Philosophy of psychiatry: theoretical advances and clinical implications.

Work at the intersection of philosophy and psychiatry has an extensive and influential history, and has received increased attention recently, with the emergence of professional associations and a growing literature. In this paper, we review key advances in work on philosophy and psychiatry, and their related clinical implications. First, in understanding and categorizing mental disorder, both naturalist and normativist considerations are now viewed as important - psychiatric constructs necessitate a consideration of both facts and values. At a conceptual level, this integrative view encourages moving away from strict scientism to soft naturalism, while in clinical practice this facilitates both evidence-based and values-based mental health care. Second, in considering the nature of psychiatric science, there is now increasing emphasis on a pluralist approach, including ontological, explanatory and value pluralism. Conceptually, a pluralist approach acknowledges the multi-level causal interactions that give rise to psychopathology, while clinically it emphasizes the importance of a broad range of "difference-makers", as well as a consideration of "lived experience" in both research and practice. Third, in considering a range of questions about the brain-mind, and how both somatic and psychic factors contribute to the development and maintenance of mental disorders, conceptual and empirical work on embodied cognition provides an increasingly valuable approach. Viewing the brain-mind as embodied, embedded and enactive offers a conceptual approach to the mind-body problem that facilitates the clinical integration of advances in both cognitive-affective neuroscience and phenomenological psychopathology.

What are delusions? Examining the typology problem.

Delusions are a heterogenous transdiagnostic phenomenon with a higher prevalence in schizophrenia. One of the most fundamental debates surrounding the philosophical understanding of delusions concerns the question about the type of mental state in which reports that we label as delusional are grounded, namely, the typology problem. The formulation of potential answers for this problem seems to have important repercussions for experimental research in clinical psychiatry and the development of psychotherapeutic tools for the treatment of delusions in clinical psychology. Problematically, such alternatives are scattered in the literature, making it difficult to follow the current development and state of the target discussion. This paper offers an updated critical examination of the alternatives to the typology problem currently available in the literature. After clarifying the two main philosophical views underlying the dominant formulation of the debate (interpretivism and functionalism), we follow the usual distinction between doxastic (the idea that delusions are a type of belief) and anti-doxastic views. We then introduce two new sub-distinctions; on the doxastic camp, we distinguish between revisionist and non-revisionist proposals; on the anti-doxastic camp, we distinguish between commonsensical and non-commonsensical anti-doxasticisms. After analyzing the main claims of each view, we conclude with some of the most fundamental challenges that remain open within the discussion. This article is categorized under: Philosophy > Foundations of Cognitive Science Philosophy > Consciousness Philosophy > Psychological Capacities Neuroscience > Cognition.

Hermeneutical injustice and unworlding in Psychopathology.

The rich literature in phenomenological psychopathology regards the communicative difficulties accompanying psychiatric illness as a product of 'unworlding': the experience of a drastic change in one's habitual field of experience. This paper argues that the relationship between speech expression and unworlding in psychiatric illness is more complex than previously assumed. Not only does unworlding cause a breakdown in speech expression, but a breakdown in speech expression can perpetuate, and even exacerbate, the experience of unworlding characteristic of psychiatric illness. In other words, I identify a two-way relationship between unworlding and the communication breakdown in psychiatric illness. Merleau-Ponty's phenomenology of speech expression is drawn upon to demonstrate how hermeneutical injustice in psychiatric healthcare can elicit unworlding for the person with a psychiatric illness.

What is formulation in psychiatry?

The practice of formulation has been both championed and severely criticised within clinical psychiatry and interest in formulation within the teaching of clinical psychiatry is at a low ebb. This article traces the history of the biopsychosocial model, the concept of diagnostic hierarchy and the role of 'verstehen' (or intersubjective meaning grasping) in the clinical assessment. All three of these concepts are considered relevant to the practice of formulation. Responding to challenges aimed at these concepts, it argues that formulation in psychiatry needs resuscitating and rethinking and provides some recommendations for a practice of formulation fit for the 21st century.

Nosology of behavioral addictions: Intersections with philosophy of psychiatry •.

Writing in this journal, Brand and colleagues have proposed criteria for other specified disorders due to addictive behaviors. Their proposal intersects with key debates in philosophy of psychiatry, including how best to define mental disorders, to validate them, and to optimize their meta-structure. Review of these debates in the context of behavioral addictions suggests several conclusions. First, these debates involve "essentially contested" constructs that require ongoing consideration and judgment. Second, the complexity of psychopathology suggests multiple legitimate approaches to delineating traits and explicating mechanisms. Third, in optimizing meta-structure, non-psychobiological considerations are crucial - the overlapping public mental health approach to addictive disorders is paramount.

A commentary on Effective Connectivity Between the Orbitofrontal Cortex and the Precuneus Differentiates Major Psychiatric Disorders: Results from a Transdiagnostic Spectral DCM Study

Translational psychiatry has been a hot topic in Neurosciences research. The authors present a commentary on the relevant findings from a transdiagnostic study applicable to clinic practice. Additional discussion on conceptual and clinical insight into this current broad line of research is explored in the integration of multi-level paradigm in Psychiatry research.

Kraepelin's psychiatry in the pragmatic age.

The movement of a pendulum is often used as a metaphor to represent the history of twentieth century American psychiatry. On this view, American psychiatry evolved by swinging back and forth between two schools of thought in constant competition: somatic accounts of mental illness and psychodynamic ones. I argue that this narrative partly misrepresents the actual development of American psychiatry. I suggest that there were some important exchanges of ideas and practices in the transition from German biological approaches to American psychodynamic approaches. In particular, two kinds of pragmatism played an important role in this transition: Kraepelin's methodological pragmatism, and pragmatic values present in the American psychiatric context, due in part to the influence of William James. From a historical standpoint, I suggest that the metaphor of the pendulum doesn't capture the full complexities of this shift in psychiatry at the turn of the century; from a philosophical standpoint, my discussion brings to light two strands of pragmatism salient to scientific psychiatry.

Mental Disorder and Suicide: What's the Connection?

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.

Top-down causation in psychiatric disorders: a clinical-philosophical inquiry.

Psychiatry has long debated whether the causes of mental illness can be better explained by reductionist or pluralistic accounts. Although the former relies on commonsense scientific bottom-up causal models, the latter (which typically include environmental, psychological, and/or socio-cultural risk factors) requires top-down causal processes often viewed with skepticism, especially by neuroscientists. We begin with four clinical vignettes which illustrate self-interventions wherein high-order psychological processes (e.g. religious beliefs or deep interpersonal commitments) appear to causally impact the risk for or the course of psychiatric/behavioral disorders. We then propose a model for how to understand this sort of top-down self-causation. Our model relies centrally on the concept of a control variable which, like a radio tuning dial, can implement a series of typically unknown physical processes to obtain the desired ends. We set this control variable in the context of an interventionist account of causation that assumes that a cause (C) produces an effect (E) when intervening on C (by manipulating it) is associated with a change in E. We extend this framework by arguing that certain psychological changes can result from individuals intervening on their own mental states and/or selection of environments. This in turn requires a conception of the self that contains mental capacities that are at least partially independent of one another. Although human beings cannot directly intervene on the neurobiological systems which instantiate risk for psychiatric illness, they can, via control variables at the psychological level, and/or by self-selection into protective environments, substantially alter their own risk.

Explanatory methods in psychiatry: interview with Paul McHugh, MD.

This interview with Paul McHugh, MD, delves into his Perspectives approach to psychiatry. Building on the philosophical work of forerunners such as Adolf Meyer and Karl Jaspers, the Perspectives approach identifies four explanatory methods underlying the practice of the profession: the perspectives of brain diseases, personality dimensions, motivated behaviours, and life encounters. The disease perspective describes how neurobiological injuries can disrupt the functioning of the brain, as with delirium or dementia. The dimensional perspective describes the vulnerabilities of some individuals to emotional unrest tied to aspects of the self-defining features characterising them, as with intellectual disability or personality disorders. The behaviour perspective describes problematic, habit-sustained activities that arise from the teleological features, as with anorexia nervosa or alcohol dependence. The life story perspective describes how emotional distresses is generated by the interaction of life events and the extrinsic/experiential features of mind, as with grief, post-traumatic stress disorder, or demoralisation. The Perspectives approach structures and operationalises the several elements of a psychiatric formulation, with the understanding that the approach to an individual patient requires us to take into account several different aspects of their life and state of mind in making sense of their presentation.

Medicine's metaphysical morass: how confusion about dualism threatens public health.

What position on dualism does medicine require? Our understanding of that question has been dictated by holism, as defined by the biopsychosocial model, since the late twentieth century. Unfortunately, holism was characterized at the start with confused definitions of 'dualism' and 'reductionism', and that problem has led to a deep, unrecognized conceptual split in the medical professions. Some insist that holism is a nonreductionist approach that aligns with some form of dualism, while others insist it's a reductionist view that sets out to eradicate dualism. It's important to consider each version. Nonreductive holism is philosophically consistent and clinically unproblematic. Reductive holism, however, is conceptually incoherent-yet it is the basis for the common idea that the boundary between medical and mental health disorders must be vague. When we trace that idea through to its implementation in medical practice, we find evidence that it compromises the safety of patient care in the large portion of cases where clinicians grapple with diagnosis at the boundary between psychiatry and medicine. Having established that medicine must embrace some form of nonreductionism, I argue that Chalmers' naturalistic dualism is a stronger prima facie candidate than the nonreductive alternatives. Regardless of which form of nonreductionism we prefer, some philosophical corrections are needed to give medicine a safe and coherent foundation.

Scepticism of the gentle variety: interview with Derek Bolton, PhD.

This interview with Derek Bolton, PhD, goes into a discussion of his philosophical work on the diagnosis and definition of mental disorder, the basis of the standards or norms by which we judge that a person has a mental disorder, and the validity of the distinction between abnormal and normal mental functioning. Bolton argues that the notion that emerges from a conceptual analysis of psychiatry's diagnostic manuals is not a naturalist notion of disorder, but one that is focussed on harm and suffering, and in which the personal, the social and the biological cannot be clearly distinguished. The implications of this thinking with regards to the relationship between the medical model and the psychological approaches are also discussed. His most recent philosophical work reconceptualizes the biopsychosocial model as a philosophical theory of biopsychosocial causal interactions and he argues that there are causal regulatory functions within the psychological domain, and this is so independent of whether they can be captured by a physicochemical description of brain processes.

Mental disorder and social deviance.

Social deviance refers to actions or behaviours that violate social norms. Since the declassification of homosexuality and development of DSM-III, one of the aims of a definition of mental disorder has been to make explicit the distinction between mental disorder and social deviance. It is well-recognized that psychiatric disorders frequently manifest as violations of social norms, and the validity of the distinction between disorder and deviance has been of great interest to philosophers of psychiatry. This article provides an overview of some of the major conceptual strategies that have been discussed as a means of discriminating between mental disorder and social deviance, and the extent to which these strategies can be said to be philosophically successful. Specifically, we review DSM's definition of mental disorder, notions of dysfunctions (commonsensical, clinical, naturalist), intrinsic and socially constituted distress, disability, 3E perspectives and functional norms, and ethical and political approaches to this question. Current philosophical strategies don't offer a distinct dividing line between disorder and deviance, but they help illuminate the relevant considerations involved. It may be concluded that the distinction between disorder and deviance is not simply discovered but also negotiated between competing values.

Conceptual and historical evolution of psychiatric nosology.

Psychiatric taxonomies exist within conceptual frameworks which presuppose certain conceptions of psychiatric distress and offer guiding principles. This article provides an overview of the historical development of psychiatric classifications with an emphasis on their methodological assumptions. After identifying roots of scientific psychiatric classifications in the works of Sydenham and Linnaeus and discussing early classification systems, our survey focuses on the Kahlbaum-Hecker-Kraepelin paradigm (with its emphasis on longitudinal course of illness), the Wernicke-Kleist-Leonhard tradition (with its emphasis on neural systems), the development of the ICD and the DSM classifications (with their roots in medical statistics, their pragmatic nature, and their emphasis on descriptive and operationalized criteria), psychodynamic and idiographic perspectives (e.g. the Psychodynamic Diagnostic Manual), and transdiagnostic approaches (e.g. Research Domain Criteria). The central philosophical questions of nosology (descriptive vs aetiological, symptoms vs course of illness, idiographic vs nomothetic, categorical vs dimensional, etc.) have appeared and reappeared throughout this evolution. Ongoing controversies reflect the epistemological and ontological difficulties inherent in defining and classifying mental illness. It may be that no single taxonomy can satisfy all clinical, research, and administrative needs, and that, echoing the ideas of Aubrey Lewis, multiple systems may be required to serve different needs.

Psychiatric disorders as an imperfect community: interview with Peter Zachar, PhD.

This interview with Peter Zachar, PhD, discusses his 2014 book 'A Metaphysics of Psychopathology', and explores his application of the philosophy of scientifically-inspired pragmatism to psychiatric classification, his critique of essentialistic thinking in psychiatry, and his notion of the imperfect community model with regards to psychiatric disorders. The imperfect community is a non-essentialist idea, namely, that the various members of the class of psychiatric disorders have many things in common, but there is no one thing (an essence) that they all have in common that distinguishes them as a group from non-disorders. The resulting domain is, however, not random or arbitrary - new constructs have been introduced for reasons that reflect our scientific goals and pragmatic interests. Zachar is sceptical about the possibility of a single correct and privileged psychiatric classification, but he recognises that the ways in which psychiatric symptoms empirically cluster together places constraints on psychiatric classification that, for instance, don't apply to organising libraries. Classifications are contingent on multiple factors, including our scientific knowledge and goals. Epistemic and evaluative commitments, once identified, work together in a non-arbitrary way to constrain what counts as a good solution to the question of classification.

Digital Phenotyping: Ethical Issues, Opportunities, and Threats.

This paper explores the potential threats of digital phenotyping and the ways it may redesign our body experience and conceptualization. We argue that technology in digital medicine, and in psychiatry in particular, is not merely an extrinsic device to achieve improvements in knowledge, diagnosis, and treatment of diseases; rather, it intrinsically and unavoidably implies potential effects on what it is to be a human person, namely the embodiment and relatedness in human affairs, and not only in the clinical setting. Last but not least, digital phenotyping may improve prediction of abnormal behaviour, but not improve its causal explanation or psychological understanding.

Addiction from the harmful dysfunction perspective: How there can be a mental disorder in a normal brain.

Is addiction a medical disorder, and if so, what kind of disorder is it? Addiction is considered a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Critics argue that the brain changes result instead from normal neuroplasticity and learning in response to the intense rewards provided by addictive substances, thus addiction is not a disorder but rather a series of normal-range if problematic choices. Relying on the harmful dysfunction analysis of medical disorder to evaluate disorder versus nondisorder status, I argue that even if one accepts the critics' reinterpretation of NIDA's brain evidence and rejects the brain disease account, the critics' conclusion that addiction is not a medical disorder but is rather a matter of problematic nondisordered choice does not follow. This is because there is a further possible account of addiction, the evolutionary "hijack" view, that holds that addiction is due to the availability of substances and stimuli that were unavailable during human species evolution and that coopt certain brain areas concerned with human motivation, creating biologically undesigned peremptory desires. I argue that if the hijack theory is correct, then it opens up the possibility that addiction could be a true motivational medical disorder for which there is no underlying neurological-level dysfunction. Finally, I explore the implications of this account for how we see the social responsibility for addiction and how we attempt to control it.

Striking the balance with epistemic injustice in healthcare: the case of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis.

Miranda Fricker's influential concept of epistemic injustice (Oxford University Press, Oxford, 2007) has recently seen application to many areas of interest, with an increasing body of healthcare research using the concept of epistemic injustice in order to develop both general frameworks and accounts of specific medical conditions and patient groups. This paper illuminates tensions that arise between taking steps to protect against committing epistemic injustice in healthcare, and taking steps to understand the complexity of one's predicament and treat it accordingly. Work on epistemic injustice is therefore at risk of obfuscating legitimate and potentially fruitful inquiry. This paper uses Chronic Fatigue Syndrome/Myalgic Encephalomyelitis as a case study, but I suggest that the key problems identified could apply to other cases within healthcare, such as those classed as Medically Unexplained Illnesses, Functional Neurological Disorders and Psychiatric Disorders. Future work on epistemic injustice in healthcare must recognise and attend to this tension to protect against unsatisfactory attempts to correct epistemic injustice.

The harm of medical disorder as harm in the damage sense.

Jerome Wakefield has argued that a disorder is a harmful dysfunction. This paper develops how Wakefield should construe harmful in his harmful dysfunction analysis (HDA). Recently, Neil Feit has argued that classic puzzles involved in analyzing harm render Wakefield's HDA better off without harm as a necessary condition. Whether or not one conceives of harm as comparative or non-comparative, the concern is that the HDA forces people to classify as mere dysfunction what they know to be a disorder. For instance, one can conceive of cases where simultaneous disorders prevent each other from being, in any traditional sense, actually harmful; in such cases, according to the HDA, neither would be a disorder. I argue that the sense of harm that Wakefield should employ in the HDA is dispositional, similar to the sense of harm used when describing a vile of poison: "Be careful! That's poison. It's harmful." I call this harm in the damage sense. Using this sense of harm enables the HDA to avoid Feit's arguments, and thus it should be preferred to other senses when analyzing harmful dysfunction.

In Defense of Madness: The Problem of Disability.

At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgments, and the second arises from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism, the applicability of the social model to madness, and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter.