Debate In Psychiatry Research Articles

Book Symposium: <i>"Why Delusions Matter"</i>

This Symposium aims to contribute to the discussion on "Why Delusions Matter" by Lisa Bortolotti (2023), published by Bloomsbury. In her book, Bortolotti attempts to decouple delusions from pathology, and argues that delusions should not be dismissed as meaningless, because engaging with them at an epistemic level fosters a deeper understanding of the speaker’s perspective and agency. The Symposium opens with a précis of the book (Bortolotti, 2024a), followed by four commentaries that critically engage with Bortolotti’s argument. Bacchi (2024) suggests that insights from the authenticity debate in psychiatry could support Bortolotti’s claim that delusions could foster agency. Drawing from the literature and from her own lived experience with delusions, Russel (2024) explores the ways in which some delusions can be epistemically valuable. Williams (2024) challenges the implication that popular, non-clinical delusions deserve a more positive reputation. Vintiadis (2024) links Bortolotti’s work to the discussion on comforting delusions in psychedelic-assisted psychotherapy. The Symposium concludes with a reply from Bortolotti (2024b).

Is it me or my delusion? Harnessing authenticity for an agential view of delusionality

In the revisionist part of the book, Bortolotti aims at defending a non-pathologising view of delusions, according to which they not only compromise but support our agency. By construing delusions as meaningful protective responses, the author attempts to decouple delusionality from pathology. Nevertheless, it is not clear how, according to her approach, delusions could foster agency. Even when seen as a “way of life” and not as psychiatric symptoms, the defensive nature of delusions undermines the person’s sense of agency, for the symptom or defence mechanism never stems from the person themselves. Notwithstanding the benefits delusions might bring along, they seem to display their own intentionality to the detriment of the agent. Here, I suggest that insights from the authenticity debate in psychiatry could support Bortolotti’s revisionist aim and benefit her discussion on identity beliefs. For this purpose, I introduce the concept of self-illness ambiguity (Sadler, 2007) and compare de Haan’s notion of existential stance (2020) and Stanghellini’s concept of position-taking (Stanghellini et al., 2023) to argue that the person’s agency resides in their ability to take a stance on their (psychiatric) condition, especially when struggling with questions of authenticity. Finally, I explore why one cannot just get rid of a delusion and why, when one attempts to, it feels urgent to replace it.

Too soon to discard Kraepelin: improving diagnosis by appropriate use of neo-Kraepelinian and unitary psychosis models

SUMMARYThere is a debate in psychiatry regarding whether it is better to use neo-Kraepelinian diagnostic categories or unitary models of psychosis in clinical practice. This article argues that clinicians should use either model as appropriate for the case in question, along with the conceptual framework used in the clinical management of psychosis without a clear biological cause. It first explores the values involved in the development of psychiatric classification systems, the purpose of classification and how we reached the current DSM/ICD and unitary models of psychosis. It then describes a diagnostic approach in which the choice of model should depend on the case in question, and offers a diagnostic protocol to guide the decision.

Rationality, irrationality and irrationalism in the anti-institutional debate in psychiatry around the second half of the 1970s in italy

The movements and protests of 1968 worldwide criticized the traditional idea of normality. From the 1970s onwards, psychiatry and antipsychiatry became an ideological battleground centered on the boundaries between normality and madness. In this scenario, characterized by a deep cultural and political transformation within the Left, the traditional concept of rationality and its very connection with irrationality was called into question. As a consequence, the very ideal of reason was questioned. This paper will explore the debate on rationality, irrationality and irrationalism within the so-called anti-institutional psychiatry and its reception in the Italian New Left during the second half of the 1970s.

Critical psychiatry: an embarrassing hangover from the 1970s?

Critical psychiatry is associated with anti-psychiatry and may therefore seem to be an embarrassing hangover from the 1970s. However, its essential position that functional mental illness should not be reduced to brain disease overlaps with historical debates in psychiatry more than is commonly appreciated. Three examples of non-reductive approaches, like critical psychiatry, in the history of psychiatry are considered.

Pierre Pichot et ses rapports avec la psychiatrie espagnole. Notes de sa présence au Pays basque espagnol, 1993–2006

Not only is Pierre Pichot closely connected to the development of Spanish psychiatry in the second half of the 20th century, but is known for his ties with the most significant people in the Spanish academic world. As an expert in Spanish history, he maintains a close relationship with Hispanists in France, which makes him a reference in Spanish psychiatry. However, our intention is to highlight his uninterrupted presence from 1993 until 2006 to inaugurate the Psychiatric Convention in Vitoria on the latest psychiatric developments. At present this Congress is the longest – lasting gathering of experts in Psychiatry in Spain apart from the National Yearly Congress of Psychiatry. During these 15 inaugural conferences presented by Pichot, one can find a complete thought and reflection on the important questions and debates in Psychiatry. His book, Present Day Psychiatry, is a compendia of each one of his presentations. The studies found in this work do not shy away from the most controversial topics. Pierre Pichot's rigour of psychiatric thought is initially found in the 60s with the publication of Los Test Mentales. As has been previously pointed out, this text replaced the Pieron Tratado. Undoubtedly, Pichot is the one to whom today's psychologists and psychiatrists owe the advance of psychometry in dealing with mental pathology. In the best sense of the word Pichot was an eclectic, capable of dealing with topics of interest from a wide range of perspectives. Therefore, he reflected on psychotherapy and to need to avoid sectarianism in schools, which is so closely related to present day efforts to spread and insure psychotherapeutic trading for psychiatric professionals. This, in this article we will summarize some of the contributions Pichot carried out in his presentations while he attended the congresses in Vitoria for 15 years. The first contribution to be covered is the evolution of the concept of affective disorders. This is proof of how week he was familiar with the semiological evolution itself concerning this matter. In addition, the term, psychosis and its lack of clarity will be dealt with. This will provide the opportunity to later continue on with the history of severe psychotic disorder and the influence Pichot holds as a representative of the French school for the autonomous inclusion of severe psychotic disorder in DSM-III and above all in CIE-10. Pichot does not shy away from the debate on the medical discipline to which the treatment of Alzheimer's belongs. In his opinion the discovery of cerebral lesions from Alzheimer's is not a decisive argument to include Alzheimer's or any mental disorder in the field of neurology. Finally and beyond all that is the importance of Pichot as the one who introduced DSM-III in Europe, which definitely makes him worthy to form part of Psychiatry itself in Europe. Without a doubt, Pichot forms part of a line of psychiatrists who have changed everything, who defined what mental illness was as well as what a psychiatrist was. Together with the group from Washington University in Saint Louis, Pichot dealt with the question of diagnosis in a rational way, far from the unclear way of DSM-II. The contribution of all those men and women to modern Psychiatry is fundamental to the history of our specialization.

Commentaire du texte de Spitzer et Endicott 1978 : « Troubles médicaux et mentaux : proposition d’une définition et de critères », un article clé du débat sur la nosographie psychiatrique

The article of Spitzer and Endicott (1978) is part of the preparatory work for the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III). This article highlights the need to define the concept of mental disorder to better identify guiding principles for determining which conditions should be included in the classification, which conditions should be excluded, and how these conditions should be delineated. The article describes a proposed definition and criteria for delineating a medical condition. The first originality of this article is to propose a reversal: the mental disorder will be delimited from a general definition of disorder in medicine. The second originality is to propose a hybrid position: the medical disorder is defined at the intersection of a physiological perspective (based on facts) and a social perspective related to the notion of disability (based on values). Despite the originality of the positions of Spitzer and Endicott and the interests to clarify the current debate in psychiatry, the major issue of the proposed definition is the absence of an attempt to link together the level of physiological dysfunction inside the human organism with the level of disability. This absence could be related to the fact that the authors do not propose a reference theory of cerebral and mental functioning. We will therefore analyze how the recent Research Domain Criteria (RDoC) project can highlight the limit of the original Spitzer and Endicott project. It will be emphasized, however, that explanatory models in medicine are not entirely guided by physiological knowledge but remain fundamentally a pragmatic choice. Thus an intermediate level of physiological explanation will be proposed between the level of explanation of brain function (such as the neurosciences constitute it), and the practice level of psychiatric medical action.

Contemporary public perceptions of psychiatry: some problems for mental health professions

Social constructionist critiques of psychiatry have primarily focussed on the function of diagnosis for society. Less attention has been paid to the diverse ways that service users and carers have come to construct mental disorder. Social movements led by service users/survivors have worked to contest biomedical models whilst carer groups have campaigned for a greater emphasis on biomedicine. However, population-based research reveals a more complex picture, indicating that whilst public acceptance of biomedicine has grown, the public continue to see mental disorder as being highly influenced by social factors and display a high degree of ambivalence towards psychiatric treatment. Through focussing on debates in psychiatry, social work and nursing in the UK, we argue that public perceptions have particular consequences for the mental health professions. Specifically, they impact on the way that professionals can present themselves as holding a specialist knowledge base. Professional mental health workers therefore need to be transparent about the assumptions and limitations of psychiatric knowledge and base therapeutic decisions around the way in which service users and carers construct mental disorder.

Psychiatric genres as HPCs: a new approach to the discrete/continuous debate in psychiatry

Riassunto: Questo lavoro cerca di mostrare come i disordini psichiatrici non possano essere inquadrati in chiave essenzialista, cioe non possano essere individuati attraverso proprieta necessarie e sufficienti. Preliminarmente introdurremo un modello chiamato Homestatic Property Cluster (HPC), che risultera strumentale per comprendere, in prima istanza, la natura continua o discreta delle entita “disordini psichiatrici”. Sosterremo che i disordini mentali sono entita discrete. In seguito, per quanto riguarda la nostra critica all’essenzialismo, analizzeremo il disease model (un modello essenzialista molto utilizzato in ambito medico), ponendo l’attenzione soprattutto sui suoi limiti, cercando di mettere in rilievo varie obiezioni rispetto alla sua applicabilita. Infine, cercheremo di illustrare come il modello HPC possa essere un buon punto di partenza per identificare e classificare i generi psichiatrici e come esso possa mediare tra una visione rigidamente discreta e una visione rigidamente continua dei generi psichiatrici, poiche il modello HPC, a nostro avviso, combina in maniera virtuosa proprieta di entrambe le concezioni. Parole chiave: Modello HPC; Generi naturali; Continuo; Discreto; Filosofia della psichiatria Psychiatric Kinds as HPC: A new Approach to the Discrete/Continuum Controversy in Psychiatry Abstract: This paper aims to show that psychiatric disorders cannot be defined within an essentialist perspective – i.e. by means of necessary and sufficient properties. We introduce the Homeostatic Property Cluster model (HPC) which proves useful for addressing the question as to whether psychiatric disorders are continuous or discrete entities. From this discussion we find that psychiatric kinds are discrete. We then analyze the disease model – recognized in the medical field as an essentialist model – bringing attention to its limitations and raising objections to its applicability. Finally, we argue that the HPC model offers a good starting point for identifying and classifying psychiatric kinds, and show how it can provide a bridge between the rigidly discrete and rigidly continuous perspectives on kinds, bringing together aspects of both. Keywords: HPC Model; Natural Kinds; Continuous; Discrete; Philosophy of Psychiatry

Psychiatric Penguins

The British mass-market publisher Penguin produced a number of texts on psychiatric topics in the period c.1950– c.1980. Investigation of editorial files relating to a sample of these volumes reveals that they were shaped as much by the commercial imperatives and changing aspirations of the publisher as by developments and debates in psychiatry itself. A number of economic imperatives influenced the publishing process, including the perennial difficulty in finding psychiatrists willing and able to enter the popular book market; the economic pressures exerted on peer-review protocols; and the identification of a niche market in popular psychiatry, latterly of a politically radical flavour. As well as offering a materialist standpoint for the study of popular psychiatric texts, this investigation allows an opportunity to adapt, apply and assess theoretical approaches to mass-market publishing by psychiatrists.

DSM over time: From legitimisation of authority to hegemony

The proposed revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), has reignited a protracted debate in psychiatry and clinical psychology regarding the criteria used to diagnose and classify mental disorders. Drawing on the concepts of legitimisation and hegemony, the aim of this study is to deconstruct how the authoritativeness of the DSM was discursively constructed, legitimised and consolidated over time. To fulfil this purpose, we combine a critical psychology perspective with critical discourse analysis and adopt a multi-level model of analysis that embraces the notions of genre and repertoire in scientific discourse. The materials were approached considering the following interrelated dimensions: (a) semantic macro-areas; (b) discursive strategies; and (c) linguistic means. The data set is constituted by the Forewords and Introductions of different editions of the DSM, from the DSM-I through to the DSM-5. The analysis highlights the discursive strategies that play an important role in self-legitimisation and the construction of a dominant hegemonic discourse.

Psychiatric comorbidity: fact or artifact?

The frequent occurrence of comorbidity has brought about an extensive theoretical debate in psychiatry. Why are the rates of psychiatric comorbidity so high and what are their implications for the ontological and epistemological status of comorbid psychiatric diseases? Current explanations focus either on classification choices or on causal ties between disorders. Based on empirical and philosophical arguments, we propose a conventionalist interpretation of psychiatric comorbidity instead. We argue that a conventionalist approach fits well with research and clinical practice and resolves two problems for psychiatric diseases: experimenter’s regress and arbitrariness.

Delving into the perpetual debate in psychiatry.

Delving into the perpetual debate in psychiatry.

Enrico Morselli's Psychology and “Spiritism”: Psychiatry, psychology and psychical research in Italy in the decades around 1900

This paper traces Enrico Morselli's intellectual trajectory from the 1870s to the early 1900s. His interest in phenomena of physical mediumship is considered against the backdrop of the theoretical developments in Italian psychiatry and psychology. A leading positivist psychiatrist and a prolific academic, Morselli was actively involved in the making of Italian experimental psychology. Initially sceptical of psychical research and opposed to its association with the ‘new psychology’, Morselli subsequently conducted a study of the physical phenomena produced by the medium Eusapia Palladino. He concluded that her phenomena were genuine and represented them as the effects of an unknown bio-psychic force present in all human beings. By contextualizing Morselli's study of physical mediumship within contemporary theoretical and disciplinary discourse, this study elaborates shifts in the interpretations of ‘supernormal’ phenomena put forward by leading Italian psychiatrists and physiologists. It demonstrates that Morselli's interest in psychical research stems from his efforts to comprehend the determinants of complex psychological phenomena at a time when the dynamic theory of matter in physics, and the emergence of neo-vitalist theories influenced the theoretical debates in psychiatry, psychology and physiology.

Age of onset of dependence: Does it help our understanding of opioid dependence by generating meaningful categories or by acting as a useful dimension? A critical examination of the classic debate in psychiatry.

Background:Category vs. dimension is a classic debate in psychiatry. Applying age of onset of dependence (AOOD) to categorize opioid dependence into early- (EO) and late-onset (LO) types provides a unique opportunity to critically examine this debate.Aim:To study if EO and LO subjects differ significantly on ‘validating variables’ from five explanatory domains: Clinical (severity), genetic (family history), psychological (sensation-seeking and impulsivity), neuropsychological (attention–concentration and executive functions), and neurophysiological (P300-evoked response potential).Materials and Methods:In a cross-sectional design, 60 ICD-10 DCR-diagnosed opioid-dependent male subjects (30 with AOOD≤20 years and 30 with AOOD≥22 years) comprised the two index groups (EO and LO, respectively), with their respective age-matched control groups (EOC and LOC). They were administered an extensive battery of instruments and tests based on the above domains.Results:The two groups differed significantly on only three out of nearly 30 variables tested. However, there emerged a clear and consistent pattern of continuum of scores across the groups and across all the variables: The EO subjects were the most impaired or affected, the LO subjects were intermediate, and the control groups fared the best. Further, nine test variables correlated significantly and meaningfully with AOOD when the dichotomy was abolished and the sample was combined into one.Conclusions:These results suggest that, in this particular case, the variable AOOD is more meaningful when it is used as a dimension rather than for generating categories perforce.

Changes in the Diagnosis of Autism: How Parents and Professionals Act and React in France

The category of autism has undergone huge changes over the past 20 years. This study was undertaken to analyze the changes and how parents have experienced the diagnostic process in France. Data were obtained from in-depth interviews with parents and psychiatrists, and from 248 questionnaires with open-ended questions filled in by parents. We compared the experiences of parents with adult autistic children to those of parents with young autistic children. Progressively earlier age at diagnosis was evidenced. These changes occurred later than in North America and the UK, due to the reluctance of French professionals to adopt the new classifications of diseases which they viewed as undervaluing both the physician's holistic clinical skills, and psychoanalytical interpretations. Parents' experiences and interviews with psychiatrists were analyzed in order to document changes over time in the diagnostic process following tensions between parents and professionals, and intra-professional debates in psychiatry. Our data support the notion that the diagnosis of autism is historically and nationally contingent. The interactions between changes in the diagnostic process, policy, and parental experiences have led to changes in the way autism is defined, understood, and experienced.

Suicides and Time Zone Lines: West Side Story

The effect of sunlight on suicides is a longstanding debate in psychiatry and sociology. While lack of sunlight is linked to seasonal affective disorder, suicides peak in spring/summer, and midday. I exploit a novel controlled test to identify the role of sunlight separate from other confounding effects. I explore the suicide rates 1979-2007 in counties adjacent to the three American time zone lines. Living immediately west of any boundary, with an hour less sunlight at night, elevates the suicide rate by 5%. Just this ribbon of counties has seen an additional 740 suicides in 29 years.

The Rodewisch (1963) and Brandenburg (1974) propositions

The Classic Text presents two documents of the development of modern social psychiatry. Both show the early beginnings of the reform movement in the GDR — in contrast to the FRG where the reform did not take place until the late 1970s. Adopted in 1963, the Rodewisch propositions formulate for the first time the central issues of the German reform debate in psychiatry. The Brandenburg propositions (1974) document how the reform movement was shifting from a political to a more individual perspective in the GDR.

Are psychiatrists an endangered species?

Are psychiatrists an endangered species?

Ian Hacking, Learner Categories and Human Taxonomies

I use Ian Hacking’s views to explore ways of classifying people, exploiting his distinction between indifferent kinds and interactive kinds, and his accounts of how we ‘make up’ people. The natural kind/essentialist approach to indifferent kinds is explored in some depth. I relate this to debates in psychiatry about the existence of mental illness, and to educational controversies about the credentials of learner classifications such as ‘dyslexic’. Claims about the ‘existence’ of learning disabilities cannot be given a clear, simple and unambiguous interpretation. In particular I show that science cannot deliver a definitive taxonomy of learner categories, and that this has important implications for teachers and policy makers.