Category Archives: Disease Entity

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).

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.