This paper explores how the diagnosis of mental disorder may affect the diagnosed subject’s self-concept by supplying an account that emphasizes the influence of autobiographical and social narratives on self-understanding. It focuses primarily on the diagnoses made according to the criteria provided by the Diagnostic Statistical Manual of Mental Disorders (DSM), and suggests that the DSM diagnosis may function as a source of narrative that affects the subject’s self-concept. Engaging in this analysis by appealing (...) to autobiographies and memoirs written by people diagnosed with mental disorder, the paper concludes that a DSM diagnosis is a double-edged sword for self- concept. On the one hand, it sets the subject’s experience in an established classificatory system which can facilitate self-understanding by providing insight into subject’s condition and guiding her personal growth, as well as treatment and recovery. In this sense, the DSM diagnosis may have positive repercussions on self-development. On the other hand, however, given the DSM’s symptom-based approach and its adoption of the Biomedical Disease model, a diagnosis may force the subject to make sense of her condition divorced from other elements in her life that may be affecting her mental- health. It may lead her frame her experience only as an irreversible imbalance. This form of self-understanding may set limits on the subject’s hopes of recovery and may create impediments to her flourishing. (shrink)

A pressing need for interrater reliability in the diagnosis of mental disorders emerged during the mid-twentieth century, prompted in part by the development of diverse new treatments. The Diagnostic and Statistical Manual of Mental Disorders (DSM), third edition answered this need by introducing operationalized diagnostic criteria that were field-tested for interrater reliability. Unfortunately, the focus on reliability came at a time when the scientific understanding of mental disorders was embryonic and (...) could not yield valid disease definitions. Based on accreting problems with the current DSM-fourth edition (DSM-IV) classification, it is apparent that validity will not be achieved simply by refining criteria for existing disorders or by the addition of new disorders. Yet DSM-IV diagnostic criteria dominate thinking about mental disorders in clinical practice, research, treatment development, and law. As a result, the modernDSMsystem, intended to create a shared language, also creates epistemic blinders that impede progress toward valid diagnoses. Insights that are beginning to emerge from psychology, neuroscience, and genetics suggest possible strategies for moving forward. (shrink)

This paper provides a historical analysis of a shift in the way animal models of mental disorders were conceptualized: the shift from the mid-twentieth-century view, adopted by some, that animal models model syndromes classified in manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), to the later widespread view that animal models model component parts of psychiatric syndromes. I argue that in the middle of the twentieth century the attempt to (...) maximize the face validity of animal models sometimes led to the pursuit of the ideal of an animal model that represented a behaviorally defined psychiatric syndrome as described in manuals such as the DSM. I show how developments within psychiatric genetics and related criticism of the DSM in the 1990s and 2000s led to the rejection of this ideal and how researchers in the first decade of the twenty-first century came to believe that animal models of mental disorders should model component parts of mental disorders, adopting a so-called endophenotype approach. (shrink)

The fifth text-revised iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) defines paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners”. Paraphilic disorders specifically denote a paraphilia that is “currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others”. A diagnosis of (...) paraphilic disorder either demands the personal distress and/or impairment of function that is caused by the atypical sexual urges and fantasies to be present, or the status of non-consent of the other person that these sexual fantasies and urges are directed towards when acted upon by the patient. This paper discusses how consent not only becomes the standard for permissible and legal sexual activity with other persons, but also, when the diagnostic criteria are taken at face-value, for sexual pathology in the DSM-5-TR when the patient acts on their sexual urges. After a close investigation of various possible interpretations of the element of non-consensuality in the diagnostic criteria for paraphilic disorders, this paper concludes that the DSM-5-TR does not offer a clarifying explanation on how mental health professionals should under-stand its approach to diagnosing paraphilic disorders, leaving us with an ambiguous, unclear and unsettled conceptualisation of what it would mean to fulfil its diagnostic criteria. (shrink)

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

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders included the Social Communication Disorder as a new mental disorder characterized by deficits in pragmatic abilities. Although the introduction of SPCD in the psychiatry nosography depended on a variety of reasons—including bridging a nosological gap in the macro-category of Communication Disorders—in the last few years researchers have identified major issues in such revision. For instance, the symptomatology of SPCD is notably close (...) to that of Autism Spectrum Disorder. This opens up the possibility that individuals with very similar symptoms can be diagnosed differently and receive different clinical treatments and social support. The aim of this paper is to review recent debates on SPCD, particularly as regards its independence from ASD. In the first part, we outline the major aspects of the DSM-5 nosological revision involving ASD and SPCD. In the second part, we focus on the validity and reliability of SPCD. First, we analyze literature on three potential validators of SPCD, i.e., etiology, response to treatment, and measurability. Then, we turn to reliability issues connected with the introduction of the grandfather clause and the use of the concepts of spectrum and threshold in the definition of ASD. In the conclusion, we evaluate whether SPCD could play any role in contemporary psychiatry other than that of an independent mental disorder and discuss the role that non-epistemic factors could play in the delineation of the future psychiatry nosography. (shrink)

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

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

Since the dawn of the internet, pornography has effectively become ubiquitous, pervasive, and increasingly normalised. Study findings show remarkable similarities in how the brain reacts to pornography, and other known addictive substances, and indicate that consuming pornography is comparable to consuming other known addictive substances. Moreover, two of the biggest risk factors for addiction are the substance’s availability and its easy accessibility, particularly in the case of younger persons. To date, pornography addiction has been conceptualised as a behavioural addiction. However, (...) the body of research data on pornography addiction does not provide conclusive support for behavioural addiction. The aim of this thesis is to put forward the idea that pornography can, and should, be conceptualised as an addictive substance, and, that when pornography is consumed, an addictive substance is consumed. In order to support this claim, there are many factors that must be addressed. I first clarify what pornography entails by exploring how it is conceptualised, what pornography ‘does’, and what it means to be a pornography consumer. Secondly, I examine the conceptualisations of substances, substance consumption and addiction, respectively, as well as the subsequent difference between substance and behavioural addiction. Thirdly, I give an inclusive overview of pornography addiction by not only examining the most recent perspectives of researchers, but also of pornography consumers. I conclude by suggesting how we should go about conceptualising pornography addiction, and then propose how the set of diagnostic criteria for pornography use disorder should be formulated for a future iteration of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. I argue that, given the abundance of academic research on substance addiction, compared to the scarcity of research on behavioural addiction, conceptualising pornography as an addictive substance is more likely to create a sense of urgency for the future research of pornography addiction than would be the case if it is considered a potential behavioural addiction. Furthermore, I argue that the classification of pornography as an addictive substance, and the inclusion of pornography use disorder in a future iteration of the DSM, will raise awareness of the potential adverse effects of pornography consumption and, therefore, the harmful consequences of pornography use disorder. (shrink)

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

In this volume, leading philosophers of psychiatry examine psychiatric classification systems, including the Diagnostic and Statistical Manual of Mental Disorders, asking whether current systems are sufficient for effective diagnosis, treatment, and research. Doing so, they take up the question of whether mental disorders are natural kinds, grounded in something in the outside world. Psychiatric categories based on natural kinds should group phenomena in such a way that they are subject to the same type (...) of causal explanations and respond similarly to the same type of causal interventions. When these categories do not evince such groupings, there is reason to revise existing classifications. The contributors all question current psychiatric classifications systems and the assumptions on which they are based. They differ, however, as to why and to what extent the categories are inadequate and how to address the problem. Topics discussed include taxometric methods for identifying natural kinds, the error and bias inherent in DSM categories, and the complexities involved in classifying such specific mental disorders as "oppositional defiance disorder" and pathological gambling. -/- Contributors George Graham, Nick Haslam, Allan Horwitz, Harold Kincaid, Dominic Murphy, Jeffrey Poland, Nancy Nyquist Potter, Don Ross, Dan Stein, Jacqueline Sullivan, Serife Tekin, Peter Zachar. (shrink)

The Axis II Work Group of the Task Force on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions of psychopathy and to international criteria. R. D. Hare et al describe an alternative to the approach taken in the DSM-III—Revised (DSM-III—R; American Psychiatric Association, 1987), namely, the revised (...) Psychopathy Checklist. The authors also discuss the multisite APD field trials designed to evaluate and compare 4 criteria sets: the DSM-III—R criteria, a shortened list of these criteria, the criteria for dyssocial personality disorder from the 10th edition of the International Classification of Diseases (World Health Organization, 1990), and a 10-item criteria set for psychopathic personality disorder derived from the revised Psychopathy Checklist. (PsycINFO Database Record (c) 2015 APA, all rights reserved). (shrink)

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

his article develops a set of recommendations for the psychiatric and medical community in the treatment of mental disorders in response to the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, that is, DSM-5. We focus primarily on the limitations of the DSM-5 in its individuation of Complicated Grief, which can be diagnosed as Major Depression under its new criteria, and Post-Traumatic Stress Disorder (PTSD). We argue that the (...) hyponarrativity of the descriptions of these disorders in the DSM-5, defined as the abstraction of the illness categories from the particular life contingencies and personal identity of the patient (e.g., age, race, gender, socio-economic status), constrains the DSM-5's usefulness in the development of psychotherapeutic approaches in the treatment of mental disorders. While the DSM-5 is useful in some scientific and administrative contexts, the DSM's hyponarrativity is problematic, we argue, given that the DSMs are designed to be useful guides for not only scientific research, but also for the education of medical practitioners and for treatment development. our goal therefore is to offer suggestions for mental health practitioners in using the DSM-5, so that they can avoid or eliminate the problems that may stem from the limitations of hyponarrativity. When such problems are eliminated, we believe that effective psychotherapeutic strategies can be developed, which would be successful in repairing the very relationships that are strained in mental disorder: the patient's relationship to herself, her physical environment, and her social environment. (shrink)

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

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)

Editor’s Note: If all goes as planned, the American Psychiatric Association will release a new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013. Since 1980, the DSM has provided a shared diagnostic language to clinicians, patients, scientists, school systems, courts, and pharmaceutical and insurance companies; any changes to the influential manual will have serious ramifications. But, argues Dr. Steven Hyman, the DSM is a poor mirror of clinical and biological realities; (...) a fundamentally new approach to diagnostic classification is needed as researchers uncover novel ways to study and understand mental illness. (shrink)

In this paper I review how the notion of gender is understood in psychiatry, specifically in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). First, I examine the contraposition between sex and gender, and argue that it is still retained by DSM-5, even though with some caveats. Second, I claim that, even if genderqueer people are not pathologized and gender pluralism is the background assumption, some diagnostic criteria still conceal (...) a residue of gender dualism and essentialism. Third, I consider gender dysphoria, which is characterized by an incongruence between one’s experienced or expressed gender and one’s assigned gender; since this condition pertains to distress and disability, not to the incongruence per se, it does not pathologize transgender people. Still, I contend that it should be removed from DSM-5 for theoretical reasons. (shrink)

If we already had a periodic table of mental illness in hand, there would be less need for a book of this type. Although some psychiatrists do think of themselves as chemists, the analogy is without warrant. Not only does psychiatry lack an analogue of the periodic table, its principal tool -- the Diagnostic and Statistical Manual of Mental Disorders (DSM) -- is a contentious document. Even subsequent to the publication of DSM-III in 1980, (...) which was intended to serve as an operational guideline for clinical practice, it and its heirs (DSM-V was published in 2013) have often fueled rather than quelled controversy. Although beginning with that third major revision of DSM a concerted effort has been made to ensure greater consistency in diagnoses, psychiatry remains beset by concerns that it is insufficiently scientific, unduly influenced by the pharmaceutical industry, indecisive as to whether it should focus on the mind or the brain, incapable of distinguishing among types of diseases, inclined to expand illness criteria without adequate justification, overly reliant on subjective judgments, wont to conflate clinical and ethical judgments, and engaged in indiscriminate use of psychoactive drugs. These worries concerning its scientific and ethical status are among the reasons that psychiatry attracts the attention of philosophers. (shrink)

Some researchers and autistic activists have recently suggested that because some ‘autism-related’ behavioural atypicalities have a function or purpose they may be desirable rather than undesirable. Examples of such behavioural atypicalities include hand-flapping, repeatedly ordering objects (e.g., toys) in rows, and profoundly restricted routines. A common view, as represented in the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-TR (APA, 2000), is that many of these behaviours lack adaptive function or purpose, interfere with learning, (...) and constitute the non-social behavioural dysfunctions of those disorders making up the Autism Spectrum. As the DSM IV-TR continues to be the reference source of choice for professionals working with individuals with psychiatric difficulties, its characterization of the Autism Spectrum holds significant sway. We will suggest Extended Mind and Enactive Cognition Theories, which theorize that mind (or cognition) is embodied and environmentally embedded, as coherent conceptual and theoretical spaces within which to investigate the possibility that certain repetitive behaviours exhibited by autistics possess functions or purposes that make them desirable. As lenses through which to re-examine ‘autism-related’ behavioral atypicalities, these theories not only open up explanatory possibilities underdeveloped in the research literature, but also cohere with how some autistics describe their own experience. Our position navigates a middle way between the view of autism as understood in terms of impairment, deficit and dysfunction and one that seeks to de-pathologize the Spectrum. In so doing we seek to contribute to a continuing dialogue between researchers, clinicians and self- or parent advocates. (shrink)

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in 2013 containing the following changes from the previous edition: gone are the subcategories ‘Autistic Disorder,’ ‘Asperger Syndrome’ and ‘PDD-NOS,’ replaced by the single diagnosis ‘Autism Spectrum Disorder,’ and there is a new category ‘Social Communication Disorder.’ In this paper I consider what kind of reasons would justify these changes if one were (a) a realist about autism, or (b) one (...) were a constructivist. I explore various analyses of autism in the research literature that portray it as essentially either a psychological, neurological or genetic phenomenon, and discuss these by reference to the diagnostic criteria and by analogy with the way we understand race and sex categories. I conclude that no realist reasons are available to justify the changes in the diagnostic criteria, and further, that the only way the changes could be justified is if one takes the position that the DSM categories are social constructs. I conclude by exploring what implications follow from this. (shrink)

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was published in 2013. This manual classifies all known mental disorders and provides operationalized criteria for their diagnosis. The goal of this manual is to facilitate communication, treatment and research with reliable and valid diagnoses. This article will provide a study of what this diagnostic validity actually entails. Firstly, it will include a discussion of the different conceptions of (...) validity that have appeared in the literature so far. To decide between these different conceptions, diagnostic validity will be defined as ”picking out a natural kind’. Secondly, two different accounts of natural and psychiatric kinds are examined, namely, essentialism and pragmatism. Both of these will be rejected in favor of conceiving natural kinds as causal-epistemic kinds. Thirdly, it is argued that the multidimensional complexity of psychiatric disorders does not exclude the possibility of psychiatric kinds being natural kinds. However, pragmatic considerations in classifying disorders have meant that the DSM most likely does not distinguish causal-epistemic kinds very well. I argue that the need to have a single classification both for clinicians and researchers and the priority given to reliability rather than validity has ultimately compromised the diagnostic validity of the DSM. (shrink)

Current health care standards, in many countries, Australia included, are regrettably poor. Surprisingly, practitioners and treating teams alike in mental health and disability sectors, in particular, make far too many basic care-related mistakes, in addition to the already abundant diagnostic mistakes that cause and amplify great harm. In part, too many practitioners also fail to distinguish adverse effects for what they are and all too often treat adverse effects, instead, as comorbidities. Diagnostic failures are dangerous, the result (...) of which generates and perpetuates harms that are extremely costly in terms of patient welfare, in addition to the financial burden placed on everyone. In this essay, I contend that the authority bestowed upon psychiatry is misplaced. Subsequently, this misplaced authority affects the governing and investigatory institutions reliant and informed by psychiatry. The examination process undertaken in this investigation traces the metaphysics of psychiatric disorders relative to the Diagnostic-Statistical-Manual (DSM) in all its iterations and to the epistemological construction process that serves to underpin the fundamentals of psychiatric practice. There exists a crisis of confidence in psychiatric practice and I urge drastic reform be undertaken to arrest the damage. (shrink)

The notion of harm is frequently used in the discussion of the nature of mental disorder. Harm also plays important roles in the prominent diagnostic manuals such as DSM and ICD. Recently, however, Cristina Amoretti and Elisabetta Lalumera have questioned the idea that harm should be a necessary constituent of mental disorders. They argue that the notion of harm is underspecified and potentially leads to false negatives in diagnosing mental disorders. Given that harm plays (...) significant roles in medical diagnosis and treatment indicates that we should be reluctant to remove it as a criterion for deciding whether some condition is a mental disorder. Instead, we argue that harm should be understood in the prudential sense and harm in this sense provides a way of responding to worries raised by Amoretti and Lalumera, while staying true to the conception of harm that is relevant for psychiatric practice. (shrink)

Attention Deficit Hyperactivity Disorder (ADHD) continues to be controversial with arguments for and against its veracity being waged by individuals representing a variety of disciplines from behavioral scientists to philosophers. Our perspective focuses on the epistemological underpinnings of what is now commonly known as ADHD. Its ignominious history and current disputes may stem from a "pessimistic" epistemology, meaning that truth is only the province of persons in authority and power. The authoritative organizations that govern the diagnostic labels and criteria (...) are the American Psychiatric Association and their Diagnostic and Statistical Manual and the World Health Organization that sponsors the International Classification of Disease. We contrast the pessimistic epistemology with criteria for truth from the scientific method. Although scientific scrutiny has been and is being applied subsequent to "authoritarian edicts" of the disorder, we opine that ADHD currently does not have status beyond that of the "hypothetical construct." Moreover, current brain-based causal models have failed to provide rigorous supporting data that comes from testing falsifiable hypotheses. (shrink)

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)

Naturalistic accounts of mental disorder aim to identify an objective basis for attributions of mental disorder. This goal is important for demarcating genuine mental disorders from artificial or socially constructed disorders. The articulation of a demarcation criterion provides a means for assuring that attributions of 'mental disorder' are not merely pathologizing different forms of social deviance. The most influential naturalistic and hybrid definitions of mental disorder identify biological dysfunction as the objective basis of (...) mental disorders: genuine mental... (shrink)

In this paper I examine the ways in which our language and terminology predetermine how we approach, investigate and conceptualise mental illness. I address this issue from the standpoint of hermeneutic phenomenology, and my primary object of investigation is the phenomenon referred to as “mania”. Drawing on resources from classical phenomenology, I show how phenomenologists attempt to overcome their latent presuppositions and prejudices in order to approach “the matters themselves”. In other words, phenomenologists are committed to the idea that (...) in our everyday, natural attitude, we take for granted a number of prejudices and presuppositions that predetermine how we conceive of and understand what we experience. In order to properly approach the phenomena themselves, we need to find ways of neutralising our presuppositions and prejudices in order to develop new (and hopefully more accurate) accounts of the phenomena under investigation. One of the most popular examples of such an attempt at neutralisation is what Edmund Husserl calls the epoché, which is the practice of bracketing out or suspending presuppositions. However, later phenomenologists developed alternative approaches. Martin Heidegger, for instance, engaged in etymological analyses to discover latent meanings in our language and terminology. Hans-Georg Gadamer also engaged in historical analyses of how our traditions sediment into latent prejudices. After discussing the various ways in which phenomenologists have attempted to neutralise presuppositions and prejudices prior to engaging in their investigations, I apply some of these principles and methods to the domain of psychopathology, and discuss some of the prejudices inherent in contemporary discussions of the phenomenon of mania. I examine recent attempts to link the phenomenon that we today refer to as “mania” with the ancient Greek concept of “μανία” (mania), and argue that the practice of linking contemporary and historical concepts can be detrimental to attempts at reclassifying disorders. In addition, I consider the implications of the shift in terminology from “manic depressive illness” to “bipolar disorder” – especially how conceiving of mania as one of two “poles” predetermines its description by both clinicians and patients. Finally, I address the implications of the headings under which mania and bipolar disorder are discussed within diagnostic manuals. For example, I discuss the removal of the headings of affective and mood disorders in the DSM-5, and the explicit decision by the authors to place bipolar disorder between depressive disorders and schizophrenia. What I aim to accomplish in this paper is not so much a phenomenological investigation of mania as it is a pre-phenomenological investigation. In other words, I offer a preparatory investigation of the phenomenon (or phenomena) referred to as “mania” in contemporary discourse, with the intention of laying the groundwork for further phenomenological and psychological research. (shrink)

In the Netherlands and Belgium, it is lawful for voluntary euthanasia to be offered on the grounds of psychiatric suffering. A recent case that has sparked much debate is that of Aurelia Brouwers, who was helped to die in the Netherlands on account of her suffering from borderline personality disorder. It is sometimes claimed that whether or not a mentally ill person’s wish to die is valid hinges on whether or not that wish is a symptom of the person’s (...) class='Hi'>mental disorder. This article addresses the philosophical problems raised by this claim, with a specific focus on the diagnosis of borderline personality disorder. After considering descriptivist and causal conceptualizations of mental disorder, I argue that the current approach to borderline personality disorder in psychiatry precludes the possibility of dissociating the wish to die from the disorder. I then examine the implications of this analysis for the question of whether or not the request for voluntary euthanasia in the case of borderline personality disorder can be considered valid. Ultimately, I conclude that the inability to dissociate the wish to die from the disorder does not invalidate the wish in the case of borderline personality disorder. (shrink)

In psychiatry, pharmacological drugs play an important experimental role in attempts to identify the neurobiological causes of mental disorders. Besides being developed in applied contexts as potential treatments for patients with mental disorders, pharmacological drugs play a crucial role in research contexts as experimental instruments that facilitate the formulation and revision of neurobiological theories of psychopathology. This paper examines the various epistemic functions that pharmacological drugs serve in the discovery, refinement, testing, and elaboration of neurobiological theories (...) of mental disorders. I articulate this thesis with reference to the history of antipsychotic drugs and the evolution of the dopamine hypothesis of schizophrenia in the second half of the twentieth century. I argue that interventions with psychiatric patients through the medium of antipsychotic drugs provide researchers with information and evidence about the neurobiological causes of schizophrenia. This analysis highlights the importance of pharmacological drugs as research tools in the generation of psychiatric knowledge and the dynamic relationship between practical and theoretical contexts in psychiatry. (shrink)

At present, psychiatric disorders are characterized descriptively, as the standard within the scientific community for communication and, to a certain extent, for diagnosis, is the DSM, now at its fifth edition. The main reasons for descriptivism are the aim of achieving reliability of diagnosis and improving communication in a situation of theoretical disagreement, and the Ignorance argument, which starts with acknowledgment of the relative failure of the project of finding biomarkers for most mental disorders. Descriptivism has also (...) the advantage of capturing the phenomenology of mental disorders, which appears to be essential for diagnosis, though not exhaustive of the nature of the disease. I argue that if we rely on the distinction between conceptions (procedures of identification) and concepts (reference-fixing representations), which was introduced in the philosophical debate on the nature of concepts, we may understand a limited but valid role for descriptive characterizations, and reply to common objections addressed by those who advocate a theoretically informed approach to nosology. (shrink)

Abstract: At present, psychiatric disorders are characterized descriptively, as the standard within the scientific community for communication and, to a cer- tain extent, for diagnosis, is the DSM, now at its fifth edition. The main rea- sons for descriptivism are the aim of achieving reliability of diagnosis and improving communication in a situation of theoretical disagreement, and the Ignorance argument, which starts with acknowledgment of the relative fail- ure of the project of finding biomarkers for most mental (...) class='Hi'>disorders. Descrip- tivism has also the advantage of capturing the phenomenology of mental dis- orders, which appears to be essential for diagnosis, though not exhaustive of the nature of the disease. I argue that if we rely on the distinction between conceptions (procedures of identification) and concepts (reference-fixing representations), which was introduced in the philosophical debate on the nature of concepts, we may understand a limited but valid role for descrip- tive characterizations, and reply to common objections addressed by those who advocate a theoretically informed approach to nosology. (shrink)

In this chapter I investigate the kinds of changes that psychiatric kinds undergo when they become explanatory targets of areas of sciences that are not “mature” and are in the early stages of discovering mechanisms. The two areas of science that are the targets of my analysis are cognitive neuroscience and cognitive neurobiology.

This contribution focuses on what type of question “Are mental disorders brain disorders?” is and what task Anneli Jefferson performs in her book with the same title. I distinguish between conceptual engineering and conceptual choice, the former involving the individuation of an adequate concept for a specific goal, and the latter involving the normative problem of whether we should employ the concept at hand. I contend that Anneli Jefferson’s book is a work of conceptual engineering, which is (...) valuable in and of itself, but that this is insufficient to answer an equally essential version of the question, “Are mental disorders brain disorders?”, namely, whether we should adopt the newly engineered concept or not, considering a broader range of goals for mental health research and practice. (shrink)

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

In psychiatry, pharmacological research has played a crucial role in the formulation, revision, and refinement of neurobiological theories of psychopathology. Besides being utilized as potential treatments for various mental disorders, pharmacological drugs play an important epistemic role as experimental instruments that help scientists uncover the neurobiological underpinnings of mental disorders (Tsou, 2012). Interventions with psychiatric patients using pharmacological drugs provide researchers with information about the neurobiological causes of mental disorders that cannot be obtained in (...) other ways. This important source of evidence for the biological causes of mental disorder is often overlooked in philosophical analyses of psychiatry, especially in skeptical analyses that debase the biological aspects of psychopathology (e.g., Szasz, 1960; Scheff, 1963; Laing, 1967). In discussing pharmacological interventions as a form of evidence for the physical basis of mental disorders, this paper aims to clarify the nature, reliability, and limitations of this evidence. In addition, it illustrates the central role that pharmacological findings in applied clinical contexts play in the acquisition of neurobiological knowledge in research contexts. (shrink)

This paper offers a philosophical analysis of the connection between mental disorder and suicide risk. In contemporary psychiatry, it is commonly suggested that this connection is a causal connection that has been established through empirical discovery. Herein, I examine the extent to which this claim can be sustained. I argue that the connection between mental disorder and increased suicide risk is not wholly causal but is partly conceptual. This in part relates to the way suicidality is built into (...) the definitions of some psychiatric diagnoses. It also relates to the broader normative assumption that suicidal behavior is by definition mentally disordered behavior. The above has significant epistemological implications, which I explore. I propose that the claim that suicide is connected with mental disorder cannot be justified solely by appealing to empirical evidence but also warrants a justification on conceptual and normative grounds. (shrink)

Recent trends in psychiatry involve a transition from categorical to dimensional frameworks, in which the boundary between health and pathology is understood as a difference in degree rather than as a difference in kind. A major tenet of dimensional approaches is that no qualitative distinction can be made between health and pathology. As a consequence, these approaches tend to characterize such a threshold as pragmatic or conventional in nature. However, dimensional approaches to psychopathology raise several epistemological and ontological issues. First, (...) we review major sources of evidence usually recruited in support of the dimensional trend (focusing on clinical observation and biological data), and we show that these are connected to different conceptualizations of how dimensional traits extend across health and pathology. Second, we criticize two unquestioned assumptions that stand at the core of the dimensional trend: a) that there is continuity from health to pathology at the symptomatic level; b) that such continuity reflects an underlying continuity in the genetic liability for pathological conditions. Third, we argue against the idea of a conventional threshold by showing that such a view implies a linear relationship between the genotype and the phenotype. Fourth, drawing on epigenetics and developmental biology, we offer a characterization of mental disorders as stable and dynamic constellations of multi-level variables that differ qualitatively from ‘healthy states’. We conclude by showing that our account has several theoretical advantages over both categorical and dimensional approaches. Notably, it provides crucial insights into psychological development over time and individual differences, with major implications in terms of intervention and clinical decision-making. (shrink)

Recently there has been a trend of moving towards biological and neurocognitive based classifications of mental disorders that is motivated by a dissatisfaction with the syndrome-based classifications of mental disorders. The Research Domain Criteria (indicated with the acronym RDoC) represents a bold and systematic attempt to foster this advancement. However, RDoC faces theoretical and conceptual issues that need to be addressed. Some of these difficulties emerge when we reflect on the plausible reading of the slogan “ (...) class='Hi'>mental disorders are brain disorders”, that according to proponents of RDoC constitutes one of its main presuppositions. Some authors think that endorsing this idea commits RDoC to a form of biological reductionism. We offer empirical and theoretical considerations for concluding that the slogan above should not be read as a reductionist thesis. We argue, instead, that the slogan has a pragmatic function whose aim is to direct research in psychopathology. We show how this function might be captured in the framework of a Carnapian explication as a methodological tool for conceptual engineering. Thus, we argue that a charitable interpretation of the aims of the proponents of RDoC should be understood as an attempt at providing an explication of the concept of mental disorder in terms of brain disorder whose main goal is to provide a more precise and fruitful notion that is expected to have a beneficial impact on classification, research, and treatment of psychiatric conditions. (shrink)

Our main objective is to locate and analyze some philosophical issues about the concept of mental illness and the manner it is used, especially in contemporary psychiatry. It is even difficult to find a standard meaning in the main psychiatric textbooks; and, when there is some exposition of the concept, it is sparse, uncritical and vague. As an immediate consequence of these issues, practical guidelines and protocols for the clinic arise, which become almost “automatic”, unreflective behaviors, practices translated as (...) health interventions and public mental health policies. An example is the problem of overdiagnosis, in which the use of medical technology (categories, drugs, clinical exams, etc.) has generated more harm and risks to the subject's health than benefits. Exposing these issues from a philosophical perspective can eventually contribute to the field of mental health. For this work, the main manuals and textbooks of psychiatry were selected to analyze how they deal with the concept of mental illness or disorder, in addition to locating the present discussion in authors from both philosophy and the psychiatric field and how they contribute to its clarification. (shrink)

Meaning-making plays a central role in how we deal with experiences of suffering, including those due to mental disorder. And for many, religious beliefs, experiences, and practices (hereafter, religious engagement) play a central role in informing this meaning-making. However, a crucial facet of the relationship between experiences of mental disorder and religious engagement remains underexplored—namely the potentially positive effects of mental disorder on religious engagement (e.g. experiences of bipolar disorder increasing sense of God’s presence). In what follows, (...) I will present empirical findings from two recent studies of mine which shed light on the extent to which participants experienced these positive effects, specific components of these effects, and how they fit into their understanding of their mental disorder and its relationship to their religious identity. In doing so, I will draw on and expand Tasia Scrutton’s Potentially Transformative view (2015a, 2015b, 2020) according to which mental disorders may provide opportunities for spiritual growth. My empirical results align with and help deepen an account according to which mental disorders are potentially spiritually transformative by providing further insight into such instances: specifically, which symptoms and internal and external factors are often involved, as well as which religious beliefs, experiences, and/or practices are often affected. After presenting these results and articulating their relevance for a potentially transformative view of mental disorder, I will then address some potential objections to the theoretical account as well as some limitations of the empirical work, before sketching possible promising directions for future research. (shrink)

The current rise of neurodevelopmental disorders poses a critical need to detect risk early in order to rapidly intervene. One of the tools pediatricians use to track development is the standard growth chart. The growth charts are somewhat limited in predicting possible neurodevelopmental issues. They rely on linear models and assumptions of normality for physical growth data – obscuring key statistical information about possible neurodevelopmental risk in growth data that actually has accelerated, non-linear rates-of-change and variability encompassing skewed (...) distributions. Here, we use new analytics to profile growth data from 36 newborn babies that were tracked longitudinally for 5 months. By switching to incremental (velocity-based) growth charts and combining these dynamic changes with underlying fluctuations in motor performance – as the transition from spontaneous random noise to a systematic signal – we demonstrate a method to detect very early stunting in the development of voluntary neuromotor control and to flag risk of neurodevelopmental derail. (shrink)

Although enactive approaches to cognition vary in terms of their character and scope, all endorse several core claims. The first is that cognition is tied to action. The second is that cognition is composed of more than just in-the-head processes; cognitive activities are externalized via features of our embodiment and in our ecological dealings with the people and things around us. I appeal to these two enactive claims to consider a view called “direct social perception” : the idea that we (...) can sometimes perceive features of other minds directly in the character of their embodiment and environmental interactions. I argue that if DSP is true, we can probably also perceive certain features of mental disorders as well. I draw upon the developmental psychologist Daniel Stern’s notion of “forms of vitality”—largely overlooked in these debates—to develop this idea, and I use autism as a case study. I argue further that an enactive approach to DSP can clarify some ways we play a regulative role in shaping the temporal and phenomenal character of the disorder in question, and it may therefore have practical significance for both the clinical and therapeutic encounter. (shrink)

As it emerged from philosophical analyses and cognitive research, most concepts exhibit typicality effects, and resist to the efforts of defining them in terms of necessary and sufficient conditions. This holds also in the case of many medical concepts. This is a problem for the design of computer science ontologies, since knowledge representation formalisms commonly adopted in this field do not allow for the representation of concepts in terms of typical traits. However, the need of representing concepts in terms of (...) typical traits concerns almost every domain of real world knowledge, including medical domains. In particular, in this article we take into account the domain of mental disorders, starting from the DSM-5 descriptions of some specific mental disorders. On this respect, we favor a hybrid approach to the representation of psychiatric concepts, in which ontology oriented formalisms are combined to a geometric representation of knowledge based on conceptual spaces. (shrink)

The tendency to draw mind-brain dichotomies and evaluate mental disorders dualistically arises in both laypeople and mental health professionals, leads to biased judgments, and contributes to mental health stigmatization. This paper offers a theory identifying an underlying source of these evaluations in social practice. According to this theory, dualistic evaluations are rooted in two mechanisms by which we represent and evaluate the beliefs of others in folk psychology and theory of mind: the doxastic conception of (...) class='Hi'>mental disorders and doxastic voluntarism. Tracing these origins contributes to our understanding of mental state representation in cognitive science and philosophy of psychiatry, the concept of belief in philosophy of mind, and may help improve patient experience and treatment in light of social stigmatization and bias toward mental illness. (shrink)

The extended mind thesis maintains that the functional contributions of tools and artefacts can become so essential for our cognition that they can be constitutive parts of our minds. In other words, our tools can be on a par with our brains: our minds and cognitive processes can literally ‘extend’ into the tools. Several extended mind theorists have argued that this ‘extended’ view of the mind offers unique insights into how we understand, assess, and treat certain cognitive conditions. In this (...) chapter we suggest that using AI extenders, i.e., tightly coupled cognitive extenders that are imbued with machine learning and other ‘artificially intelligent’ tools, presents both new ethical challenges and opportunities for mental health. We focus on several mental health conditions that can develop differently by the use of AI extenders for people with cognitive disorders and then discuss some of the related opportunities and challenges. (shrink)

The mental risk poses a high threat to the individuals, especially overseas demographic, including expatriates in comparison to the general Arab demographic. Since Arab countries are renowned for their multicultural environment with half of the population of students and faculties being international, this paper focuses on a comprehensive analysis of mental health problems such as depression, stress, anxiety, isolation, and other unfortunate conditions. The dataset is developed from a web-based survey. The detailed exploratory data analysis is conducted on (...) the dataset collected from Arab countries to study an individual’s mental health and indicative help-seeking pointers based on their responses to specific pre-defined questions in a multicultural society. The proposed model validates the claims mathematically and uses different machine learning classifiers to identify individuals who are either currently or previously diagnosed with depression or demonstrate unintentional “save our souls” (SOS) behaviors for an early prediction to prevent risks of danger in life going forward. The accuracy is measured by comparing with the classifiers using several visualization tools. This analysis provides the claims and authentic sources for further research in the multicultural public medical sector and decision-making rules by the government. (shrink)

This paper discusses the representation and explanation of relationships between phenomena that are important in psychiatric contexts. After a general discussion of complexity in the philosophy of science, I distinguish zooming-out approaches from zooming-in approaches. Zooming-out has to do with seeing complex mental illnesses as abstract models for the purposes of both explanation and reduction. Zooming-in involves breaking complex mental illnesses into simple components and trying to explain those components independently in terms of specific causes. Connections between existing (...) practice and zooming-out are drawn, and zooming-in is criticised. (shrink)

In this Introduction, I situate the underlying project “Autonomy and Mental Disorder” with reference to current debates on autonomy in moral and political philosophy, and the philosophy of action. I then offer an overview of the individual contributions. More specifically, I begin by identifying three points of convergence in the debates at issue, stating that autonomy is: 1) a fundamentally liberal concept; 2) an agency concept and; 3) incompatible with (severe) mental disorder. Next, I explore, in the context (...) of decisional capacity assessments, the difficulties to reconcile 1) and 2) with 3) which they at the same time seem to imply. Having clarified the centrality of a cogent notion of mental disorder for addressing these difficulties, I comment on three promising lines of inquiry about the nature and scope of autonomy that emerge from the following chapters. (shrink)

According to a standard picture of agency, a person’s actions always reflect what they most desire, and many theorists extend this model to mental illness. In this chapter, I pin down exactly where this “volitional” view goes wrong. The key is to recognize that human motivational architecture involves a regulatory control structure: we have both spontaneous states (e.g., automatically-elicited thoughts and action tendencies, etc.) as well as regulatory mechanisms that allow us to suppress or modulate these spontaneous states. Our (...) regulatory abilities, however, are bounded. Mental illnesses, I argue, arise precisely where these bounds are reached, thus allowing inappropriate spontaneous states to regularly manifest in thought and action. I conclude that the volitional view of mental illness is wrong: when a person with mental illness reaches the limits of control, what they do often does not reflect what they most prefer. (shrink)