[W6] - Readings Flashcards
How complex is defining mental health/normalcy, and why does it matter?
There is an enduring complexity associated with defining mental health and normalcy.
These definitions are crucial for diagnosing mental disorders and determining appropriate treatments.
History of the DSM
The APA created the DSM-I in 1952 after realizing that the psychological evaluation of soldiers might predict their job suitability
→ the DSM-I and its successor in 1968 were influenced by Freudian theory
→ dissatisfaction with this model lead to a more biological focus on mental disorders (inspired by Emil Kraepelin’s stance)
→ the DSM’s evolution reflects a significant shift from psychoanalytic theories to more Standardized, Symptom-focused approaches
→ the DSM’s definitions are ONLY APPROXIMATIONS, relying on experts’ judgment to assess the severity and necessity of interventions
→ mental disorders are typically associated with significant suffering or impairment in daily life, though the presence of such suffering is a matter of philosophical debate
→ cultural and societal NORMS play a role in distinguishing normal behavior from mental disorders, emphasizing the normative aspect of these definition
→ mental disorders in the DSM are NOT described as being caused by biological dysfunctions (unlike what Insel says)
Three Classic Views on Classification
→ the DSM is a classification system
→ it intends to explain a person’s situation, guide experts, and provide information about the prognosis
→ From a philosophical point of view, we can distinguish three general ways to distinguish things
(each with their own perspective on building classification systems)
Essentialism
→ Essentialism assumes that things have an intrinsic quality, an ESSENCE, to distinguish them
- This presumes philosophical realism (there is an outside world that is INDEPENDENT of us, conscious beings)
→ if you want to find out what kind of thing something is, you simply look at its essence
→ Too simple for more complex systems (like looking for clear biomarkers which don’t exist)
Social Constructionism
→ Describes facts as being brought into being by human activities, as opposed to realism.
- Many believe that social constructs are not worth discussing (because of the common view that only natural sciences are ‘hard sciences’, and psychology/social sciences have a lower status)
→ SC highlights how definitions of normalcy and abnormality are SHAPED BY SOCIETY and institutional power.
- However, these classifications can have profound and sometimes harmful consequences, underscoring the influence of Social Constructs in psychiatry.
→ Social constructs, though not physically tangible, play a CRUCIAL ROLE in our lives and can be more impactful than many purely physical realities (e.g., social constructs like money are deeply “real” in their effects.)
Pragmatism
→ Pragmatism holds that we should just do ‘what works’
- It suggests that researchers’ theories and entities are the TOOLS they use to do their work rather than necessarily reflecting something in the world.
→ There are different stakeholders in mental healthcare: Patients, Health Insurance Providers, and Clinicians/Scientists - who all have varying perspectives on what constitutes health and how it should be measured.
→ The Pragmatic approach helps navigate these COMPETING interests by focusing on PRACTICAL outcomes (diagnosis, treatments, effectiveness, etc.)
- The DSM’s approach ALIGNS WITH PRAGMATISM, as it offers a practical tool for clinicians who need to make decisions without waiting for theoretical debates on mental disorder classifications to be resolved!
Difficulties in defining addiction
→ The dictionary defines addicted as “being physically and mentally dependent on a particular substance”.
→ Dependence, in turn, means the “state of relying on or being controlled by someone or something else” (externally controlled?)
- Addiction was demonized in prohibition U.S (Graham-Mulhall labelled opium the demon flower, and characterized addiction as a moral downfall - viewing it through a moral instead of medical/psychological lens)
- Robins’ research after Vietnam suggested drug availability and stigma play crucial roles in addiction likelihood.
→ Drug dependence seems to be a biopsychosocial phenomenon that cannot merely be reduced to the features of a substance or the genes of a consumer alone.
DSM Difficulties with Addiction
→ DSM-5-TR addresses addiction within “Substance-Related and Addictive Disorders”
→ it refrains from explicitly using the term “drug addiction” as a diagnostic label
→ it emphasizes “use disorders”, acute intoxication, and withdrawal symptoms
→ this avoidance may reflect the absence of a universally agreed-upon definition of addiction
→ Gambling disorder has also been added as the only non substance-related addictive disorder
→ Two notable symptoms are: gambling when feeling distressed -
relying on others and their money to alleviate financial issues.
→ Note that poverty may contribute to distress, while financial dependence on others may be less prevalent among wealthy individuals!
→ Internet gaming disorder is also recognized in the ICD-11, reflecting different expert perspectives.
→ Two pragmatic approaches to assessing alcohol dependence are the German Cancer Research Center’s method and the Alcohol Use Disorders Identification Test (AUDIT) by WHO
→ both highlight the complexity of dependence, involving factors like psycho-behavioral loss of control, impaired daily functioning, psychological process, and psycho-physiological effects.
→ Broad definitions of addiction suggest that a significant portion of the population may experience addictive behaviors!
- This emphasizes the importance of careful definition and measurement in research and diagnosis.
New disorders
- Prolonged grief disorder
→ gender dysphoria replaced gender identity disorder in the DSM-5 to reduce stigma
→ Orthodoxia nervosa (excessive discipline concerning food).
- Sluggish cognitive tempo (concentration deficit disorder)
Are mental disorders static?
NO!
- They are dynamic and culturally influenced phenomena.
- Hacking likened them to “moving targets,” suggesting that they are SHAPED by clinicians, scientists, and societal institutions.
→ Attempts to reduce them to purely biological states or concrete entities often fall short
→ Diagnostic categories formulated by experts MAY NOT FULLY CAPTURE individuals’ experiences and behaviors.
Biological vs. Chemical realism/essentialism
There are two main types of realism:
- based in the hard science of chemistry → things (like elements in the periodic table) are clear and independent of what humans think.
- based in the hard science of biology → focuses on biological things like species; species can be a bit fuzzy around the edges, with features that vary and sometimes overlap with other species.
→ When it comes to understanding psychiatric disorders, the biological kind of realism makes more sense.
→ Both kinds, however, believe that scientific THINGS EXIST WHETHER OR NOT WE STUDY THEM - we don’t create psychiatric disorders, we ‘discover’/find them
The two arguments against realism for psychiatric disorders
- Pessimistic Induction
- Historical Contingency
Pessimistic Induction:
→ this argument says that past scientific theories have been proven false, suggesting that current theories might also be replaced in the future
(the counterargument is that current theories are correct, unlike past ones)
→ however, it is implausible to claim that current theories are infallible!
→ given the history of changing diagnostic systems, can we claim that the current DSM and ICD categories are actually definitive?
→ it is likely that current categories will be seen as false or sub-optimal in the future
Historical Contingency:
→ if we rewind civilizations by 10,000 years about a hundred times, it is still unlikely that our current menu of psychiatric disorders would be consistently rediscovered (with a changed history, we wouldn’t have the system we have)
→ our diagnostic system is highly dependent on some particular historical events
Four ways we could modify the Realistic Position on Psychiatric Disorders
- Homeostatic Property Clusters
- A More Limited View of Realism for Psychiatric Disorders
- Types of Psychiatric Disorders versus Tokens
- A Historical Perspective Applied to Psychiatric Disorders
Homeostatic Property Clusters:
→ a homeostatic property cluster model suggests that the nature of biological entities arises from a cluster of interrelated properties that remain stable over time
→ essentialist thinking persists in psychiatry, but this approach may not capture the complex, interconnected nature of psychiatric disorders
→ homeostatic property clusters allow a more nuanced understanding of the interrelationship between symptoms
→ Borsboom proposes assuming direct causal relationships between symptoms rather than assuming each symptom reflects the essence of the disorder
A More Limited View of Realism for Psychiatric Disorders:
→ philosophy has two prominent theories of what it means for something to be true
→ the correspondence theory suggests that something is true if it corresponds to an objective reality
applying this to psychiatry presents challenges:
→ diagnosis conditions like schizophrenia relies on complex criteria that is sometimes hard to pinpoint with ‘objective’ reality
→ the coherence theory defines truth based on how well it fits with other known facts
this is more practical for psychiatry
→ diagnoses are considered true to the extent that they fit well with existing scientific knowledge
Types of Psychiatric Disorders versus Tokens:
→ in philosophy, we can distinguish between:
types → represent broader categories
tokens → specific instances within those categories
→ it is argued that we should prioritize the reality of psychiatric types over tokens
broader constructs like neurodevelopmental or psychotic disorders are more likely to endure compared to specific diagnostic categories
→ there should still be a balance between types and tokens
it’s important not to overlook the value of individual diagnostic categories in clinical practice and research
A Historical Perspective Applied to Psychiatric Disorders:
→ medical diagnostic concepts can be classified as progressive or degenerative
progressive concepts keep providing new insights over time, making them more “real”
→ this aligns with the coherence theory of truth
→ Kraepelin’s differentiation between major depression and bipolar illness + the separation of panic disorder and generalized anxiety disorder have led to clear differences in treatment and understanding
