“A philosopher who is not trained in a
scientific discipline and who fails to keep his scientific interests alive will
inevitably bungle and stumble and mistake uncritical rough drafts for
definitive knowledge. Unless an idea is
submitted to the coldly dispassionate test of scientific inquiry, it is rapidly
consumed in the fire of emotions and passions, or else it withers into a dry
and narrow fanaticism”
Karl Jaspers
Way to Wisdom, p. 159
I encountered 2 philosophical ideas today that I did not
have any disagreement with and decided I would take that as a sign and discuss
them here on my blog. Readers may have noticed that I am very skeptical about
what philosophy adds to psychiatry and have posted numerous examples over the
years. Today the above quote was posted on Twitter and it is an idea that I
completely agree with. One of the problems that I have with philosophy in
psychiatry is that is generally written as a rhetorical attack on the field.
That is easy to do when you control the premise and that premise is generally
false. There are numerous examples but the most obvious one is defining what
you consider a disease to be and then concluding that no mental illnesses are
diseases. More specific examples are available such as using similar
definitions for addiction and then concluding that addiction is not a disease.
Many of the people posting these arguments are not scientists or clinicians but
in some cases are clinicians who have yet to have ever seen the patient they
are talking about or who have never seen a patient – period. To a large extent I think this is what
Jaspers is focused on in this quote. It comes from a chapter in the reference
book that is labeled as “Appendix 1: Philosophy and Science” and states that it
was reprinted by permission from the Partisan Review.
The second opinion piece was from Kenneth Kendler, MD a
leading expert in psychiatry, genetics and psychiatric research. He also has
written extensively on the evolution of psychiatric thought over the decades
and how philosophy applies to psychiatry. I have probably read at least a
hundred papers written by Dr. Kendler in the past 30 years – and that is a
small number of the papers he has written. I have also read his book Why
Does Psychiatry Need Philosophy wherein he and his co-authors are focused
on issues of phenomenology, nosology, and the degree of explanation as the
subtitle suggests.
In the opinion piece (3), he takes a brief look at the
philosophy of science and how that applies to the DSM. He describes the main philosophical divisions
as scientific realism and instrumentalism as they apply to
diagnoses. With scientific realism
whatever the diagnostic construct - it is accepted at face value. They are thought to really exist that way. The
best examples I can think of from the DSM are Dissociative Identity Disorder
and Intermittent Explosive Disorder.
Both are highly problematic and yet – there they are in the DSM. Further
- the people who believe they exist seem undeterred in their use and they seem
to be just carried along with subsequent revisions of the DSM. Instrumentalism on the other hand sees
diagnostic constructs as a work in progress.
They are not accepted as ultimate diagnoses but are subject to the
scientific process of validation by empirical evidence. A good example in that
case would be schizophrenia subtypes.
Previous editions of the DSM had 5 subtypes of schizophrenia including paranoid,
catatonic, disorganized, residual, and undifferentiated. Psychiatrists treating acute schizophrenia
noticed that the subtypes were not consistent over time and the same person
could be diagnosed with different subtypes. On that basis, the DSM-5 revision
dropped the subtype classification but unfortunately implemented a schizophrenia
spectrum of disorders. I think that
applying a physical concept to heterogeneous group of biologically determined
disorders is probably a step in the wrong direction and that an instrumentalist
approach will eliminate spectrums in the future along with Dissociative
Identity Disorder and Intermittent Explosive Disorder
Kendler goes on the discuss 5 arguments in favor of an
instrumentalist approach. Before I raise
those points, why would everyone not be in favor of this approach? Certainly,
math and science majors would. Even though you can specialize in physical and
biological science before medical school and students at that level don’t get
much explicit instruction in the history of science – it happens nonetheless.
Most high school students in the US are exposed to Darwin, Lamarck, and the DNA
double helix as sophomores in high school. Almost all of the main concepts in
physics and chemistry include some discussion of innovation and how earlier
theories were rejected. That approach is more notable in medical school where
some of the timelines and necessary technology become clearer. All of that
information greatly favors an instrumentalism over scientific realism. Although psychiatry is a relatively new
discipline, it is clear that diagnostic systems have been greatly modified over
the past 100 years from the Unitary Psychosis model o the 19th
century.
His first argument - pessimistic induction
highlights the history of changes in diagnoses in the past and suggests that we
should expect the same pattern in the future. A counterargument is that
significant refinement has occurred and we can expect fewer errors than in the
past but at any rate these observations need to be made. The second argument is that given the
nature of descriptive diagnoses rather than direct test observation determining
validity will always require an instrumentalist approach. The third argument is that the
uncertainty about two competing diagnoses can be empirical or conceptual.
Kendler favors the latter and that means changing the construct. The fourth
argument is that scientific advances in psychiatry cannot be predicted or
anticipated and are potentially transformative.
An empirical approach is required to test the future approaches against
the current approaches and make the indicated modifications. The fifth argument reduces a reverence
bias toward existing diagnoses, much like clinicians use the provisional
diagnosis term to reflect diagnostic uncertainty.
He touched on the problem of how polygenic heterogeneous
disorders can lead to the philosophical problem of multiple realizability. That is - multiple genotypes leading to the
same phenotype and the implications that has for moving to a diagnostic system
that includes etiology. He points out that psychiatric disorders have higher
degrees of polygenicity. He briefly
alludes to the potential problem of scientists with epistemic privilege
studying nosology and phenomenology – but concludes on a more positive note
about current research methods not available to previous generations.
Al things considered this did not seem like a powerful
argument for philosophy in psychiatry. The current arguments in favor of
instrumentalism seem like the general process of science. The exceptions mentioned for psychiatry did
not seem that specific relative to other specialties diagnosing complex
polygenic disorders. I really wonder who the psychiatrists are who accept DSM
diagnoses at face value? I don’t think
that I have ever met one.
That leads to the question of whether there are philosophical
approaches that might be useful to psychiatry.
In my research for this post – I did find a fairly interesting one
called constructive empiricism by von Fraassen (7,8). Simply defined constructive empiricism states:
“Science aims to give us theories which
are empirically adequate; and acceptance of a theory involves as belief only
that it is empirically adequate.” This
is a departure from scientific realism and the premise that science is giving
us the truth and belief in the theory means believing it is true. There is
debate regarding the empirical adequacy of a theory with the critics
using circularity arguments and the defenders pointing out that it is
determined by scientists for specific goals. Philosophical debates tend to be
endless and there are seldom any clear answers.
To me constructive empiricism seems to be an accurate description
of what happens in psychiatry both at the biological and phenomenological
levels. It certainly applies to the diagnoses of schizophrenia spectrum as opposed
to subtypes and Dissociative Identity Disorder used in the original paper and
many other papers written by Kendler on the evolution of various diagnoses over
time.
The critics of psychiatry are another story. There are
people in the world right now who attack the entire diagnostic system of
psychiatry. They either don’t have alternatives or the suggested alternatives
have not been widely validated or adopted. In some cases, the theoretical basis
for their proposed system is highly questionable. These same critics always
seen to caricature the diagnostic process as one that is based on neither scientific
realism or instrumentalism. The best example I can think of is any paper written that
characterizes the DSM as the Bible of psychiatry. That speaks not only to a general level of
ignorance about how it is regarded in the field but also the philosophical bias
suggesting the approach to the DSM has been static and not based in reality - even though major disorders have been present for centuries. The critics also have
an associated lack of knowledge about the biological constraints – even as they
are briefly outlined in this opinion piece.
These critics whether they are antipsychiatrists or not seem to believe that what is in the DSM is accepted as the truth based on blind belief by psychiatrists and there is no evidence that is true now or at any point in time. The observable changing diagnostic criteria over time and teaching future generations about all of the constraints is the best way to address empirical adequacy.
George Dawson, MD, DFAPA
References:
1: Jaspers K. Way To Wisdom. Yale University Press, New
Haven, 1951: p. 151.
2: Kendler KS. Why does psychiatry need philosophy? In:
Kendler KS, Parnas J, eds. Philosophical
Issues In Psychiatry: Explanation, Phenomenology, Nosology. Baltimore, MD; The
Johns Hopkins University Press, 2008: 1-16.
3: Kendler KS.
Potential Lessons for DSM From Contemporary Philosophy of Science. JAMA
Psychiatry. 2022 Feb 1;79(2):99-100. doi: 10.1001/jamapsychiatry.2021.3559.
PMID: 34878514.
4: Chakravartty, Anjan, "Scientific Realism", The Stanford Encyclopedia of Philosophy (Summer 2017 Edition), Edward N. Zalta (ed.), https://plato.stanford.edu/archives/sum2017/entries/scientific-realism
5: Eronen MI. Psychopathology and Truth: A Defense of Realism. J Med Philos. 2019 Jul 29;44(4):507-520. doi: 10.1093/jmp/jhz009. PMID: 31356663.
6: Kendler KS. Toward a limited realism for psychiatric nosology based on the coherence theory of truth. Psychol Med. 2015 Apr;45(6):1115-8. doi: 10.1017/S0033291714002177. Epub 2014 Sep 2. PMID: 25181016.
7: Monton, Bradley and Chad Mohler, Constructive Empiricism. The Stanford Encyclopedia of Philosophy (Summer 2021 Edition), Edward N. Zalta (ed.), https://plato.stanford.edu/archives/sum2021/entries/constructive-empiricism.
8: von Fraassen, Bas. Constructive Empiricism Now. Philosophical Studies, 2001; 106: 151–170https://www.princeton.edu/~fraassen/abstract/docs-publd/CE_Now.pdf
Concept Credit: Dr. Ahmed Samei Huda a colleague from the UK came up with the concept that the critics of psychiatry are functioning at the level of scientific realism when psychiatrists are not. That occurred during a Twitter discussion.
Supplementary 1: In the philosophy world there
are much more detailed and varying definitions of scientific realism (4) than
what Kendler discusses in the opinion piece.
The most accessible article I could find on the subject is by Eronen (5)
that is more or less a refutation of Kendler and Zachar’s position on
scientific realism. I say more or less because the author takes various
positions to illustrate that scientific realism is necessary or at the minimum
his Kendler and Zachar’s position on scientific realism may be closer to his
that not. What I like about the Eronen paper is that he uses very clear
examples with clear diagnoses like anorexia nervosa to make his point.
My longstanding arguments about the validity of major psychiatric diagnoses is
that they have always been there and more than anything that has driven the
need for psychiatry and psychiatric care.
Graphics Credit:
Karl Jaspers downloaded from WikiMedia Commons on 2/27/2022
per the following:
Universitätsbibliothek Heidelberg, CC BY-SA 4.0
<https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons at the following URL: https://commons.wikimedia.org/wiki/File:Karl_Jaspers_(HeidICON_33479).jpg
