Category Archives: Classification

Subtyping autism workshop

Autism, Classification, Subtyping, ,

On the 19th of November (16.30 to 19.00 at London South Bank University (LSBU)) I am hosting (with collaborators) a workshop on subtyping autism. Below are some reasons why I am interested in this topic and more details on the event (note that these are reasons why I, rather than my collaborators or the presenters, am interested in the topic of subtyping).

My main academic interest is showing that psychiatric diagnoses are in principle scientifically legitimate. I argue that some (though not all) psychiatric diagnoses can be used in a similar way to how models are used in more respectable sciences. They cannot do everything a typical model can do in other sciences. Also, what they can do is usually done with less precision than occurs in other sciences. However, what level of similarity that they do have means that they have significant scientific worth (and this is true even though they typically cover a heterogeneous symptom picture and are causally heterogeneous).

Of course, psychiatric diagnoses can vary significantly in their scientific worth. Various ways of formulating them can impact this. The main diagnosis I am interested in is autism and one alternative way of formulating it is to add subtypes. This could alter its scientific worth as well as having many practical impacts outside of the scientific domain. This workshop will hopefully generate interesting discussion about these issues. Also, many speakers and attendees have a diagnosis of autism (or are in the process of being assessed) so lived experience might contribute some insight to both scientific and practical consequences of subtyping. Below is the initial abstract that was part of the call for papers and then the list of speakers.

This was the initial call for papers: Prior to and after the publication of the 2013 DSM there was much controversy over whether Asperger’s syndrome should be removed from the diagnostic manual. Members of the neurodiversity movement made contributions to this debate, drawing upon their lived experience of being autistic and their knowledge of the ways in which being diagnosed can be (or is not) beneficial. This conference aims to consider the question of autism and subtypes more broadly. What benefits or disadvantages are there for autistic people in adding substantive subtypes to autism? It is commonly stated that autistic people can present in many different ways. Might subtypes help add accuracy and nuance to clinical pictures? On the other hand, the boundaries between subtypes are typically vague and they can be placed in multiple places. This raises the danger that they are arbitrary impositions which do not reflect autistic experience. This conference draws upon the experience of autistic people to help resolve these issues. Possible areas for discussion include whether self-understanding for those diagnosed would be increased through being diagnosed with a more specific subtype or if this would unhelpfully impose unnatural constraints? Would the non-autistic be better able to understand different ways autism can manifest if there are significant subtypes, or would it help perpetuate unhelpful stereotypes based on an imposed limited number of ways autism would be proposed to manifest? Would the neurodiversity movement benefit from the subtypes bringing greater focus upon different ways autism can manifest or would this lead to unhelpful fracturing of the autistic community?

These are the papers that are being presented:

Autistic observable and unobservable experiences, and erroneous subtyping: Introducing the Internal and External Autistic Space (Chloe Farahar  & Annette Foster )

Exploring an autistic derived classification of autism (Mary Doherty)

Online discourse on autism does not need autism subtyping (Dafne Zuleima Morgado Ramirez)

An historical overview of subtyping (Sam Fellowes)

Demand Avoidance Phenomena: The circularity, integrity and validity of PDA: a commentary on the PDA Conference held by the National Autistic Society (2018) (Richard Woods)

Reviewing Re-Thinking Autism

Autism, Causation, Classification, Disease Entity, Methodology, Validity, , ,

Re-Thinking Autism contains, to my knowledge, the most sustained attack upon the diagnosis of autism found within a single book. The editors claim it is the first book in the field of critical autism studies. It contains 17 different papers which are grouped into three areas, namely ‘What is autism’, ‘Deconstructing autism’ and ‘Challenging Practice’. The editors see critical autism studies as focusing on two questions. Firstly, is the diagnosis of autism valid and secondly, is it useful. Most articles are very critical of the diagnosis of autism. Since I felt I benefited immensely from being diagnosed with autism I was probably always going to have reservations. However, in the spirit of engaging with the critical autism studies movement, I will suggest that the book did not address some important questions and issues which would significantly help any attempted challenge to autism.

In relation to validity, multiple articles criticised the scientific foundations of autism. Some give an useful overview of the very heterogeneous causal underpinnings of autism. Whilst this is a very relevant point when assessing autism I feel the consequences were insufficiently explored. There were relatively few details about why the causal heterogeneity makes autism deeply flawed and in need of replacement. Some articles contain statements that autism is not a biological entity or a scientific entity but these are usually asserted rather than argued for. I think these claims face some challenges. Firstly, virtually all psychiatric diagnoses are causally heterogeneous. Therefore, I feel that critical autism studies scholars need either explain why autism need replacing whilst other diagnoses do not or need explicitly endorse a whole rejection of DSM type psychiatric diagnoses (perhaps in favour of person centred approaches). A few articles do seem closer to the latter approach though there are few explicit statements. Additionally, there is little discussion about why causal heterogeneity is problematic and why it makes something not a biological or scientific entity. There was also little mention of other important factors when assessing a scientific theory (such as simplicity, tractability or coherence). These are admittedly deeply philosophical questions which are debated by philosopher of psychiatry (and I was pleased to see a few articles reference philosophers of psychiatry) but I feel these are the sorts of questions which critical autism studies needs engage in. Perhaps the arguments which critical autism studies employ are fully defensible but they currently need more development.

In relation to usefulness, some articles question whether it is helpful to give people a label and other articles question whether it helps in educational settings or support settings. Some of these authors making these arguments have a wide range of experience and expertise. Consequently, I felt they had a viewpoint that was at minimum worth hearing. That said, there was very little input from people diagnosed with autism (only one author was described as being autistic). Very few of the reasons why I find being diagnosed so useful were mentioned. Of course, being autistic does not make me automatically correct on this issue. Perhaps my positive feelings about how useful being diagnosed was are based upon flawed reasoning. Despite this, it would have been good if the book engaged in reasons why some autistic people find being diagnosed so useful even if only to then challenge those reasons.

I feel the biggest problem was a lack of alternatives being outlined. If autism is deeply flawed then what should replace it? Even some vague suggestions (i.e. split it up, add subtypes, merge it with other diagnoses) would have been helpful if I am to assess whether an alternative to autism would be preferable. Additionally, outlining alternatives would give an easier route to challenge autism. There would be no need to argue autism is deeply flawed, rather, there would instead be the easier task of arguing that autism can be useful but an alternative diagnosis is even more useful.

It is worth nothing that the articles are quite diverse and so the degree to which these criticisms are applicable to any given article will vary significantly. Additionally, I felt around a quarter of the articles were pretty good (these were usually the ones which critically analysed autism rather than wished to replace the diagnosis).

To conclude, I felt many articles avoided important questions which are relevant for assessing scientific concepts. I would like to see the critical autism movement engage more with philosophy of science and philosophy of psychiatry. Also, it would be more helpful if criticisms of autism were also accompanied by actual concrete suggestions for alternatives to autism. Despite this, I am glad I bought it and read it. If you want a single book which contains multiple different criticisms of autism then this is the book to go for. I suspect I cite multiple articles from this volume (admittedly, mainly to criticise).

Report on the Philosophy of Psychiatry Work in Progress Day, Lancaster University, 2nd of June 2017

Causation, Classification, Methodology, Philosophy

The 2nd of June saw the annual Philosophy of Psychiatry Work in Progress Day. This has been going on for longer than I have been at Lancaster and is the fifth one I have presented at. There was good attendance and it went smoothly, an enjoyable day of seeing papers from multiple perspectives in the philosophy of psychiatry. I shall give a summery of the talks below.

Rachel Cooper (Lancaster) presented on “Intentional actions, symptom checklists, and problems with cross-cultural validity”. She discussed standardised tests for personality disorders and how they included intentional actions. She then discussed how intentional actions are often given different interpretations in different cultures, creating problems for such standardised personality tests.

Marcin Moskalewicz (Oxford) presented on “Ipseity, self-consciousness, and the problem of time in schizophrenia”. He outlined ways in which time is perceived and explained how altered self-consciousness in schizophrenia can lead to an altered sense of time.

Moujan Mirdamadi (Lancaster) presented on “Death-consciousness and Depression in Iran”. She discussed the Iranian focus upon death and described how she felt this influenced some of the descriptions she received from her qualitative study of depressed Iranian patients.

Ian Hare (UEA) presented on “Qualitative Methods: a Philosophical Toolkit for Cognitive Psychiatry”. He outlined how qualitative studies can be used to gain greater descriptive understanding of a diagnosis and this can be used to provide a firmer basis for constructing psychological and psychiatric theories.

Rachel Gunn (Birmingham) presented on “The Delusional Experience as a Breakdown in Affective Framing”. She described how experience of delusions was not just purely mental but also involved many physiological and experiential changes. She then suggested that this means non-cognitive therapy approaches could be of value.

Dan Degerman (Lancaster) presented on “If you’re not psychiatry, you’re antipsychiatry – Exploring how American psychiatrists perceive their critics”. He outlined how psychiatrists perceived anti-psychiatrists and how they often labeled critics with many divergent views as anti-psychiatrist. He then suggested this can unfairly devalue psychiatric patients, who often have valuable concerns over psychiatry, thereby reducing their political agency.

Anneli Jefferson (Birmingham) presented on “Mental disorders and brain disorders – an obsolete distinction?”. She looked popular and influential arguments against seeing mental disorders and brain disorders which employ a hardware-software analogy. She criticised this argument on causal grounds then looked at counter arguments to her claims.

Joel Kruger (Exeter) presented on “Unworlding and Affective Externalism in Schizophrenia”. He discussed notions of the external mind, how perception and cognition can involve parts of the external world, and used it to understand notions of breakdown of affective scaffolding in schizophrenia and the sense of unworlding it leads to.

Victoria Allison-Bolger presented on ” ‘A thing like the ocean’ – using metaphor in understanding psychoses”. She discussed how many psychiatric diagnosis did not fit typical notions of a good classifications and suggested this means we should modify notions of good classifications to fit the diagnosis rather than make diagnosis fit our preconceptions about what is a good classification.

Gloria Ayob (UCLan) presented on “Personal autonomy and serious psychopathology”. She discussed the difficulties and possibilities of attaining a value neutral notion of serious psychosis. She tried to see if the Liberal notion that everyone should be free to believe what they wish providing it does not harm anyone could fit the notion that some people have deluded views of the world.

Finally, I presented on “Causal Structures vs Causal Mechanisms: Implications for RDoC”. I will outline these ideas in the future.

Overall, an enjoyable day with a lot of paper presented on interesting and diverse areas. The workshop typically runs every year, usually in May, June or July, and it would be worth looking for the announcement of the 2018 workshop next year.

Philosophical analysis of Neurotribes

Autism, Classification

My article, ‘Putting the Present in the History of Autism’ has been published in Studies in the History and Philosophy of the Biological and Biomedical Sciences (a pdf of the uncorrected proofs can can be found here). Though the article title mentions history, there is much philosophical content in article.

I focus upon Silberman’s extremely positive message about autism, discussing his portrayal of the past as being mistaken about the diagnostic criteria for autism and how the modern diagnostic criteria for autism has effectively got it right. I felt strangely conflicted about Silberman’s argument. One on hand, I thought he was unfair to many historical diagnostic criteria for autism. On the other hand, I still broadly agreed with his position. I agree with Silberman with that autism is getting something right about the world, being a worthy scientific concept and describing the world to at least a reasonably degree of accuracy. On this basis I significantly share Silberman’s positive message. However, as much as I believe in modern autism, I might believe even more in an alternative diagnostic approach to autism (whether it be one similar to one used in the past or something new), such as one with a greater number of subtypes or one with slightly altered boundaries. I felt Silberman’s positive message unfairly downplayed such alternatives. I think we need do research and consider our values to decide if the current diagnostic approach is superior to alternative diagnostic criteria and possible subtypes. We need study alternative approach and subtypes to see if we can make autism get even more right about the world or, alternatively, become more confident about modern autism by showing it works better than possible alternative views. So whilst I share Silberman’s positive views, I felt they risked reducing interest in scientifically investigating alternative approaches to autism, hence I both agreed with Silberman yet was critical of his position. I outline my views fully in the article.

Reviewing Psychiatry Disrupted

Classification, Medication, Philosophy

Psychiatry Disrupted was released in 2014, making it a relatively new book on the topic of anti-psychiatry. The editor’s introduction argues that anti-psychiatrists often do not focus enough on what an alternative to psychiatry would look like and this book is intended to fill this gap. Since most the well known classic anti-psychiatry texts are rather old and since they usually criticise psychiatry without sufficiently outlining an alternative I was interested in this book. Whilst I am far from being an anti-psychiatrist myself, I wanted to see what a modern alternative to psychiatry would look like. Unfortunately, I think this book fell quite far short of this objective.

Firstly, many articles often criticise psychiatry without actually explaining why psychiatry might be wrong. This does not occur on every issue but sometimes it is stated as a given that psychiatry is in error. For example, some authors simply criticise psychiatric classifications without explaining why they might be flawed. This is problematic because the problems with classifications are complicated. Generally, most psychiatric classifications are trade-offs, a committee having choices over how to formulate them and generally any advantages to a way of classifying will also involve disadvantages. For example, lumping vs splitting, or not otherwise specified being vague but allows more coverage, or having narrow but specific diagnosis vs broader ones which over-lap with each other. Now, it could be argued that psychiatrists are choosing a bad combination of advantages and disadvantages, or that any possible combination of advantages are always outweighed by disadvantages. I don’t think that myself but at least making that argument would be better than an outright dismissal without argument. This occurs too many times in the book.

Secondly, there was relatively little on what an alternative to psychiatry would look like. There is quite a lot of detail about how different groups with diverse interests could get together to oppose psychiatry. In a sense this moves the anti-psychiatry movement forward, in that we know anti-psychiatry objects to psychiatry and this book shows new ways to go about objecting. But I’m still uncertain what should replace psychiatry. I got the impression that an alternative would involve more psychotherapy, less drugs, more user involvement and more user choice. In principle, I could agree with all that, but doing this would not require an end to psychiatry. This would still leave room for psychiatrists to classify and proscribe drugs, just that psychiatrists would more often refer people for psychotherapy and involve the user more. So this is hardly a massive overhaul of psychiatry. If the anti-psychiatry movement has something more radical in mind then I want to see it explicitly outlined, a detailed alternative of what would replace psychiatry.

The book did have some good points. It went into quite a lot of detail about how various different interests groups might conflict and gave some reasoned arguments about how to resolve these conflicts or who should get priority. It also had some innovative ideas about how different groups could work together. Additionally, it did highlight, often with practical examples, various ways in which psychiatric patients can be oppressed, devalued or misinterpreted, primarily due to false assumptions on the part of psychiatrists and care workers. Some of these issues were subtle and worth reading about.

Thoughts on Kendell’s The Role of Diagnosis in Psychiatry

Categorical, Classification, Dimensional, Disease Entity, Reliability, Validity


Robert Kendell (1935-2002) (not to be confused with Kandell or Kendler) was a Welsh psychiatrists who explored many fundamental questions about psychiatry. He is perhaps most famous among philosophers for his 2003 article with Jablensky (distinguishing between utility and validity of psychiatric syndromes), indeed, my interest in that article has resulted in me exploring his earlier work.

His 1975 book covers a lot of ground, including reliability, validity, categorical, dimensional and disease entities. It gives a qualified defense of psychiatry, partly reacting to anti-psychiatrists whilst discussing contemporary issues which were then influencing the formulation of DSM III. His basic message might be ‘psychiatry is not as bad as people make out but it could be improved and we have lots of options for going about doing so’. The book is primarily a discussions of those options for the future.

What struck me was just how familiar it read, the problems he identifies and the various solutions he discusses look very recognizable to a modern philosopher of psychiatry. This was especially true in the introduction (that introduction would be a candidate for employment on undergraduate teaching for philosophy of psychiatry). I just felt like modern philosophy of psychiatry had told me little new on these topics which Kendell’s book had not already discussed (granted, discussed in limited detail, being a short book which covers a lot of ground). An exception would be statistical approaches to validity, where modern statistical approaches are more sophisticated than what he addresses. The second exception is that, whilst his discussion of reliability is sophisticated, he uses empirical studies of the 1970s and beforehand to highlight his claims, whereas today we have much more empirical information about how psychiatrists employ diagnosis.

One possible reasons for the lack of progress is that issues over validity, reliability and categorical really were not so controversial once the DSM III framework was adopted. If you want a reliable categorical system which easily lends to testing for disease entities then DSM is pretty good at this. The problem, and why lack of progress is so concerning, is that after about 40 years of testing categorical classifications for disease entities we simply have not found them. Existing DSM classifications have not been validated. If 40 years ago people said ‘lets see if there are disease entities out there’ then I think the DSM and validity project have done a reasonable job of testing this. However, since the answer came up as generally no, we really need develop something new, something outside traditional approaches. Kendell does discuss dimensional systems and alternatives to disease entities but concludes these are usually difficult to put into practice. So either we need work out how to put them into practise or we need some new developments, something beyond disease entity non-disease entity dichotomy, beyond valid invalid dichotomy. The same may be true for categorical vs dimensional, and even the notion of reliability may need challenging.

Classifications and medication

Classification, Medication

Washington Post headline “Most antipsychotic drugs prescribed to teens without mental health diagnosis, study says” (from article). From the article: “60 percent of those ages 1-6, 56.7 percent of those ages 7-12, 62 percent of those ages 13-18, and 67.1 percent of young adults, ages 19-24, taking these drugs had no outpatient or inpatient claim indicating a mental disorder diagnosis”.

The implicit notion here seems to be one of surprise and concern: surely people should have a diagnosis before they are given drugs. Interestingly, many philosophers of psychiatry might disagree. Philosophers of psychiatry often complain that most people do not neatly fit classifications, typically they meet the diagnostic criteria for numerous classifications, they exhibit symptoms below the threshold of criteria some classifications, their behaviour changes over time so they no longer fits previously diagnosis, the cut off points required for diagnosis are arbitrary conventions, etc. In essence, many philosophers reject the current categorical approach (you have either have this diagnosis or you do not) and instead prefer a dimensional model (you lie on a continuum with normality, exhibiting a range of symptoms to varying degrees [this is somewhat of a simplification]).

A consequence of the dimensional approach is that classifications are not so important. On a dimensional approach a doctor needs know what symptoms you exhibit, not which classification you does a half-hearted job of describing your symptoms. Surely then prescribing medication without providing a diagnosis is perfectly acceptable.

I personally prefer a categorical approach and plausibly this issue over drugs shows an advantage of categorical classifications. You need meet a set of fairly stringent criteria to get a diagnosis. On one hand this means some people who have some but not all the symptoms go undiagnosed, on the other it means diagnosis cannot be (should not be) handed out to all who want it. If a diagnosis is generally required to prescribe strong medication then we have an additional safety net above and beyond the judgment of a single doctor prescribing drugs since diagnosis usually requires a specialist. Of course, there are times when someone needs medication immediately and cannot wait for diagnosis, but surely that situation would not cover half of all adolescents?