian revolution in the conception of mental illness. Genetic markers may define novel clusters of patients having diverse clinical presentations but sharing a common genetic and mechanistic basis. Such clusters may differ radically from the conventional classification schemes of psychiatric illness. However, the reduction of even (...) relatively simple Mendelian phenomena to molecular genetics has been shown to be a surprisingly complex and problematic enterprise. Mental illnesses exist at many levels of including social, environmental, and developmental interactions. Reductionistic shifts in the classification of such a disease entity will have to address the interlevel dynamics that take place within the structure of theories of mental illness. The question of how molecular analysis of psychiatric disease will impact on the structure of existing theories and classification systems is the central topic of this paper. (shrink)

Mental disorders have been suggested to differ from somatic diseases because they lack an organic correlate. We show that this argument is both empirically wrong and theoretically irrelevant, because diseases are defined by functional impairments and not biological variation. Due to human diversity, a multitude of functions can be defined, and any selection of medically relevant functional impairments is necessarily value-based. We suggest that such values include individual survival and living in a shared world with others, and that their (...) definition requires public debate and a critical reflection by Philosophical Anthropology. However, the presence of functional impairments that are generally relevant for human life and survival only fulfils the so-called disease criterion, which is necessary but not sufficient to diagnose a clinically relevant malady. This would only be justified if such functional impairments cause individual harm, either because they are accompanied by suffering (the illness criterion) or because they interfere with basic activities of daily living such as personal hygiene and food intake (the sickness criterion of a clinically relevant malady). We apply this theory to mental disorders, conclude that only a fraction of such “disorders” currently listed in international classifications of diseases are clinically relevant mental maladies, suggest focusing on the needs of persons with such maladies and recommend avoiding “pathologization” of human diversity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ambiguities of Mild Cognitive ImpairmentTim Thornton (bio)Keywordsclassification, disease, mild cognitive impairment, normative, valuesCorner and Bond's paper (2006) raises some key ethical questions about the classification and diagnosis of mild cognitive impairment (MCI). In this commentary, I wish to revise some of the general issues about the classification of mental disorder raised by this particular classificatory concept. The central issue raised is the connection between the (...) pathologic status of a condition and what I term the plain facts about the frequency and nature of its symptoms.There are a number of ethical questions raised by applying the label of MCI. Centrally, perhaps, is the concern, illustrated by the case vignettes, that a diagnosis carries negative repercussions that might outweigh the more narrowly medical advantages of an early diagnosis. But although that concern may be appropriate, such ethical complications are a danger of any psychiatric classification or diagnosis, even the most well grounded. Any psychiatric diagnosis can carry a danger of stigma, for example.What seems to make such ethical concerns more serious in this case—at least to a philosopher outsider—is the implicit further concern that MCI is not a real, objective, or, to use a more medical term, valid category or classification. If it is not valid, then any negative connotations of the diagnosis will not be outweighed by medical technological achievements. In other words, the further ethical issues are given much greater weight if the question of validity is not satisfactorily resolved.The question of the reality, objectivity, or validity of MCI can be divided into two issues:1. Is MCI a real, objective, or valid feature of psychological phenomenology?2. Is MCI a real, objective, or valid psychological illness, disease, or pathology?A condition might be a real, objective, or valid feature of psychological phenomenology without being a real illness. It might be some other aspect of human living. Szasz (1960) suggests that this is the case with mental illness (he might more properly say "so-called mental illness") as a whole. But, less controversially, the unusual ability to calculate, mentally and in a flash, the date of future Easter Sundays is a genuine feature of human living—some people possess the ability even if most do not—without either it, or its lack, being an illness. Being real as an illness is a very specific kind of being. It is this, I suggest, that raises difficulties in the case of MCI by contrast with the easier question of whether something is a genuine feature of human living in some other way. [End Page 21]From "normal" and "normative" to "correct" and "incorrect"Corner and Bond (2006) usefully suggest that the question of whether MCI is real is made more difficult by an ambiguity in the sense of the word normal. They suggest that although "physiologic and cognitive decline is assumed to be a normal experience" this still leaves "boundary problems" about "distinguishing normal aging from disease" (Corner and Bond 2006, 3–4). Thus, if the symptoms of MCI are continuous with the ordinary phenomena of physiologic and cognitive decline, then they might also be merely normal. But this does not settle the status of MCI because normal can mean either "normative, that is, usual; or it can mean nonpathologic" (Corner and Bond 2006, 4).On the assumption that MCI is at least continuous with phenomena that are normal, then its symptoms might be normal in the sense of usual but nevertheless pathologic: an inevitable illness. Or they might be usual and nonpathologic, that is, merely a feature of aging that, although regrettable, lacks the connotations of illness (e.g., the appropriateness, if not the possibility, of treatment). (In principle on the assumption in play—that the symptoms of MCI are normal—they might be unusual but nonpathologic akin, for example, to an improved ability to solve crosswords with age that might affect a small lucky proportion of the population. Perhaps such a crossword puzzler might be reassured by their doctor: "Well that is very unusual but there is no need to worry: it is not a symptom of any illness. You are perfectly normal.")Thus the question "Is MCI normal... (shrink)

The problem of names of illnesses is both a problem of words and values that should address not only the classification of disorders, but also a fundamental question both for medical sciences and humanities: can psychiatric nosology and classifications fit with the ontological constitution of human beings? This paper aims to discuss the so-called “psychiatric object” and its language and it intends to provide a hermeneutical-phenomenological account to mental health. In doing so, the paper will firstly examine the (...) “psychiatric object” and its language; secondly, it will show the difference between taxonomy and ontology, both of interest for the psychiatric object; third, it will insist on the critique of the epistemological status of psychiatry conceived from a natural point of view following three main paths: a metaphysical one (Heidegger, Jaspers), a social one (Szasz, Foucault, Basaglia), and an ethical one (Laing). Finally, it will clarify why phenomenology and in particular hermeneutical-phenomenology can illuminate the understanding of the psychiatric object and its implications in a cultural context, in order to achieve a more humanistic psychiatry. (shrink)

Essential Philosophy of Psychiatry is a concise introduction to the growing field of philosophy of psychiatry. Divided into three main aspects of psychiatric clinical judgement, values, meanings and facts, it examines the key debates about mental health care, and the philosophical ideas and tools needed to assess those debates, in six chapters. In addition to outlining the state of play, Essential Philosophy of Psychiatry presents a coherent and unified approach across the different debates, characterized by a rejection of reductionism (...) and an emphasis on the ineliminability of uncodified skilled judgement. The first part, Values, outlines the debate about whether diagnosis of mental illness is essentially value-laden and argues that the prospects for reducing illness or disease to plainly factual matters are poor. It also explains the important role of skilled contextual judgement, rather than a principles-based deduction, in ethical judgement. The second part, Meanings, examines the central role of understanding and a shared first person perspective, both against attempts to reduce meaning to basic information-processing mechanisms and to explain away the difficulties of understanding psychopathology in recent models of delusion. The third part, Facts, shows the importance of uncodified clinical judgements, both in assessing the validity of psychiatric taxonomy and in the application of Evidence Based Medicine. Despite advances in the codifaction of practice and operationalism of diagnosis, an element of judgement remains in the assessment both of what, at one level, is good evidence for diagnosis and treatment and what, at a higher level, is good evidence for the validity of classification overall. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Bad, the Ugly, and the Need for a Position by PsychiatryLloyd A. Wells (bio)Keywordsvice, psychiatric education, psychiatry-law interface, medicalizationSadler’s paper is thought provoking and will resonate with many psychiatrists who deal with the interface of vice and psychiatric syndromes. This interface and the dilemmas it poses are perhaps most discussed by residents, who are dealing with the issue for the first time and who often debate what is (...) “psychiatric” about these cases. Many residents have their own informal systems of classifying vice, often with a divide between the criminal population and those perceived as avoiding work and responsibility. These unofficial classifications are usually judgmental and often pejorative, but the residents rarely get much help from faculty in this area. Indeed, many of the faculty have equally judgmental and pejorative views, which are neither systematized nor subject to systematic analysis.By clarifying the importance of the issue of the vice–mental disorder relationship (VMDR) to psychiatry, Sadler may move this topic to one that receives Socratic discourse in our training programs and serious consideration in the training of psychiatrists rather than an idiosyncratic lumping of these patients into the broad category of “patients I don’t like.”Sadler asks for comments in several categories: historical intractability, goals of psychiatry, taxonomy, implications for the criminal justice system, implications for the law, and ethical/political implications.Issues of historical intractability are long standing. In A Tour of the Whole Island of Great Britain, written in the early eighteenth century, Daniel Defoe (1724–1727) describes many asylums, often with the comment, “as it is a madhouse, so is it also a house of correction.” Some of the great public hospitals of the seventeenth and eighteenth centuries were built at least as much to get antisocial and homeless people off the streets as to provide care for the mentally ill. The moral treatment of France and Great Britain, which added much to the practice of psychiatry, clearly had punitive “treatments” for patients with vice-laden behaviors, and this was very explicit in the American moral model of treatment of the late nineteenth century with its obsessive need to prevent patients from masturbating. In the nineteenth and early twentieth centuries, there was great debate about the inclusion of Pritchard’s “moral insanity”—now sanitized into “personality disorders”—into the psychiatric domain, and Kraepelin referred to this group as “enemies of society.”Sadler next asks us to consider the goals of psychiatry in regard to “a proper VMDR.” He wonders [End Page 43] whether a strict medicalization account can be defended. I think it is clear from a large literature and from clinical experience that it cannot be defended —now. But it may become defensible in this century, which will pose enormous challenges to psychiatry, lawmakers, and the courts (vide infra). A strict moralization model is defended by many in society, including some psychiatrists, but has severe limitations and seems illogical. It is hard to make a case (though juries have done so) that, for example, a very delusional young woman with postpartum psychosis who murders her children because of the belief that far worse things than death will happen to them imminently if they live, fits the moralization approach. The Dahmer case is especially instructive. Although there was enormous “vice” (and perhaps “evil”), it is hard to make a case that a sane man would make temples out of the body parts of victims and would attempt to commune with the dead through them.He wonders whether a “mixed” version of medicalization/moralization can be developed and defended. I would argue for both a mixed approach and a “shared” approach. A middle adolescent with bipolar disorder burned his house to the ground. (Fortunately, he and family members were injured but not killed.) He was wildly manic at the time and set the fire because he wanted to prove that he was immortal and totally impervious to flames. He was delusional, extraordinarily impulsive, and completely without judgment, and it would be extraordinarily difficult to exclude the medical frame in any consideration of the vice involved. The vice, indeed, may be more involved in his decision while euthymic to stop taking... (shrink)

The history of mental illnesses is as old as human history. Mental disorders are affected by changing social and cultural factors during the historical process, and have been conceptually restructured and their definitions and classifications have been changed. The evolution of obssessive-compulsive disorders with roots as old as human history into modern concepts took place in the 19th century. The first scientific views on the spiritual origin of OCD belong to S. Freud. Freud observed that mental causes (...) in OCD are different from other mental disorders, and he examined obsession as a separate and specific disorder. Over time, it has been understood that OCD is a very common disorder. The American Psychiatric Association (APA) has classified OCD under an independent title in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by removing it from the category of anxiety disorders. OCD is a mental disorder caused by mental actions such as obsessive thoughts (obsessions) and / or repetitive and compulsive behaviors (compulsion). The patient is often aware that such thoughts and behaviors are irrational and absurd. For this reason, he tries to get away obsessive thoughts that he finds contrary to his beliefs, opinions, moral values and logic from his mind. However, as he tries, obsessive thoughts become more and more frequent and create a great anxiety in the person. This time, the patient resorts to compulsions to alleviate the anxiety he feels or to get rid of it completely. As his compulsions repeat, his anxiety increases and he goes into a vicious circle. There are many symptom subgroups of OCD that seriously worsen the quality of life of the individual. One of these, and even the most overwhelming, is religious obsessions. It has been thought that there has been a relationship between religion and OCD for a long time in the psychology literature, and some remarkable studies have been conducted to clarify this relationship. Although there are many research findings showing that religion is an indispensable element in the protection of the mental health integrity of the individual, some forms of religious understanding and some experiences gained as a result of religious experiences may affect the concerns about OCD. This stage of religiosity is closely related to some sub-symptom groups of OCD. The explanations of the founder of the psychoanalytic method, Freud psychoanalytic method, and his followers made a great contribution to the understanding of OCD. However, since the psychoanalytic method exhibits a theoretically reductionist approach to religion, it is possible that the individual's devotion to religion is initially evaluated as a pathology or at least an important obstacle to insight. Today, cognitive behavioral psychotherapies are considered the most effective psychological treatment method for OCD, but their success rates in the treatment of religious OCD are low. Since religious OCD concerns often involve spiritual issues rather than concrete repeatable situations, behavioral methods can be quite difficult to apply in the treatment of religious OCD. Therefore, traditional psychotherapy approaches, even if they are not openly against religions, are insufficient to relieve the suffering in the lives of individuals with religious obsessions, as they generally neglect the religious dimension. Due to the vacuum that arises from restricting spiritual treatments to secular approaches, religious patients are threatened by the illegal practices of people who abuse religious feelings. Clinically, religious obsessions are more worrying and overwhelming. Therefore, their treatment is more difficult than others. Selective approaches that use different scientific disciplines together in the treatment of OCD and can stretch around religious beliefs and values can create more effective treatment models. Thus, the success rate in the treatment of religious OCD can be carried to higher levels thanks to the appropriate cooperation of the disciplines of medicine, psychology and theology. There is a rich religious cultural heritage that can support this collaboration in terms of theological disciplines. As an example, Abū Zayd al-Balkhī (d. 322/934), in his Maṣāliḥ al-abdān wa-l-anfus, probably made a clear distinction between neuroses and psychosis and classified neurotic disorders for the first time about ten centuries before Freud. In this study, the importance of approaching to religious obsessions as both a psychological disorder and a theological problem is emphasized. For this reason, cooperation of psychiatric and psychological approaches with spiritual counseling and guidance is recommended in the treatment of religious OCD. The difficulty in distinguishing whether the symptoms seen in a religious person are normal, natural religious thoughts and behaviors of religious life or abnormal appearances in the religious guise necessitates this interdisciplinary cooperation. (shrink)

As a contribution to a wider discussion on moral discernment in theological anthropology, this paper seeks to answer the question “What is the impact of mental illness on an individual’s ability to make moral decisions?” Written from a clinical psychiatric perspective, it considers recent contributions from psychology, neuropsychology and imaging technology. It notes that the popular conception that mental illness necessarily robs an individual of moral responsibility is largely unfounded. Most people who suffer from mental (...) health problems do not lose the capacity to make moral decisions, and mental illness on its own rarely explains anti-social or criminal behaviour. Moreover, the assumptions of some scientists, that recent developments in neuropsychology and brain imaging suggest biological determinism, must be treated with caution. (shrink)

This volume addresses some of the most prominent questions in contemporary bioethics and philosophy of medicine: ‘liberal’ eugenics, enhancement, the normal and the pathological, the classification of mental illness, the relation between genetics, disease and the political sphere, the experience of illness and disability, and the sense of the subject of bioethical inquiry itself. All of these issues are addressed from a “continental” perspective, drawing on a rich tradition of inquiry into these questions in the fields (...) of phenomenology, philosophical hermeneutics, French epistemology, critical theory and post-structuralism. At the same time, the contributions engage with the Anglo-American debate, resulting in a fruitful and constructive conversation that not only shows the depth and breadth of continental perspectives in bioethics and medicine, but also opens new avenues of discussion and exploration. (shrink)