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)

Psychiatry is unique in medicine in being on the border between science and the humanities. Science provides insight into the 'causes' of a problem, enabling us to formulate an 'explanation', while the humanities provide insight into its 'meanings' and helps with our 'understanding'. The new interdisciplinary field of 'philosophy of psychiatry' has developed to explore the range of issues relevant to this border country. The Oxford Textbook of Philosophy and Psychiatry is a unique textbook which provides a detailed introduction to (...) the field, a framework for study and skill development, and an overview of current research. It focuses on case studies in 5 key topic areas. 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. (shrink)

Rodrigues and Banzato related the validity of diagnostic categories to their meaningfulness and I wish to explore this relation further without attempting to make criticisms. To commence, if a diagnostic category is to be valid, it must mean something.

Three revolutions in psychiatry characterised the closing decade of the twentieth century: 1) in the neurosciences, 2) in patient-centred models of service delivery, and 3) in the emergence of a rapidly expanding new cross -disciplinary field of philosophy and psychiatry. Starting with a case history, the paper illustrates the impact of this third revolution - the new philosophy of psychiatry - on day-to-day clinical practice through training programmes and policy developments in what has become known as values - based practice. (...) Derived from philosophical value theory and phenomenology, values-based practice is a partner to evidencebased practice in supporting clinical decision-making in the highly complex environment of mental health care. The paper concludes by setting values-based practice in context with other potentially practical important areas of the new philosophy of psychiatry arguing that all three revolutions need to be brought together if psychiatry is to meet the challenges of the twenty-first century. (shrink)

Let’s begin by imagining a hypothetical psychotic illness called “Schneider’s Disease”, recognized for over 100 years. Let’s assume there has been great controversy as regards the “most valid” set of diagnostic criteria for SD.

In view of the publication of the DSM-V researchers were asked to discuss the theoretical implications of the definition of mental disorders. The reasons for the use, in the DSM-III, of the term disorder instead of disease are considered. The analysis of these reasons clarifies the distinction between the general definition of disorder and its implicit, technical meaning which arises from concrete use in DSM disorders. The characteristics and limits of this technical meaning are discussed and contrasted to alternative definitions, (...) like Wakefield’s harmful/dysfunction analysis. It is shown that Wakefield’s analysis faces internal theoretical problems in addition to practical limits for its acceptance in the DSM-V. In particular, it is shown that: a) the term dysfunction is not purely factual but intrinsically normative/evaluative; b) it is difficult to clarify what dysfunctions are in the psychiatric context (the dysfunctional mechanism involved being unknown in most cases and the use of evolutionary theory being even more problematic); c) the use of conceptual analysis and commonsense intuition to define dysfunctions leaves unsatisfied empiricists; d) it is unlikely that the authors of the DSM-V will accept Wakefield’s suggestion to revise the diagnostic criteria of any single DSM disorder in accordance with his analysis, because this is an excessively extensive change and also because this would probably reduce DSM reliability. In conclusion, it is pointed up in which sense DSM mental disorders have to be conceived as constructs, and that this undermines the realistic search for a clear-cut demarcation criterion between what is disorder and what is not. (shrink)

The aim of the Validation Theory (VT) as a meta-empirical construct is to introduce a new vista in the reorganization of the neuroscience, in its role of a science of the Mind-and-Brain unification. The present study focuses on existing discrepancies and contradictions between the methods of basic neurosciences and those prescribed by the psychological science. Our view is that these discrepancies are based on a high penetration of traditional neuroscience methods into the biological processes, coupled with low extrapolation (experimenting with (...) animal models) and vice versa for the psychological and psychopathological methods. A novel epistemological model for integrating psychological and neuroscientific knowledge is proposed. It is represented as a simultaneous investigation of the brain activity with penetrating high resolution functional Magnetic Resonance Imaging and in extenso application of set of psychological tests for exploring correspondence (cross-validation) between their compounds. The proposed approach leads to a revision of the neuroscientific and psychological terms, methods and data, followed by a revision of their relative interplay. This would make possible a practical exchange of expensive but objective fMRI with the lower costing psychological instruments (effect of "minimization"). The approaches proceeding from VT will infiltrate diagnostics and prevention in psychiatry. On a further stage the pharmaco-psychological monitoring will uncover new opportunities. This proofs' based research and practice represents an integral counterpart of the values-based mental health care. In conclusion VT is an evolutionary corner stone in order to traverse the stage of a Brain-Brain paradigm and to reach the point of development of the Mind-Brain paradigm. (shrink)

The logical-pragmatic perspective on the psychiatric diagnosis, presented by Rodriguez and Banzato contributes to and develops the existing conventional taxonomic framework. The latter is regarded as grounded on the epistemological prerequisites proponed by Carl Gustav Hempel in the late 1960s, adopted by the DSM task force of R. Spitzer in 1973.

Background: Despite being often taken as the benchmark of quality for diagnostic and classificatory tools, 'validity' is admitted as a poorly worked out notion in psychiatric nosology. Objective: Here we aim at presenting a view that we believe to do better justice to the significance of the notion of validity, as well as at explaining away some misconceptions and inappropriate expectations regarding this attribute in the aforementioned context. Method: The notion of validity is addressed taking into account its role, the (...) framework according to which it should be assessed and the specific contents to which it refers within psychiatric nosology. Results and Conclusions: The notion of validity has an epistemological thrust and its foremost role is distinguishing correct reasoning and truth from what is irrational or false. From it follows not only that 'validity' always refers to elements of knowledge and rationality such as arguments, inferences and propositions, but also that the appropriate frameworks to assess 'validity' are logics and scientific methodology. When the validity of a psychiatric diagnostic category is at stake, the contents to which it refers are those relevantly related to the notion of 'diagnostic concept'. The consequences of our reading on the notion of 'validity' are discussed vis-à-vis the challenges faced by psychiatric nosology in order to have its diagnostic categories validated. (shrink)

Dear Editor, in a previous paper we have tried to delve into what validity means in the context of psychiatric nosology, arguing for a pragmatic view of it. Here we want to briefly reassert the basic points of our analysis, make a few clarifications and address some issues raised by commentators.