Patil and Giordano Flashcards
A common theme in the contemporary medical model of psychiatry ..
is that pathophysiological processes are centrally involved in the explanation, evaluation, and treatment of mental illnesses.
Implied in this perspective is that clinical descriptors of these pathophysiological processes are sufficient to distinguish underlying aetiologies.
Abstract
Psychiatric classification requires differentiation between …
what counts as normality (i.e.- order), and what counts as abnormality (i.e.- disorder). The distinction(s) between normality and pathology entail assumptions that are often deeply presupposed, manifesting themselves in statements about what mental disorders are.
Abstract
In this paper …
we explicate that realism, naturalism, reductionism, and essentialism are core ontological assumptions of the medical model of psychiatry. We argue that while naturalism, realism, and reductionism can be reconciled with advances in contemporary neuroscience, essentialism - as defined to date - may be conceptually problematic.
However we also caution against the overuse of any theory, and claim that practical distinctions are important to the establishment of clinical thresholds. We opine that as we move ahead toward both a new edition of the Diagnostic and Statistical Manual, and a proposed Decade of the Mind, the task at hand is to re-visit nosologic and ontologic assumptions pursuant to a re-formulation of diagnostic criteria and practice.

Abstract
Traditionally, medicine has been successful in establishing …
aetiology of diseases and disorders, and developing focal therapies based upon such mechanistic conceptualisations.
The acts of medicine (i. e.- diagnosis, therapeutics, and prognosis) depend upon the ability to distinguish between what is “normal” and what is pathologic, and the evolution and practice of psychiatry has attempted to adopt and utilise the medical model in this regard.
Yet, as neuroscience probes ever deeper into the workings of the brain, it becomes evident that the “mind” remains somewhat enigmatic, and thus, any attempt to link mental events to biology must confront what Chalmers has referred to as the “hard problem” of consciousness [1]. But given the continued ambiguity of the brain-mind relationship, unresolved questions remain of 1) how can, and perhaps should psychiatry proceed to formulate a viable system of characterising mental normality and abnormality, and 2) how might such formulation affect the scope and tenor of psychiatric practice?
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In the The Myth of Mental Illness …
Szasz disputed psychiatry’s claims of medical legitimacy. Szasz was concerned about the validity of psychiatric concepts, and his critique raised questions about the evaluative nature of the psychiatric enterprise.
To Szasz, psychiatry utilised terms (such as delusions, compulsions, and obsessions) that lacked the descriptive objectivity of other domains of medicine.
Szasz did not deny that neuroanatomical lesions could result in dysfunctional behaviours, however, such abnormality is, strictly speaking, a brain disease.
Labelling various forms of behaviour as pathological “… rests on a serious, albeit simple, error: … mistaking or confusing what is real with what is imitation; literal meaning with metaphorical meaning; medicine with morals” [3].
If psychiatry lacked terms that could definitively individuate normality from pathology, how could psychiatrists issue seemingly objective diagnoses and prognoses while relying on a predominantly subjective (and elastic) epistemology?
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This conceptual tension in psychiatry mirrors larger debates about objectivity and normativity in the philosophy of science.
In The Structure of Scientific Revolutions, Thomas Kuhn argued that science is sensitive to the normative practices of social communities [4]. Scientists (and clinicians) undergo training and develop expertise within localised academic institutions. As a consequence, intellectual traditions tend to bind scientists and clinicians within a coherent community of practitioners.
Kuhn noted that members of a particular academic community tend to hold similar constructs and values about what constitute a good theory, and these values were largely assumed, unquestioned, and maintained as valid within the group.
For Kuhn at least, the collective nature of scientific theory-building suggested that communities’ values matter in the content of scientific discourse and theorisation (and, we might add, clinical practice).
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Postmodern criticisms of science generally impugn this relativistic bend, and pose the question:
If science evolves within a cultural frame (just like other ideologies), then in what sense is it immune from the normative practices of society [5]?
The crucial issue is not whether the unique status of science (and by extension, clinical medicine) hinges on cultural biases, but whether its epistemology is better than other ideologies at obtaining knowledge about the natural world.
Science values a self-correcting process through which increasingly refined and robust characterisations about the natural world can be made over time. If new observations become difficult to reconcile with standing hegemonic beliefs, then those initial assumptions are usually abandoned.
Thus, scientific epistemology allows for large scale reorganisations of ontological assumptions, or what Kuhn called “paradigm shifts” [4].
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In applying this framework to the medical model of psychiatry, we see a reliance upon four main ontological assumptions.
These are
1) Realism: the claim that mental properties (such as desires, beliefs, and thoughts) are real phenomena and not merely artefacts of sociocultural norms
2) Naturalism: the concept that disturbances in neural structures are causally implicated in the formation and persistence of mental disorders
3) Reductionism: the view that at some level, disturbances in neural structures are necessary to account for mental disorders, and
4) Essentialism: the assertion that mental disorders have underlying ‘essences” that allow distinction of one type from another.
Are each and all of these assumptions warranted and necessary in order to arrive at a valid concept of mental disorder?
We assert that naturalism, realism, and reductionism are reconcilable with advances in contemporary neuroscience, but that essentialism has proven to be, and may still be somewhat more problematic, vis-a-vis the medical model of psychiatry, at least to date.
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Realist position asserts that …
terms used in scientific theories map onto actual properties in the external world, even if the relevant phenomena are not necessarily observable.
Properties referred to be scientific theories are independent of our linguistic practices or socio-cultural norms - they hold true regardless of human circumstance.
Realism entails that a mental realm does not exist separately from the physical, and so an acceptance of realism necessitates a rejection of dualism. Simply, there is not an ontologically separate mental world, independent of its physical instantiation in the brain. The idea of an overriding mind, metaphysically independent of the brain, becomes untenable when we realise that lesions to various regions of the brain have profound consequences for subsequent subjective experience.
A rejection of dualism would logically mean that all mental disorders are (in some way) biologically based. The tenet claims that every mental process, pathological or otherwise, arises in and from the brain [6]. It is important to note that nothing has been claimed about how neural structures causally produce mental states (naturalism), or whether mental states are best under- stood through their more basic, physical components (reductionism).
According to Cash, “…people’s intentions, beliefs, thoughts and decisions are different in kind, not just in scale, from causal mechanisms in the brain. The nature of this ‘difference in kind’ can be revealed by considering the nature of the public criteria we use to ascribe intentional states to one another” [7]. The veridicality of intentional states often depends upon the requisite conditions; intentional states can mean or be about something. The property of about- ness cannot be mapped onto reality in any law-like way.
One can sidestep this criticism by noting that realism is best approached as an epistemological constraint. It is not the case that the tentative plausibility of a certain theoretical term commits us to finding its ‘real world” equivalent.
Critics of realism often conflate the object of scientific knowledge with the process of knowledge construction. Fundamentally, science is an interpretative process; it is something people do.
Knowledge, in the form of theories and explanations, is interpretational and should be regarded as a change- able social product. This does not mean that the object of any such knowledge is always dependent upon socio- cultural constructions. Science describes entities of nature, but “proof” comes through our success in interpreting, interacting with, manipulating (and often, controlling) them.
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Naturalism:
Naturalistic theories of mind generally assume that mental properties, such as thoughts or beliefs, are derived from neurobiological structures in a causally relevant way. In order to legitimize the naturalistic characterization of a mental disorder, the observed clinical expressions of behavior should have causal roots in biology. This is not to claim that all mental behavior should only be understood through biology, but rather that we - as dynamic organisms within complex environments - will undoubtedly be influenced by a variety of interact- ing variables, including biology.
A pressing question in naturalistic theories is how is it, exactly, that neurobiological disorders can be causally linked to certain behavioral outcomes? The steps implicated in the causal chains from the biochemical to the behavioral level(s) are vast and endless, and as Hume noted, we cannot “see” causation [9]. In science, we observe event regularities, and if such regularities occur with sufficient frequency, then we tentatively accept these observations as truly causal. Such observations are affirmed through the use of statistical theories, which provide a mathematical measure for the probability of an event occurring solely by chance.
These types of observations have prompted many philosophers (since Hume) to posit that causality can, at best, be understood as event regularities. We cannot determine by reasoning alone which of the observed (or potentially unobserved) effects actually cause the phenomena in question. To arrive at such conclusions, however, is to be led astray by words. As Ross states, “… to the extent that we have culturally universal intuitions about causation, this is a fact about our ethology and cognitive dispositions, rather than a fact about the general structure of the world” [11]. In other words, naturalistic intuitions are not evidence of their content.
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REDUCTIONISM:
Over the last few decades, neuroscience has elucidated a biological basis for several mental disorders. These developments have fuelled the quest to explain mental properties by reducing them to an interaction of their putative substrates. Given that interactions of neurobio- logical structures are causally implicated in aberrant of behavior, a logical paradigm would grant underlying genetic and biochemical entities explanatory primacy. Subjective experience and cultural influences can play a role in psychiatric disorders, but the “true” explanatory locus would rest in pathological structures and functions.
Many of these overly reductionist tendencies can be assuaged by revisiting some of Dennett’s work that attempts to clarify the relations and predictions of men- talistic behavior through the use of three levels of expla- natory abstraction [12]. The first is the Physical Stance, in which behavior could be predicted, in principle, from physical laws governing the interactions of material components. The second is the Design Stance, which predicts behavior, not from an understanding of the physical con- stitution of the mind, but through an understanding of the mind’s purpose, function, and design. The final level of abstraction is the Intentional Stance, which requires neither an understanding of the physical constitution of the mind nor any design principles, but instead predicts behavior by considering what moves a rational agent would make in a given circumstance.
The brain and its potential representations are a pri- mary focus of neuroscience, and neuroscientific information sustains both an evolving philosophy of mind, and the profession and practice of psychiatry. But
it is important to recall that neuroscience, as a science, remains a process, and in so far as people are working on the common project of explanation, the objects of knowledge need to be interpreted. Normativity cannot be expunged from science, nor should it be. We make sense of the world and explain it with our theories, and it is inevitable that practical considerations will play an important role in theory choice. This means that reduc- tionism need not be the raison d’être for the naturalistic project, but neither should it imply that reductionism is not possible, in principle. It is important to note that defining mental content in this way becomes a practical consideration. Accordingly, behavior can be interpreted using a level of abstraction that depends upon the needs of the investigator (and/or clinician).
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ESSENTIALISM
A more controversial ontological assumption of the medical model of psychiatry is essentialism. This is the claim that psychiatric disorders, as defined by clinical nosology, map onto reality in a discrete way, and that these disorders possess essential properties, without which they would not be what they are. We argue that this assumption is highly questionable, and that as currently conceived, is anachronistic at best, and remains inconsistent with scientific thinking (at worst), and therefore is in need of re-examination and revision.
Science routinely organizes its body of knowledge into categories. How we sort things into categories largely depends on what measures we value. That is, we classify objects for a particular reason or to serve a specific function; to these ends, classification schemes cannot be arbitrary or random assortments. As Sadler notes, “…this non-arbitrariness is essential to a classification because it provides the basis for users with common purposes to talk about the same things. For us to discuss ‘major depression’ productively, we have to agree, in large part, about what major depression is, and in what practical context such a notion arises” [13].
An important concern for classification is the concept of validity. The validity of a category is related to the degree that it fits within a consonant body of explanatory theories. So, to group lungfish and cows in a similar category would require that there are genuine motivations for doing so. If one were an evolutionary biologist, such a grouping would align with what is known about macro-evolutionary processes. If one were a fisherman, the validity of such a pairing would seem impractical.
A criticism of the construct of essentialism is found in the later work of Ludwig Wittgenstein. Summarising the Wittgensteinian view, Garth Hallett writes: Suppose I show someone various multi-coloured pictures, and say: “The colour you see in all these is called “yellow ochre”… Then he can look at, point to, the common thing.” But “compare this case: I show him samples of different shades of blue and say: “The colour that is common to all these is what I call “blue”.”’ Now what can be looked at or pointed to save the varied hues of blue? And don’t say, “There must be something common, or they would not, be called ‘blue,”’ “but look and see whether there is anything in common at all” [14].
The crucial argument here is that the property of “blue” is reliant, to some extent, upon practical considerations and constraints.
Yet, a form essentialism persists in psychiatry. This is clearly articulated by Robins and Guze who claim that, “…the finding of an increased prevalence of the same disorder among the close relatives of the original patients strongly indicates that one is dealing with a valid entity” [15]. In this framework, genetic and bio- chemical factors are attributed as primary causes, and the role of psychiatry is to locate these pathological qualities within the physical brain. While experience does play a role in one’s mental health, this model is decidedly oriented toward brain function. In this way, genetic and biochemical causes are seen as exerting their influences uni-directionally and any/all manifest symptoms are the consequence of unique and individuated aetiologies.
The medical model of psychiatry views the current classifications as representing discrete organic disease states as opposed to heterogeneous symptom clusters. Validation of these symptom clusters often occurs via post-hoc quantitative and statistical analyses (such as hierarchical cluster analysis or pattern recognition paradigms) of the clinical data to ascertain which combinations of symptoms tend to group together. The problem with creating these types of discrete definitions for many contemporary psychiatric conditions is that “…no amount of clustering can get around the fact that several variables used in such models may have little or no biological plausibility” [16]. Without clear biological mechanisms, it is unclear whether symptom clusters represent different ways of labeling the same affliction, socio-cultural influences, or other biological confounds. Peter Zachar and Nick Haslam have presented a strong case that psychiatric categories do not uniformly individuate to underlying essences, but are defined, to a large part, by practical considerations [17-24]. In many ways, this recalls the Szaszian argument for mental ill- ness as “myth” - here literally used to denote a practical, explanatory narrative.
We do not refute, or even doubt that practical considerations are important to define the threshold(s) at which a particular set of signs and symptoms may be deemed clinically relevant. But, if we are to regard essentialism as critical to the medical model of psychiatry, and adopt practice standards in accordance, then the task at hand is to establish how and what essential criteria are pertinent to any construct of normality and order (versus abnormality and disorder), as relates to brain function, mental processes and expressions of cognition, emotion and behavior (within a social milieu).
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CONCLUSION
Psychiatry has increasingly adopted a categorical approach in delineating mental disorders. This has been beneficial insofar as the defined categories reflect clear and well-understood biological mechanisms. For certain psychiatric conditions, such as schizophrenia, bipolar disorder, and other psychoses that involve clear dysfunctions of mechanisms that regulate perception, cognition, and communication, a categorical approach may be reasonable [2]. Human beings, however, have a range of behaviors whose normality or pathology is constrained within certain socio-cultural niches. Various phobias, compulsions, obsessions, and emotions cannot easily be explained by a singular biological mechanism. As well, manifestations of the same condition may be the result of heterogeneous mechanisms working in concert
Essentialism is evidently important to the medical model, and as such persists in contemporary psychiatry.
One of the central tenets in essentialism is the existence of natural kinds. According to Zachar, a natural kind is “…an entity that is regular (nonrandom) and internally consistent from one instance to the next” [24]. That is, once the property that captures the essence of a specific natural kind is known, that property can identify any other prototypical instantiation of that kind with accuracy. But, if a category cannot be identified with respect to its essential properties, then such a category is not, in the strict definitional sense, a natural kind, but an artificial category.
Rom Harré argues that the philosophy of science is such that the idea of a ‘natural kind’ is a fancy, and that a ‘natural kind’ is a concept which can only be under- stood within the double framework of practice and theory [27]. The validity of a category is contingent upon how well it integrates within a diverse, multidimensional system of fact(s) and explanation(s).
it is the practical context that distinguishes accidental properties from essential ones, and we opine, perhaps more importantly, what extent of properties will be deemed relevant to regard and guide action(s).
Biological systems (including the embodied brain-mind) display complex network properties, …
and behavioral processes are often best characterized as non-linear interactions between physiological systems and the environment [29]. The extent to which the activity of the system as a whole reflects the response(s) of its component networks will vary based upon the condition of the system and its sensitivity, and relative attractors and constraints that exist; each and all of these may be differentially expressed in certain individuals, at various points throughout the lifespan. More- over, there is evidence to suggest that the activity and response-parameters of constituent parts and networks (i.e.- “bottom-up” effects) may be responsive to, and affected by the activity of the entire system as a whole - inclusive of psycho-social factors in which it is nested (i. e- “top-down” effects) [30].
At some point, the distinction between what is normal
and abnormal, ordered and disordered will need to be …
made, and any such distinction must be practical in the sense of its viability to sustain the good of patient-centered clinical care. Therefore, it may be that the task (for the Decade of the Mind project, development of the DSM-V, and for psychiatry, if not medicine, writ large) is to clarify how syndromes are related (within various spectrum disorders), and adapt or create a classification scheme, nomenclature (and thus ontology) that communicates the meaning and value of taxonomy and diagnosis. Whether an attempt to elucidate the “natural basis” of mental function and dysfunction will serve such practical ends remains to be seen.
