Reviewing Philosophical issues in Psychiatry III: Nature and Sources of Historical Changes


This is the third book in the series, started in 2008 and then the second volume in 2012. All three volumes have been edited by Kenneth Kendler and Joseph Parnas, bringing together contributions from psychiatrists, philosophers of psychiatry and historians of psychiatry. Each volume takes the same format, an overall introduction by one of the editors and then individual papers grouped by themes. Each paper is fronted by a brief introductory article by one author, then the main article by another author and then a commentary by a third author. This means each book contains an immense number of articles (43 in the case of this volume) despite only being 380 pages long. The introductions and commentaries are almost always worth reading, often making significant points in their own right which are not present in the main article they are discussing. This makes the book an excellent source for a multiplicity of viewpoints and, since sometimes the introductions and commentaries disagree with the main article, diverging points of view. If you wish to find an academic expressing a philosophical viewpoint on psychiatry, or multiple academics expressing contrary viewpoints, then turning to one of these volumes is a good idea.

Of the three volumes, this one is the most diverse in approach, mainly because it closely integrates philosophy and history. It has three sections. The first discusses ontological, epistemic and methodological issues relating to changes in psychiatry, relating to issues like why does psychiatry keep changing, are these changes for the better, what sort of changes should we aim for, etc. Secondly, what specific broad changes have occurred in psychiatry, such as development and decline of psychoanalysis, operationalism and genetic explanations. Thirdly, philosophically informed histories of specific diagnosis, such as schizophrenia, depression and autism. All three sections are worth reading, though how much you will get out of each section will likely vary considerably on your specific interests. As someone interested in questions of belief in psychiatric classifications, I primarily found the first section useful. I think psychiatric diagnosis can potentially merit belief even if there is not one fixed, eternal true set of psychiatric diagnosis – the causes of mental illness change, mental illnesses manifest differently as social settings change and our values which we use to interpret mental illness change. Though not all articles in this section addressed these specific issues, I found they gave much to think about on such question and offered some novel approaches and novel possible solutions to such issues.

Though I could comment on many articles (and may do so in future blog posts), the one which most interested me is by German Berrios. This articles challenges a long standing approach in philosophy of psychiatry. Generally, most mental illnesses are seen as separate from their environment. Internal biological and psychological causes (potentially set off by environmental causes) produce symptoms which express themselves in a social context. So on this model, the social context is not itself a cause of the symptoms but is a cause of how the symptoms are expressed, i.e. the symptoms interact with a social environment. However, Berrios challenges this, arguing the social context is itself part of the symptom, the social context cannot be separated out as something the symptoms interact with but are themselves part of the causal process. This makes causation in psychiatry much more complicated but I think much more realistic. It makes mental illness less static, less fixed, more embedded within the environment, rather than viewing mental illnesses as fixed and static yet malleable in how they are expressed. At a minimum, it raises important questions about how we should think about causation in psychiatry, where we should put the boundaries between things, their causes, and the environment in which they causally manifest in. At minimum, Berrios shows an alternative way of parsing up that equation and argument is needed to take the symptom manifesting in social context approach as superior to social context as part of symptoms.

Reviewing Peter Hobson’s The Cradle of Thought

Peter Hobson’s The Cradle of Thought is a philosophically and scientifically informed discussion of how thought develops in early life. Hobson’s main argument is that “interpersonal engagement contributes to the development of the mind – and [that] disordered interpersonal relations affect development of thinking” (p.143). He discusses many scientific studies which show how the level and nature of interpersonal relationships can impact the capacity for thought, suggesting deficient interpersonal relationships can lead to impoverished thinking.

Hobson highlights this through discussing individuals who are often not as capable of interpersonal interactions as most humans. He primarily discusses autism in detail, suggesting the usual thinking of autistic individuals (such as theory of mind differences) arise from lack of normal social and emotional interactions in early life. He heavily emphasizes that autism has a genetic component which results in biological differences (rejecting notions of poor mothering causing autism which some psychoanalysis used to believe) but argues the abnormal thinking itself is not primarily just due to biological difference. Rather, the biological differences result in difficultly interacting normally socially and emotionally, and this abnormal social and emotional experience results in abnormal thinking.

One might ask, why not just say the biological differences are responsible for both the abnormal interactions and for the abnormal thinking? Hobson uses a novel strategy to answer this question, primarily by looking at other types of individuals who also can face difficulties interacting normally. He considers individuals who are blind from birth and individuals who had very little social or emotional interaction in early life when raised in Romanian orphanges. These individuals often could not relate to other people in early life in the same way as most children. He then shows that these individuals sometimes develop some symptoms of autism, at substantially higher probabilities than would occur at random. Autistic individuals have biologically abnormal minds, blind individuals lack sight and Romanian orphans presumably have no major biological differences, yet all can exhibit some similar behaviour we associate with autism. Therefore, Hobson argues, some autistic behaviour is not directly the product of the biologically abnormal mind, but the biologically abnormal mind sets up abnormal interpersonal relationships and those interpersonal relationships result in symptoms associated with autism. Hobson also provides some evidence from how mothers with boarderline personality disorder interact with their children and how chimpanzees lack some parts of human socialising, suggesting both these cases can contribute to less than fully developed thinking.

Even though considered a developmental disorder, there is often a suggestion within scientific literature that the psychological development purely follow biological developments, rather than biological development resulting in psychological developments which then result in further psychological developments. I think a simple biological leading to psychological approach often present in modern science is far too simplistic, but I am unsure whether I think Hobson is correct or if I prefer a middle ground between Hobson and that modern science picture. Reguardless, the book is highly recommended for raising some important questions, presenting a solid evidence basis (often from very diverse sources which are not usually discussed in the context of autism) and for being highly accessible, being effectively popular philosophy and popular science.

Science and its use for philosophers

Really nice quote about the relationship between philosophy of science and philosophy more generally: “As long as there was no such subject as ‘philosophy of science’, all students of philosophy felt obligated to keep at least one eye part of the time on both the methodological and the substantive aspects of the scientific enterprise. And if the result was often a confusion of the task of philosophy with the task of science, and almost equally often a projection of the framework of the latest scientific speculations into the common sense picture of the world … at least it had the merit of ensuring that reflection on the nature and implications of scientific discourse was an integral and vital part of philosophical thinking generally. But now that philosophy of science has nominal as well as real existence, there has arisen the temptation to leave it to the specialists, and to confuse the sound idea that philosophy is not science with the mistaken idea that philosophy is independent of science” Wilfrid Sellars (quoted in an article from the book What is Philosophy?, C. P. Ragland, Sarah L. Heidt (editors)).

Much has changed since 1956 when Sellars wrote this but it raises an important issue. I’ve long believed we need closer merge science and philosophy, and whilst many philosophers do not integrate science in their work, plenty do. This is positive. However, I’m often concerned that when philosophers do use science to further their arguments, they often take scientific evidence too concretely, as something which either logically supports their argument or does not. Generally, however, scientific theories are models that describes idealised probabilities. They do not easily function as premises which entail logically valid arguments or function as clear counterarguments. Rather, they function more analogously to risk factors, scientific claims being individual sources of evidence which push an argument in one direction or another. Sellars claims general philosophers paid more attention to the methodology of science. I wonder if this is lacking today. Whilst it is great that philosophers not infrequently turn to science to support their arguments, those philosophers should realise how tentative, how heavily inferential and how probabilistic many scientific claims are. When philosophical claims rest upon such scientific claims then the strength of those philosophical claims is reduced. I think this is generally the case and philosophy would be better to recognise this. Just like scientists, philosophers employing science need both knowledge of science and knowledge of methodology of science.

Book Review of Alternative Perspectives on Psychiatric Validation: DSM, ICD, RDoC, and Beyond

The December issue of History of Psychiatry contains my book review of Alternative Perspectives on Psychiatric Validation: DSM, ICD, RDoC, and Beyond (edited by Peter Zachar, Drozdstoj St. Stoyanov, Massimiliano Aragona and Assen Jablensky).

Though the book review appears in History of Psychiatry, the book is primarily philosophical (plus a few history chapters). Some papers discuss what notions of validation can be legitimately applied to, some discuss under what conditions validation succeeds and others discuss exactly what validating something accomplishes. For its interesting and diverse discussion of validation it is recommended for both philosophers and psychiatrists.

Realism vs… coherence? Relativism?

One of my philosophical interests is establishing if psychiatric classifications are real. This question has many, many dimensions and I feel it is often portrayed in untenable terms. A useful starting point is: what does it mean for a scientific thing (an electron, Newtons laws) to be real? (Note some interesting subquestions: are scientific things real in different ways to non-scientific things? Is there one overarching notion of real for all sciences or would psychiatry need a different notion of reality to physics). Here is an interesting and potentially useful diagram:

Realism Antirealism
[Note that I found this on Twitter [https://pbs.twimg.com/media/CJlcwSXUAAAc9Wq.jpg:large], I do not know who the author is but I did not create it].

It gives an interesting perspective on how various elements interrelate. I do not fully agree with it. Should correspondence and coherence be put at opposite ends of a scale? I wonder if coherence might be better put somewhere closer to the center, replacing the end of that arrow with relativism. Perhaps Psillos is correctly placed for his earlier works but I think his later writings place much greater emphasis on theoretical virtues, hence needs to go closer to coherence (but without moving too far from correspondence). Also, where would a neo-Kantian position in the style of Massimi and Kitcher go? The middle ground might seem the obvious place but I would not like to associate them with Constructive Empiricism or Instrumentalism. Anyway, the table has got me thinking and it certainly makes some interesting claims in a convenient visual form.

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?

Making psychology more textual but still statistical

I just read a couple of textbooks on anxiety. I was looking to see if anxiety was ever described as manifesting in a particular way and I found both textbooks to be largely unhelpful. They were severely lacking in qualitative descriptions of patients, very little on the experience of anxiety. Instead it is mainly statistical, describing statistical correlations between anxiety and gender, age, upbringing, other psychological traits etc.

I was particularly concerned by how anxiety was demarcated from other psychological states (depression, worry, fear etc) and different types of anxiety were demarcated (social, agoraphobia, phobia, PTSD, etc) without employing much qualitative descriptions by patients. Without such information are we really sure the boundaries between, say, anxiety and depression have been adequately drawn, similarly so with boundaries between different types of anxiety. Psychologists certainly have criteria, checklists and questionnaires to make such distinctions on but how much trust should we put in them? To be fair, both textbooks were aware of this problem but unfortunately seemingly suggested more studies using those same criteria would solve the problem, rather than trying think about and improve the criteria.

If we want to get clear about something then you might consider asking a philosopher to think about it, to analysis the concepts, to look for assumptions. All well and good. However, I also think this approach is severely limited, since philosophers have a tendency of making distinctions on obscure grounds little connected to everyday experience. Also, it is difficult to put diverse human experience like anxiety into necessary and sufficient without risking turning the concept of anxiety into some abstract notion far removed from human experience. In my experience, sometimes conceptual analysis of psychological states results in something largely unrecognisable. The psychologists ‘anxiety’ I can relate to, this will not always be the case with the philosopher’s ‘anxiety’.

There may be a middle ground. Conceptual analysis is important but can only go so far, at some point concepts should be opperationalised and need applying to the world. Philosphers should ideally give their concepts formalised criteria and then do statistical studies on them. Statistics hopefully should show the concept has some ‘fit’ with the world and the concepts can be modified in light of those statistics to get the fit better, to make it more relevant to patient reports. Unlike the psychologists though, make the opperationalised criteria rich and textual, highlight them with patient case studies, analyse those case studies conceptually to draw boundaries between concepts and draw inter-relations between concepts. More importantly, recognise these are only concepts and recognise that concepts rarely (perhaps never) fully mesh with the world, so employ many different concepts, formulate many different opperationalised criteria for statistical studies rather than continually employing the same old criteria. A psychology which willing drew different boundaries between anxiety and depression in different studies would have greater difficulty comparing results of different experiments but those results themselves would likely be so much more richer empirically, the statistics would reveal so much more.

I’m not sure how closely they can be merged or how exactly how it would be best done (major institutional changes would be ideal!) but the qualitative and the statistical can be brought closer together and this may require both psychologists and philosophers learning from one another.