Category Archives: Classification

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

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

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

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 Brexit for British psychiatry

On the 23rd of June Britain voted to leave the EU. It will take many years before we ultimately know how things turn out. Here I will only discuss certain possible implications for psychiatry. Whilst issues surrounding funding of British research and collaboration with European research have been discussed in the media, there may also be an impact on the nature of mental illness itself.

The media is often calling Brexit the biggest decision in UK politics in the last fifty years. Philosophers of psychiatry rightly emphasise that people with mental illnesses are social beings living in a social environment. Even if there are set biological or psychological causes of many DSM diagnosis individuals with those diagnosis will still be affected by the social environment they are in. Consequently, different social environments could mean mental illnesses turn out differently. Now, exactly how much this is the case is difficult to judge, it is certainly very easy to focus too heavily on people as just being their abstract diagnosis disembodied from the environment but equally it is easy to just simply see mental illness as a social phenomena. Exactly how much weight we should place on each is difficult to say, and this may vary both for different diagnosis and for individuals with the same diagnosis. However, I do think it is credible to say social factors are important and can with some regularity make mental illness turn out differently. To the degree there are significant social changes then, for symptoms with social causes, there could be differences in which symptoms are expressed or in how they are expressed. For example, if there was an economic downturn then this could reduce the quality of life of many people, pushing many over the threshold for a diagnosis of anxiety or depression. Equally, it might mean people who are currently diagnosed now face new challenge and thus express symptoms in different ways. It may impact comparisons of studies taken from different decades, and impact ongoing longitudinal studies, if there are significant changes in the population of the UK. It could also impact comparisons with studies done in Europe.

It also raises more deeper philosophical questions. If mental illness can be influenced by social factors, should we have classificatory systems like the DSM and ICD which are typically treated as universal? I think this is a question which would need be informed by empirical research, studies of exactly how mental illness manifests in different settings, and even after that the decision would be influenced by difficult practical questions. If universal classificatory systems were rejected, then how broad should they be? Do we want to be part of the American classificatory system, the European one or have a unique British one? Of course, for better or for worse, the American and European systems are very similar, so in that reguard any detachment from Europe does not leave a binary choice between choosing between contrary American and European systems.

Thoughts on Kendell’s The Role of Diagnosis in Psychiatry


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

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?