Michael A. Schwartz

Typifications: The First Step for Clinical Diagnosis in Psychiatry

Reigning views on psychiatric nosology regard as “too subjective” certain features of diagnosis which respected psychiatrists have reported and several empirical studies have confirmed. We describe two of these persistent “mysteries” of psychiatric nosology: rapid diagnoses and the praecox feeling. We then demystify these mysteries by explicating the workings of “typification” in the diagnostic process. The criteria of disorders which are provided by classification manuals, such as DSM-III, are shown to presuppose such typifications. Psychiatric typification, although a preconceptual skill, can be rendered fully scientific and objective.

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

The six most essential questions in psychiatric diagnosis: A pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

Toward a Husserlian Phenomenology of the Initial Stages of Schizophrenia

Schizophrenic patients confront the psychiatrist with a wide array of extraordinary experiences. Such patients may assert that other people make their thoughts, actions, and desires. They can hallucinate voices which talk about them, commenting on their actions, praising and condemning them. They may complain that their thoughts and feelings are transparent to the world or insist that their bodies incarnate seemingly random features from the surrounding world. In order to explain experiences like these, psychiatrists have invoked terms and formulations such as ego weakness, ego boundary disturbance, ego pathology, depersonalization and derealization, and the breakdown or violation of the unity of the self (Spitzer 1988, pp. 167–183).

The Phenomenology of Schizophrenic Delusions

Writers on delusions, such as Karl Jaspers and Kraupl Taylor, have rather consistently seen certainty and incorrigibility of belief as two of their defining characteristics (Jaspers 1963, Kraupl-Taylor 1966, 1983, American Psychiatric Association 1987). In this paper we shall challenge this by now customary view. More specifically, we shall challenge this view as its applies to a particular sub-class of delusions: the delusions of patients suffering from schizophrenia. We shall, on the other hand, concede that certainty and incorribility of belief do indeed characterize another species of delusions, the delusions of delirious patients. Moreover, we shall admit that schizophrenic patients regularly claim that they are certain about their delusions or that they “know” some things to be the case that normal people would regard as delusional. We shall interpret these pervasive claims, however, as expressions on the part of schizophrenics that are motivated by a determination to believe something indubitably precisely because they both believe it and doubt it while they seek to eradicate their doubt. More simply put, their assertions of absolute conviction do not depict their actual experience but rather a desired one, an experience they seek to make real precisely by insisting that it is now real.

Phenomenological/Descriptive Psychiatry: The Methods of Edmund Husserl and Karl Jaspers

While there can be no doubt that philosophy and psychiatry are different fields of inquiry, there can also exist little doubt that there is a growing interest in philosophical issues in psychiatry,1 How are these two fields related? How are we to appreciate both their differences and their common ground? What can psychiatry expect from philosophy, and vice versa? In this paper we will focus on phenomenology, which for several reasons remains at the heart of the questions just posed. We will do so by addressing the similarities and differences of the meaning of the term “phenomenology” as used in psychiatry and philosophy. Our focus on phenomenology should not obscure, however, our firm conviction that psychiatry must employ a variety of methods, concepts, and theories in order to illuminate and treat mental disorders.

The six most essential questions in psychiatric diagnosis: a pluralogue. Part 4: general conclusion.

In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined.

Phenomenology, language & schizophrenia

Phenomenology represents a mainstream in the philosophy of subjectivity as well as a rich tradition of inquiry in psychiatry. The conceptual and empirical study of language has become increasingly relevant for psychiatric research and practice. Schizophrenia is still the most enigmatic and relevant mental disorder. This volume represents an attempt to bring specialists from different fields together in order to integrate various conceptual and empirical approaches for the benefit of schizophrenic research.

Psychopathology in the light of emergent trends in the philosophy of consciousness, neuropsychiatry and phenomenology

A controversy rages in philosophical approaches to mind that goes to the core of the mind/body problem in psychiatry:how is it possible that a physical system, no matter complex, can give rise to the subjective experience of consciousness? Taking this irreducibility of consciousness into account, philosophical approaches to cognitive neuroscience and psychopathology, as well as the rapid evolving cognitive neurophychiatry, have been forcing new resolutions to the mind/body problem and other traditional dualisms which plague the older psychiatric explanatory models. Attempts to operationalize subjectivity in psychiatric research, however, are more concordant with the present trend to unburden clinical decision making by algorithmic formulas (as dictated by the pressures of managed care and operationalized research) than engaging and developing the skills of the clinician in terms of his or her total potential. Such dilemmas require a renewed reading of classical psychiatrists who have attempted to take account of the subjective experience of consciousness in their seminal psychopathologies.