The purpose of this chapter is to describe what we see as several important new directions for philosophy of medicine. This recent work (i) takes existing discussions in important and promising new directions, (ii) identifies areas that have not received sufficient and deserved attention to date, and/or (iii) brings together philosophy of medicine with other areas of philosophy (including bioethics, philosophy of psychiatry, and social epistemology). To this end, the next part focuses on what we call (...) the “epistemological turn” in recent work in the philosophy of medicine; the third part addresses new developments in medical research that raise interesting questions for philosophy of medicine; the fourth part is a discussion of philosophical issues within the practice of diagnosis; the fifth part focuses on the recent developments in psychiatric classification and scientific and ethical issues therein, and the final part focuses on the objectivity of medical research. (shrink)

This paper reviews the recent (post-DSM) history of subjective and semi-structured methods of psychiatric diagnosis, as well as evidence for the superiority of structured and computer-aided diagnostic techniques. While there is evidence that certain forms of therapy are effective for alleviating the psychiatric suffering, distress, and dysfunction associated with certain psychiatric disorders, this paper addresses some of the difficult methodological and ethical challenges of evaluating the effectiveness of therapy.

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)

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)

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 clinical medicine, a diagnosis can offer an explanation of a patient's symptoms by specifying the pathology that is causing them. Diagnoses in psychiatry are also sometimes presented in clinical texts as if they pick out pathological processes that cause sets of symptoms. However, current evidence suggests the possibility that many diagnostic categories in psychiatry are highly causally heterogeneous. For example, major depressive disorder may not be associated with a single type of underlying pathological process, but with a range (...) of different causal pathways, each involving complex interactions of various biological, psychological, and social factors. This paper explores the implications of causal heterogeneity for whether psychiatric diagnoses can be said to serve causal explanatory roles in clinical practice. I argue that while they may fall short of picking out a specific cause of the patient's symptoms, they can nonetheless supply different sorts of clinically relevant causal information. In particular, I suggest that some psychiatric diagnoses provide negative information that rules out certain causes, some provide approximate or disjunctive information about the range of possible causal processes, and some provide causal information about the relations between the symptoms themselves. (shrink)

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

The aim of this paper is to analyze, from a philosophical perspective, the scientific robustness of the construct of psychopathy as measured by the Psychopathy Checklist Revised that was developed by Robert Hare (1991; 2003). The scientific robustness and validity of classifications are topics of many debates in philosophy of science and philosophy of psychiatry more specifically. The main problem consists in establishing whether scientific classifications reflect natural kinds where the concept of a natural kind refers to the (...) existence of some objective divisions in nature that do not depend exclusively on subjective judgments of the classifier. The construct of psychopathy is especially interesting since the diagnosis of psychopathy has substantial social consequences. In the light of the recent debates regarding the problem of natural kinds in philosophy of psychiatry, we advocate the following distinction between two types of scientific classifications: natural and practical kinds. Natural kinds refer to those categories that are united by common causal mechanisms or properties. Practical kinds refer to categories that fulfill some practical classificatory goals such as prediction. We argue that the construct of psychopathy can fulfill the role of a practical kind. In addition, we contend that our current scientific knowledge about psychopathy does not allow us to conclude that this category is a natural kind. (shrink)

Invited commentary on Nicole A. Vincent and Emma A. Jane, “Interrogating Incongruence: Conceptual and Normative Problems with ICD-11’s and DSM-5’s Diagnostic Categories for Transgender People” Australasian Philosophical Review, in press. -/- The core of Vincent and Jane’s Interrogating Incongruence is critical of the appeal to the concept of incongruence in DSM-5 and ICD-11 characterisations of trans people, a critique taken to be ground-clearing for more trans-positive, psychiatrically-infused medical interventions. I concur with Vincent and Jane’s ultimate goals but depart from the (...) view developed in the paper on two fronts. The first is that I remain sceptical about the overall prospects for truly trans-positive psychiatry. Trans should follow homosexuality and other categories of sexual orientation that have been abandoned rather than reformed as constituents of psychiatric diagnosis and categorisation. The second is that I think that the authors’ central criticisms of the appeal to incongruence are misplaced. (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)

Within the last decade, epistemic injustice has been a valuable framework for those working on exposing oppressive practices within the healthcare system. As this work has evolved, new terminology has been added to the epistemic injustice literature to bring to light previously obscured epistemic harms in healthcare practices. This paper aims to explore an important concept that has not received the attention it deserves: epistemic isolation. By developing Ian Kidd and Havi Carel’s concept of epistemic isolation, a new range of (...) epistemic harms are brought to the fore, as some of the most marginalised in our society are forced to operate from positions of ignorance. In the words of Kidd and Carel, epistemic isolation occurs in ‘situations where a person or group lacks the knowledge of, or means of access to, particular information; for instance, if they live within a politically repressive society which forbids access to the necessary sources of information in order to protect the government’s hegemony’ (183–184). This paper will demonstrate that such epistemic isolation is uniquely devastating for those with psychiatric illness, exacerbating their already challenging circumstances. (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 (...) 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)

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way and used (...) to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (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)

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 chapter aims to distinguish between pathologies of agency in the strict sense and mere sources of impediments or distortion. Expanding on a recent notion of necessarily less-than-successful agency, it complements a mainstream approach to mental disorders and anomalous psychological conditions in the philosophy of mind and action. According this approach, the interest of such clinical case studies is heuristic, to differentiate between facets of agency that are functionally and conceptually separate even though they typically come together. Yet, in (...) the absence of independent criterion for a pathology of as opposed to inner obstacle to agency, this heuristic is at risk of becoming circular or uninformative, falling back on a clinical diagnosis it is meant to take as a starting point only. The chapter develops such a criterion and shows how it could work tracking agential achievement across two core dimensions of agency: planning and responsiveness to reasons. The discussion concludes with some implications on assessing decisional capacity and safeguarding agent autonomy in psychiatric settings. (shrink)

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

In psychiatry some disorders of cognition are distinguished from instances of normal cognitive functioning and from other disorders in virtue of their surface features rather than in virtue of the underlying mechanisms responsible for their occurrence. Aetiological considerations often cannot play a significant classificatory and diagnostic role, because there is no sufficient knowledge or consensus about the causal history of many psychiatric disorders. Moreover, it is not always possible to uniquely identify a pathological behaviour as the symptom of a (...) certain disorder, as disorders that are likely to differ both in their causal histories and in their overall manifestations may give rise to very similar patterns of behaviour. -/- Consider delusions as an example. It wouldn’t be correct to define delusions as those beliefs people form as a result of a neurobiological deficit and a hypothesis-evaluation deficit (as some versions of the two-factor theory of delusions suggest), because for some delusions no neurobiological deficit may be found, and reasoning biases and motivational factors may be contributors to the formation of the delusion (e.g. McKay et al., 2005). Moreover, it would be a mistake to define delusions as symptoms of schizophrenia alone, because they occur also in other disorders, including dementia, amnesia, and delusional disorders. Thus, aetiological considerations may appear in the description and analysis of delusions, but do not feature prominently in their definition. -/- In this paper I argue that the surface features used as criteria for the classification and diagnosis of disorders of cognition are often epistemic in character. I shall offer two examples: confabulations and delusions are defined as beliefs or narratives that fail to meet standards of accuracy and justification. Although classifications and diagnoses based on features of people’s observable behaviour are necessary at these early stages of neuropsychiatric research, given the variety of conditions in which certain phenomena appear, I shall attempt to show that current epistemic accounts of confabulations and delusions have limitations. Epistemic criteria can guide both research and clinical practice, but fail to provide sufficient conditions for the identification of delusions and confabulations, and fail to demarcate pathological from non-pathological narratives or beliefs. -/- Another limitation of current epistemic accounts – which I shall not address here – is the excessive focus on epistemic faults of confabulations and delusions at the expense of their epistemically neutral or advantageous features (see Bortolotti and Cox, 2009). This may lead to a misconception of delusions and confabulations, and to an oversimplification in the assessment of the needs of people who require clinical treatment for their psychotic symptoms. (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)

This paper offers an overview of the philosophical work on epistemic injustices as it relates to psychiatry. After describing the development of epistemic injustice studies, we survey the existing literature on its application to psychiatry. We describe how the concept of epistemic injustice has been taken up into a range of debates in philosophy of psychiatry, including the nature of psychiatric conditions, psychiatric practices and research, and ameliorative projects. The final section of the paper indicates future directions (...) for philosophical research of epistemic injustices and psychiatry, concerning neurocognitive disorders, identity prejudices in psychiatric illness, concepts of epistemic privilege in psychiatry, and the prospects for combining phenomenological psychopathology and epistemic justice. We argue that much remains to be done in the conceptualization of these epistemic injustices and suggest that this future work should be multidisciplinary in character and sensitive to the phenomenology of psychiatric conditions. (shrink)

Digital phenotyping will potentially enable earlier detection and prediction of mental illness by monitoring human interaction with and through digital devices. Notwithstanding its promises, it is certain that a person’s digital phenotype will at times be at odds with their first-person testimony of their psychological states. In this paper, we argue that there are features of digital phenotyping in the context of psychiatry which have the potential to exacerbate the tendency to dismiss patients’ testimony and treatment preferences, which can be (...) instances of epistemic injustice. We first explain what epistemic injustice is, and why it is argued to be an extensive problem in health and disability settings. We then explain why epistemic injustice is more likely to apply with even greater force in psychiatric contexts, and especially where digital phenotyping may be involved. Finally, we offer some tentative suggestions of how epistemic injustice can be minimised in digital psychiatry. (shrink)

The aim of my paper is to review the discussion concerning various difficulties which surround the definition of depression and the methods of diagnosing and treating the disease against the background of the now dominant reductionist paradigm in psychiatry, as well as to answer the question whether a new approach to psychiatric disorders proposed by philosophers of psychiatry working within the phenomenologically inspired embodied and enactive paradigm indeed offers a solution to these difficulties. I present the issues specific to (...) the subject of depression in light of the more general problems related to biological psychiatry that have recently caused much debate. In the second part of the paper, I consider enactive, phenomenological and embodied theories of depression and the possibilities of new methods of treatment. My goal is to assess whether these theories indeed add anything important to the conceptions that are already present in psychiatry. I conclude that even if the embodied philosophy of psychiatry does not solve many of the problems faced by modern psychiatry, it can, nevertheless, provide a useful theoretical basis for future changes. (shrink)

Medical assistance in dying, which includes voluntary euthanasia and assisted suicide, is legally permissible in a number of jurisdictions, including the Netherlands, Belgium, Switzerland and Canada. Although medical assistance in dying is most commonly provided for suffering associated with terminal somatic illness, some jurisdictions have also offered it for severe and irremediable psychiatric illness. Meanwhile, recent work in the philosophy of psychiatry has led to a renewed understanding of psychiatric illness that emphasises the role of the relation (...) between the person and the external environment in the constitution of mental disorder. In this paper, I argue that this externalist approach to mental disorder highlights an ethical challenge to the practice of medical assistance in dying for psychiatric illness. At the level of the clinical assessment, externalism draws attention to potential social and environmental interventions that might have otherwise been overlooked by the standard approach to mental disorder, which may confound the judgement that there is no further reasonable alternative that could alleviate the person’s suffering. At the level of the wider society, externalism underscores how social prejudices and structural barriers that contribute to psychiatric illness constrain the affordances available to people and result in them seeking medical assistance in dying when they otherwise might not have had under better social conditions. (shrink)

In somatic medicine, diagnostic terms often refer to the disease processes that are the causes of patients' symptoms. The language used in some clinical textbooks and health information resources suggests that this is also sometimes assumed to be the case with diagnoses in psychiatry. However, this seems to be in tension with the ways in which psychiatric diagnoses are defined in diagnostic manuals, according to which they refer solely to clusters of symptoms. This paper explores how theories of reference (...) in the philosophy of language can help to resolve this tension. After the evaluation of descriptive and causal theories of reference, I put forward a conceptual framework based on two-dimensional semantics that allows the causal analysis of diagnostic terms in psychiatry, while taking seriously their descriptive definitions in diagnostic manuals. While the framework is presented as a solution to a problem regarding the semantics of psychiatric diagnoses, it can also accommodate the analysis of diagnostic terms in other medical disciplines. (shrink)

Winner of the 2020 Essay Competition of the International Social Ontology Society. -/- Ian Hacking uses the looping effect to describe how classificatory practices in the human sciences interact with the classified people. While arguably this interaction renders the affected human kinds unstable and hence different from natural kinds, realists argue that also some prototypical natural kinds are interactive and human kinds in general are stable enough to support explanations and predictions. I defend a more fine-grained realist interpretation of interactive (...) human kinds by arguing for an explanatory domain account of the looping effect. First, I argue that knowledge of the feedback mechanisms that mediate the looping effect can supplement, and help to identify, the applicability domain over which a kind and its property variations are stably explainable. Second, by applying this account to cross-cultural case studies of psychiatric disorders, I distinguish between congruent feedback mechanisms that explain matches between classifications and kinds, and incongruent feedback mecha- nisms that explain mismatches. For example, congruent mechanisms maintain Western auditory experiences in schizophrenia, whereas exporting diagnostic labels inflicts incongruence by influencing local experiences. Knowledge of the mechanisms can strengthen explanatory domains, and thereby facilitate classificatory adjustments and possible interventions on psychiatric disorders. (shrink)

Psychiatric language and concepts, and the norms they embed, have come to influence more and more areas of our daily lives. This has recently been described as a feature of the ‘psychiatrization of society.’ This paper looks at one aspect of psychiatrization that is still little studied in the literature: the psychiatrization of our emotional lives. The paper develops an extended account of emotion pathologizing as a form of affective injustice that is related to psychiatrization and that specifically harms (...) psychopathologized people, i.e., people who are socially perceived to be mentally ill. After introducing an initial account of emotion pathologizing as articulated in Pismenny et al. (2024), we extend the account by demonstrating how processes and practices of emotion pathologizing are informed by (1) the dominant biomedical approach to psychiatry and (2) sanism, a system of discrimination and oppression that disadvantages people who have received a psychiatric diagnosis, or are perceived as in need of psychiatric treatment. We then argue that emotion pathologizing can manifest as an affect-related hermeneutical injustice that disadvantages psychopathologized individuals by unfairly constraining how they make sense of and understand their own emotional experiences. (shrink)

In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an (...) alternative justification. However, this approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis. (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)

Diagnoses are central to the practice of medicine, where they serve a variety of functions for clinicians, patients, and society. They aid communication, explain symptoms, inform predictions, guide therapeutic interventions, legitimize sickness, and authorize access to resources. Insofar as psychiatry is a discipline whose practice is shaped by medical conventions, its diagnoses are sometimes presented as if they serve the same sorts of function as diagnoses in bodily medicine. However, there are philosophical problems that cast doubt on whether the functions (...) of psychiatric diagnoses can legitimately be considered to be equivalent to those of medical diagnoses. The aim of this chapter is to explicate some of these problems, particularly conceptual and epistemological problems pertaining to the roles of diagnoses as explanations. I begin with an overview of the various functions that medical diagnoses normally serve and suggest that many of these functions receive justificatory support from the explanatory roles of the diagnoses. I then present issues regarding the epistemic functions of psychiatric diagnoses and how these issues have featured in the arguments of prominent critics of psychiatry. (shrink)

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

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 tests the predictions of an epistemological model that considered the DSM psychiatric classification (in the neopositivist and neo-Kraepelinian shape introduced by the DSM-III) as a scientific paradigm in crisis. As predicted, the DSM-5 did not include revolutionary proposals in its basic structure. In particular, the possibility of a dimensional revolution has not occurred and early proposals of etiopathogenic diagnoses were not implemented due to lack of specific knowledge in that field. However, conceiving the DSM-5 as a bridge (...) between the present phenomenally based operational diagnostic criteria and the neuro-cognitively based RDoC criteria introduces an internal tension into the system. It is expected that a liberalization of the research criteria will occur, the DSM operational criteria being only one possible way to select research subjects. (shrink)

Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and ‘ordinary’ experience to escape the fear-related prejudices associated with the imagined ‘otherness’ of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a ‘likeness-based’ (...) and ‘unlikeness-based’ conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns. (shrink)

Philosophical speculation about how psychiatric externalism might function in practice has yet to fully consider the multitude of externalist psychiatric systems that exist beyond the bounds of modern psychiatry. Believing that anthropology can inform philosophical debate on the matter, the paper illustrates one such case. The discussion is based on 19 months of first-hand ethnographic fieldwork among Akha, a group of swidden farmers living in highland Laos and neighboring borderlands. First, the paper describes the Akha set of medicinal, (...) ritual, and shamanic practices, analyzing issues of stigma and medical pluralism within it. Second, it makes the case that the Akha realize a functioning biopsychosocial system which comes with a well-developed set of resources for treating the social dimension of illness. Externalism among the Akha re-frames psychiatric illness as a ‘problem in living,’ which becomes manageable as such. The paper claims that, in so doing, the Akha system succeeds in many of the areas where modern internalist psychiatry falls short, and that it does so because Akha society is structured in such a way so that its practitioners can shift the social environment around the patient. As a takeaway for philosophers, it suggests that the development of an externalist psychiatry must begin from questioning the accepted ontology of the social causes of psychiatric illness. (shrink)

Philosophy has always been concerned with mental health and mental disorder, and many prominent historical figures have held views that have drawn attention to these issues. In recent years, however, there has been a surge of interest in philosophical issues surrounding psychiatry. As a result, the philosophy of psychiatry has emerged as a distinct, well-established field of inquiry.

This dissertation is a contribution to the contemporary field of phenomenological psychopathology, or the phenomenological study of psychiatric disorders. The work proceeds with two major aims. The first is to show how a phenomenological approach can clarify and illuminate the nature of psychopathology—specifically those conditions typically labeled as major depressive disorder and bipolar disorder. The second is to show how engaging with psychopathological conditions can challenge and undermine many phenomenological presuppositions, especially phenomenology’s status as a transcendental philosophy and (...) its corresponding anti-naturalistic outlook. In the opening chapter, I articulate the three layers of the subject matter of phenomenological research—what I refer to as “existentials,” “modes,” and “prejudices.” As I argue, while each layer contributes to what we might call the “structure” of human existence, they do not do so in the same way, or to the same degree. Because phenomenological psychopathology—and applied phenomenology in general—aims to characterize how the structure of human existence can change and alter, it is paramount that these layers be adequately delineated and defined before investigating these changes. In chapters two through five, I conduct hermeneutic and phenomenological investigations of psychopathological phenomena typically labeled as major depressive disorder or bipolar disorder. These investigations address the affective aspects of depression and mania, and the embodied aspects of depression. In addition to clearly articulating the nature of these phenomena, I show how certain psychopathological conditions involve changes in the deepest or most fundamental layer of human existence—what I refer to as existentials. As I argue, many of the classical phenomenologists (including Husserl and Heidegger) believed that these structural features were necessary, unchanging, and universal. However, this presupposition is challenged through the examination of psychopathological and neuropathological conditions, undermining the status of phenomenology as a transcendental philosophy. While this challenge to classical phenomenology is only sketched in the early chapters, in chapters six and seven I develop it in more detail in order to achieve two distinct ends. In chapter six I argue that psychopathology and neuropathology not only challenge phenomenology’s status as a transcendental philosophy, but also supply a key to developing a phenomenological naturalism (which I contrast with a naturalized phenomenology). Phenomenological naturalism, as I articulate it, is a position in which phenomenology is not subsumed by the metaphysical and methodological framework of the natural sciences, but nonetheless maintains the capacity to investigate how the natural world stands independent of human subjectivity (and how events in the natural world can bring about changes in the most fundamental structures of human existence). In the seventh chapter I argue that a phenomenology in which existentials are contingent and variable rather than necessary and unchanging allows phenomenologists to contribute to new dimensional approaches to psychiatric classification. Rather than begin from distinct categories of disorder, these approaches begin from distinct core features of human existence. These features, referred to as either dimensions or constructs, can vary in degree and are studied in both normal and pathological forms. (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)

It is often claimed in parts of the psychiatric literature that neuroscientific research into the biological basis of mental disorder undermines dualism in the philosophy of mind. This paper shows that such a claim does not apply to all forms of dualism. Focusing on Kenneth Kendler’s discussion of the mind–body problem in biological psychiatry, I argue that such criticism of dualism often conflates the psychological and phenomenal concepts of the mental. Moreover, it fails to acknowledge that there are (...) different varieties of dualism, and so overlooks the important metaphysical insights of contemporary dualist philosophers. I argue that while the neuroscientific research underpinning biological psychiatry challenges the traditional dualism of René Descartes, it does not pose any problem for the more modern dualism of David Chalmers. It is possible to take seriously the scientific claims of biological psychiatry while holding that this latter form of dualism is true. This has implications for the positioning of the mind–body problem in psychiatry. While the “easy” problem of explaining psychological processes is relevant to the aims of biological psychiatry, psychiatrists need not worry about the “hard” problem of consciousness. (shrink)

This chapter examines the history of philosophy of psychology and philosophy of psychiatry as subfields of philosophy of science that emerged in the late twentieth and early twenty-first century. The chapter also surveys related literatures that developed in psychology and psychiatry. Philosophy of psychology (or philosophy of cognitive science) has been a well-established subfield of philosophy of mind since the 1990s and 2000s. This field of philosophy of psychology is narrowly focused on issues (...) in cognitive psychology and cognitive science. Compared to the thriving subfield of philosophy of cognitive science, there has been a lack of corresponding interest among philosophers of science in broader methodological questions about different paradigms and fields of study in psychology. These broader methodological questions about psychology have been addressed in the field of theoretical psychology, which is a subfield of psychology that materialized in the 1980s and 1990s. Philosophy of psychiatry emerged as a subfield of philosophy of science in the mid-2000s. Compared to philosophy of psychology, the philosophy of psychiatry literature in philosophy of science engaged with issues examined in an older and more interdisciplinary tradition of philosophy of psychiatry that developed after the 1960s. The participation of philosophers of science in the literature on theoretical psychology, by contrast, has been limited. (shrink)

This dissertation seeks to examine the validity of the justification commonly offered for a coercive(1) psychiatric intervention, namely that the intervention was in the ‘best interests’ of the subject and/or that the subject posed a danger to others. As a first step,it was decided to analyse justifications based on ‘best interests’ [the ‘Stage 1’ argument] separately from those based on dangerousness [the ‘Stage 2’ argument]. Justifications based on both were the focus of the ‘Stage 3’ argument. Legal and philosophical (...) analyses of coercive psychiatric interventions generally regard such interventions as embodying a benign paternalism occasioning slight, if any, ethical concern. Whilst there are some dissenting voices even at the very heart of academic and professional psychiatry, the majority of psychiatrists also appear to share such views. The aim of this dissertation is to show that such a perspective is mistaken and that such interventions raise philosophical and ethical questions of the profoundest importance.(2) The philosophical well-spring of the Stage 1 dissertation argument lay in an observation made by Philippa Foot (3) that the “… right to be let free from unwanted interference” is one of the most fundamental and distinctive rights of persons, a right which takes precedence over any “… action we would dearly like to take for his sake.” This – in conjunction with the recognition that some coercive psychiatric interventions are of a gravity as to result in the personhood of the subject being severely damaged if not destroyed – suggested that the concept of personhood play a central role in the formulation of the dissertation argument. For ease of analysis it was presumed that the term ‘person’ could be defined by a set of necessary and sufficient conditions of which ‘minimum levels of rationality’ and ‘ability to communicate’ were the only conditions relevant to the formulation of justifications for coercive psychiatric interventions. This presumption was explicated into a number of postulates which enabled the construction of a rigorous foundation on which to develop the dissertation argument. This argument then sought to determine whether psychiatric assessments of irrationality were accurate and reliable. In furtherance of this analysis it was necessary to examine the reliability of psychiatric determinations in other areas of claimed expertise namely diagnosis, treatment and assessment of dangerousness. This ‘crossing of the disciplinary threshold’ brought to light the dearth of studies on psychiatric misdiagnosis and iatrogenic harm. A variant of the Precautionary Principle was developed to enable the extent of such harms to be estimated. The not insignificant levels of psychiatric misdiagnosis and iatrogenic harm and erroneous assessments of dangerousness which were thus found are of considerable relevance to any ethical analysis of the justification for coercive psychiatric intervention and serve to undermine simple paternalistic justifications. ---- (1)The term ‘coercive’ (rather than ‘non-consensual’) is used to indicate an intervention carried out against the explicit and contemporaneous objections of the subject (2)Not least because the number of individuals detained in Irish psychiatric hospitals is of a comparable order of magnitude to the number detained in Irish prisons subsequent to a criminal conviction. (3) See Foot (1977), p.102. (shrink)

The biopsychosocial (BPS) model in psychiatry has come under fire for being too vague to be of any practical use in the clinic. For many, its central flaw consists in lack of scientific validity and philosophical coherence: the model never specified how biological, psychological and social factors causally integrate with one another. Recently, advances in the cognitive sciences have made great strides towards meeting this very ‘integration challenge.’ The paper begins by illustrating how enactivist and predictive processing frameworks propose converging (...) accounts of biopsychosocial integration that are far superior to those of previous theories. It argues, however, that the main problem of implementing the BPS model has less to do with integration than with the lack of a social etiology. Psychiatric practice leans heavily towards ‘bio’ and ‘psycho’ approaches, without an equally developed set of explanatory and therapeutic resources for dealing with the ‘social’ dimension of illness. This leaves psychiatry essentially internalist in orientation. As illustrated most poignantly by conditions such as functional neurological disorders, internalism comes with the risks of stigma and the curtailment of therapeutic possibilities. The paper argues that the answer to the failings of the BPS model lies in combining the integration challenge with the development of an ‘externalist psychiatry,’ which casts both causes and treatment of psychiatric illness onto the social environment. The following two papers explore the conditions that might make this idea a reality. (shrink)

Delusions have traditionally been considered the hallmark of mental illness, and their conception, diagnosis and treatment raise many of the fundamental conceptual and practical questions of psychopathology. One of these fundamental questions is whether delusions are understandable. In this paper, we propose to consider the question of understandability of delusions from a philosophy of language perspective. For this purpose, we frame the question of how delusions can be understood as a question about the meaning of delusional utterances. Accordingly, (...) we ask: “what meaning(s) can delusional utterances possibly have?”. We argue that in the current literature, there is a standard approach to the meaning of delusional utterances, namely the descriptive account which assumes that a delusional utterance “p” means that p is the case. Drawing on Speech Act Theory, we argue that solely relying on the descriptive account disregards essential ways of how linguistic meaning is constituted. Further, we show that Speech Act Theory can prove a helpful addition to the theoretical and clinical “toolbox” used for attempting to understand delusional utterances. This, we believe, may address some of the theoretical and clinical shortcomings of using only the currently predominant descriptive account. (shrink)

Advances in emotion and affective science have yet to translate routinely into psychiatric research and practice. This is unfortunate since emotion and affect are fundamental components of many psychiatric conditions. Rectifying this lack of interdisciplinary integration could thus be a potential avenue for improving psychiatric diagnosis and treatment. In this contribution, we propose and discuss an ontological framework for explicitly capturing the complex interrelations between affective entities and psychiatric disorders, in order to facilitate mapping and (...) integration between affective science and psychiatric diagnostics. We build on and enhance the categorisation of emotion, affect and mood within the previously developed Emotion Ontology, and that of psychiatric disorders in the Mental Disease Ontology. This effort further draws on developments in formal ontology regarding the distinction between normal and abnormal in order to formalize the interconnections. This operational semantic framework is relevant for applications including clarifying psychiatric diagnostic categories, clinical information systems, and the integration and translation of research results across disciplines. (shrink)

Psychiatric research is in crisis because of repeated failures to discover new drugs for mental disorders. Lack of measurement validity could partly account for these failures. If researchers do not actually measure the effects of drugs on the disorders they aim to investigate, one should expect suboptimal treatment outcomes. I argue that this is the case, focusing on depression, and fear & anxiety disorders. In doing so, I show how psychiatric research illustrates a more general phenomenon that I (...) call “validity drift.” A validity drift occurs when, in the course of developing new measurement procedures, researchers end up studying something different from what they originally aimed to study. I analyze the different ways in which scientists attempt to validate procedures for measuring mental disorders for the purpose of testing drugs in animal models. I show how those validation efforts might fail, thereby leading to validity drifts. Overall, this analysis highlights the complex interplay between the development of new measurement procedures, their calibration, and scientific theories of the target phenomena. (shrink)

To date, diagnosing Attention Defi cit Hyperactivity Disorder remains indeed one of the most controversial issues in contemporary psychiatry and behavioural sciences. Most of the conceptual problems regarding the validity of this diagnostic category arise from the heterogeneity of syndromal pictures and the high rate of comorbidity observed in subjects diagnosed with ADHD at all stages of the longitudinal course of the disorder. In this regard, DSM 5 increased complexity by allowing a diagnosis of comorbidity between ADHD and autism (...) spectrum disorders while these two diagnoses were mutually exclusive in DSM-IV-TR. (shrink)

Aims and Methods: The general conceptual issues involved in psychiatric classification seem to be increasingly neglected in contrast to a focus on specific and empirical aspects which appear to have come to dominate the study of classification in the field. This article explores how the psychiatric field (in the UK and US) has chosen to analyse classification over time. Publication trends of articles in both The American Journal of Psychiatry and The British Journal of Psychiatry over a fifty (...) year period (1960-2010) can be viewed as indicators of the levels of interest within the psychiatric field toward classification. In an exploratory analysis, articles explicitly focusing on classification were counted and further sub-divided according to whether they focused on empirical or conceptual aspects and whether they adopted a general perspective or focused on a more specific aspect of classification. Results: Interest in classification was apparent in a minority of published articles (4.7% of all published articles). Interest in conceptual aspects dropped throughout the fifty years and was found to be considerably less than for empirical approaches which steadily increased over time. General papers about classification have been gradually on the decline and have been increasingly outnumbered by more specifically-focused articles. Clinical Implication: Classification, as a foundational endeavour within the psychiatric field, requires increased attention in the literature. This literature should address conceptual as well as empirical issues. (shrink)

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

Externalist theories hold that a comprehensive understanding of mental disorder cannot be achieved unless we attend to factors that lie outside of the head: neural explanations alone will not fully capture the complex dependencies that exist between an individual’s psychiatric condition and her social, cultural, and material environment. Here, we firstly offer a taxonomy of ways in which the externalist viewpoint can be understood, and unpack its commitments concerning the nature and physical realization of mental disorder. Secondly, we apply (...) a strongly externalist approach to the case of Autistic Spectrum Disorder, and argue that this condition can be illuminated by appeal to the hypothesis of extended cognition. We conclude by briefly considering the significance this strongly externalist approach may have for psychiatric practice and pedagogy. (shrink)

Jakovljevic and Crnčevic review the concept of comorbidity in relation to mental disorders, which is timely. Yet they seem to ignore a longstanding and important notion of comorbidity, highlighted in psychiatry particularly by Sigmund Freud. The ignored notion is that of compensatory comorbidity. Compensatory comorbidity is a special case of compensatory phenomena in relation to disrupted health.