- Bibtex: @kendler2016
- Bibliography: Kendler, K. S. The nature of psychiatric disorders. World Psychiatry 15, 5–12 (2016).
Why and when I was reading this
I was doing a deep dive into “What are psychiatric disorders?”
Summary & comments
Three ways to think about psychiatric disorders.
- Realism: The content of science is real and independent of human activities.
- Pragmatism: Seeking categories that perform well in the world, makes no claim about the reality of those disorders.
- Constructivism: Social forces play a role in psychiatric disorders.
“Because so many prior psychiatric diagnoses have been proposed and then abandoned, can we really claim that our current nosologies have it right?”
“If we re-run the tape of history over and over again, the DSM and ICD would not likely have the same categories on every iteration.”
Pragmatism
One big drawback: It’s unambitious and reluctant to make claims about the underlying reality of psychiatric disorders.
In my scientific worldview, the mind is part of the body and its disorders are just as real. It would be inconsistent, or an admission of defeat, to regard psychiatric disorders as being of a different status than classical physical-medical disorders.
Constructivism
It’s associated with some anti-psychiatry writings and loaded for many researchers and practitioners.
What are socially constructed things? They are the sorts of ideas and things that humans make like euros, passports…
To say something is socially constructed is not to say that it is not “real” in a practical sense.
He then gives examples of diagnoses that have been included in DSM because of changes in society: PTSD in DSM-III due to the politics around the Vietnam war and premenstrual dysphoric disorder in DSM-5 because feminism had changed and fluoxetine had been approved as a treatment for premenstrual dysphoric disorder in 2000.
Critically, I am not saying that social forces created PTSD or PMDD. Rather, I assert that social forces influenced the debate about the recognition of these disorders in our official nosology.
A case of “true” social construction is perhaps found in the U.S. epidemic of multiple personality disorder, often accompanied by repressed memories of bizarre ritual abuse. It is likely that the symptoms were “constructed” by patient-therapist interactions and therapist expectations.
Two arguments against realism
While an attractive point of view, realism is plagued by two strong arguments against its use as a model for psychiatric disorders. Pessimistic induction and Historical contingency.
Four possible modifications of the realistic position for psychiatric disorders
Homeostatic property clusters
Rather than looking for the “essence” of psychiatric disorders, we should note that psychiatric syndromes arise from inter-connected networks that can be understood at different levels.
Psychiatric disorders can then be understood as emergent syndromes arising from disturbances in mind- and brain-based networks rather than concrete “things/essences” that exist in some definable place in the mind or brain.
A more limited view of realism for psychiatric disorders
We can use a coherence theory or truth rather than a correspondence theory of truth.
- Correspondence: A statement is true if and only if it corresponds to something in the world that we can easily verify
- Coherence: Something is true when it fits well with the other things we know confidently about the world
Types of psychiatric disorders versus tokens
- Tokens are specific manifestations of a broader general class
- Types are the broad class, which can have several levels
… we could say that psychiatric disorders would be the superordinate type, subtypes would include “mood disorders” and “psychotic disorders”, and the tokens would be the individual disorders: schizophrenia, panic disorder and pathological gambling
An historical perspective applied to psychiatric disorders
This is an addition to the coherence theory of truth for psychiatric disorders. Disorders become real over time if they “keep on giving”, providing us with continued fresh insights into etiology and treatment.
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Paperpile notes
Page 1: Highlight annotation by Oskar Flygare on January 29th 2018, 11:52:05 am: ecause so many prior psychiatric diagnoses have been proposed and then abandoned, can we really claim that our current nosologies have it right? Much of our current nosology arose from a series of historical figures and events which could have gone differently. If we re-run the tape of history over and over again, the DSM and ICD would not likely have the same categories on every iteration. Page 1: Highlight annotation by Oskar Flygare on January 29th 2018, 11:52:17 am: I will review and critique three major theories about the nature of psychiatric disorders: realism, pragmatism and con- structivism. Page 2: Highlight annotation by Oskar Flygare on February 12th 2018, 3:55:28 pm: on one important limitation. Prag- matism, in its classic form, is unambitious and is reluctant to make claims about the underlying reality of psychiatric disor- ders. This for me Page 2: Highlight annotation by Oskar Flygare on January 29th 2018, 11:56:09 am: The features of a species typically vary over its range, and at its limits the dividing line between sister species can become indistinct. Page 2: Highlight annotation by Oskar Flygare on January 29th 2018, 11:56:26 am: The species we know about only exist in our biosphere and are tem- porally limited, existing only between their emergence and extinction. An element such as hydrogen is universal and prac- tically timeless. Third, unlike elements, species have no essence. Thereisnoonethingthatdefinesaspeciesthatmakesawalrus, robin or drosophila. Fourth, not all members of a species are identical to one another, as are atoms of any element. Page 2: Highlight annotation by Oskar Flygare on February 12th 2018, 3:57:01 pm: es as “real”? In my scientific worldview, the mind is part of the body and its Page 2: Highlight annotation by Oskar Flygare on February 12th 2018, 4:14:48 pm: What are socially constructed things? They are the sorts of ideas and things th Page 2: Highlight annotation by Oskar Flygare on February 12th 2018, 4:14:55 pm: ip-hop music. To say something is socially con- structed isnotto say that it is not “re Page 3: Highlight annotation by Oskar Flygare on February 12th 2018, 4:27:23 pm: Let us turn to the harder question of true “social con- struction” for psychiatric disorders. Consider the epidemic in the U.S. in the 1990s of multiple personality disorder (MPD), which was often accompanied by repressed memories of bizarre ritual sexual abuse9 . While I cannot possibly do justice to this complex story here, there is good reason to think that a proportion of these individuals had iatrogenic disorders – ones that were actually “constructed” from the expectations of their thera Page 3: Highlight annotation by Oskar Flygare on February 12th 2018, 4:27:50 pm: I do not mean to imply that such individuals were not in some ways “disordered” when they sought treat- ment. Rather, I argue that in most if not all such cases the spe- cific syndrome of MPD and associated “recovered” memories was constructed by patient-therapist interactions. A similar story has been told about the grand hysteria constructed under Charcot’s care in Paris in the late 19th century11 .To please the professor, his patients became actresses displaying the expected sequence of symptoms and signs before his pub- lic aud Page 4: Highlight annotation by Oskar Flygare on February 15th 2018, 11:09:57 am: These two arguments are inter-related. If there are many steps between the overt manifestations of psychiatric illness on the one hand and the creation of an official psychiatric nosology on the other, and some of these steps involved his- torical contingencies, then we would expect that re-running the “tape of time” over and over would not always produce the same DSM or ICD categories. Page 5: Highlight annotation by Oskar Flygare on February 15th 2018, 11:12:16 am: As noted above, the properties of a species do not arise from a single essence like the properties of carbon can be derived from its number of protons. Rather, the nature of a lion or starling arises from a cluster of properties that inter-relate with one another in a stable manner over time. Page 5: Highlight annotation by Oskar Flygare on February 15th 2018, 11:12:29 am: While we have sought for the key to humanness by comparing the genomes of humans with those of chimps and gorillas, it is clear that there are hundreds of meaningful genetic differences between us and our nearest primate relative, no one of which is definitional Page 5: Highlight annotation by Oskar Flygare on February 15th 2018, 11:22:42 am: What if we wanted to be less demanding of ourselves in calling something true? A humbler approach can be found in the coherence theory of truth. This theory considers some- thing to be “true” when it fits well with the other things we know confidently about the world. Page 5: Highlight annotation by Oskar Flygare on February 15th 2018, 11:13:26 am: Is it not more likely that our psy- chiatric syndromes arise from inter-connected networks that can profitably be understood at the level of mind (e.g., symp- toms of guilt leading to ideas of suicide) or at the level of brain (e.g., disturbed reward systems produce anhedonia which then impacts on appetitive systems producing decreased appetite)? Psychiatric disorders can then be understood as emergent syn- dromes arising from disturbances in mind- and brain-based networks rather than concrete “things/essences” that exist in some definable place in the mind or brain. Page 5: Highlight annotation by Oskar Flygare on February 15th 2018, 11:15:35 am: What makes each psychiatric disorder unique are sets of causal interactions amongst a web of symp- toms, signs and underlying pathophysiology across mind and brain systems. Page 5: Highlight annotation by Oskar Flygare on February 15th 2018, 11:23:13 am: What do we mean when we want to say that one diagnostic concept (e.g., our modern concept of schizo- phrenia) is more real than another (e.g., the concept of frenzy in the early 19th century)?” Using a coherence theory of truth, the answer is simple. To be more real means to be connected to more already existing things we know. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:28:28 am: Specific psychiatric disorders may come and go, but the phenomena that we now describe as psychiatric disorders are likely part of the human condition, and will exist and be described in some way by any human culture during any historical time period. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:24:48 am: I do not want to underestimate the potential importance of adopting a coherence theory for psychiatric illness, because it departs in some important ways from our conventional ideas about truth. Indeed, it moves our ideas about “truth” in a dis- tinctly pragmatic direction. Right now we can do a much bet- ter job of applying this more modest and practical view of truth to psychiatric illness than we can with the more ambi- tious correspondence theory. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:29:45 am: I will here borrow from the philosopher of science I. Lakatos28 . As he suggested, research programs can be progressive or degenerative. I suggest that diagnostic concepts in medicine, in general, and psychiatry, particularly, can also be progressive or degenerative. I will define “progressive” for our purposes as roughly “continuing to yield new insights into etiology, course and treatment”. For our discussion here, I want to suggest that, as disorders con- tinue to provide us new insights, they become more “real”. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:26:20 am: To parse this in psychiatric terms, we could say that psychi- atric disorders would be the superordinate type, subtypes would include “mood disorders” and “psychotic disorders”, and the tokens would be the individual disorders: schizophre- nia, panic disorder and pathological gambling. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:27:39 am: I want to argue that we should be more committed to the reality of psychiatric types than of psychiatric tokens. Think of the historical contingency argument. The probability that our current diagnostic category of histrionic personality disorder would show up every time we re-ran the tape of time, over and over again, strikes me as low. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:30:18 am: I do not think that in psychiatry we have any story of suc- cessful diagnostic “splitting” that can compete with the diabe- tes mellitus story. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:27:53 am: What about the stability over multiple “replications” of human history of the broad concept of personality disorder? That sounds like a better bet to me. Page 6: Highlight annotation by Oskar Flygare on February 15th 2018, 11:30:35 am: Kraepelin’s concept of manic-depressive insanity included what we now call major depression and bipolar illness. For a range of reasons, some having to do with writings of Leon- hard17 , bipolar illness was separated out from major depres- sion in the middle of the 20th century. We now know that this too has been a “progressive” diagnostic splitting, leading to clear differences in treatment and etiology, including molecu- lar genetic findings. Page 7: Highlight annotation by Oskar Flygare on February 15th 2018, 11:31:02 am: So, this tentative line of thought would suggest another way to think about how our disorders become more “real”. In an historical extension of the coherence theory of truth, those dis- orders become real if over time they “keep on giving”, providing us with continued fresh insights into etiology and treatment. Page 7: Highlight annotation by Oskar Flygare on February 15th 2018, 11:33:21 am: The best framework that I have found for this is networks of interacting causes and symptoms like Boyd’s homeostatic property clusters. The sta- bility of our disorders over space and time is an emergent property of the human mind-brain system – not the result of one essence from which all the symptoms and signs develop. Page 7: Highlight annotation by Oskar Flygare on February 15th 2018, 11:34:01 am: We should not get backed into a corner claiming that social processes play no role in the construction of our categories. That is not a defensible position. There is no shame here. All scientific enterprises have social components. To suggest that we could keep psychiatry immune from social processes is unrealistic. However, we can vigorously defend the difference between social processes in our science and nosology, and socially created disorders. It is this latter category that we must assiduously guard against. Page 7: Highlight annotation by Oskar Flygare on February 15th 2018, 11:34:16 am: The pessimistic induction and historical contingency arguments are too powerful for me to be able to confidently defend our current system as “true”, as many of our diagnostic categories are tentative working models that are likely to change. Page 7: Highlight annotation by Oskar Flygare on February 15th 2018, 11:34:42 am: One of the key compromises I am willing to make with pragmatism is the adoption of the coherence theory of truth as our working model. Page 7: Highlight annotation by Oskar Flygare on February 15th 2018, 11:34:58 am: in the end, it is in the grounding of our disorders in our empirical science (via vali- dators) that we have the greatest probability of producing last- ing, valid and “true” categories. Page 8: Highlight annotation by Oskar Flygare on February 15th 2018, 11:35:12 am: a true disorder is one that over time grows more and more valid, explains things about the world for us and increasingly fits in our world view. Page 8: Highlight annotation by Oskar Flygare on February 15th 2018, 11:37:08 am: In conclusion, I would advocate for a “soft” realist position for psychiatric disorder – one that is much closer to biology- than chemistry-based realism and has elements of the prag- matic position. Our disorders are unlikely to have essences in a classic sense, with their natures probably arising from “net- works” of causes, symptoms and signs, as postulated within homeostatic property clusters. We need to soften the realist position through the use of coherence theories of truth. The best available antidote against the power of the pessimistic induction and historical contingency arguments is to place more trust in our psychiatric types than the specific tokens of psychiatric illness which now populate our diagnostic manuals. In our project to study and justify the nature of psychiatric dis- orders, we ought to be broadly pragmatic but not lose sight of our underlying commitment to the reality of psychiatric illness.