Does DBS change a patient’s personality? This is one of the central questions in the debate on the ethics of treatment with Deep Brain Stimulation (DBS). At the moment, however, this important debate is hampered by the fact that there is relatively little data available concerning what patients actually experience following DBS treatment. There are a few qualitative studies with patients with Parkinson’s disease and Primary Dystonia and some case reports, but there has been no qualitative study yet with patients (...) suffering from psychiatric disorders. In this paper, we present the experiences of 18 patients with Obsessive-Compulsive Disorder (OCD) who are undergoing treatment with DBS. We will also discuss the inherent difficulties of how to define and assess changes in personality, in particular for patients with psychiatric disorders. We end with a discussion of the data and how these shed new light on the conceptual debate about how to define personality. (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)

Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community’s interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS—though a much more precise and refined treatment than its predecessors—is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of (...) psychosurgery can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS. (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)

Psychiatric and neurological disorders have historically provided key insights into the structure-function rela- tionships that subserve human social cognition and behavior, informing the concept of the ‘social brain’. In this review, we take stock of the current status of this concept, retaining a focus on disorders that impact social behavior. We discuss how the social brain, social cognition, and social behavior are interdependent, and emphasize the important role of development and com- pensation. We suggest that the social (...) brain, and its dysfunction and recovery, must be understood not in terms of specific structures, but rather in terms of their interaction in large-scale networks. (shrink)

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

The paper considers whether psychiatric kinds can be natural kinds and concludes that they can. This depends, however, on a particular conception of ‘natural kind’. We briefly describe and reject two standard accounts – what we call the ‘stipulative account’ (according to which apparently a priori criteria, such as the possession of intrinsic essences, are laid down for natural kindhood) and the ‘Kripkean account’ (according to which the natural kinds are just those kinds that obey Kripkean semantics). We then (...) rehearse a more permissive account: Richard Boyd’s ‘homeostatic property cluster’ (HPC) account. We argue that psychiatric kinds can in principle count as natural kinds on the HPC account. Moreover, specific psychiatric kinds (Tourette’s, schizophrenia, etc.) can be natural kinds even if the category psychiatric disorder is not itself a natural kind. (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)

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)

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

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)

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)

Although formal thought disorder (FTD) has been for long a clinical label in the assessment of some psychiatric disorders, in particular of schizophrenia, it remains a source of controversy, mostly because it is hard to say what exactly the “formal” in FTD refers to. We see anomalous processing of terminological knowledge, a core construct of human knowledge in general, behind FTD symptoms and we approach this anomaly from a strictly formal perspective. More specifically, we present here a symbolic (...) computational model of storage in, and activation of, a human semantic network, or semantic memory, whose core element is logical form; this is normalized by description logic (DL), namely by CL, a DL-based language – Conception Language – designed to formalize conceptualization from the viewpoint of individual cognitive agency. In this model, disruptions in the rule-based implementation of the logical form account for the apparently semantic anomalies symptomatic of FTD, which are detected by means of a CL-based algorithmic assessment. (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)

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)

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)

In this opinion piece we propose the investigation of psychedelic-assisted psychotherapy for the treatment of body dysmorphic disorder (BDD). BDD is a psychiatric disorder characterised by appearance-based preoccupations and accompanying compulsions. While safe and effective treatments for BDD exist, non-response and relapse rates remain high. Therefore, there is a need to investigate promising new treatment options for this highly debilitating condition. Preliminary evidence suggests safety, feasibility, and potential efficacy of psychedelic treatments in disorders that share similar psychopathological mechanisms (...) with BDD. Drawing on this evidence, as well as on relevant qualitative reports and theoretical proposals, we argue that it would be worthwhile to conduct a phase 2a study aimed at assessing the safety and feasibility of psychedelic-assisted psychotherapy in BDD. We also offer some suggestions for how future research ought to proceed. (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)

Discussions of psychiatric nosology focus on a few popular examples of disorders, and on the validity of diagnostic criteria. Looking at Anorexia Nervosa, an example rarely mentioned in this literature, reveals a new problem: the DSM has a strict taxonomic structure, which assumes that disorders can only be located on one branch. This taxonomic assumption fails to fit the domain of psychopathology, resulting in obfuscation of cross-category connections. Poor outcomes for treatment of Anorexia may be due to (...) it being pigeonholed as an Eating Disorder, when a disturbance of body perception may be a more central symptom than food restriction. This paper explores the possibility of restructuring the DSM taxonomy to allow for a pluralist classification of disorders. This change could improve treatment and research without requiring any changes to diagnostic criteria. (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.

First-person reports of Major Depressive Disorder reveal that when an individual becomes depressed a profound change or ‘shift’ to one’s conscious experience occurs. The depressed person reports that something fundamental to their experience has been disturbed or shifted; a change associated with the common but elusive claim that when depressed one finds oneself in a ‘different world’ detached from reality and other people. Existing attempts to utilise these phenomenological observations in a psychiatric context are challenged by the fact that (...) this experiential ‘shift’ characteristic of depression appears mysterious and resists analysis in scientific terms. This paper offers a way out of this predicament. The hypothesis proposed is that when an individual becomes depressed, the individual departs from a state of ordinary wakeful consciousness and enters a distinctive global state of consciousness akin to dreaming and the psychedelic state. After unpacking and motivating this hypothesis in the context of research in consciousness science, I outline two of its important implications for the neurobiology of depression and psychedelic psychiatry. The upshot is a promising and conceptually well-motivated hypothesis about depression which is apt for empirical uptake and development. (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)

It is widely agreed that obsessive-compulsive disorder involves irrationality. But where in the complex of states and processes that constitutes OCD should this irrationality be located? A pervasive assumption in both the psychiatric and philosophical literature is that the seat of irrationality is located in the obsessive thoughts characteristic of OCD. Building on a puzzle about insight into OCD (Taylor 2022), we challenge this pervasive assumption, and argue instead that the irrationality of OCD is located in the emotions that (...) are characteristic of OCD, such as anxiety or fear. In particular, we propose to understand the irrationality of OCD as a matter of harboring recalcitrant emotions. We argue that this account not only solves the puzzle about insight, but also makes better sense of how OCD sufferers experience and describe their condition and helps explain some otherwise puzzling features of compulsive behavior. (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)

Objective: Alterations in psychomotor dimension cut across different psychiatric disorders, such as schizophrenia (SCZ) and bipolar disorder (BD). This preliminary study aimed to investigate the organization of intrinsic brain activity in the subcortical-cortical sensorimotor system in SCZ (and BD) as characterized according to psychomotor dimension. -/- Method: In this resting-state functional magnetic resonance imaging (fMRI) study, functional connectivity (FC) between thalamus and sensorimotor network (SMN), along with FC from substantia nigra (SN) and raphe nuclei (RN) to basal ganglia (...) (BG) and thalamic regions, were investigated by using an a-priori-driven and dimensional approach. This was done in two datasets: SCZ patients showing inhibited psychomotricity (n = 18) vs. controls (n = 19); SCZ patients showing excited psychomotricity (n = 20) vs. controls (n = 108). Data from a third dataset of BD in inhibited depressive or manic phases (reflecting inhibited or excited psychomotricity) were used as control. -/- Results: SCZ patients suffering from psychomotor inhibition showed decreased thalamus-SMN FC toward around-zero values paralleled by a concomitant reduction of SN-BG/thalamus FC and RN-BG/thalamus FC (as BD patients in inhibited depression). By contrast, SCZ patients suffering from psychomotor excitation exhibited increased thalamus-SMN FC toward positive values paralleled by a concomitant reduction of RN-BG/thalamus FC (as BD patients in mania). -/- Conclusions: These findings suggest that patients exhibiting low or high levels of psychomotor activity show distinct patterns of thalamus-SMN coupling, which could be traced to specific deficit in SN- or RN-related connectivity. Notably, this was independent from the diagnosis of SCZ or BD, supporting an RDoC-like dimensional approach to psychomotricity. (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)

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)

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 largely unethical to sentence individuals who are addicted to drugs to prison. While substance use can be a crime, it must be treated differently from other crimes because addiction is a psychiatric disorder. Prisons are penal institutions. Legitimate goals of penal sanctions include retribution, deterrence, rehabilitation, and incapacitation.[i] Most of these goals do not speak to those with substance use disorder, and incarceration may be counterproductive given the wide availability of drugs and feeble rehabilitation efforts in prison. (...) Further, it may be the case that substance use disorder impairs an addict’s autonomy, calling into question his criminal culpability. Our understanding of substance use disorder has evolved and our prison sentencing practices must do the same. This paper will first provide background on substance use disorder as a psychiatric disorder. Then, the need to focus on rehabilitating rather than punishing those with substance use disorder who commit crimes will be explored. Finally, this paper will address whether an individual with substance use disorder can be considered culpable for any crime—regardless of severity—and whether that individual’s autonomy is impaired due to his addiction. I conclude that culpability should depend on whether the serious crime would have occurred in the absence of the drug addiction. In most cases, it is unethical to sentence an individual with substance use disorder to prison where other options such as home confinement are available. (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.

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)

Mental health challenges can be described via the application of multiple lenses, from clinical-medical perspectives, to social and community-based, to further understandings in the context of public health. While these challenges can represent multiple issues to the scientific community at-large, especially because of the translational issues attached to the application of research and practice to the sphere of community services, it is useful to understand that the triad ethics, evidence, and experience can be instrumental in navigating the complexity of the (...) issue-at-hand. Furthermore, the work of researchers and practitioners is rooted in a solid understanding of the specific needs of psychiatric patients, particularly from the perspective of possible misunderstandings, ostracization, and stigmatization of psychiatric issues and related presentation, affect, and behaviours. Years of research have indicated how a proper interaction between resources at the level of scientific research and the community is a fundamental cornerstone for a practice rooted in both science and true care for individuals affected by mental health disorders. In this presentation we will discuss the case of the Centro Salute Mentale (Mental Health Centre, CSM) of Verona. (shrink)

A striking feature of post-modernism is its distrust of the subject. If the modern period, beginning with Descartes, sought in the subject a source of certainty, an Archimedian point from which all else could be derived, post- modernism has taken the opposite tack. Rather than taking the self as a foundation, it has seen it as founded, as dependent on the accidents which situate consciousness in the world. The same holds for the unity of the subject. Modernity, in its search (...) for a single foundation, held the subject to be an indissoluble unity. Post-modernism’s position, by contrast, is announced by Nietzsche: “The assumption of one single subject is perhaps unnecessary; perhaps it is just as permissible to assume a multiplicity of subjects, whose interaction and struggle is the basis of our thought and our consciousness in general? ...My hypotheses: The subject as multiplicity.” Given this, there is a natural correspondence between the success of post- modernism and the current interest in multiple personality disorder. In the latter, we actually have the experience of a “multiplicity of subjects” in their interaction and struggle. The subject stands there before us “as multiplicity.” It gives us a concrete case, one which raises some of the pressing questions associated with the post-modern denial of the subject. Confronting it, we ask: how real are the personalities composing the multiplicity of this disordered self? What, in fact, does this multiplicity tell us about the self? about its genesis and status? What does it reveal about “our thought and consciousness in general”? I plan, in the short compass of this paper, to sketch some answers to these questions. §1. A brief description of MPD. The American Psychiatric Association gives two criteria for (MPD) multiple personality disorder. First, and most obviously, there is “the existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring pattern. (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)

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)

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are implanted. (...) It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

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)

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)

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)

Work on causation in psychopathology often emphasizes variation in the causes but variation in what is to be explained further complicates matters. Focusing on the protean nature of psychopathology, this chapter explores different ways that classificatory variation is generated. For example, choices about what features of disorders to foreground and background can produce variation. The chapter also examines, from the perspective of scientific conventionalism, how classificatory decisions made at choice points partly constitute what is classified, but not in the (...) sense of making it up. In contrast to the view that conventions are neither true nor false and thus isolated from the domain of facts, the chapter argues that scientific conventions are implemented to promote the discovery of facts. Scientific conventions must also answer to conceptual and factual constraints. The chapter concludes by looking at how classificatory choices can produce different versions of a psychiatric which may also result in variations in causal models across those versions. In agreement with ideas articulated by Putnam, the chapter argues that we cannot divide the language of psychopathology into a part that describes disorders as they are in themselves and a part that contains our conceptual contributions to what we know about disorders. (shrink)

In this paper, I am generally concerned with certain mental disorders and the doxastic attitudes that sometimes characterize them. According to recent Anglo-American philosophical studies on this topic, the latter involve beliefs that have somehow “gone wrong”: strange or irrational beliefs and cases of “motivated irrationality”. I aim to focus on pathological and deceptive phenomena such as delusion and self-deception. From a phenomenological perspective, these can also be investigated with regard to their experiential content. Adopting this approach, and starting (...) in particular with the eidetic connection between the living body and its own environment, I will examine disorders of the ecological self. Psychiatric delusion, which is at the core of this examination, is a symptom of a great number of mental disorders, such as Capgras disorder, Cotard disorder and schizophrenia. Integrating dominant (propositional) models of delusion which reduce this pathological phenomenon to a certain kind of belief, I propose an eco-phenomenological understanding of its contours. From this perspective, delusion reveals itself primarily as an illusory experience: a delusional value-perception. In particular, I offer a Schelerian-based description of a peculiar case of delusion: Capgras delusion. People who suffer from Capgras delusion claim that an otherwise familiar individual has been replaced by an impostor. I consider, although in its negative variations, the contextual (rather than internalist) character of this type of delusion. (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)

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 “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)

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)

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)

In this paper, I examine Reinforcement Learning modelling practice in psychiatry, in the context of alcohol use disorders. I argue that the epistemic roles RL currently plays in the development of psychiatric classification and search for explanations of clinically relevant phenomena are best appreciated in terms of Chang’s account of epistemic iteration, and by distinguishing mechanistic and aetiological modes of computational explanation.

How does doubt come about? What are the mechanisms responsible for our inclinations to reassess propositions and collect further evidence to support or reject them? In this paper, I approach this question by focusing on what might be considered a distorting mirror of unreasonable doubt, namely the pathological doubt of patients with obsessive–compulsive disorder (OCD). Individuals with OCD exhibit a form of persistent doubting, indecisiveness, and over-cautiousness at pathological levels (Rasmussen and Eisen in Psychiatr Clin 15(4):743–758, 1992; Reed in Obsessional (...) experience and compulsive behaviour: a cognitive-structural approach, Academic Press, Cambridge, 1985; Tolin et al. in Cogn Ther Res 27(6):657–669, 2003). I argue that the failure in OCD is of an affective nature, involving both excessive epistemic anxiety and hyperactive feelings of uncertainty. I further argue that our adaptive disposition to inquire about the right matters—that is, about propositions which are both epistemically risky and imply harmful possibilities—might depend on these affective mechanisms. (shrink)

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

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)