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)

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)

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)

Oulis pointed out that there is a great deal of interest in specific mechanisms relating to mental disorders and that these mechanisms should play a role in classification. Although specific mechanisms are important, more attention should be given to general theories. The following example from Salmon illustrates the difference.

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)

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)

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)

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)

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)

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 (...) class='Hi'>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)

English Abstract: The Antisocial personality disorder and several other psychiatric constructs are questioned and deconstructed in this review, that uses psychoanalytic approach to explain the nature of psychopathy and to give recommendations in this respect. -/- German Abstract: In vorliegender Rezension werden psychiatrische Konstrukte psychoanalytischer Bewertung unterzogen und dekonstruiert. Während die Entität „Antisoziale Persönlichkeitsstörung“ aufgrund ihrer Unwissenschaftlichkeit verworfen wird, besteht mentales Konstrukt „Psychopathie“ der Realitätsprüfung. In weiterem Verlauf der Rezension wird Versuch unternommen, das Phänomen der Psychopathie aufzuklären, um sie begrifflich (...) sowie gesundheitlich einzugrenzen. (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)

In Chapter 3 of Book I of Psychology from an Empirical Standpoint, Brentano articulates what he takes to be the four most basic and central tasks of psychology. One of them is to discover the ‘fundamental classification’ of mental phenomena. Brentano attends to this task in Chapters 5-9 of Book II of the Psychology, reprinted (with appendices) in 1911 as a standalone book (Brentano 1911a). The classification is further developed in an essay entitled “A Survey of So-Called (...) Sensory and Noetic Objects of Inner Perception,” published posthumously in Brentano 1928/1981b, as well as a 1907 dictation entitled “Loving and Hating,” reprinted in Brentano 1969. (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 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)

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.

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)

The article advances a new way of thinking about classifications in general and the classification of mental disorders in particular. By applying insights from measurement practice to the context of classification, I defend a notion of epistemic accuracy that allows one to evaluate and improve classifications by comparing different classifying methods to each other. Progress in classification arises from the mutual development of classification systems and classifying methods. Based on this notion of accuracy, the (...) article illustrates with an example how psychiatric classifications can be improved via circumscribed comparisons of different perspectives on mental disorders, without relying on complete models of their complex aetiology. When applying this strategy, the traditional opposition between symptom-based and causal approaches is of little consequence for making progress in the epistemic accuracy of psychiatric classification. (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)

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)

Are psychiatric disorders natural kinds? This question has received a lot of attention within present-day philosophy of psychiatry, where many authors debate the ontology and nature of mental disorders. Similarly, historians of psychiatry, dating back to Foucault, have debated whether psychiatric researchers conceived of mental disorders as natural kinds or not. However, historians of psychiatry have paid little to no attention to the influence of (a) theories within logic, and (b) theories within metaphysics on psychiatric (...) accounts of proper method, and on accounts of the nature and classification of mental disorders. Historically, however, logic and metaphysics have extensively shaped methods and interpretations of classifications in the natural sciences. This paper corrects this lacuna in the history of psychiatry, and demonstrates that theories within logic and metaphysics, articulated by Christian Wolff (1679-1754), have significantly shaped the conception of medical method and (psychiatric) nosology of the influential nosologist Boissier De Sauvages (1706-1767). After treating Sauvages, I discuss the method of the influential nosologist William Cullen (1710-1790), and demonstrate the continuity between the classificatory methods of Sauvages and Cullen. I show that both Sauvages and Cullen were essentialists concerning medical diseases in general and psychiatric disorders in particular, contributing to the history of conceptions of the ontology and nature of mental disorders. (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)

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)

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)

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)

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)

The question of how psychiatric classifications are made up and to what they refer has attracted the attention of philosophers in recent years. In this paper, I review the claims of authors who discuss psychiatric classification in terms referring both to the philosophical tradition of natural kinds and to the sociological tradition of social constructionism — especially those of Ian Hacking and his critics. I examine both the ontological and the social aspects of what it means for something to (...) be a mental disorder, and how the ontological status of these disorders hinges on social causation. Finally, I conclude by suggesting a way in which the biological and the social may be reconciled in an integrative model of variation in psychiatric disorder. (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)

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)

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)

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)

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)

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 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)

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)

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)

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)

A Kuhnian reformulation of the recent debate in psychiatric nosography suggested that the current psychiatric classification system (the DSM) is in crisis and that a sort of paradigm shift is awaited (Aragona, 2009). Among possible revolutionary alternatives, the proposed fi ve-axes etiopathogenetic taxonomy (Charney et al., 2002) emphasizes the primacy of the genotype over the phenomenological level as the relevant basis for psychiatric nosography. Such a position is along the lines of the micro-reductionist perspective of E. Kandel (1998, 1999), (...) which sees mental disorders reducible to explanations at a fundamental epistemic level of genes and neurotransmitters. This form of micro-reductionism has been criticized as a form of genetic-molecular fundamentalism (e.g. Murphy, 2006) and a multi-level approach, in the form of the burgeoning Cognitive Neuropsychiatry, was proposed. This article focuses on multi-level mechanistic explanations, coming from Cognitive Science, as a possible alternative etiopathogenetic basis for psychiatric classification. The idea of a mechanistic approach to psychiatric taxonomy is here defended on the basis of a better conception of levels and causality. Nevertheless some critical remarks of Mechanism as a psychiatric general view are also offered. (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 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)

Understood in their historical context, current debates about psychiatric classification, prompted by the publication of the DSM-5, open up new opportunities for improved translational research in psychiatry. In this paper, we draw lessons for translational research from three time slices of 20th century psychiatry. From the first time slice, 1913 and the publication of Jaspers’ General Psychopathology, the lesson is that translational research in psychiatry requires a pluralistic approach encompassing equally the sciences of mind (including the social sciences) and (...) of brain. From the second time slice, 1953 and a conference in New York from which our present symptom-based classifications are derived, the lesson is that, while reliability remains the basis of psychiatry as an observational science, validity too is essential to effective translation. From the third time slice, 1997 and a conference on psychiatric classification in Dallas that brought together patients and carers with researchers and clinicians, the lesson is that we need to build further on collaborative models of research combining expertise-by-training with expertise-by-experience. This is important if we are to meet the specific challenges to translation presented by the complexity of the concept of mental disorder, particularly as reflected in the diversity of desired treatment outcomes. Taken together, these three lessons – a pluralistic approach, reliability and validity, and closer collaboration – provide an emerging framework for more effective translation of research into practice in 21st century psychiatry. (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)

Abstract:In this paper, I distinguish four ways in which aspects or features of mental illness may be said to be functional. I contend that discussion of teleological perspectives on mental illness has unfortunately tended to conflate these senses. The latter two senses have played important practical roles both in predicting and explaining patterns of behavior, cognition, and affective response, atnd relatedly, in developing successful interventions. I further argue that functional talk in this context is neither inconsistent with viewing (...) some disorders as dysfunctional in one of several senses, nor inappropriately adaptationist, provided we keep these senses of function distinct, and are precise about which is in play in a given context. (shrink)

Hume describes “mental geography” as the endeavor to know “the different operations of the mind, to separate them from each other, to class them under their proper heads, and to correct all that seeming disorder, in which they lie involved, when made the object of reflection and enquiry.” While much has been written about his geography of thought in Treatise Book 1, relatively little has been written about his geography of feeling in Books 2 and 3, with the result (...) that there has been considerable puzzlement and disagreement about the meaning and grounds of many of his central theses about the passions, action, and morals. My endeavor in this chapter is to remove some common sources of perplexity about his classification of the operations of feeling “under their proper heads” in that work. I begin by explaining his three highest-level distinctions bearing on this terrain: that between impressions and ideas; that between original impressions and secondary impressions; and that between the passions and the other emotions. In order to understand this third distinction, I explain his three different senses of the term ‘emotion’ and the relations among them. I ill then examine five different kinds of secondary impressions that he recognizes. These are: (1) sensible agitations; (2) feelings of or from mental operations; (3) volitions; (4) the passions (including motives); and (5) sentiments of taste. The broad outlines of the resulting geography are mapped out in a chart at the end. (shrink)

This paper compares the free energy neuroscience now advocated by Karl Friston and his colleagues with that hypothesised by Freud, arguing that Freud's notions of conflict and trauma can be understood in terms of computational complexity. It relates Hobson and Friston's work on dreaming and the reduction of complexity to contemporary accounts of dreaming and the consolidation of memory, and advances the hypothesis that mental disorder can be understood in terms of computational complexity and the mechanisms, including synaptic pruning, (...) that have evolved to reduce it. (shrink)

The mental disorder concept has not been paid due attention to. The aim of this paper is twofold: first, to assess how much space has been given to the mental disorder concept in textbooks of psychiatry, and second, to show in how many domains both within and beyond psychiatry the mental disorder concept plays a key role. A number of textbooks written in English, German, French, Spanish, and Italian, selected as examples, have been scanned so as to (...) see if there is a chapter dealing with mental disorder, in particular with its definition. Also, the fields in which the mental disorder plays a major role have been identified, and the reasons why the concept of mental disorder is relevant for them have been explored. There is no chapter dealing with the definition of mental disorder in some textbooks of psychiatry in English, German, French, Spanish, and Italian that have been selected as examples. Yet there are numerous domains, directly or indirectly related to psychiatry, in which the mental disorder concept is a substantial element. The results show that the concept of mental disorder should be kept high on psychiatric agenda and given due space in textbooks of psychiatry accordingly. (shrink)

The paper deals with two central issues in the philosophy of neuroscience and psychiatry, namely those of the nature and the major kinds and types of psychopathological mechanisms. Contrary to a widespread view, I argue that mechanisms are not kinds of systems but kinds of processes unfolding in systems or between systems. More precisely, I argue that psychopathological mechanisms are sets of actions and interactions between brain-systems or circuits as well as between the latter and other systems in one's body (...) and external environment, both physical and social, involved in human psychopathology. According to the kinds of properties of the interacting systems or their component-parts, psychopathological mechanisms may be physical, chemical, biological, psychological, social, or, typically, mixed ones. Furthermore, I focus on two main kinds of psychopathological mechanisms involved in the causation of mental disorders, namely the pathogenetic and pathophysiological ones, stressing the importance of their careful distinction for the integrative understanding of otherwise disparate and apparently incommensurable psychiatric research findings. I illustrate my analysis with an example drawn from contemporary research on the mechanisms of acute psychosis. Finally, I stress the relevance of psychopathological mechanisms to a more scientifi cally-grounded classifi cation of mental disorders. (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)

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)