Tuesday, December 30, 2008

Review of Dominic Murphy: Psychiatry in the Scientific Image

This review is forthcoming in Philosophy in Review, Vol. 28 no. 6.

Dominic Murphy. Psychiatry in the Scientific Image.
Cambridge, MA: MIT Press 2006. Pp. 410.
US$36.00 (cloth ISBN-13: 978-0-262-134355-2).

There are many approaches to understanding mental illness; contemporary psychiatry builds on a medical approach. Murphy defends a particular version of scientific psychiatry, with a focus on how it theorizes mental illness, rather than on how it tries to help people. So his book is about the reality of mental disorders, their explanation, and classification. He explores the definition of mental illness, and discusses what a scientific psychiatric theory should and should not aim to achieve. Murphy ends with an extensive discussion of the objectivity of psychiatric classification. For most topics, he illustrates his points by discussing how they apply to one or more kinds of mental illness. Throughout he gives the reader helpful signposts as to what he has argued so far, what he is about to argue, and how that fits in with the overall structure of the book. This will be especially useful for those readers who are not planning to read the whole work, or who will read different parts at different times. This is a dense, scholarly work of over 400 pages that refers to current work in both psychiatry and philosophy, including philosophy of medicine, philosophy of mind, general philosophy of science, and philosophy of biology. There is a short, very incomplete index.

Murphy argues for a revised view of the medical model of psychiatry, which is not tied strongly to existing mental concepts. Especially since Murphy has been a student of, and co-author with, Stephen Stich, it is illuminating to see traces of eliminativism here. Murphy is quite ready to move on from old concepts when necessary, and does not take the primary task of philosophy to be conceptual analysis. He is thoroughly wedded to a scientific approach to understanding mental illness, and he is especially impressed with the success of the cognitive neurosciences. When our ordinary language or standard practice is in conflict with scientific knowledge, he argues for revising our concepts and practices. Thus, for example, he argues that our standard ways of demarcating mental illness from other illnesses and disorders cannot be rationally justified, and so we should embrace a new, initially counterintuitive understanding of mental illness that would, among other disorders, include at least some forms of blindness. In a related vein, he argues that we should abolish the distinction between psychiatry and clinical neuroscience, because cognitive neuroscience is the best science we have to understand mental illness. However, Murphy is not arguing for an extremely reductionist approach to the mind; rather, he embraces a version of the biopsychosocial model that allows different levels of explanation. At the end of the book, he argues for classification of mental disorders based on causal explanation, as found in much of the rest of medicine, but rejected by the widely used manuals of psychiatric classification. He argues that such an approach is both scientifically preferable and pragmatically more useful.

The book’s ambitious and occasionally perplexing middle section attempts to provide a theory of psychiatric explanation. It draws on philosophical discussion of explanation in cognitive psychology and in biomedicine. In Chapter 5, Murphy explores to what extent factual elements can be isolated to ground psychiatric explanation, and to what extent the explanation of mental disorder requires evaluative assumptions about what is normal or rational. He concludes that in much of psychiatry norms will run through the whole explanatory process, so that the prospects for a mechanistic program of the cognitive neuroscience of mental illness are dim. This causes considerable trouble for the scientific project since there is little prospect of getting intersubjective agreement on epistemic or moral norms. He considers in some detail the cases of delusion, addiction, and psychopathy, and in each case, finds that it is impossible to eliminate norms from the explanation of the phenomenon.

These conclusions seem to entail that Murphy’s earlier confidence in the medical model should be rather diminished. Yet he goes on, in a manner reminiscent of Hume in the case of the missing shade of blue, as if these problems are minor and do not create a problem for the whole project. His attitude seems to be that psychiatric explanation will sometimes be slightly incomplete or patchy, with no possibility of a full account of the mechanisms involved in the production of the phenomena of psychopathology, but that the scientific/medical approach is still the best one available. In Chapter 6, Murphy gives an account of causal psychiatric explanation. He coins the notion of an exemplar, which he describes as the idealized theoretical representation of a disorder — its typical course and symptoms. The explanation works by ‘displaying the causal relations among pathogenic processes that produce the symptoms’ (212). He proceeds to sketch how psychiatric explanation can proceed in some fairly simple cases and then in schizophrenia. In the next chapter, he sets out how social factors can enter into the explanation. In
Chapter 8, Murphy addresses the role of evolutionary theory in psychiatric explanation, arguing that many recent attempts at evolutionary explanation of psychopathology are unsuccessful. His analysis of the failures points to what a successful approach to evolutionary explanation should look like.

Together, the chapters in this middle section give a reasonably detailed picture of how Murphy envisions psychiatric explanation. He carries out a difficult project well: his aim is not to make strong empirical claims about which explanations are more successful, but rather to make a philosophical point about the feasible forms of psychiatric explanation. In the setting out
of his ideas, he addresses many particular controversies and debates in theoretical psychiatry and cognitive science. Owing to the nature of the subject of philosophy of psychiatry, which defies neat categorization and exceptionless generalizations, it is very difficult to arrive at one comprehensive theory or to make straightforward, unequivocal claims. Murphy’s discussion is a case study of how many qualifications and diversions are required by an even moderately thorough approach.

The final two chapters are relatively simple by comparison, because their task is simpler. Murphy covers familiar ground in his criticisms of the classification scheme used by most recent edition of the DSM (the Diagnostic and Statistical Manual of Mental Disorders). His advocacy for the merits of a causal taxonomy is powerful. He acknowledges that the lack of corroborated
theories about the causes of mental disorders will place major limits on to what extent a causal taxonomy can be carried out, but urges that it is still possible to make some progress even in the absence of a fully worked out theory. He gives some indication of how the classification would go using exemplars, and he argues that this would be useful not just for research purposes but also clinically.

Murphy’s book is a landmark achievement in the philosophy of psychiatry. Its claims are often plausible and interesting, and the arguments for them are carefully made. It is certainly the most philosophically sophisticated defense of the medical model of psychiatry that has been made to date. It is a challenging book to grasp as a whole, and there are many places where the argument could be clearer or is vulnerable to criticism, yet it deserves attention from philosophers of science and philosophers of psychology.

SEP: Murphy on Concepts of Disease and Health

Dominic Murphy (now at the Unit for History and Philosophy of Science, University of Sydney) has has an entry on Concepts of Disease and Health published in the Stanford Encyclopedia of Philosophy.

It's an excellent survey of the issues, and it discusses some issues related to psychiatry, which is inevitable given that most of the controversial cases are to do with mental illness. He sets up the debate by making the distinction between Objectivist views and Constructivist views of disease. On this divide, Boorse is an objectivist and most other people (such as Cooper, Wakefield, and Reznek) are constructivists. I'm not a fan of the terminology: I think that it is more helpful to distinguish between those who think that the concept of disease is intrinsically value-laden and those who don't. It also lumps together people who have quite different views, but that's just about inevitable in an encyclopedia article. Murphy's article is strong in its bringing together the issue with the philosophy of biology, some discussion of the nature of functions, and the problems faced by the two sides.

On Murphy's view, the main problem faced by the Objectivists is in providing a scientific basis for the distinction between normal and abnormal. For Constructivists, the main problem is in justifying any significant distinction between medical and other forms of undesirable conditions. It seems relatively clear that it would be hard to provide any general justification for our present conception of what counts as diseases or medical condition, and if we were to make our conceptual scheme with regard to medicine more rational, we would have to redraw our existing conceptions of disease.

Thursday, December 18, 2008


An article on the coming debates over DSM-V in the New York Times. Over at the Neuroethics & Law blog, Peter Reiner (pictured) emphasizes his worries about the influence of money on the decision-making process, and urges that all conflicts of interest should be avoided. Quite right too.
However, I don't envy the architects of DSM-V. They really have an impossible task. How to categorize all those disorders in the absence of any good causal theories? In the NYT article, Edward Shorter grumbles about the process, and he bemoaned the expansion of the DSM and the increase of the number of diagnostic categories over the years. But his solution is to restrict mental disorders to the severe cases of mood disorder and schizophrenia, and if DSM followed his recommendations, many people who currently get treatment for mental disorder would no longer be eligible for it, unless they were ready to pay out of pocket. The DSM architects are in a bind: they are meant to make their manual usable by clinicians, scientifically respectable, and also a tool to help people get help. They are also subject to a great deal of pressure from interested groups. The NYT article mentions parents of children diagnosed with bipolar disorder and sensory processing disorder, who have strong opinions about this. Of course, there are some scientific facts to help make the decisions, but much of the work is political. Whatever decisions the architects make, many people will say they got it all wrong and caved in to the other side. At the same time, it is hard to feel too much sympathy for those poor architects, given that they have insulated themselves from public scrutiny. With even Robert Spitzer outraged at their secrecy, they have given themselves a huge public relations disadvantage.
From a philosophical point of view, it is disappointing that the DSM-V people seem to be distancing themeselves from the intense philosophically informed discussion over DSM that has been doing good work for that last couple of decades. None of the major names in the philosophy of psychiatry seems to have been included in the DSM-V Task Force or Work Groups. Very few of the people in these groups has even entered any dialog with philosophers -- Ken Kendler on the Mood Disorders Work Group) being a notable exception. Of course, the DSM people might be able to put together a rationally coherent manual without the help of philosophers, but they would have benefitted from more philosophical input. Kendler et al argued that there should be a Conceptual Issues Work Group, but so far, it seems that their advice has been ignored.

Wednesday, December 17, 2008

What is a 'new' philosophy of psychiatry and why do we need it?

A new review article, just 3 pages long, on "What is a ’new’ philosophy of psychiatry and why do we need it?" in Volume 11 Number 4 of Medicine, Health Care and Philosophy, by Michael Quante (pictured).  It reviews many  recent books in the OUP International Perspectives in Philosophy & Psychiatry series.  I've only seen the preview, but it starts off in a positive tone.  

Neuroscience in Context

Neuroscience in Context

This group is new to me, and looks like it is doing interesting work.  They have a conference at UCLA on Critical Neuroscience on January 30.  They have held a few very interesting workshops already.  It's another sign of the rise of neuroethics, and more evidence that philosophy of psychiatry needs to be building bridges to neuroethics.

Tuesday, December 16, 2008

Weakness of Will and Responsibility for Action

Sarah Stroud has written a helpful summary of the literature on Weakness of Will for the Stanford Encyclopedia of Philosophy, published in May 2008. She sets out the basic philosophical problem -- how is weakness of will possible? -- then sets out Davidson's solution, and some problems with Davidson's view. She moves on to the question of whether weakness of will is always bad, paying attention to Nomy Arpaly's arguments that it can be rational. She concludes with a brief discussion of Richard Holton's refiguring of the debate, where he argues that weakness of will is not acting against one's values, but rather a too easy changing of one's mind and giving up one's resolutions, followed by Alison McIntyre's recent suggestion that when one is weak-willed and acting against one's values, it is better to be clear that is what one is doing, rather than to rationalize one's actions.

Holton (pictured) has extended his work on weakness of will and strength in his forthcoming book, Willing, Wanting, Waiting, (available in pre-print on his home page). His work is wonderfully clear, and is backed up by recent work in social psychology, such as the research by Roy Baumeister on self-control and ego-depletion. In a recent paper, Holton, with Stephen Shute, applies his ideas to a legal context, arguing that loss of self control needs to be taken seriously as a criminal defense. ("Self-Control in the Modern Provocation Defence")

Holton's work here has already given rise to other published discussions. The journal Criminal Law and Philosophy has a couple of accepted articles related to this: Stephen Garvey has a paper on "Dealing with Wayward Desire," and Vera Bergelson has a reply to Garvey, "The Case of Weak Will and Wayward Desire." Garvey, following Holton, argues in favor of the idea that sometimes people are unable to exercise self-control and this should be a valid legal excuse for criminal action, while Bergelson argues that such sympathy for the offender has no place in the criminal law.

Friday, December 12, 2008

Buss on Autonomy in SEP

The entry by Sarah Buss (pictured) on Personal Autonomy in the Stanford Encyclopedia of Philosophy (updated September, 2008) does a very nice job at mapping out different theories and their relation to each other, although you have to read the notes carefull to work out which philosophers hold which theories.) She has a pessimistic and somewhat puzzling conclusion:

Agents can be deprived of their autonomy by brainwashing, depression, anxiety, fatigue; they can succumb to compulsions and addictions. To what, exactly, are we calling attention when we say that, under these conditions, an agent does not govern herself, even if she acts as she does because she thinks she has sufficient reason to do so, even if she has (thorougly) considered the pros and cons of her options, and has endorsed her behavior on this basis, and even if she would have acted differently if there had been stronger reason to do so? Most agents who are capable of asking this question are confident that they are the authors of most of their actions, and are thus accountable for what they do. Nonetheless, as this brief survey indicates, the self-relation they thereby attribute to themselves is extremely difficult to pin down.

How can we be so confident about our own autonomy if we have not worked out the details of our theory of autonomy? More to the point, in the case of people with addictions, compulsions, and even delusions, how can we be sure that they lack autonomy if we haven't worked out our theory of autonomy? The answer must be that there are broad features of autonomous action that we can identify even if we haven't worked out the theoretical details. We can tell if a car is working well or broken down even if we don't know how the engine works.

But aren't the broad features all we need then for a satisfactory theory of autonomy for it to make the distinctions we need it to make, at least with regard to working out who is autonomous and who is not? Do we need to sort out the details of the debates between coherentists and externalists, or how agents authorize their desires, it sorting this out does not help us make the distinctions we want to make? Even further, can't we conclude that whatever these debates achieve, they don't really tell us more about what autonomy is. We might use the car example: we can understand the concept of a functioning car without knowing how the engine works, and furthermore, knowing how the engine works does not add anything to our concept of a functioning car. To be sure, it is useful for other purposes, but not in the basic use of the concept of functioning car. So with autonomy, the sophisticated debates about self-relations are interesting in their own terms, but they don't tell us more about what we mean by autonomy.

I'm not sure I accept this conclusion, but it certainly is tempting.

Thursday, December 11, 2008

Neuroethics special issue on psychopathy and responsibility

Neuroethics Volume 1, Number 3 / October, 2008

Moral Responsibility and the Psychopath
Walter Glannon

Psychopathy and Criminal Responsibility
Stephen J. Morse

Psychopathy Without (the Language of) Disorder
Marga Reimer

Responsibility, Dysfunction and Capacity
Nicole A Vincent

The Cognitive Neuroscience of Psychopathy and Implications for Judgments of Responsibility
R. J. R. Blair

The Mad, the Bad, and the Psychopath
Heidi L. Maibom

On the one hand, I'm thrilled that there's a whole issue on this topic. On the other hand, I wonder when I'm going to have time to read all of these! It's the price of one's area of research becoming popular.

Friday, December 5, 2008

The Philosophy of Mental Illness: What's New?

It is time for me to update my entry in the Stanford Encyclopedia of Philosophy on Mental Illness. I wrote it originally in 2001, and I did some updates in the bibliography in 2005.

It has 3 main sections:

1. Does Mental Illness Exist?
2. Is There an Objective Way to Classify Mental Illnesses?
3. When are People with Mental Illnesses Responsible for Symptomatic Behavior?

I am reluctant to cut these, but it's clear that I could add many topics, and I would want to update the existing sections. But how to prioritize? One of the most obvious missing topics is on making sense of psychosis and delusions; another is on the relation between psychiatry and cognitive neuroscience. But what else?

I'd appreciate suggestions from others on this. One thing to keep on mind is that the topic is philosophy of mental illness rather than the philosophy of psychiatry, and the original idea behind this was that it was a narrower topic, although thinking about it now, it is not so clear to me why this should be so.

Thursday, December 4, 2008

Psychiatric Coercion Not Evidence-Based

A survey of the literature reveals a lack of study and evidence regarding medicating psychiatric patients against their will.

"Coerced medication in psychiatric inpatient care: literature review"
Manuela Jarrett, Len Bowers & Alan Simpson
Journal of Advanced Nursing 64(6), 538–548

The BBC reported this as "Psychiatric drugs force queried" which isn't really what the article does. Bowers has written defending psychiatric practices, in his book The Social Nature of Mental Illness. Noting the lack of study of coerced medication and calling for more study is not the same as doubting whether it should be done at all. Doubtless it is an awful experience for the person being drugged, especially at a time when they are feeling vulnerable and possibly paranoid. One of the central issues would be what alternatives are available to health care providers, especially when drugs are relatively cheap and individual attention is expensive.

All in the Mind on Mental Health Blogging

There was a nice piece in the BBC Radio 4 show All in the Mind, Tuesday, Dec 2, 2008, about mental health blogging, with an interview with a couple of bloggers with psychiatric diagnoses.

One of the blogs was http://thesecretlifeofamanicdepressive.wordpress.com/

It has a great list of links to other blogs too. Worth checking out.

New Issue of Disability and Society

At least two articles that particularly interest me in the latest issue of Disability & Society.

"Controlling behaviour using neuroleptic drugs: the role of the Mental capacity act 2005 in protecting the liberty of people with dementia"
Geraldine Boyle
The use of neuroleptic drugs to mediate the behaviour of people with dementia living in care homes can lead to them being deprived of their liberty. Whilst regulation has been successful in reducing neuroleptic prescribing in the USA, policy guidance has been unsuccessful in reducing the use of these drugs in the UK. Yet the Mental capacity act 2005 aimed to protect the liberty of people lacking capacity and provided safeguards to ensure that they are not inappropriately deprived of their liberty in institutions. This article highlights the potential for using this law to identify when neuroleptic prescribing in care homes would deprive people with dementia of their liberty and, in turn, to act as a check on prescribing levels. However, the extent to which the Act can promote and protect the right to liberty of people with dementia is constrained by a lack of access to social rights.


"The meaning of autism: beyond disorder"
Sara O'Neil
The incidence of autism spectrum disorders has increased dramatically over the past two decades, yet these disorders are still poorly understood. By considering the viewpoints of autistics themselves, together with evidence from the scientific literature, it becomes clear that autism spectrum disorders are not always the debilitating conditions that they are sometimes portrayed as. In fact, they are often associated with a number of strengths. With a focus on the areas of intelligence, communication, social skills and stereotyped/repetitive behaviours, this article calls into question the idea that autism is a traditional disorder and argues that a new inclusive dialogue on the meaning of autism should be considered.

It's more evidence that great work is being done in disability studies that should be included in both psychiatric ethics and philosophy of medicine. Oh disciplinary walls, how I want to knock you down!

Monday, December 1, 2008

Young People and Personality Disorders

It is strange what the press picks up on. In the latest issue of Archives of General Psychiatry is the following article: "Mental Health of College Students and Their Non-College-Attending Peers: Results From the National Epidemiologic Study on Alcohol and Related Conditions," by Carlos Blanco; Mayumi Okuda; Crystal Wright; Deborah S. Hasin; Bridget F. Grant; Shang-Min Liu; Mark Olfson. The abstract of the article concludes: "Psychiatric disorders, particularly alcohol use disorders, are common in the college-aged population. Although treatment rates varied across disorders, overall fewer than 25% of individuals with a mental disorder sought treatment in the year prior to the survey. These findings underscore the importance of treatment and prevention interventions among college-aged individuals." There's nothing very surprising here. I probably would not have looked at it, but for the headline from the Associated Press on Yahoo News: "1 in 5 young adults has personality disorder." 20%? Good grief!

US News and World Report has a more measured summary. "Among college students, the most common disorders were alcohol use (20.4 percent) and personality disorders (17.7 percent). The most common disorders among young adults not in college were personality disorders (21.6 percent) and nicotine dependence (20.7 percent)." Still, the incidence of personality disorders is very high here, and without having looked at the article itself, and not being familiar with the literature, I can't say if they are using an over-expansive definition. However, this points to the suspicion that the DSM-IV criteria of personality must be too broad, or being applies in too broad a way.

Of course, the media are right in picking out the most surprising feature of the article, which isn't even mentioned in the abstract. And the overall message, that nearly half of college-aged students experience psychiatric disorders, while only one quarter get treatment, is still alarming even if it isn't surprising.