Cognition in the light of psychopathology

A preliminary step: understanding the mental in mental disorders

Valentina Card el la

1 The challenge of psychopathology

A man is at his first meeting in acute inpatient care. He talks to the psychiatrist about his recent discovery: he is decomposing. During the session, he gives some evidence of this belief (e.g., the strong smell he can perceive, the worms he feels inside his body), and talks about the precautions he’s taking (for example, he puts hydrochloric acid on his skin to kill the worms). Here’s an excerpt of the interview with the psychiatrist:

Psychiatrist (PS):

Patient (PA):

PS:

PA:

So ... do these worms eat organs too?

I think so.

How do you survive then, when these worms eat your organs?

Well, how do I know?

PS:

PA:

PS:

Your parents, what do your parents for example say?

They say' that it is not true . . .

Okay, they say that it is not true. And the fact that they say that it is not true, does not make you think that it is possible that it is not true, that it is perhaps rather your perception that you have worms in the body?

PA:

I am decomposing (Zangrilli et al., 2014: 3—6).

Another patient, with Parkinson’s disease (Mr I.) is admitted to the department of neurology'; during his meeting with the doctor, his wife is present. Suddenly, Mr I asks if it’s alright if he blows in a bottle (something he usually' does for his disease). His wife says he can, but adds that it would be better not to do it in public. Then Mr I say's: “My wife usually says that too”. Her wife’s attempts to convince him that she is his wife are unsuccessful. Further during the conversation, while his wife is in a different room, he says that the person accompanying him is extremely like his wife and acts like her, but adds: “Even though she looks like her, it doesn’t feel like it’s her” (Alstadhaug, 2019: 85).

A 31-year-old woman starts seeking medical help for her obsessive-compulsive disorder. She is obsessed with cleaning, spends 12 hours a day cleaning her house and objects, washing clothes, and taking care of her personal hygiene. Every time she comes back home, she wipes down her shoes, bag, and cell phone and those of her husband. She would not dirty the kitchen, so she buys ready-to-eat meals. Her overuse of water and cleaning products has provoked physical injury on her skin, hands, and nails. Yet, she can’t help but clean; she just can’t stop (Justo et al., 2015).

Jaspers, the founder of modern psychopathology, cites one of his patients to illustrate thought insertion, one of the most bizarre symptoms of schizophrenia. The patient is perceiving an influence over him, and he’s aware that the thoughts he’s thinking are not his own.

The thought arises and with it a direct awareness that it is not the patient but some external agent that thinks it. The patient does not know why he has this thought nor did he intend to have it. He does not feel master of his own thoughts and in addition he feels in the power of some incomprehensible external force.

(Jaspers, 1963: 122-123)

What exactly happened to those people? We look at them, we listen to them, we read their stories, and we are under the impression that something terribly wrong occurred. How is it possible that they believe impossible things, like that they are decomposing or that their partners have been replaced by a double? How did they end up spending most of their time performing senseless rituals, and being totally absorbed by their obsessions? And, finally, how can they deny such a patent, evident, unmistakable true, as the authorship of their thoughts? To make people act this way, some mental mechanism should have broken down. And then, what happened to their minds'? What went wrong with them?

Those questions seem absolutely appropriate. But even a trivial question, when including the word ‘wrong’, is not that trivial after all. ‘Wrong’ implies ‘right’, or also ‘normal’, ‘correct’, ‘common’, ‘proper’. And those are value judgements. Now, common people, when facing mental illness, can sense that ‘wrongness’, in an instinctively, pre-theoretically, ‘a-scientific’ way. But psychiatry is a medical discipline. It has to endorse an objective, impersonal view of abnormal behaviour. It must be so, given that being diagnosed as mentally ill has serious consequences, at the personal, relational, and social levels. One has to be very cautious when a person’s life is at stake.

However, what does it mean, for a discipline that deals with human fragility and suffering, to be ‘objective’? Is a mental disorder something we can detect in an ‘a-theoretic’ way? Furthermore, is it possible, for any science, to be impartial, unbiased, absolutely neutral? Every scientific enterprise, every scientific paradigm (Kuhn, 1962) has its philosophical assumptions. The more implicit they are, the more important it is for a philosopher to detect them. Psychiatry makes no exception. In this chapter, I will first outline some of those assumptions which concern the nature of mental disorders. I will show that, despite the claim of being a practical discipline, which only aims to cure people, psychiatry starts from a series of postulations, i.e., notions and beliefs that are widely shared but largely unwarranted.

  • 1 will criticize those assumptions, showing that most psychiatrists are committed to a notion of mental disorder that is flawed (or at least unjustified) and that neglects the very role of the mental. I will then show the importance, in defining mental disorders, of both a mentalist vocabulary and the reference to norms that are cultural, social, moral, and evaluative. At the end of the chapter, I will outline the importance of ethics in psychiatry.
  • 2 The strange nature of mental disorders

On the one hand our patients suffer greatly from psychiatric symptoms, and it seems wildly foolish to theorize away their suffering. On the other hand our efforts to organize and classify their suffering can seem arbitrary and confusing. We organize or categorize a symptom cluster and give it a diagnostic name, and it overlaps with another cluster. Or a patient simply has symptoms of both. We start off with the expectation that there will be a match-up between therapeutic agent and diagnostic cluster, and we discover that, at the extreme, most of our pharmacologic agents seem to treat most of our disorders. Finally, we somehow want to resolve this confusion by getting at the underpinnings of the identified disorders, and we discover that the genetics and neuroscience don’t support our groupings.

(Phillips et al., 2012: 4)

The practice of psychiatry, as described earlier, is very hard. But why is it so? Does it all come down to the mental disorder’s label, which is still too elusive, as suggested by Philips and colleagues? Or does the reason lie in the confusion concerning the biological basis of mental disorder, as stated by the same authors at the end of this quote? In other words, is a complete neurobiological framework still to come, and do we only have to wait? I’ll come back to these topics later. For the nonce, let’s start with a simple question. What are mental disorders?

As strange as it may seem, psychiatry has always been more interested to identify the meaning of the word ‘disorder’, in the ‘mental disorder’ label, rather than the word ‘mental’. Many authors (see Brulde and Radovis, 2006; Murphy, 2006; Graham, 2013) noted that what precisely is ‘mental’ in mental disorder remains unclear in the psychiatric literature. The philosopher George Graham, for example, remarks:

The very idea of the mental deployed in psychiatry as well as in the theory of mental disorder typically is unexamined or at least under-examined by psychiatrists and other writing on mental disorder.

(Graham, 2013: 30)

Murphy even claims that “psychiatry contains no principled understanding of the mental” (2006: 61). What does it mean? How is it possible that a medical discipline that has to do with disorders affecting the mind doesn’t clarify properly the meaning of mental? I will elucidate this point later on, and, by now, I will come back to the initial question: what are mental disorders? To answer this question, let’s start from another one, which looks quite trivial: are mental disorders real? That is, are mental disorders out there, existing independently of the observers, entities which psychiatric categories try to match with better and better? If this is the case, a correct nosography has to correspond to these entities, which in turn have to remain much or less the same independently from the historical and social contexts (Patil and Giordano, 2010; Kendler, 2016; Eronen, 2019). In other words, mental disorders should be what they are, regardless of our linguistic practices and social norms.

The claim that mental disorders are real phenomena is the ground for realism in psychiatry. And realism is one of the dominant conceptions of psychiatry; according to this perspective, mental disorders are discrete entities, existing independently of the way we study them, they are, in other words, natural kinds. The strong realist position is both ontological and epistemological (Pouncey, 2005): it has an ontological commitment about the existence of abstract entities called mental disorders, and an epistemological commitment about our possibility to genuinely know them. However, there is also a weaker realism, where the commitment is ontological only; in other words, one can believe that mental disorders exist in nature, but can doubt our capacity to know them as they are. This seems to be a more plausible position, because it is hard to deny that psychiatric categories are constructs, viz., the best attempts to describe mental disorders’ abstract entities based on manifest symptoms alone. Thus, the vast majority of psychiatrists probably share this last position; maybe we aren’t able to accurately characterize them, but mental disorders really exist out there. After all, does it make sense for a physician to doubt the reality of his patient’s disease? The same should be valid for a psychiatrist.

But is this ontological commitment justified? For instance, is there, in nature, something like depression, a category with essential and specific features, that can be described with objectivity and is clearly distinct from other mental disorders? The answer is no, for several reasons. First of all, psychiatric disorders don’t have sufficient and necessary conditions. To give an example, the DSM-5’s criteria for major depression involve five or more symptoms among a list of nine; thus, no single symptom is sufficient, and, as strange as it may seem, the depressed mood is not even necessary (APA, 2013a). Secondly, the boundaries among psychiatric categories are fuzzy and blurred. For example, despite the claim, that dates back to Kraepelin (1883), that affective disorders and schizophrenia are two distinct categories, experience has shown that there are many hybrid cases (the schizo-affective disorder, see Jablensky, 2016), and the same can be said of affective disorder and personality disorders, or depression and anxiety disorders, or addiction and psychiatric disorders. In other words, comorbidity, that is, the presence of more mental disorders in a single person, is very common (Maj, 2005; Roca et al., 2009; Teesson et al., 2005). As pointed out by Jablensky “It is not surprising that disorders, as defined in the current versions of DSM and ICD, have a strong tendency to cooccur, which suggests that fundamental assumptions of the dominant diagnostic schemata may be incorrect” (2016: 28). It is not surprising, then, that the last edition of DSM shifted from a categorical to a dimensional approach, giving up the aim to identify distinct mental diseases, as one can read in the highlights of changes between DSM-IV and DSM-5:

Because the previous DSM approach considered each diagnosis as categorically separate from health and from other diagnoses, it did not capture the widespread sharing of symptoms and risk factors across many disorders that is apparent in studies of comorbidity. . . . Indeed, the once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible.

(APA, 2013b: 12)

However, it is worth noticing that, in DSM-5, this dimensional model often remains a declaration of intent, rather than being an actual paradigm shift, especially when the Manual has to deal with what makes a behaviour abnormal. A clear cut-off among the different mental disorders is often really hard to find, but, and this is also more striking, the same issue regards the boundary between clinical normality and abnormality, too. Evidence has started to show that the line between normality and insanity is not a sharp one, and that mental disorders are extreme variants of normal continua (Poulton et al., 2000; van Os et al., 2009; Freeman et al., 2005; see also Chapter 7 in this book). In the general population, psychotic-like experiences are more common than expected, and it is sometimes hard to divide ‘normal’ and pathological anxiety, or ‘normal’ grief and depression. But the DSM largely ignores those evidence supporting the dimensional approach. Actually, the last edition expands the concept of mental disorder, ‘pathologizing’ normal reactions to distress or loss, like normal grief (major depressive disorder can now include people who are grieving the loss of a loved one if a patient’s distress and impairment last more than two months after the death), and including syndromes like premenstrual dysphoric disorder, caffeine withdrawal, disruptive mood dys-regulation disorder, which many experts considered flawed and that, in some cases, even raised concerns of ethicality (see, for example, Frances, 2014; Browne, 2015; Parker and Tavella, 2018). Ironically, the dimensional approach led the DSM to enlarge the area of abnormality, contributing to overdiagnosis and overmedication. Given that normality and pathology are close, the DSM’s response is to expand pathology.

Thus, it is hard to divide mental disorders into distinct categories, and, in many cases, it is also hard to identify a clear cut-off'between normality and pathology. In other words, clinical reality is not the type of reality philosophers find in natural kinds: it is fuzzy, heterogeneous, with broad areas of ambiguity and uncertainty. And there’s no need to say that, in the definition of mental illness, social and cultural norms play a role that is much more important than in medical diseases, as one can read even in the ‘objective’ and ‘atheoretical’ DSM-5: “an expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder” (APA, 2013a: 20). Many criteria indicated in the DSM for different mental disorders have a culturally bound threshold; to give some examples, the definition of social phobia, as noted by Olbert and Gala, 2015, implies a fear which is out of proportion to the sociocultural context; the decision whether depression is present rather than being a ‘normal’ response “inevitably requires the exercise of clinical judgment based on what the clinician knows about the individual in question and the individual’s cultural norms for the expression of distress in the context of loss”. The concept of mental disorder is rooted in society and has a deep normative aspect, which is absent or much less essential in the other branches of medicine.

In sum, mental disorders are not discrete entities, they don’t possess sufficient and necessary conditions for their diagnosis, there is often comorbidity within them, and, given their deep connection with cultural and social expectations, they are not independent of the observers. In other words, realism in psychiatry seems to be an assumption that lacks any evidence.

The other crucial assumption of modern psychiatry is reductionist!!. Reduc-tionism is the claim that mental disorders have roots in biology, that is, they are disturbances in neural structures. The hope is that eventually, once the different mental disorders’ biological underpinnings will be discovered, psychiatry will be reduced to neurobiology (White et al., 2012). This idea dates back to the very origins of psychiatry, in that Kraepelin (1883) endorsed it. According to him, mental disorders were somatic diseases, with causal roots in biology and physiology, and the lack of evidence for these roots was for him only a contingency, that the progress of medicine would overcome with time. After more than a century, the DSM-5 was released following this hope. The members of the Task Force who prepared this new edition had promised a ‘paradigm shift’ (another one, after that concerning the dimensional approach), since, thanks to the progress of neurosciences, it seems that the biological underpinnings of mental disorders have become much clearer. In the Preface of the Manual, the authors remark:

The revised chapter structure was informed by recent research in neuroscience and by emerging genetic linkages between diagnostic groups. Genetic and physiological risk factors, prognostic indicators, and some putative diagnostic markers are highlighted in the text.

(APA, 2013a: xlii)

The implied hope is that, eventually, in the DSM’s next edition, psychiatric categories will be superseded by neurobiological categories, which in turn would have found the essence of the different mental disorders, in terms of the underlying biological mechanisms. As stated by Banner (who, as we will see later, is actually against this view):

[Disease and disorder should be understood in terms of morbid anatomy and physiology; eventually, it will be possible to generate causal hypotheses about psychiatric disorders in terms of neuropathology or dysregulation. Whether the key theoretical concepts come from cognitive neuroscience, molecular biology' or some other basic brain science, the strong interpretation of the medical model assumes that explanations for mental disorders can be sought that cite pathogenic processes in brain systems, and that furthermore, future classifications should reflect this knowledge. Many different causal processes may operate, including social and psychological ones, but the strong interpretation relies on neurobiology' and cognitive processes being fundamental.

(Banner, 2013: 510)

Thus, Kraepelin’s dream is finally beginning to come true. Mental disorders are brain disorders, and genetics and neurosciences have begun to show how. But, is it really' so? It’s time to ask another question that looks trivial: are mental disorders brain disorders? The reason why this question looks trivial is that there is a sense in which mental disorders are obviously in the brain: they are mental, so they are in the brain. In other words, the brain is the physical basis of the mind, so it is the physical basis of mental disorder, too. But does it follow that mental disorders are disorders of the brain, viz., that the brain itself is disordered?

Not necessarily. As claimed by Graham (2013), there could be a disturbance in the body without a malfunctioning of the body; for example, I can feel sick and vomit, but this doesn’t imply that there is a damage in the body. On the contrary, this reaction is likely a body’s defence mechanism (for instance, it is eliminating toxins), and therefore the body is functioning well, even if I feel sick. Coming back to mental disorders, these disorders may' be in the brain, without being of the brain, or, in other words, mental disorders may be based in healthy' brains (Graham, 2013; Poland, 2013; Nesse and Jackson, 2011).

Actually', despite the DSM’s optimism about the discovery of neuroscientific underpinnings and genetics linkage between diagnostic groups, and despite initiatives like the Research Domain Criteria, aiming to detect biological factors in mental disorders (Insel et al., 2010), the neurobiological aetiology' of mental disorders is still lacking evidence (Ghaemi, 2012; Lakhan and Kramer, 2009). No clear biomarkers have been found for schizophrenia or other mental disorders (Stein et al., 2010; Weickert et al., 2013; Prata et al., 2014; Venkatasubramanian and Keshavan, 2016), and no neuroscientific tests can diagnose mental illnesses (Kapur et al., 2012). As claimed by Olbert and Gala, “the thesis that mental disorders are brain disorders is best understood as an ontological hypothesis regarding the nature of mental disorders that awaits empirical validation” (2015: 204). In other words, and it comes as no surprise, reductionism is a philosophical assumption, rather than an empirical finding.

Furthermore, this philosophical assumption is controversial. Claiming that mental disorders are brain disorders implies, as remarked by the same authors,

the perception that the physiological substrata of disorders are more important, basic, necessary, or causally relevant than social, psychological, or contextual aspects of disorders. Indeed, the clinical neuroscientist seems committed to the view that the psychological and social aspects of disorders possess only instrumental importance as signifiers of underlying dysfunction.

(ivi: 212)

But the clinical experience shows that, in the vast majority of cases, the contextual aspects of disorders are extremely relevant for the very ascription of the disorder itself. I’ve already pointed out some of those aspects in depression and social phobia. But the same can be said for other psychopathologies. In specific phobias, fear must be “more intense than is deemed necessary”, and “the individual’s sociocultural context should also be taken in account”, in that, for example “fear of insects may be more disproportionate in settings where insects are consumed in the diet” (APA, 2013a: 199). In generalized anxiety disorder, it is remarked the necessity to “consider the social and cultural context when evaluating whether worries about certain situations are excessive” (ivi: 224). In separation anxiety disorder, the anxiety “exceeds what may be expected” (ivi: 191). In personality disorders, the reference to community standards, social environment and others’judgement is quite impressive. For instance, the avoidant personality disorder is a “pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation”, and individuals with this disorder are “described by others as being ‘shy’, ‘timid’, ‘lonely’and ‘isolated’” (ivi: 672-3). The essential feature of histrionic personality disorder is “excessive emotionality and attention-seeking behaviour” (ivi: 667). The definition of obsessive-compulsive personality disorder is, if possible, even more normative: “a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency” (ivi: 678). It is clear that, in this definition, flexibility, openness, and efficiency are absolute values, and that being stubborn, rigid and “overconscientious about matters of morality, ethics, or values” (ibid.) is not merely a defect (thesis to be proved), but a pathology (Olbert and Gala, 2015).

Where has the brain gone? How can a brain disorder depend so much on a normative and social approach? Furthermore, is it useful to consider mental disorders as brain disorders? There is indeed a correlation between, for example, depression and low levels of serotonin. An individual with major depression usually presents this anomaly. However, one can find those depleted levels in a healthy individual in grief for the loss of her loved one, too. Is her brain malfunctioning, then? And why do we usually ascribe this malfunctioning to the first individual, and not to the second one? Where is the difference in their brains? Besides, the first subject can be a single parent with a low-paid job, who feels tired, isolated, and hopeless, and she can also feel guilty for losing her pleasure to play with her child. In saying that a course of selective serotonin reuptake inhibitors may help her, have we caught the essence of her disorder (Banner, 2013)? To be more direct: what’s the point of reductionist!! in psychiatry?

My claim is that even if neural correlates will be found in the different mental disorders, describing mental illness as a kind of brain disorder completely misses the essence of mental disorder. In most mental disorders, like depression, anxiety disorders, and personality disorders, the normative criteria for dysfunctionality originate at the level of the mental. Thus, the concept of brain disorder is inherited from the mental dysfunction, rather than being the roots or the explanation of the mental disorder itself (Jefferson, 2020). This specific role of the mental in mental disorder, and its consequences, will be the focus of the next section.

3 What is mental in mental disorders?

Whatever the aetiology of the condition or its causal pathways in the brain - whether it is genetic, the product of gene-environment interactions, psychological, social or spiritual causes - the attribution of ‘disorder* applies to the thoughts, feelings and behaviours of the person. Mental disorders are not mental disorders because of an assumed mental cause, but rather because they identify problems in the person’s mental life and relationships.

(Banner, 2013: 511)

What is the correct level of analysis for understanding that something is wrong in one’s mind? What does the attribution of disorder apply to? Does it apply to brain states or the individual? As observed by Fuchs (2010), it is hard to describe mental disorders in a detached way, using a third-person approach. But this is just what the DSM tries to do. It assumes a realist perspective, and endorses the idea that, for psychiatry to be a science, its object has to be exactly measurable; and only single symptoms and behaviours are so. It also assumes a reductionist perspective, and only very circumscribed and simplified behaviours can be reduced to brain dysfunctions. But the reality and the practice of psychiatry are totally different. Without a mentalist vocabulary, psychiatry would simply not exist. As remarked by Broome and Bortolotti (2009), a distinctive feature of psychiatric disorders is that they need the vocabulary concerning the mental. Someone has a mental disorder because she beliefs something, or she thinks something. In other words, what’s wrong is the person, the way she feels, how she suffers, and her relationship with the environment and the others. We recognize that behaviour is pathological, only understanding deviations in the social, moral, and epistemic norms (that is, norms which govern the acquisition of beliefs, see Bortolotti, 2018). The patient we opened this chapter with is detected as ‘abnormal’ for the way he holds an impossible belief, that of being decomposing. We can scan its brain to find whether something is wrong in it, but this won’t help us to understand the meaning of his delusion. Without reference to the reasons a person gives to her behaviour, without taking into account what she feels and thinks, it is impossible to detect any mental disorder. Brain abnormalities are indicative of a mental disorder only if they associate with deviations from cultural, social, moral, and evaluative norms.

Furthermore, the mentalist vocabulary is necessary not only for defining mental disorders but also for explaining the symptoms: the social isolation and the fear of going out of a paranoid subject are explained referring to his belief of being persecuted by the CIA, the compulsive cleaning of the girl I described in the first paragraph is justified by the fear to contaminate herself or her loved ones. How would we understand any symptom showed by a patient without referring to the meaning she ascribes to that symptom? As remarked by Banner (2013: 511), “in no other medical discipline is the subjective experience of the patient quite so crucial to diagnosis and the aims of treatment”.

In 1992, Wakefield joined in the debate on the description of mental disorder with a definition that became quite prominent:

I argue that a disorder is a harmful dysfunction, wherein harmful is a value term based on social norms, and dysfunction is a scientific term referring to the failure of a mental mechanism to perform a natural function for which it was designed by evolution. Thus, the concept of disorder combines value and scientific components.

(373)

The success of this definition derives from the fact that it puts together the ‘scientific’ aspect of mental disorder (‘dysfunction’) with the social one (‘harmful’). Given that some kind of dysfunction must be present, much importance should be ascribed to the social background, too. The role of the environment can hardly be overrated. It is society that decides whether some dysfunction is harmful or not. And, in many cases, it is society that makes this dysfunction harmful. This is one of the reasons why mental disorders are not brain disorders.

[IJn championing the brain as the locus of disorder at the expense of the person-level, we are making a powerful, and in my view, mistaken, judgement about how the disorder is conceptualized and what kinds of approaches should be taken towards treatment. A recent controversial article in the New York Times sums up this problem well. Dr Michael Anderson, a child psychiatrist in Georgia, frequently prescribes medication such as Ritalin and Adderall to children from poor socio-economic backgrounds who are struggling academically in inadequate, underfunded schools. He argues ‘we’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid’.

(Banner, 2013: 511)

As I tried to show in the previous paragraph, the DSM’s last version didn’t inherit Wakefield’s view, in that the importance of the social aspect is almost entirely dismissed, except for the brief notes concerning the culture-related diagnostic issues of each mental disorder.

I’m in favour of Wakefield’s definition, but in a stronger sense. In psychiatry, we can’t divide the ‘factual’ component from the ‘value’ component. The two aspects are intertwined. There are no ‘naked’ facts, nor ‘pure’ abnormalities.

The difference between fracture as a man made and a natural category is trivial, unless you’re in a philosophical argument. But when it comes to psychiatry, something changes. To call a snapped femur an illness is to make only the broadest assumptions about human nature - that it is in our nature to walk and to be out of pain. To call fear generalized anxiety disorder or sadness accompanied by anhedonia, disturbances in sleep and appetite, and fatigue depression requires us to make much tighter, and more decisive, assumptions about who we are, about how we are supposed to feel, about what life is for. How much anxiety is a creature cognizant of its inevitable death supposed to feel? How sad should we be about the human condition? How do you know that? To create these categories is to take a position on the most basic, and unanswerable, questions we face: what is the good life, and what makes it good? It’s the epitome of hubris to claim that you have determined scientifically how to answer those questions, and yet to insist that you have found mental illnesses in nature is to do exactly that.

(Greenberg, in Phillips et al., 2012: 11)

Is there, in nature, the generalized anxiety disorder? The answer is no. As Greenberg suggests, this category is simply how we call something, something that depends on an evaluative stance. In this view, psychiatry is philosophical at its very core, in that being a psychiatrist means judging what a good life is, what amount of sadness is reasonable, what emotive reactions we are supposed to show, and so on.

But that’s not to say that you can’t determine scientifically patterns of psychic suffering as they are discerned by people who spend a lot of time observing and interacting with sufferers. The people who detect and name those patterns cannot help but organize what they observe according to their lived experience. The categories they invent then allow them to call those diseases into being. They don’t make the categories up out of thin air, but neither do they find them under microscopes, or under rocks for that matter. That’s what it means to say that the diseases don’t exist until the doctors say they do. Which doesn’t mean the diseases don’t exist at all, just that they are human creations, and, at their best, fashioned out of love.

(ivi: 12)

In other words, does this unavoidable evaluative stance mean that mental disorders are not real? Not at all. Mental illness is real in that it changes a person’s life, in that the individual must deal with it, in that, ultimately, she suffers because of it.

Suffering is real. We cannot deny what it feels to be a person with a mental disorder. Maybe, as claimed by Loughlin and Miles (2014), we need a less restrictive conception of reality. And, most of all, psychiatrists must be aware of the centrality of ethics in their discipline. It makes no sense to invoke an objective, scientific, atheoretical approach to mental illness. The difficulties of this approach are evident in the last version of DSM, with its increasing number of mental disorders and the mention of an underpinning biological cause which is still to be found. But what is problematic is this demand of scientificity:

The problem is philosophical: the influence of scientism and the idea that ‘objective reality’ consists only of that which is detectable and measurable according to certain methods. Only when we make that idea explicit, identify it as the problem, and reject it, can we move forward and start to talk about the sort of value-judgments that unavoidably inform diagnosis, and discuss their rationale with reference to a defensible conception of the human good. That’s the point to which we must return, before we can recommence our journey to validate our notions of mental health and illness. The debate we need to have is within the field of ethics. Ethics is not a side issue but conceptually central to psychiatry.

(Loughlin and Miles, 2014: 156)

Psychiatry is not just a medical discipline among others. It has to do with ethics. Mental wellness is the aim of psychiatrists, that want people to feel better, but mental health is a practical concept, based on value judgements about what is good and what is not.

It is not as though one can study the epistemology of psychiatry and then, as a separate task, discuss its ethics, as the latter forms an inseparable part of the former: taking up an evaluative stance toward the nature of psychiatric disorders is an essential component of understanding what a psychiatric disorder is.

(ivi: 161)

What are the consequences of this ethical view of psychiatry? The first consequence concerns the very definition of mental disorder. The ‘mental’ in mental illness is not a ‘temporary’ label, intended to be replaced by the different brain anomalies that neuroscience or genetics will find someday. Even if those biological bedrocks will be found, the essence of mental disorder will still lie in the relationship with the others and the environment. A mental disorder is mental because it has to be described with a mentalist vocabulary, and because it needs the others’ look at the patient’s mind, be this look empathic, judgemental, scared, and so on.

The second consequence of this view is that the phenomenological approach, rather than being an alternative perspective on mental disorder, must be taken into account when trying to understand the nature of the mental disorder itself

(Fuchs, 2010). That is, symptoms can be described using an impersonal, third-person approach, but only when the psychiatrist becomes familiar with the way the patient experiences those symptoms, and the meanings she ascribes to them, a real comprehension (and a therapeutic path) is possible. Going back to the patient doubting the agency of his thoughts, only focusing on his self-experience, and understanding what this passivity phenomenon means for him, the psychiatrist can grasp the meaning of this symptom and what it is like to be schizophrenic for him. I’m not saying that the two approaches, the impersonal and the phenomenological one, are mutually exclusive, but on the contrary that the objectivity of the medical gaze must be combined, in psychiatry, with the phenomenological, empathic stance that recognizes the role of the mental in mental disorder.

A farther implication of this view is the acknowledgement of psychiatry’s subjective essence. Here, subjective doesn’t mean that all considerations, opinion, and attitudes towards mental illness have the same value. For instance, a psychiatric diagnosis, even if it’s value-laden, can be true or false. And incorrect diagnoses could be very harmful, as in all branches of medicine. However, psychiatry is subjective, in that it can’t lose track of the subject. In psychiatry, it is not a matter of detecting symptoms, but of understanding the personal significance of those symptoms to the subject.

The last, but not least, implication is actually a lesson in humility. Uncertainty is at the core of psychiatry. It is hard to know someone else’s mind for real. And when there is something fundamentally different in this mind, when the way this mind works challenges our intuitions and comprehension, the task gets harder. As Philips et al. rightly pointed out:

[I|f psychiatry were to officially recognize this fundamental uncertainty, then it would become a much more honest profession - and, to my way of thinking, a more noble one. For it would not be able to lose sight of the basic mystery of who we are and how we are supposed to live.

(2012: 12)

References

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