Tuesday, May 15, 2012

Mental Illness (Stanford Encyclopedia of Philosophy)

Mental Illness (Stanford Encyclopedia of Philosophy)

Mental Illness

First published Fri Nov 30, 2001; substantive revision Mon Feb 22, 2010
Psychiatry involves theories of the mind, theories of the causes of mental disorders, classification schemes for those disorders, research about the disorders, proven treatments and research into new treatments, and a number of professions whose job it is to work with or on behalf of people with mental disorders. The philosophical study of psychiatry discusses conceptual, ethical, metaphysical, social, and epistemological issues that arise in all these aspects of psychiatry. Central to this study is the nature of mental illness.
The central philosophical debate over mental illness is not about its existence, but rather over how to define it, and whether it can be given a scientific or objective definition, or whether normative and subjective elements are essential to our concept of mental illness. One desideratum for a successful definition of mental illness is that it will settle debates over particular purported mental illnesses.
The connection between philosophical issues in the study and treatment of mental illness and these other areas of philosophy is in many cases obvious, as in the question of when and how people with mental disorders are responsible for their actions is connected with the insanity defense in law, and the more general debate over the justification of punishment. The philosophical investigation of the nature of mental illness is therefore relevant to many other areas of philosophy. While there is no sharp divide between the philosophical discussion of the nature of mental illness and the wider philosophical discussion of psychiatry, we can focus on four major issues that have preoccupied the philosophical literature.

What can philosophy do for psychiatry?

What can philosophy do for psychiatry?

World Psychiatry. 2004 October; 3(3): 130–135.
PMCID: PMC1414692
What can philosophy do for psychiatry?
Kenneth WM Fulford,1,2,3 Giovanni Stanghellini,3,4 and Matthew Broome3,5
1Department of Philosophy, University of Warwick, Coventry, UK
2Department of Psychiatry, University of Oxford, UK
3WPA Section on Philosophy and Humanities in Psychiatry
4Department of Mental Health, University of Florence, Italy
5Institute of Psychiatry, University of London, UK
This article illustrates the practical impact of recent developments in the philosophy of psychiatry in five key areas: patient-centred practice, new models of service delivery, neuroscience research, psychiatric education, and the organisation of psychiatry as an international science-led discipline focused on patient care. We conclude with a note on the role of philosophy in countering the stigmatisation of mental disorder.
Keywords: Concepts of disorder, classification, neuroimaging, early diagnosis, values-based practice, patient-centred practice
According to the great 20th century psychologist and philosopher William James, philosophy is "an unusually stubborn effort to think clearly" (1). The need for clear thinking in psychiatry arises from the fact that our subject raises problems of meaning alongside empirical difficulties in a particularly acute way. A recent Forum in World Psychiatry, dealing with "the challenge of psychiatric comorbidity" (2), makes the point. That Forum covered empirical issues such as the likely impact on psychiatric classifications of future advances in behavioural genetics (2, 3), but much of the debate was about conceptual difficulties; about the meanings, for example, of such key terms as "disease" and "disorder" (4), and "syndrome" (5); about the tension between "reliability" and various aspects of "validity" (6); and about the competing claims of categorical and dimensional classifications to reflect "the state of nature, not merely how clinicians think about the state of nature" (7).
As Allen Frances pointed out in his role as Chairperson of the DSM-IV Task Force (8), it is one thing to recognise the importance of conceptual difficulties in psychiatry, it is quite another to do something about them. In this article, therefore, we will be focusing not on problems but on solutions. The last few years have witnessed a remarkable explosion of cross-disciplinary work between philosophy and psychiatry (9). Rather than attempting a full review of the field, however, we will be illustrating what philosophy can do for psychiatry, with examples of what it is already doing in five key areas: a) patient-centred practice, b) models of service delivery, c) research, d) education and e) international organisations.
Philosophy, through a new model linking values with evidence, called values-based practice (VBP), gives us specific tools to help make science work for us in a more patient centred way (10). VBP is the theory and skills-base for effective healthcare decision-making where different (and hence potentially conflicting) values are involved. VBP, somewhat like a political democracy, starts from respect for different values and relies on good process for its practical effectiveness.
Good process in VBP, as shown in Table Table1, depends1, depends on 10 key "pointers". The starting point of good process in VBP is careful attention to individual patients' values (pointer 1). Where values conflict, however, VBP seeks to achieve a balanced approach to clinical decision-making by drawing on a range of different value perspectives, represented here by the multi-disciplinary team (pointer 2). Achieving a balance of value perspectives in turn depends on four key clinical skills: raising awareness, reasoning skills, knowledge and communication skills (pointers 3 to 6). Values-based and evidence-based approaches, as the next three pointers (pointers 7 to 9) indicate, are complementary. In particular, as David Sackett, one of the leaders of evidence-based practice, has emphasised, they are both essential to building genuine partnership between professionals, their patients and their patients' families (11). This aspect of good process in VBP is reflected in the partnership model of decision-making summarised in Table Table11 in pointer 10.
Table 1
Table 1
Ten pointers to good process in values-based practice
The philosophical sources of VBP include abstract formal disciplines such as linguistic analysis, phenomenology and hermeneutics (10). But its practical applications already include a number of both treatment (12) and policy and service development initiatives within the Modernisation Agency of the UK's National Health Service (www.connects.org.uk/conferences). Central to all these initiatives, is a training workbook covering the skills of VBP (13). This workbook, which is the result of a unique collaboration between a Philosophy Department (at Warwick University) and an in-service training provider (the Sainsbury Centre for Mental Health), has been recently launched in London by the Minister of State responsible for mental health, Rosie Winterton, and will be the basis for training of front-line clinical staff from April of next year in each of the main national health service (NHS) regions of England and Wales.
Future developments in VBP will be supported by a lively international programme of ongoing research. A particular focus of this research is the role of values in classification and diagnosis. The American psychiatrist and co-editor (with Fulford) of the international journal Philosophy, Psychiatry, & Psychology, John Sadler, has been particularly active in this field (14, 15). A research methods meeting last year in London, funded by the UK government, brought together work on values in diagnosis from phenomenological (16, 17) and empirical (18) as well as philosophical sources. This work will contribute to the development of more inclusive models of psychiatric classification through the work of the WPA Sections on Philosophy and Humanities in Psychiatry and on Classification, Diagnostic Assessment and Nomenclature (19).
There is also ongoing educational research. Werdie van Staden, a psychiatrist and philosopher at Pretoria University, and founder, with Tuviah Zabow at Capetown University, of the Philosophy Special Interest Group in the South African Society of Psychiatrists, has established a joint educational research programme with Warwick University Medical School, dealing with the effectiveness of training in VBP for medical students.
Mental health services in many parts of the world are nowadays delivered by multi-disciplinary teams. This ensures that a variety of different skills– medical, psychological, social, etc. – are available to meet the needs of individual patients. However, team working is too often associated with conflicts and failures of communication, with the result that patients are at risk of "falling through the net" through lack of collaborative decision-making (20). In addition, there are some cultures with very different models of disorder altogether, for example where families and social networks are valued more highly than individual autonomy (21).
In a study combining philosophical work on concepts of disorder with empirical social science methods, Anthony Colombo and colleagues at Warwick University have shown that such difficulties in multi-disciplinary team working are often driven by unrecognised differences in models of disorder (22). Despite the contested status of the concept of mental disorder, most mental health professionals nowadays claim to work within a shared biopsychosocial model (23). But what Colombo et al's study showed is that in practice, and often without being aware of it, different professional disciplines actually work with very different implicit models – hence the conflicts and difficulties in multi-disciplinary teamworking. Studies paralleling Colombo et al's project are currently underway at Linköping University in Sweden and at the Maudsley Hospital in London.
Colombo et al's study illustrates one of the general roles of philosophy in psychiatry. As the Oxford philosopher J. L. Austin put it, the characteristic output of philosophical "clear thinking" is to give us a more complete picture of the full meanings of the complex concepts by which we make sense of the world around us (24).
Phenomenology, and its close relatives existentialism and hermeneutics, are particularly helpful in giving us a "more complete" picture. Phenomenology, as Karl Jaspers (25, 26) recognised, provides a range of practical tools for working with personal meanings, alongside scientific findings, in psychopathology. This is important in research (see below). But phenomenology and related disciplines are already generating new models of service delivery more directly geared to individual and cultural meanings. Such models include the Irish psychiatrist and philosopher Patrick Bracken's use of Heideggerian phenomenology to support new approaches to the management of post-traumatic stress disorder in traditional societies (27), the American psychologist and philosopher Steven Sabat's use of discursive analysis to improve communication with Alzheimer's disease sufferers (28), and the Dutch philosopher Guy Widdershoven's work on collaborative decision-making, also in Alzheimer's disease, employing the "hermeneutic circle" (29).
It is no coincidence that the emergence of a new and vigorous philosophy of psychiatry in the closing years of the 20th century coincided with dramatic advances in the neurosciences (9). As no less a neuroscientist than Nancy Andreasen has pointed out, the neurosciences themselves are among the factors pushing traditional philosophical problems, such as the nature of personal identity and of our knowledge of "other minds", to the top of our agenda in psychiatry (30).
The new philosophy of psychiatry is certainly not shy of problems of this magnitude (31-33). The British psychiatrist Sean Spence's brain imaging studies of hysteria, for example, raise a number of the traditional problems of psychiatry in exactly the challenging way that Andreasen anticipated (34), and a joint research programme between Warwick and Oxford Universities and the Institute of Psychiatry in London, funded by the McDonnell-Pew Centre for Cognitive Neuroscience in Oxford, has brought together philosophers, neuroscientists and patients, in a collaborative study of schizophrenia published as a special double issue of Philosophy, Psychiatry, & Psychology, edited by the Warwick philosopher Christoph Hoerl (35).
It is however particularly through the phenomenological tradition, with its focus on subjective experience, that the new philosophy of psychiatry is connecting most directly with neuroscience research (36-39). Imaging studies, in particular, demand more sophisticated ways of characterising and defining the contents of experience and how these are linked to brain functioning (40, 41). The work of the Cologne group on early detection and prediction of psychotic illnesses, for example, draws directly on phenomenological methods (42). Research in this area is a two way process, however, in which phenomenology and philosophy of mind also draw on the rich varieties of psychopathology (43, 44).
Early in the field with the potential applications of phenomenology to psychopathology was of course Karl Jaspers (45), perhaps the first philosopher-psychiatrist. Building on a strong 20th century tradition of conceptually informed work on classification and diagnosis (46, 47), the new philosophy of psychiatry has picked up Jaspers' concern to link meanings with causes in psychopathology (48-51). But a strong tradition of phenomenological work was maintained through much of the 20th century in a number of European countries (notably France, Germany and Italy), in Japan and in South America (9).
It is impossible within the scope of this article even to list the many distinguished recent contributors to this tradition. The main areas of work include both specific symptoms (52-55) and wider issues of psychiatric nosology (56). Examples of work in this area, drawing on the phenomenologies of such seminal 20th century philosophers as Martin Heiddegger, Maurice Merleau-Ponty and Jean Paul Sartre, are included in a number of recent collections (9, 57); new work is reviewed regularly in the History and Philosophy section of Current Opinion in Psychiatry (e.g., 58); and a more comprehensive treatment will be given in one of the volumes in the new book series from Oxford University Press on International Perspectives in Philosophy and Psychiatry (59).
Research in the philosophy of psychiatry requires the same high-level skills as in any other technical discipline. When it comes to education and training, however, philosophy has a wider contribution to make to psychiatry, through the development of the generic thinking skills, the "clear thinking" of William James' aphorism (above), that are essential in all areas of practice.
The training manual for VBP noted above is a well-developed example of the effectiveness of philosophy in this respect (13). The exercises used for the development of VBP-skills are based directly on ideas from philosophers such as J.L. Austin (24) and R.M. Hare (60), working in the most abstract areas of philosophical value theory. Yet, these training exercises have been particularly well received, in pilot studies, not by academic psychiatrists, but by patient advocates, mental health nurses, social workers and others, working in such challenging areas of front-line mental health practice as crisis intervention and assertive outreach (61).
A full curriculum for philosophy of psychiatry has been introduced in the latest revision of the Royal College of Psychiatrists' curriculum for higher psychiatric training, the "MRCPsych" (62). Besides other sources cited in this article, training in this area will build on rich resources from classical philosophy (63, 64) and history of ideas (65, 66).
Psychiatry is peculiar among medical disciplines in being particularly vulnerable to abusive uses for purposes of political or social control. The notorious "delusions of reformism", the basis on which political dissidents were diagnosed with "schizophrenia" in the former Soviet Union, is but one example of our vulnerability in this respect (67).
The prevention of such abuses involves a wide range of resources –political, scientific, legal and educational. Philosophy contributes generally in each of these areas, drawing on cross-cultural (68) and historical (69, 70) scholarship and political philosophy (71). Among other results, such work shows that the underlying vulnerability of psychiatry in this respect arises from a failure to maintain a balance of different perspectives. In the Soviet Union, it was the unbalanced dominance of the Soviet ethic that distorted diagnostic judgements (72). This led to a kind of conceptual blindness arising from what the 17th century political philosopher, and founder of British empiricism, John Locke, called "enthusiasms" (73). We have seen similar "enthusiasms" in psychiatry throughout the 20th century– for psychoanalysis at one stage in America, for example, and more recently, in some quarters, for a narrow model of "biological psychiatry" (74).
We can counter such "enthusiasms" only by maintaining what Jim Birley, a Past President of the Royal College of Psychiatrists, and founder chair of the reforming organisation Geneva Initiative for Psychiatry, has called an "open society" in international psychiatry (75). The new philosophy of psychiatry will contribute to maintaining such an open society, partly through the more complete picture of the conceptual structure of the subject which, as noted above, is its characteristic output, but also, and importantly, through its own organisation as an open and collegial discipline, inclusive of methodological pluralism, and embracing intellectual and cultural diversity (9).
Future international developments in the philosophy of psychiatry will be supported by an International Network for Philosophy and Psychiatry (INPP), launched from South Africa as part of the 2002 biennial meeting of the South African Society of Psychiatrists, hosted by Professors Tuviah Zabow and Werdie van Staden. The INPP has been set up to support local, national and subject based organisations. Collaborating closely with new Sections in both the WPA and the European Psychiatric Association, the INPP will aim to contribute to the development of international psychiatry as a strongly dynamic "open society" of the kind Jim Birley envisaged.
Perhaps the deepest difficulty with which psychiatry ended the 20th century was the continuing stigmatisation to which both patients and practitioners were subject. Despite developments in the neurosciences, psychiatry was still perceived by many as being somehow "unscientific" (76), and mental disorders continued to carry unwarranted negative associations such as violence and untreatability (12).
Philosophy, in giving us a more complete picture of the conceptual structure of psychiatry, shows that our subject, far from being scientifically deficient, is simply a good deal more difficult than other areas of healthcare. Philosophy is important in psychiatry for much the same reason that it is important in theoretical physics. Both disciplines demand clear thinking about concepts as well as sophisticated scientific instruments for gathering data.
As we enter the 21st century, however, other areas of medicine, besides psychiatry, will increasingly face conceptual difficulties driven by scientific advances (77). In engaging with philosophy, therefore, across the five key areas outlined in this article, psychiatry, far from running second to the rest of medicine as it did in the 20th century, is leading the way for 21st century medical science.
The Table is based on a figure published in Woodbridge K, Fulford KWM. Whose values? A workbook for values-based practice in mental health care. London: Sainsbury Centre for Mental Health (in press), and we are grateful to the Sainsbury Centre for Mental Health in London for permission to reproduce it here.
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Philosophy and Mental Health - Tim Thornton

Philosophy and Mental Health - Tim Thornton

Philosophy and Mental Health
Because of its very nature, mental health care raises as many conceptual questions as empirical ones. The philosophy of mental health - also called the 'new philosophy of psychiatry' although it is not narrowly psychiatric - is a rapidly developing field developed by philosophers, clinicians (e.g. psychiatrists and mental health nurses) and mental health service users.
As well as its youth, the new philosophy of psychiatry has two further features that make it stand out. Firstly, it is not a 'natural kind'. There is not an established set of inter-related problems with familiar, if rival, solutions. It is an area where philosophical methods, accounts and theories can be applied to psychiatric phenomena and thus it also serves to test those accounts. To take one type of example, psychopathology is a test track for theories in the philosophy of mind. Symptoms such as thought insertion, where subjects experience their thoughts as somehow not their own, challenge accounts of the everyday 'ownership' of thoughts. But there is also traffic the other way. Three centuries of discussing the relationship of mind and body have furnished philosophers with a variety of subtle models (from forms of dualism, through gradations of physicalism, to eliminativism with modern alternatives such as enactivism) which can help in the interpretation of psychiatric data.
Secondly, unlike some areas of philosophy, philosophy of psychiatry can have a genuine impact on practice. It is a philosophy of, and for, mental health care. It provides tools for critical understanding of contemporary practices, and of the assumptions on which mental health care more broadly, and psychiatry more narrowly, are based. Thus it is not merely an abstract area of thought and research, of interest only to academics. In providing a deeper, clearer understanding of the concepts, principles and values inherent in everyday thinking about mental health, psychiatric diagnoses and the theoretical drivers of mental health policy, it can impact directly on the lives of people involved in all aspects of mental health care.
Values, meanings, facts
A brief examination of the history of the subject reveals why the discipline of psychiatry is particularly suited to contributions from philosophy. Whilst the father of psychopathology, the German philosopher and psychiatrist Karl Jaspers, combined psychiatric and philosophical expertise, within the English speaking tradition philosophy and psychiatry went their separate ways throughout most of the twentieth century. (By contrast, in mainland Europe the connection between psychiatry and phenomenological philosophy has continued since Jaspers' day.)
But towards the end of the twentieth century, the rise of the anti-psychiatry movement prompted a resurgence of philosophical interest in psychiatry. This was because a key element of the anti-psychiatric criticism of mental health care turned on a contentious claim about the nature of mental illness: mental illness does not exist; it is a myth. Such a sceptical claim is paradigmatically philosophical and one of the main proponents of anti-psychiatry, the psychiatrist Thomas Szasz, put forward a number of philosophical arguments in support of it. These turned on the fact that psychiatric diagnosis is essentially evaluative. From this he concluded that, unlike physical illness, it could not be medically treated because as illness it was not real. (The apparent reality of mental illness is best explained, according to Szasz, as the reality of non-medically treatable life problems.)
Szasz's sceptical arguments spurred responses by both psychiatrists and philosophers questioning whether diagnosis is, after all, essentially evaluative and, if it is, whether Szasz's conclusions followed. Thus the analysis of mental illness, and the role of values in that analysis, lies at the heart of recent philosophy of psychiatry.
In addition to the importance of values, two further key areas of mental health care prompt immediate philosophical questioning. Firstly, psychiatry since Jaspers has sought to balance two key elements: investigation of the bio-medical facts and empathic investigation of subjects' experiences. Both bio-medical facts and meanings (broadly construed to include experiences, beliefs and utterances) need somehow to be integrated into mental health care. This marks a sharp delineation from other areas of medicine where subjects' experiences are subordinate to the physically described symptoms and organic pathology with which they present. By contrast, psychiatric disorders seem to involve problems of the 'self' (however this is construed) in which experiences, behaviour and beliefs play a fundamentally important role in the onset, course and recovery of symptoms.
This raises questions of both the nature of the distinction between explanation according to the canons of the natural sciences (the 'realm of law') and understanding meaningful connections (in the 'space of reasons') and the relationship between natural scientific facts and meanings. If there is a clear distinction and meanings are conceptually irreducible to biomedical facts, efforts to understand the nature of this relationship become all the more philosophically interesting.
Secondly, there has been much work by psychiatrists since the Second World War to develop psychiatric classification or taxonomy. This has, historically, been in response to a concern about a lack of agreement or reliability about psychiatric diagnosis. More recently, there has been growing concern that reliability has been improved but only at the cost of validity, or underlying truth, of classificatory schemas. The worry is that psychiatric diagnostic systems may not 'carve nature at the joints'. This concern has also been reflected in philosophy of psychiatry as an instance of a broader question of the role of science in mental health care. Thus the nature of the facts in question is still very much up for grabs.

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience): Dr. John Z. Sadler MD, Dr. Osborne P. Wiggins Jr. PhD, Dr. Michael A. Schwartz MD: 9780801847707: Amazon.com: Books

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience): Dr. John Z. Sadler MD, Dr. Osborne P. Wiggins Jr. PhD, Dr. Michael A. Schwartz MD: 9780801847707: Amazon.com: Books

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience) [Paperback]

Dr. John Z. Sadler MD (Editor), Dr. Osborne P. Wiggins Jr. PhD (Editor), Dr. Michael A. Schwartz MD (Editor)


Book Description

April 1, 1994 The Johns Hopkins Series in Psychiatry and Neuroscience
As the biological and psychosocial technologies in psychiatry continue to expand, the need for careful critical reflection on the scientific, ethical and practical aspects of psychiatry becomes ever greater. In "Philosophical Perspectives on Psychiatric Diagnostic Classification", John Osborne Wiggins, Michael Scwartz and others present a philosophical exploration of conceptual difficulties in psychiatric taxonomies or nosologies, using the current official American Psychiatric Association diagnostic handbook, the "Diagnosis and Statistical Manual of Mental Disorders (DSM)" as an example.

Editorial Reviews


"The book begins with a 'must read' introductory and historical chapter by Edwin R. Wallace IV that provides a good foundations for readers embarking on a philosophical journey through psychiatric taxonomy." -- Journal of the American Medical Association

Values and Psychiatric Diagnosis - John Z. Sadler - Google Books

Values and Psychiatric Diagnosis - John Z. Sadler - Google Books

Front Cover
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Values and Psychiatric Diagnosis

By John Z. Sadler

Break Up the Psychiatric Monopoly - Friday, May 11, 2012 - By ALLEN FRANCES | D.S.M. Panel Backs Down on Diagnoses - Tuesday, May 08, 2012 - By BENEDICT CAREY - NYT > Psychiatry and Psychiatrists - Behavior and Law

Behavior and Law

NYT > Psychiatry and Psychiatrists

Behavior and Law: Mike Nova: American Psychiatry At The Crossroads - short version

Behavior and Law: Mike Nova: American Psychiatry At The Crossroads

Thursday, 8:23 AM 5/13/2012

Mike Nova: American Psychiatry At The Crossroads

Mike Nova: American Psychiatry At The Crossroads

Last Update: 8:55 AM 5/11/2012

"It should broaden its theoretical and conceptual outlook... it should assume its rightful leadership role in World Psychiatry... by discarding the outdated stereotypes, not reinforcing them" |

Thank you, Dr. Frances; for your previous work and for your courageous and independent stand now. |

James Phillips: "Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations." |

Did American Psychiatry sell its soul to profit-hungry (Psycho)Pharmaceutical Industry for a couple of their logo pens? Is it not the time to stop all this "DSM-s In Perpetuity" madness? And not to spend another $25 or more ml. for the next round of controversies and wide-spread public scepticism and criticism?" |

"Empirical explanation and treatment repeatedly fail for psychiatric diagnoses. Diagnosis is mired in conceptual confusion that is illuminated by Ludwig Wittgenstein's later critique of philosophy (Philosophical Investigations).

A diagnosis is a sort of concept that cannot be located in or explained by a mental process. Conclusion: A diagnosis is an exercise in language and its usage changes according to the context and the needs it addresses."

Psychiatric diagnoses are not mental p... [Aust N Z J Psychiatry. 2012] - PubMed - NCBI


"Much less clear, even in the US, is whether
the approach is commonly used by clinicians in ordinary
practice, thus really resulting in an increase of the reliability
of psychiatric diagnosis in clinical settings. It has been, for
instance, reported that several US clinicians have difficulties
to recall the DSM-IV criteria for major depressive disorder
and rarely use them in their practice (e.g., 2). Furthermore,
some of the DSM-IV cut-offs and time frames have been
found not to have a solid empirical basis (e.g., 3) and to
generate a high proportion of sub-threshold and “not otherwise
specified” cases (e.g., 4).

The spontaneous clinical process does not
involve checking in a given patient whether each of a series
of symptoms is present or not, and basing the diagnosis on
the number of symptoms which are present. It rather involves
checking whether the characteristics of the patient
match one of the templates of mental disorders that the clinician
has built up in his/her mind through his/her training
and clinical experience."

Mario Maj
President, World Psychiatric Association
Psychiatric diagnosis: pros and cons of prototypes...

Drug companies like Pfizer are accused of pressuring doctors into over-prescribing medications to patients in order to increase profits - GALLO/GETTY


American Psychiatry should broaden its theoretical and conceptual outlook beyond the narrow professional concerns about diagnostic systems and classifications (at this time, with all the enormous importance of these issues, we are not ready for the true scientific approach towards resolving them; and the practical problems with "reimbursements" and "parities" should be left for actuaries and medical records departments to resolve). Recent controversies about DSM-5 indicate that the whole conceptual direction of improving and perfecting diagnostic pseudonosological labeling system (and the professional and social power of labeling that comes with it) hit a roadblock and is in "no exit" blind alley. How can we introduce a true, medically scientific and evidence based classification system for mental disorders if we still know so little about their nature and origins? The attempts to codify the current clinical labels are methodologically and epistemologically dangerous because they reinforce the current clinical belief system with its multitude of misconceptions. The history of science and medicine in particular is replete with these kind of errors. Preoccupation with improving the reliability by forced agreement (which by itself proved to be impractical and next to impossible) does not affect the much more important issues of validity of psychiatric diagnosis, and, if anything, leads to their neglect and displacement (not only in psychodynamic, but real sense) from our area of interests and scientific horizons, almost relegating these issues to the province of "conspiracy of silence". How can we agree on something, if we don't really know what this "something" is or if it even really and "truly scientifically" exists? And why should we agree on this "unknown something?"
Medicine and psychiatry are empirical and "practical sciences"; we are not just "talkers" and "labellers"; we are "doers": our task is to ease mental pain and suffering (of which this world is aplenty) for individuals, groups and societies. We do it in the dark, our knowledge is still limited and trues are hidden. We should not reinforce these limitations, presenting "blind spots" as medical facts, but should accept them, be aware of them and work further, relentlessly, and completely with an open mind to resolve them. Narrow professional concerns with "parities and reimbursements" or any business interests of any kind (including the profits from publishing  a manual - APA is not just a publishing house) should not be a consideration and should not stand in the way of scientific research and progress in modern psychiatry. This probably was the "primal and original sin" which lead the whole DSM improvement effort astray.
American Psychiatry should assume its rightful leadership role in World Psychiatry with its bold and broad, open and independent minded, scientifically eclectic stance, discarding the outdated stereotypes, not reinforcing them; the stance worthy of this great nation and its spirit.

References and Links:

Mike Nova: Breivik Trial and The Crisis Of Psychia...

Thursday, April 19, 2012

Mike Nova: Breivik Trial and The Crisis Of Psychiatry As A Science

Mike Nova

Breivik Trial and The Crisis Of Psychiatry As A Science

Breivik is not the only one who is on this trial. Psychiatry as a science is on this trial also, just like on many other trials where forensic psychiatric involvement is sought. This is highlighted by the two contradictory psychiatric assessments of the accused, with their directly opposing diagnostic impressions and directly conflicting main general conclusions. The first forensic psychiatric evaluation, completed on November 29, 2011 by the psychiatrists Torgeir Husby and Synne Sørheim found Breivik to be "paranoid schizophrenic" and "psychotic" at the time of the alleged crime and presently and therefore legally "insane". A leaked copy of the initial psychiatric examination described his crusader fantasy as a product of the "bizarre, grandiose delusions" of a sick mind.
The second evaluation, about 300 pages long, made by the psychiatrists Terje Toerrissen and Agnar Aspaas on a request from the court after widespread criticism of the first one, was completed on April 10, 2012, just six days before the trial, but was not released, and according to the leaked information, found him afflicted with "narcissistic personality disorder" with "grandiose self" and not psychotic at the time of the alleged crime and presently and therefore legally "sane".
The latest psychiatric report was confidential, but national broadcaster NRK and other Norwegian media who claimed to have seen its conclusions said it described Breivik as narcissistic but not psychotic.
Torgensen gets the impression that Breivik found an ideal place to nourish his delusions of grandeur in the anti-Islamic scene full of crusader fantasies. “This was coupled with an extremely sadistic disorder,” Torgensen says. “This disastrous combination could explain the scale of his violence.”
The new report from forensic psychiatrists Terje Tørrissen and Agnar Aspaas concludes that he did not have “significantly weakened capacity for realistic evaluation of his relations with the outside world, and did not act under severely impaired consciousness”.
"Our conclusion is that he (was) not psychotic at the time of the actions of terrorism and he is not psychotic now," Terje Toerrissen, one of the psychiatrists who examined Breivik in prison, told The Associated Press.
Thus, as it almost always happens in complex forensic psychiatric cases, it was left for the infinite wisdom and common sense of the court, unburdened by the "sophisticated" and empty psychiatric jargon, to decide by itself, and rightly so, the "main questions" of the accused's mental illness or mental health and his "sanity" or "insanity" and to make its own, judicial decision regarding the issue of legal responsibility. Both mutually conflicting (but not mutually exclusive) forensic psychiatric evaluations, which, no doubt, were performed in good faith and with utmost professional diligence, will be taken into account by the court, but were rendered almost irrelevant by their contradictions. Once again, psychiatry, pretending to be a medical discipline and a science, was humiliated and reduced to the position of a laughing stock for the public and the media.
Mr. Breivik's skillful and astute lead defense lawyer, Mr. Geri Lippestad, treating his client with respect and at the same time with appropriate professional distance and apparently convinced of his client's mental illness and "insanity", chose a strategy of presenting Mr. Breivik to the court and to the public "as is", letting him to reveal himself and his presumed mental illness fully as the engine of alleged criminal behavior, apparently counting that it will be convincing enough for both the judges and for the court of public opinion.
“This whole case indicated that he is insane,” Geir Lippestad told reporters. “He looks upon himself as a warrior. He starts this war and takes some kind of pride in that,” Lippestad said. Lippestad said Breivik had used “some kind of drugs” before the crime to keep strong and awake, and was surprised he had not been killed during the attacks or en route to Monday’s court hearing.
Lippestad, a member of the Labour party whose youth wing had been the target of Friday’s shooting rampage, said he would quit if Breivik did not agree to psychological tests.
Geir Lippestad said the new report means Breivik's testimony will be crucial "when the judges decide whether he is insane or not." The trial started on April 16 and is scheduled to last 10 weeks.
Mr. Breivik declared himself undoubtedly and completely "sane" and consistently, if somewhat eerily out of place and time, painted a self-portrait as a model and self-sacrificing ideological warrior, taking as an insult any, albeit "professional" opinions otherwise and dismissed them with anger and indignation.
“On this day,” he said, “I was waging a one-man war against all the regimes of Western Europe. I felt traumatized every second that blood and brains were spurting out. War is hell.”
"Breivik told the court that "ridiculous" lies had been told about him, rattling off a list which accused him of being a narcissist who was obsessed with the red jumper he wore to his first court hearing, of having a "bacterial phobia", "an incestuous relationship with my mother", "of being a child killer despite no one who died on Utoya being under 14".
He was not insane, he repeated many times. He claimed it was Norway's politicians who should be locked up in the sort of mental institution he can expect to spend the rest of his days if the court declares him criminally insane at the end of the ten-week trial. He said: "They expect us to applaud our ethnic and cultural doom... They should be characterised as insane, not me. Why is this the real insanity? This is the real insanity because it is not rational to work to deconstruct ones own ethnic group, culture and religion."
All this is fine and dandy, and, no doubt, the aforementioned infinite wisdom of Scandinavian level headed justice (embodied in a stern but motherly demeanor of the presiding Judge Wenche Elisabeth Arntzen) will eventually emanate from its somewhat obscure, slowly but surely turning and unstoppable wheels, hopefully to almost every one's satisfaction. And eventually, this horrendous crime, the purp and the trial will be almost forgotten and placed into archives for further studies.
But the nagging questions remain and will remain for some, and probably a long time: is psychiatry really a science? Or is it just a collection of "professional" opinions, mixed with convenient labels and outdated jargon? What is "sane" and what is "insane"? And how far should the justice go in its modern "humane" stance?

"Grete Faremo, Norway’s justice minister, has said that it plans to establish a committee to examine the role of forensic psychiatrists. She told Norwegian daily Aftenposten on April 13 the committee would have a “broad mandate” that would examine three key questions: What is sanity? What is the role of the forensic psychiatrist? And how do we take care of security when an insane man is sentenced?
“Much suggests that the medical principle is inadequate,” said Faremo. “It is a historic step we are now taking. It is an important step in light of the terrible incident and the trial we face and in consideration of people's sense of justice.”
“This is a big thing,” says Abrahamsen. “If it hadn’t been for Breivik, we wouldn’t have discussed this.”

References and Links

Psychiatry May Also Face Scrutiny at Norway Killer's Trial - NYTimes.com

Breivik trial: Norwegians rethink role of psychiatry in courts - CSMonitor.com

Breivik Trial and The Crisis Of Psychiatry As Science - Links


Friday, April 27, 2012

Response to Dr. Wessely

Response to Dr. Wessely

Normality or psychopathology of belief or belief system is determined first of all by the intrinsic qualities of belief in question. It is not determined by the fact that belief is shared or not shared: "Delusions are beliefs that are not only wrong, in the sense of not corresponding to the world as we know it, but they must also not be shared with others of the same cultural background."
There are many delusional beliefs that are or were shared, and some of them on a rather large scale. For example, the ancient Maya believed, that for the sun to rise they had to offer human sacrifices (of their best and brightest) every day, otherwise all kind of life on earth would come to a halt. This belief was shared very widely in precolumbian Maya culture, which does not make it less delusional.
Breivik's ultra nationalist anti-immigrant ideology is shared by great many people of various cultural backgrounds. The goal of his forensic psychiatric evaluation is to assess his own particular belief system, with all its peculiarities and idiosyncrasies, in order to determine its nature, qualities and psychopathological aspects, regardless of other similar beliefs. In the end, it was him, not others, who took these ideas to their logical (or rather illogical and "sick") extreme, although the (possibly facilitating) role of "significant others" in his case still has to be determined.
Neither the "monstrosity" and "grievous consequences" of his actions nor "popular misconceptions" should cloud the picture. The most important factor in his forensic psychiatric assessment is the presence or absence of identifiable and diagnosable mental illness and the degree of its causal relationship with the crime. In my opinion, whatever it is worth, psychopathological qualities of Breivic's beliefs: their highly systematised, structured, all embracing "world view" quality, along with their unshakable, messianic conviction and "call for action", indicate with high degree of probability the presence of Delusional Disorder, mixed, persecutory-paranoid type, and the direct and overwhelming causal connection of his psychopathology with the criminal act.
The cognitive aspect in psychopathology of Delusional Disorders (abnormalities and/or dysfunctions in concept selection, elimination and confirmation), indicating possible subtle but decisive organic involvement is much under-researched area, probably due to our neglect or inattention to biological aspects of these disorders and overestimation of its psychodynamic aspects. Delusional jealousy, secondary to chronic alcoholism (a very discrete and specific syndrome) is the case in point.
"The... misconception... that the purpose of psychiatry is to “get people off”" might be as wide spread as any other misconception, which does not make it any less of a misconception. The historically formed legal concept of "NGRI: not guilty by reason of insanity" is a witness to humanity and rationality on a  part of a society; not to mention other, less important but present factors, such as political and social convenience, expediency and cultural traditions. (E.g.: Disraeli to Queen Victoria: "Only a madman can think about assassinating your Majesty..."). Modern psychiatry, very likely, was born out of the M'Naghten rules, as some psychiatric historians suppose.
And last, but certainly not least, is the difficult and complex subject of "Schizophrenia", its clinical concept (and/or misconcept) and diagnosis (and/or misdiagnosis). The diagnostic label of "Schizophrenia" became so wide spread and all encompassing (because it is so easy to apply, and is applied almost indiscriminately), as to loose its meaning and clinical value. In our rush to nosological (and reimbursement) parity with the rest of medicine we jumped over our heads too soon, introducing the (man made) diagnostic criteria based "nosological" system, which leads to premature ossification and codification of clinical concepts and experience, impeding the independent minded research greatly and precluding the normal development (albeit slow and lagging) of psychiatry as a medical science. Is it not more correct and probably clinically more productive, especially in the field of psychopharmacology, to return to syndromologically based classification system and to try to define, refine and research these historically formed clinical syndromes further, before rushing to judgements about their pseudonosological "pigeon holes"?
This is what Breivic trial, along with other issues, brings to the front. And these issues deserve a deep and long thought.

Michael Novakhov, M.D.

References and Links

Anders Breivik, the public, and psychiatry : The Lancet

Anders Breivik, the public, and psychiatry : The Lancet

The Lancet, Volume 379, Issue 9826, Pages 1563 - 1564, 28 April 2012
doi:10.1016/S0140-6736(12)60655-2Cite or Link Using DOI


Sanity - Wikipedia, the free encyclopedia

In The Sane Society, published in 1955, psychologist Erich Fromm proposed that, not just individuals, but entire societies "may be lacking in sanity". Fromm argued that one of the most deceptive features of social life involves "consensual validation."[3]:

It is naively assumed that the fact that the majority of people share certain ideas or feelings proves the validity of these ideas and feelings. Nothing is further from the truth... Just as there is a folie à deux there is a folie à millions. The fact that millions of people share the same vices does not make these vices virtues, the fact that they share so many errors does not make the errors to be truths, and the fact that millions of people share the same form of mental pathology does not make these people sane.[4]

Fromm, Erich. The Sane Society, Routledge, 1955, pp.14–15.

sane society - Google Search

Erich Fromm - From Wikipedia, the free encyclopedia
Sunday, May 13, 2012

Mike Nova: I support Dr. Frances' idea about founding some new... interdisciplinary body for establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis

Last Update: 9:20 AM 5/13/2012

Mike Nova: I support Dr. Frances' idea about founding some new, superpsychiatric (possibly under combined umbrella of all the appropriate agencies that he mentioned) interdisciplinary body for

Establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis,

which should include efficient participation of philosophers, neuroscientists, geneticists, biologists, psychologists, sociologists, specialists in forensic behavioral sciences and lawyers.

Maybe, with a little help from our friends the "heavenly gate" to a new, broader scientific paradigm in psychiatry will crack open; a little.

And this might lead to true and real (not imaginary, as a product of the wishful thinking), scientifically revolutionary "paradigm shift". Any new paradigm in psychiatry (just like in any other scientifically oriented ideational activity, according to Kuhn) has to be significantly broader than the previous one, incorporating the new body of knowledge, disciplines and theories in a new conceptual framework, resolving the "anomalous contradictions" of the old paradigm which becomes conceptually inadequate to contain them.

This new paradigm must also fit into the larger current paradigmatic systems of scientific and cultural beliefs, and the present lively debate about the meanings and the essence of psychiatric diagnosis is one, and maybe the best indication that the old paradigm "does not fit", that it is scientifically (which is not synonymous with medical practice) - inadequate.

It is also interesting to observe that the battle for this new paradigm is waged in a mainstream media, which might also indicate "the revolutionary situation" expressed as a heightened public awareness and concerns which are absolutely justified, legitimate and significant.