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What Kind of Kinds Are Psychiatric Diagnostic Categories (Part 2)? More on Zachar

This post is a continuation of the questions raised in this blog previously. I read clinical psychologist Peter Zachar’s book A Metaphysics of Psychopathology (2014), a dense and ambitious work that elaborates upon on the “instrumental nominalist” position about psychiatric categories that Zachar and Kendler signaled in their earlier article, while grounding in the radical empiricism of William James. Zachar seeks to bring the question of what kind of kinds psychiatric diagnostic categories are together with discussions in contemporary philosophy of science about realism and anti-realism of scientific entities, debates in analytic philosophy about natural kinds, the American pragmatists philosophical uptake of Darwin, and careful case analyses of debates about the status of such diagnoses as narcissistic personality disorder (NPD), the bereavement exception for major depressive disorder in the original DSM-5, or hysteria. 

I want to state very briefly what I take to be Zachar’s answer to the question of what kind of kinds psychiatric categories are. In Chapter 8, Zachar contrasts two positions. The first is an extreme nominalism, which contends that psychiatric categories are whatever psychiatrists treat. This is similar to the view that illness is whatever doctors treat. Both positions have their actual defenders. The obvious problem with this sort of viewpoint is that it leaves no purchase for critique of psychiatric practice. There are some standard examples that get trod out at this point in the debates: the pathologization of homosexuality until it was taken out of DSM-II in 1974 or Samuel Cartwright’s nineteenth-century diagnosis of drapetomania, whereby the propensity of enslaved people to run away from slavery was taken as an indication of mental illness. Were homosexuality and drapetomania “really” forms of mental illness, valid psychiatric diagnostic categories, prior to 1974 or the Civil War? It would seem not.

But why not? Here, to go in the other direction, Zachar brings up philosopher-social worker Jerome Wakefield’s highly influential “harmful dysfunction” (HD) theory of psychiatric disorder. I cannot do Wakefield justice here, and I’ve been planning to return to his series of influential articles in the future. In a nutshell, Wakefield is a naturalist about mental illness, much like the earlier philosopher Christopher Boorse, who, in the 1970s, and in no small part in reaction to both the anti-psychiatry of Thomas Szasz and the removal of homosexuality from DSM-II, offered a purportedly value free, objective, biologically-based account of what disease and health are. The key concept in Boorse, and taken up again in Wakefield, is natural function. For Wakefield, mental disorder (Wakefield, like many writers on this subject, understands disorder to be a more capacious concept than disease) involves a decline in functioning of a very specific sort, that is, a failure to perform some kind of naturally-selected function. It is easier to grasp this idea with respect to physiological functions, such as are associated with the heart, the liver, or the eyes (e.g., blindness). Yet both Boorse and Wakefield hold that we can speak of naturally-selected psychological functions as well. Wakefield then takes this idea of dysfunction and adds to it a normative judgment, namely, that it is harmful to the individual. Someone has a mental disorder, then, when they suffer from a harmful dysfunction.

It is in contrast to both the extreme nominalist view and the HD view that Zachar positions his own approach, instrumental nominalism of the “imperfect community” of psychiatric disorders. I do wonder whether this is not a rather muddied way of introducing his position, for there are really two different questions going on here:

·       (1) What is the difference between mental disorder and mental health?

·       (2) How are we to classify mental disorders, and what kind of status do these classifications occupy? Are the classifications “real,” or are they “constructs”? (Scare quotes to indicate fuzzy words indicative most likely of false dichotomies.)

It makes sense for Zachar to introduce the second question by way of the first but without answering the first definitively, for he wants to borrow something from Wakefield without taking over the whole messy baggage of the idea of “natural functions.” Zachar is a pragmatist about the first question in the strict sense that what makes something a mental disorder has to do with norms embedded in human practices.

I think this is roughly how Zachar’s argument then proceeds: 

  • Although the notion of natural functions is suspect, a more “minimalist notion of dysfunction” does prove useful. This more minimalist notion simply involves a decline in function that is “intersubjectively confirmable” and that cannot be denied (p. 122). Likewise, by analogy with the HD view, the decline is unwanted.
  • A number of such unwanted dysfunctions came to be treated by asylum doctors in the early nineteenth century. These conditions had in common that they were “functional disorders” without a clear physiological cause. Such disorders were labeled and studied and formed a kind of “community” of conditions.
  • Gradually over the course of the nineteenth century, the “imperfect community” of these conditions widened out into penumbral regions, such as manie sans délire, neurasthenia, and hysteria. The penumbral regions were connected to specific members of the original community, but did not necessarily all resemble each other or each member of the original community. For example, to use contemporary categories, there is a certain resemblance between obsessive rumination about specific perceived bodily defects (body dysmorphia) and somatic delusions.
  • The merging of neurology with asylum medicine at the end of the nineteenth century, and the further widening of the community to the “neuroses” with psychoanalysis and the massive screening and testing processes mobilized by the Second World War, all dramatically expanded the imperfect community outwards. “Variations” on previously identified “symptom-clusters” have been gradually added (p. 115).
  • Nevertheless, despite this porousness, this openness, this lack of fixed limits, not anything at any time can become a psychiatric disorder.

In short, Zachar is an anti-essentialist. He denies that there are necessary and sufficient conditions for being a mental disorder. But he also denies that the mere act of naming something a mental disorder by authorities makes it a mental disorder. Mental disorders are members of the “imperfect community,” a term of art that Zachar borrows from the philosopher Nelson Goodman. In Zachar’s terms, “Applied to the domain of psychiatric disorders, the imperfect community model holds that there are symptoms and symptom clusters in the domain because they overlap with other symptoms/clusters in the domain, but there is no way in which they are all alike and that can be literally named” (p. 238).  

In a later interview with psychiatrist-philosopher Awais Aftab, Zachar analogizes the expansion of the imperfect community with evolution: 

The outcome of this gradual expansion of the scope of practice has been an imperfect community composed of disorders that are alike in many ways, but there is no one way that they are all alike. But the domain is not random or arbitrary - new constructs have been introduced for reasons. Like evolution, the process is ongoing although the rate of change varies over time. We should be open to the possibility that there may be many relevant symptoms that have not yet been recognized or perhaps ‘seen as’ symptoms.

There is a lot more to say here, and I will return to this book in a future post. First off, it would be interesting to compare Zachar to Goodman on the imperfect community variant of nominalism. Second, objections will need to be considered. After all, some people will probably not be satisfied with this kind of response: Homosexuality (or drapetomania) is not a mental disorder because there was an attempt to bring it into the imperfect community of psychiatric disorders and homosexuality just didn’t fit in. Finally, I haven’t said anything yet about the causal network model of mental disorders that Zachar embraces here.

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