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 ?C 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 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.     

The psychology and physiology of temperament: pragmatism in context

This paper traces William James's famous "temperament thesis" according to which the philosophical stance that individuals take depends on their "temperaments." It seeks to understand James's conception of temperament by locating James within a set of contemporary investigations that linked the sources of mental, and even higher, intellectual processes to the physiological and organic constitution of the individual. The paper argues that James understood temperament along the reflex-arc model and discusses the implications of that physiological account of temperament for James's overall conception of philosophy.     

Logical pragmatism and dialectical materialism: The beginning of dialogue

A philosophical movement, correctly called logical pragmatism, is growing up around the philosophy of W. V. O. Quine, Soviet scholars follow this development with clear and well-grounded understanding of the origins and tenets of the system. This essay continues the dialogue between contemporary Marxism-Leninism and logical pragmatism recommended by Soviet scholars.A Russian translation of this article is being published inFilosofskie nauki (Moscow).     

The absent body in psychiatric diagnosis,treatment, and research

Synthese - Discussions of psychiatric nosology focus on a few popular examples of disorders, and on the validity of diagnostic criteria. Looking at Anorexia Nervosa, an example rarely mentioned in...     

Foundations of clinical praxiology part I: The relativity of medical diagnosis

The question is raised whether it would be beneficial to establish a clinical praxiology for the sake of a multi-focused inquiry into the foundations of clinical pratice. Beginning with the concept of medical diagnosis, a framework is presented which makes it possible to view diagnosis as an element of a complex structure whose adequate analysis requires at least comparative diagnostic methodology and epistemology.     

Live supervision in the postmodern era of family therapy: Issues,reflections, and questions

This article asserts that the family therapy field is approaching an epistemological shift from structuralism and positivism to postmodernism and relativism. The confluence of these movements: feminism, constructivism/constructionism, and cultural relativism is cited as a major impetus for the shift. Live supervision is examined within the context of this transformation, with a discussion of implications for the future.     

The K-BIT: A screen for IQ in six diverse populations

Performance data were collected on the Kaufman Brief Intelligence Test (K-BIT) from a total of 196 individuals from six diverse populations. College students did best, followed closely by closed head-injured adults and their controls; the order of performance then was learning-disabled children, psychiatric patients, and finally, neurosurgical patients in the acute stages of recovery.     

The diagnostic accuracy of questions about past experiences of being mechanically restrained in a population of psychiatric patients

Information about stressful life experiences obtained from patients during diagnostic interviews is an important foundation for clinical decision making. In this study self-reports from 115 committed psychiatric patients of experiences of mechanical restraint were compared with medical records. The sensitivity of patient self-reports was 73% (11/15) and the specificity was 92% (92/100). No clear relationship between psychiatric symptoms and reliability of self-reports was identified. The results highlight the subjective qualities of narratives about past experiences.     

The promises and perils of pragmatism: commentary on Fins, Bacchetta, and Miller

Fins, Bacchetta, and Miller's clinical pragmatism has several appealing features: an emphasis on dialogue, a commitment to consensus, a focus on particular individuals rather than persons in general, and a strong interest in the process as well as the product of moral decision making. Nevertheless, for all its protests to the contrary, clinical pragmatism has a tendency to privilege medical facts over nonmedical values, to conflate appropriate medical decisions with right moral decisions, and to conceive problems at the bedside in terms of "getting" patients and families to "go along" with the treatment plans of clinicians. In sum, there is within clinical pragmatism the potential for physicians to take back some of the power they ceded to patients during the height of the patients' rights and autonomy movement. Provided that clinicians guard against the temptation to use clinical pragmatism manipulatively, however, the method promises, more than most other methods of moral problem solving, to help increasingly diverse individuals make good moral decisions about patients' care under conditions of enormous uncertainty.     

Behavioral testing of anxiety: Issues,diagnosis, and practice

This paper cites certain issues of concern in the area of assessment of anxiety and the anxiety disorders. It attempts to describe, in general terms, the potential of behavioral testing for clarifying these issues and for using these tests to supplement clinical interviews, rating scales, and self-report measures. Moreover, the paper describes a potential compatibility between objective behavioral testing and the most recent (third revision)Diagnostic and Statistical Manual of Mental Disorders.The opinions expressed in this paper are those of the author alone and do not necessarily reflect the position of the National Institute of Mental Health.     

The play's the thing how the essential processes of therapy are seen most clearly in child therapy

Analytic child therapy techniques developed as modifications of techniques from adult psychoanalysis. Child therapy continues to be regarded as an adaptation of adult analysis and to give a central place to the methods and conditions of adult analysis, such as interpretation, in its understanding of how therapy heals. I propose that child therapy is not a modified form of therapy and that the essential processes of therapy are fully present in child therapy. In fact, they often may be seen more clearly there than in adult therapy. I suggest two interrelated processes as the essential ones in all analytic therapy. The first is play. I examine several interrelated aspects of play, specifically as they occur in child therapy. These include the emergence and integration of dissociated self‐states, symbolization, and recognition. The second process I propose as essential in analytic therapy is the renegotiation of self—other relationships through action. This renegotiation is what can help patients become able to play in therapy when they have difficulty doing so. Since I suggest that action is at the heart of analytic therapy, I go on to consider the role of talking in an action therapy. Finally, I explore the dimensions of mutuality in the relationship between child and therapist, including mutual influence and regulation, mutual recognition, and mutual regression. The intersubjective nature of psychotherapy, which is increasingly appreciated in adult analytic therapy but not in child therapy, provides a fertile context for the evolution of play and for the productive renegotiation of self—other relationships.     

The utility of the A1 and A2 criteria in the diagnosis of PTSD

In the field of posttraumatic stress disorder (PTSD), the revisions to the DSM-IV definition of a potentially traumatic event are contentious. Proponents praise the subjective emphasis, while others contend that the changes to the criterion broadened the conceptualization of PTSD. This study examined the predictive utility of Criterion A events, examining the stressor (A1) and subjective emotional response (A2) components of the definition of a traumatic event. Rates of Criterion A events and PTSD were calculated for three diverse samples, and predictive power, sensitivity, specificity, and ROC curves were computed to determine the predictive utility of Criterion A requirements for PTSD symptom, duration, and functional impairment diagnostic criteria. Across all samples, the current Criterion A requirements did not predict much better than chance. Specifically, A2 reports added little to the predictive ability of an A1 stressor, though the absence of A2 predicted the absence of PTSD-related symptoms, their duration, and impairment. Notably, the combination of three A1 and A2 criteria showed the best prediction. Confronted events also showed less predictive ability than experienced events, with more variable performance across samples. These results raise fundamental questions about the threshold or "gate" that Criterion A ought to play in our current nosology.     

Dual diagnosis in an Australian forensic psychiatric hospital: prevalence and implications for services

Despite a growing awareness of the unique needs of psychiatric patients with co-occurring substance abuse and dependence disorders (i.e. dual diagnosis), there is a dearth of research investigating the prevalence of dual diagnosis in forensic psychiatric populations. Similarly, little work has been done to determine the implications of dual diagnosis for forensic psychiatric patients. Patients at the Thomas Embling Hospital in Victoria, Australia, were assessed to determine the prevalence of substance abuse disorders and mental illnesses within this population. Results reveal that the majority of patients (approximately 74%) have a lifetime substance abuse or dependence disorder. Information was collected concerning patients' criminal histories and the Level of Service Inventory, Revised, was completed for each patient who participated. Results suggest that patients with both major mental illnesses and substance abuse disorders have more extensive criminal histories and demonstrate a higher level of risks and needs when compared with patients with major mental illness alone. The implications for the development and delivery of effective forensic mental health services that address both co-occurring disorders are also discussed.     

Developing coherence in community and clinical psychology: the integration of idealism and pragmatism

Illustrations of how ideas from community psychology may be integrated with clinical psychological thinking and practice are described from the perspective of a clinical psychologist working in the NHS. The intentions are to consider socially relevant conceptualizations of the causes of people's well-being and distress, and to develop ways of helping individuals and communities to clarify and address these causes. Incorporating an analysis of social power also necessitates a critical awareness of the limited potency of psychological interventions. © 1998 John Wiley & Sons, Ltd.