Introduction: Assessment and Diagnostic Categories
Abstract and Keywords
In this introduction to Section VI, the thrust of the component chapters is described. The classification and diagnosis of mental disorders collects a number of philosophical challenges to the field that call for responses from a variety of philosophical resources: hermeneutics, phenomenology, philosophy of mind, narrative theory, philosophy of science, epistemology-to name a few. The authors in this section address the general challenges in the classification of psychopathology, as well as address particular kinds of mental disorders, including autism, dementia, mania, psychotic disorders, and personality disorders.
In the opening seconds of a psychiatric interview, the clinician is confronted with a myriad of philosophical-methodological questions: How to start? What kind of relationship do I want to develop with this person? How can I be sure that the information I gain from this relationship will be true? Am I to believe my own observations or the patient’s report of her own experiences? What kinds of information are important, and which marginal? How do I draw the line between existential, normal distress and psychopathology? For that matter, how do I characterize or interpret this person’s experience? What does science have to offer the unique ordeal of this person? This list could go on and on. For better and for worse, the psychiatric assessment process is enshrined in a series of highly stylized and traditional structures—the history, examination, adjunctive studies, and diagnostic formulation to be brief—which enable a clinician to not be frozen by a crisis of philosophical overload. However, every one of the fundamental metaphysical, pragmatic, ethical, and even aesthetic questions that philosophy can pose to psychiatry can have direct and indirect impacts on the clinician’s tasks of helping, healing, caring, and curing.
The challenge of the philosophy of psychiatry, however, is not just reserved for psychiatrists, as the practice of psychiatry, the science of psychiatry, and the phenomena of psychopathology pose their own sets of myriad challenges to philosophers. From this standpoint, the philosophy of psychiatry overlaps with intellectual territories of philosophy of science, hermeneutics, phenomenology, narrative theory, epistemology, philosophy of mind—again the list is long. The ten essays which make up this section illustrate many of these challenges, particularized into a dynamic interaction between clinical problems and philosophical problems.
In Chapter 44, the psychologist/philosopher team of Jeffrey Poland and Barbara Von Eckardt address one of the fundamental and important questions faced by clinicians and clinical scientists: how to “map” the domain of mental illness, a domain which is metaphysically and ethically complex. They frame their task by offering an evaluative triad of challenges to any mapping scheme: such schemes should be empirically adequate, conceptually adequate, and foundationally (concerning metaphysical assumptions) adequate. This triad of evaluation becomes a template for their lucid and systematic working-through of the (p. 732) adequacy of several approaches to mapping mental illness. Most of their effort is focused upon the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the emerging DSM-5 effort, which they find wanting. They then illustrate how some alternative conceptual systems for classifying mental distress tally up against their evaluative triad, including the US National Institute of Mental Health’s Research Domain Criteria (RDoC) neuroscience-directed system, as well as the connectivity-analysis approach of Buckholtz and Meyer-Lindenberg. What emerges in Poland and Von Eckardt’s conclusions is that the context of use of classificatory systems is crucial, because of the unavoidable trade-offs of value and aptitude to context. What emerges as especially problematic for DSM efforts is that system’s “all-things-to-all-people” objectives, trying to make a universally valid diagnostic system which satisfies the needs of scientific, administrative, clinical, and educational contexts.
While Poland and Von Eckardt address value commitments in mapping domains of mental illness, John Sadler, in Chapter 45, addresses the influence of values in the development of diagnostic systems as well as in the particular kinds of evaluations that frame diagnostic criteria and diagnostic categories. He summarizes a philosophical method for values-analysis in psychiatric discourses, and then demonstrates the utility of this method for key issues in current DSM categories, framing recent work in this area from other authors. He then addresses, in more detail, sample areas of controversy in the ongoing DSM-5 effort as examples of the ongoing vitality of this method.
In Chapter 46, Matthew Broome, Paolo Fusar-Poli, and Philipe Wuyts use another DSM-5 controversy, concerning the proposed category of attenuated psychotic disorder, as one of several examples of the general conceptual and ethical issues posed by considerations of “prodromal” phases of psychosis. They introduce a continuum concept of psychosis, with early signs and symptoms posing conceptual and ethical challenges. The conceptual challenges revolve around the limiting sets of assumptions provided when the neuroscience, brain-centered model of psychosis is used, over against more intersubjective, phenomenological conceptions of psychotic illnesses. The ethical challenges are posed by the idea of preventive treatment during prodromal stages of illness—treatments which at this phase are unproven, have substantive toxicities of their own, and may inflict social stigma upon individuals who may never have a full-blown psychotic illness.
Using the clinical phenomenon of mania as his focus, Nassir Ghaemi (Chapter 47) elegantly combines two agendas: one, to describe contemporary thought on the phenomenology of manic conditions, and two, to apply this thinking critically to traditional psychoanalytic and social-constructionist conceptions of mania as a reaction to depressive illness. Setting aside traditional conceptions of mania as a mood disorder, Ghaemi instead formulates it as a disorder fundamentally characterized by psychomotor activation, creativity, and insight. He subsequently criticizes the idea of mania being environmentally reactive, at least in the traditional psychodynamic sense as a reaction against depressing life events, citing key sources from the history of psychiatry, as well as empirical research to support his formulation.
Peter Hobson points out in Chapter 48 that autistic disorders offer challenges to both psychiatrists and philosophers. He provides a thorough consideration of theory of mind and situationist theories of autism, drawing upon the philosophical work of Wittgenstein, Buber, Merleau-Ponty, Sartre, and others in the process. Hobson’s chapter is an exercise in the mutual benefit between philosophy of mind, on the one hand, and developmental (p. 733) psychology and psychopathology, on the other. Hobson shows how philosophical theory can generate testable hypotheses about development; as well as developmental psychology’s aptitude to challenge philosophical theories of mind. In this regard, Hobson shows how philosophy is an essential tool in interpreting scientific facts generated by empirical science.
An expert in old-age (geriatric) psychiatry, Julian Hughes uses clinical topics of dementia and Alzheimer’s disease as foils to explore the epistemic notion of essentialism in psychiatry in Chapter 49. Essentialism, the ideal of the invariant concept, is problematic in multiple ways for Hughes. One way is that fuzzy concepts with vague boundaries, like “dementia,” when released into common lay use, become reified and presumed to be much sharper concepts than they prove to be, given proper scrutiny. Hughes finds no sharp boundaries between aging processes and “dementia,” leading him to question the ethics of using the latter term. The “edges” of the Alzheimer concept are framed by value considerations, not sharp epistemic boundaries. Hughes sees the clinical challenge of aged people as how to regard them as “being-with” rather than formulating how to “do-to.”
In Chapter 50, the problem of essentialism raised by Hughes is explored by Walter Sinnott-Armstrong and Hanna Pickard with regard to the concept of addiction. As still another fuzzy but clinically crucial concept, the authors suggest that the kind of definition of addiction that is needed is a “precising” definition—one that is not excessively stipulative to restrict application unduly, but one which avoids the “vagueness of common usage.” They then consider a series of concepts of addiction, starting with that of DSM-IV-TR, finding its polythetic structure (different sets of independent diagnostic criteria can be met, yielding non-uniform populations) inadequate to the “precising” challenge. They then consider in detail three core features which reflect common usage but offer potential for a precising definition: appetites, control, and harm. For Sinnott-Armstrong and Pickard, although variability exists in severity of appetite for drugs, ability to control use, and degrees of harm, these three frameworks for the concept offer the potential for practical criteria to address boundaries of diagnosis and treatment, particularly when the particular concept of use of addiction concept is specified.
Chapter 51 is a frank personal memoir, as well as commentary on “memoir,” by philosopher Owen Flanagan, inspired by his own addiction and recovery experience. One of the many things memoir teaches us, and Flanagan, is the myriad ways the habit of drinking interweaves with one’s sense of self—indeed, personal identity—not the least of which is one’s sense of “feeling safe in the world.” Philosophy and narrative are one of the ways which sufferers and their would-be helpers can help each other navigate, understand, and overcome such harrowing existential situations.
In Chapter 52, Peter Zachar and Robert Krueger approach the fuzzy concept of personality disorder(s) from the standpoint of a historical and philosophical analysis of validity for these conditions. Zachar and Krueger frame the issue of personality disorders alongside the problem of characterizing “personality” in normal psychology, including the latter’s relationship to the older notion of “self.” They frame their discussion about the conceptual validity of personality disorders from three standpoints: (1) What role do values and moral evaluations play in personality disorder concepts? (2) What determines whether a personality is disordered? (3) Is “personality” causally substantive, or simply an epiphenomenon of other causal factors? Particularly for the third set of considerations, Zachar and Krueger break new ground, inviting scholars to explore this difficult area with them.
(p. 734) The phenomena of multiple personality disorder/dissociative identity disorder have fascinated philosophers for over two decades, making this topic one of the most generative problem areas in the philosophy of psychiatry. Stephen R. L. Clark makes it easy to see why. In Chapter 53, the concluding chapter in this section, Clark explores both reciprocities of the philosophy of psychiatry vis-à-vis these conditions: what philosophy has to offer psychiatry in comprehending these uncommon but perplexing conditions, and what psychiatry has to offer philosophical theories of personal identity. It turns out these conditions are problematic for both groups of scholars! Clark reviews perspectives of both psychiatric theories of dissociation as well as philosophical theories of personal identity, showing us in the process a model for bilateral scholarship in the field.