Disorders of the Mind - The Philosophy of Psychiatry

07 March 2015

There’s something odd about how psychiatry defines mental disorders—namely, by their symptoms. It’s to be expected, on some level. After all, how else could doctors diagnose psychiatric disorders, if not, in part, by their symptoms?

The problem, though, is that in medicine, a cluster of symptoms isn’t usually what defines the disorder. Illnesses are identified by the underlying condition that causes the symptoms. And for good reason.

Imagine you come down with a fever, body aches, and vomiting—those are your symptoms. You go see a doctor, but before the doctor decides how to treat you, she has to figure out something very important—the underlying cause of your symptoms. You could have a flu, or food poisoning, heat stroke, or any other number of conditions. Until that underlying cause is identified, a proper diagnosis can’t be made. So maybe the doctor orders some tests to be performed to identify the cause. In part, that’s what makes medicine a science—it deals with underlying causes, not just symptoms.

But, in fairness to psychiatry, the mind is pretty opaque, and probably more so when it comes to discovering the source of psychological problems. Moreoever, psychiatry as a science is not that old, so there’s probably still a lot to be discovered about the underlying causes of mental disorders. In the meantime, the best approach is to define them by symptoms and use that provisional definition to further research and investigate what’s really going on.

But is that actually what happens in psychiatry? Take the DSM—the Diagnostic and Statistical Manual of Mental Disorders—which is basically the bible for psychiatrists in the US. In the old days, it included homosexuality as a “mental disorder.” That was removed years ago. But in the current edition, the DSM-5, grief is now categorized as a “depressive disorder,” when deep sadness in response to the death of a loved one is usually considered normal. Including grief as a disorder is definitely a stretch—at best. It makes you wonder, what the hell were they thinking? What could possibly be motivating that?

So what should we conclude from this? Does it follow, for example, that there’s no such a thing as clinical depression? I don’t think so. Some people feel extremely depressed all the time and it’s got nothing to do with the circumstances of their lives. They haven’t lost anyone close to them, they didn’t get fired from their job, their marriage didn’t fall apart.

Granted, it is a depressing world in many respects. Even without some specific incident, like the death of a loved one, to trigger depression, it can be difficult to deal with all the stresses of modern life, be they economic, health-related, social, or what have you. How do we say what’s a normal response to these stresses and what’s a disorder? In addition to identifying the symptoms, isn’t some account of the underlying cause needed to properly define what counts as a “mental disorder”?

If psychiatry is to be considered a real science, it must also pay attention to its methodology. Why was homosexuality once considered a mental disorder? The most likely explanation is cultural and personal bias. Why is grief that lasts more than two weeks now considered a mental disorder? I’m sure the answer to that is rather complicated and involves insurance companies, who won’t pay for treatment unless it’s called a “disorder,” (otherwise they think it’s “all in your head”?) and then there’s the big drug companies, who want to pathologize normal responses to life’s many troubles so more people will buy their products. If these are the kinds of influences—cultural, economic, political—that determine what counts as a disorder and what counts as normal, then it’s hard to take the notion of a psychiatric disorder seriously.

All that is not to say that there aren’t any real psychiatric disorders that we can study scientifically. But psychiatry is going to have to clean up its act if it is to be considered a legitimate science.

 

Comments (12)


Gary M Washburn's picture

Gary M Washburn

Sunday, March 8, 2015 -- 5:00 PM

Therapy assumes a well

Therapy assumes a well understood state of health. Well, doctors practice medicine with no very clear notion of being well, other than the riddance of known symptoms or causes. Pathology requires a powerful and sustained self-examination. William James was more a folk psychologist than a real one, and Freudianism is a dud. "Hysteria", after all, was largely cured by freeing its sufferers from their corsets, and letting them vote. The pathology he addressed was clearly social and not individual, and so talking honestly about it did the trick, for a while. But the apothecary leaped in where talk failed. And a little (seeming) success encouraged them to wild claims of highly profitable courses of treatment for what they could not quite define as real at all. And in clinical psychiatry can a diagnosis be differentiated from a hunch? A hunch influenced by large fees. The question never seems to be asked, what are emotions for? Are all emotions pathology? Or is the pathology the assumption that there is an objective test of health? If our emotions are a way reason has of evidencing the inadequacy of the very structure of reasoning, then we as philosophers ought to pay attention, and stop letting the matter rest with the pathologists. If we don't know how to feel, maybe this only means we not done yet feeling it. Don't tell me how to feel, but respond so as to let the changes in how we are unable to know how to feel clarify how we both do feel. That clarity, I submit, is emotional health. Observation is poison to it. Participation is the only real therapy. Condition Absolute, I believe it has been called.
Alzheimer's is real enough, I have seen it twice now, and the professional seem quite stumped, which leaves the matter to us poor emotional wretches to sort out as best we can. The disappointment in this area should be a raging scandal in the face of professional claims of effective treatment in so many areas that are not well defined as abnormal at all. Depression is not real in the same sense, though I have had a bout I later recognized as some form of Lyme disease. Fear is not the hunter, it's the prey. Anxiety is to be expected in a life that has little room for introspection, and even finds in it only pathology. American life is divided between, not eros and thanatos, but thumos and depression, enthusiastic applause and anguish that has no terms of expression because only thumos, only frenzied enthusiasm, is given right of place.

Gary M Washburn's picture

Gary M Washburn

Monday, March 9, 2015 -- 5:00 PM

Another important point.

Another important point. Again, the idea of pathology implies a holistic comprehension, which is not justified by the current state of understanding. It is all well to isolate glaring cases of disorders and try to sort out some ad hoc remedial actions to take against it. It is quite another to brush aside the implication of the whole and to use pathology to carve the issue into manageable pieces. That is, to suppose that the pathology of specific damage to the brain not only obviates the lack of a holistic understanding, but provides the best means of achieving it. This, as so much else in philosophy, is ass backwards thinking. But then so much in philosophy is now awry that many of our number look for channels of expression that do an end-run around the mess it is in. The interpretive pathway, blazed by Adorno and others, is one obvious example. But another is cognition. But where the aesthetics of interpretation proceeds properly from whole to parts, "cognitive science" falls into the error of pathology bereft of a more complete notion of its subject. As I have noted elsewhere, the most scathing criticism of a philosopher is that he does not know he's talkng about. If you do not know your antecedent your inferences are worthless.

Sonoma Listener's picture

Sonoma Listener

Monday, March 9, 2015 -- 5:00 PM

I recommend that you read

I recommend that you read Robert Whitaker's book, "Anatomy of an Epidemic" for a comprehensive and well researched examination of the history and current issues with the use of psychotropic drugs.

Or's picture

Or

Friday, April 17, 2015 -- 5:00 PM

~~I wonder what the role of

I wonder what the role of cultural and societal norms is in establishing the parameters of mental disorders. I also wonder about the subjective, individual contribution to these definitions is, especially when biological and/or genetic evidence for a disease is not readily available or easily understood.  It seems that more and more situations like general dissatisfaction with one?s, for example, economic status as compared to the status of someone else or one?s understanding of hardships could play a role in assuming that one needs therapy or medication for some type of mental disorder. Objectivity and clarity are clouded by one?s perception of what is accepted in our society or by one?s ability to endure stress or to cope with or adapt to a less comfortable existence. Isn?t depression, for example, a commonly used word in our world (aside from clinical diagnosis)? It?s literally everywhere, used for everything, applied to so many situations. But then, if one feels depressed to the point that it affects one?s daily activities, shouldn?t this be the line at which the ailment is considered enough to be categorized as a symptom/mental disorder that necessitates treatment? Grief is another puzzle for me: it is said that you have one year to experience normal grief before it is considered pathological. After that point, you need to be treated, as it becomes a mental disorder. One year? What if the individual naturally resolves grieving after one and a half years or what if grieving naturally becomes a part of an individual?s existence? Do all these individuals necessarily suffer from a mental disorder? I believe that for as long as the field of psychiatry will not incorporate a scientific and holistic approach to understanding and regulating certain ?pathologies,? we all risk to be suffering someday from a mental disorder.

Jack Redford's picture

Jack Redford

Tuesday, October 13, 2015 -- 5:00 PM

Moreoever, psychiatry as a

Moreoever, psychiatry as a science is not that old, so there?s probably still a lot to be discovered about the underlying causes of mental disorders. In the meantime, the best approach is to define them by symptoms and use that provisional definition to further research and investigate what?s really going on. 

Guest's picture

Guest

Monday, November 23, 2015 -- 4:00 PM

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Herlin Farnandis

PlatonZhirkov's picture

PlatonZhirkov

Tuesday, June 7, 2016 -- 5:00 PM

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Harold G. Neuman's picture

Harold G. Neuman

Friday, November 17, 2017 -- 12:59 PM

I am not so certain that

I am not so certain that Psychiatry can, at this later date, clean up its act. It has been the butt of jokes for so long that any other guise, legitimate or contrived, seems likely to be futile. I recall, in the nineteen sixties and seventies, manic depression was the term of art for a kind of mental illness. Jimi Hendrix sang about it, calling it a frustrating mess. More recently, it appears that the term has morphed into bi-polar disorder. Sounds less dramatic, doesn't it? Less threatening, maybe. And perhaps for those who are diagnosed as such, it may be less stigmatic. So, I just don't know...there is academic knowing and there is experiential knowing. The gulf between those realms is wide and the human mind gives up its' secrets with extreme prejudice. Wait a bit, and bi-polar disorder may evolve into cookie-jar syndrome.

Gerald Fnord's picture

Gerald Fnord

Sunday, November 19, 2017 -- 11:30 AM

0.) To be fair, the D.S.M.

0.) To be fair, the D.S.M. does not consider normal grief at the loss of a loved one pathological—there is if course great room for argument as to the limits of 'normal', but it's not as if it calls the widower sobbing at the funeral 'clinically depressed'.
1.) As a physicist, I try not just to be smug at every science trying to reach the condition of physics—I want also to mention that all the sciences include long periods in which most if what they _can_ do is to observe and to tentatively classify. (In physics, I will note, noöne before Einstein had a good explanation for the observed fact that the mass of an object as defined by inertia exactly matched its mass as measured by gravity.)
2.) The pathologisation of everyday life tracks the extent to which normal life has seemed to have become more precarious. We opted for not having a First World welfare state, largely because we have an horror of The Unworthy getting by without sufficient pain, and now children are taught that one wrong move and their future lives will be hell…and parents for whom children didn't 'just happen' feel like it would be all their fault.

Gerald Fnord's picture

Gerald Fnord

Sunday, November 19, 2017 -- 11:35 AM

s/if course/of course/1

s/if course/of course/1

Gerald Fnord's picture

Gerald Fnord

Sunday, November 19, 2017 -- 11:37 AM

WWII veterans both had a lot

WWII veterans both had a lot of company who might at least potentially understand them, were overwhelmingly told that what they had done was virtuous, and typically spent months not fighting then weeks on a troop ship to adjust.

Drsook's picture

Drsook

Tuesday, November 21, 2017 -- 8:34 AM

There is a science of

There is a science of subjective experience, but it differs from materialist science, bench research, etc. The principles of science are still to reflect on clinical reality, share perspectives with others in the field, assess interventions, models and outcomes- as well as n egative consequences of theory.
The DSM5 is a categorical system without psychodynamics, etiologic, treatment or neurophysiologic factors. It simply creates clusters of symptoms and course. This was useful when medication trials required some shared criteria for research. This is no longer sufficient. Dimensional criteria for diagnosis are the future of psychiatric nosology--cognitive, social/cultural, economic, medical, intellectual, etc.
Meanwhile, Freud attempted theory 100 years ago. Anyone who thinks that represents modern psychological science is ignorant or foolish.
Research & theory on attachment and brain development have made profound impact on understanding human suffering and guiding clinical technique. and therapeutics.
Non-clinicians (sociologists, philosophers and patients?) may not have thought enough about these issues or faced responsibility to provide care--so they opine in a vacuum.

 
 
 

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