Ghaemi discussion: illness vs. conditions that aren't pathological

In our discussion last Friday, we looked at Ghaemi's proposal to sharply distinguish biologically-based mental illness (citing schizophrenia and bipolar disorder as examples) from conditions that aren't pathological (personality disorders for example). This news item about the Breivik case in Norway appeared on the BBC website yesterday, and it broadly reflects the division we explored in our discussion: http://www.bbc.co.uk/news/world-europe-18440743

Mental Health Reading Group: Taking disease seriously: beyond “pragmatic” nosology by S. Nassir Ghaemi

Summary of discussion on the 8^th of June, 2012

Discussed paper: Taking disease seriously: beyond “pragmatic” nosology by S. Nassir Ghaemi

From Kendler, K.S. and Parnas, J. (eds) (2012) Philosophical Issues in Psychiatry II: Nosology Oxford: Oxford University Press (International Perspectives in Philosophy & Psychiatry)

At this meeting, the question of the adequacy of the philosophical conception underpinning the DSM IV was addressed. This was followed by concerns about how the author’s proposal would affect service users. Finally, we reflected on the possible paths that nosology could take in the near future.  Some of the most important points discussed during the meeting were the following:  

1. Ghaemi appears implicitly to endorse the concept of natural kinds and to consider that categories in mental illness can be well defined and clearly demarcated. For Ghaemi, in identifying these categories we would be carving out nature at its joints.

2. Concerns were raised about Ghaemi’s claim that there is no need to have a definition of the notion of mental illness (in general), in order to identify and study specific types of mental illness. One difficulty that arises is this: Ghaemi seems to think, on the one hand, that a condition’s having an identifiable aetiology is sufficient for rendering it an illness; but on the other hand, at various points in the paper he seems to assume that what is required for pathology is a biological aetiology specifically. Without a generic definition of mental illness, however, it is difficult to see why mental pathologies must have specifically biological causes.

3. One practical difficulty with Ghaemi’s proposal is that if only biologically based conditions were included in the DSM, this would exclude many important disorders which are currently addressed at least partly by medical means.

4. However, Ghaemi’s discussion highlights an important feature of the conceptual landscape: the tendency to argue by analogy. Ghaemi uses the spirochete/syphilis example as a model for mental disorders that he considers to be genuinely pathological, e.g. schizophrenia and bipolar disorder). By contrast, thinkers who adopt a pragmatic approach to classification (rather than an essentialist one) point instead to the paucity of success in identifying definitive biological markers for mental disorders (identified using existing categories). There is an important issue, when using analogical reasoning, of determining the strength of the favoured analogy; and it would be interesting to work out the strength of Ghaemi’s analogy, compared with the competing alternatives.

5. To reinforce his position, Ghaemi also makes the point that we should be more reluctant to draw generalisations about the nature of mental illness on the basis of what we don’t know (i.e. he thinks that our general attitude to mental disorder is unduly influenced by the fact that there are so few instances in which definitive biological markers have been identified for mental disorders). Ghaemi contends that we should recognize what we do know, recognize what we don’t know, and not draw hasty generalisations about the nature of mental pathology from just the latter condition.

6. There were several comments made in the discussion on the tendency of GPs to prescribe medicine even to non-sick patients in order to alleviate some common non-severe symptoms (such as grief or sadness that do not imply organic depression), and this may reflect on the possibility of a new approach in which medicine aims at the enhancement of well-being, not just at curing illness or alleviating the symptoms of illness. If enhancement becomes the aim of medical practice, then classification may no longer be considered something essential. Under this envisaged approach, the importance is centered mainly on the service user’s choice to alleviate his symptoms.  

7. It was also discussed that current psychiatric practice in the USA has a deep concern over diagnosis because they usually have to work under the pressure of informing about their professional opinion to insurance companies. 

8. In general, we all agreed that although Ghaemi has some valid criticisms on the DSM IV, his arguments are heavily based on isolated cases which do not properly justify the change he is proposing. His essentialist/biological approach would not solve the problems that arise in the current version of DSM.    

Delusional atmosphere, the everyday uncanny and the limits of secondary sense

My paper:

Thornton, T. (2012) ‘Delusional atmosphere, the everyday uncanny and the limits of secondary sense’ Emotion Review 4: 192-6

has just been published in a special issue of Emotion Review on emotions in psychopathology. It is one of the outcomes of Matthew Ratcliffe’s project on this topic at Durham combining philosophical and empirical. The issue has a range of articles including papers by Shaun Gallagher, Peter Hobson, Lisa Bortolloti and Matt Broome and the late Peter Goldie, who died suddenly last year.

My own paper expresses my combined fascination with and scepticism about Louis Sass’ attempt to use Wittgenstein to articulate a phenomenological accout of schizophrenia in his rightly respected book Paradoxes of Delusion (Sass, L. A. (1994). The paradoxes of delusion. New York, NY: Cornell.) Since Sass reviewed my paper, it was a somewhat bumpy ride.

Tim Thornton