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. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Inappropriate RegretClaire Pouncey (bio)Keywordsanxiety, inappropriate guilt, moral sentiments, supererogation, regretThis delightful and provocative vignette has many interesting clinical facets, and I thank Dr. Bailey for his candid introspection. For me, this essay calls attention to an asymmetry in our culture, in which women tend to feel more comfortable than men in expressing anxieties about our unpredictable and often dangerous world. Women's fears, however, often are dismissed or minimized, revealing (...) an overall social discomfort with expressed anxiety, and a sense that anxiety itself is, somehow, feminine. When I read Dr. Bailey's essay, I am struck that two self-aware men need the metaphors of war and heroism to address their own anxieties.The vignette builds around a soldier, Colin, who presents with guilt about having been deployed to Iraq, but not engaging in combat. Guilt is a moral sentiment, a feeling that one ought to have acted otherwise in a given situation. It is a self-imposed sanction for a moral failure. In mental health care, we use the term ‘inappropriate guilt’ to describe a clinical symptom commonly associated with depression. Clinicians understand inappropriate guilt as a manifestation of the self-criticism and low self-esteem often associated with depressive disorders. In Colin's case, it did fit with a constellation of symptoms that suggested depression. Dr. Bailey's essay explores the psychodynamics of Colin's guilt, and possible responses to it.As I understand the situation, Colin sees himself as having a moral obligation to exceed his contractual obligation to the military. In the terminology of ethics, he imposes upon himself a duty to be supererogatory, that is, a duty to go beyond the call of duty, which some moral philosophers have considered oxymoronic. For Colin to feel guilty about not engaging in combat, he must have understood a moral obligation to participate in combat that goes beyond his obligation to follow orders. It seems to me that soldiers have a nonmoral, contractual obligation to train, deploy, follow orders, and if circumstances so dictate, fight. But if the circumstances do not lead to combat (Nagel might call this good moral luck), it does not seem to me that a soldier has failed either a contractual or a moral obligation by not being sent into battle. Supererogation aside, to my mind, Colin's guilt is inappropriate: he is holding himself to an unreasonable moral standard, according to which he is required not only to do what the military demands, but also to sacrifice or suffer from the experience in some meaningful way.Although the notion of inappropriate guilt fits with the description of Colin's depression, it occurs to me that the word ‘guilt’ may be too strong here. Perhaps what Dr. Bailey is seeing is better characterized as ‘inappropriate regret’ that Colin missed “his last, best chance to be a hero.” ‘Regret’ is the sentiment that one could have (rather than should have) acted otherwise, perhaps to a better eventual end. Dr. Bailey agrees that Colin's guilt is inappropriate, that no one is ever required [End Page 233] to be a hero. But he seems to share, and even encourage, what I am calling Colin's ‘inappropriate regret,’ which suggests that if Colin had engaged in combat, he would not experience feelings of helplessness or insecurity in our uncertain world. What fascinates me is that Dr. Bailey accepts this premise, and even reflects on his own fears about self-protection in his own urban setting.Rather than challenging it, Dr. Bailey clearly shares Colin's concern that he may not be able to respond adequately should a real threat arise. Both therapist and patient seem to want reassurance that they can keep themselves and their families safe when danger strikes. But this is not a matter of achieving or going beyond the call of duty. Rather, it is an expression of familiar and diffuse anxiety that is unrelated to wartime. In the essay, heroism seems to serve as a metaphor, a filter that makes the expression of anxiety more palatable to both the patient and the therapist. I am fascinated that these two sensitive and introspective interlocutors need to filter their anxieties through... (shrink)

In "On the Concept of 'Psychiatric Disorder,'" Miriam Solomon strives to resolve the tension between thinking of bereavement as a normal reaction to loss, and recognizing that its most extreme forms look very much like major depressive episodes and benefit from psychiatric treatment. To do this, she introduces the idea that a condition can be both normal and a mental disorder, or in other words, that some mental disorders are normal. Although I very much like the idea that some mental (...) are predictable responses to stressors, I have trouble making sense of the argument Solomon provides. I am going to focus on two reasons why.First, the concept of psychological injury is not new and does not do the work Solomon needs... (shrink)

I thoroughly enjoyed Dr. Freedman’s paper on “Akratic Believing.” Often, philosophy of psychiatry offers insights to clarify psychological and psychiatric concepts. Less frequently, it involves a real dialogue between philosophy and psychological science. Dr. Freedman’s account of what is bothersome, rather than just philosophically wrong-headed, about the concept of epistemic akrasia demonstrates that, at least where anxiety is concerned, the a posteriori world may have a great deal to offer theoretical philosophy. Freedman argues that understanding somatic responses to trauma, or (...) more broadly construed, to anxiety, dissolves the problem of why there seems to be more to the problem of epistemic... (shrink)

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. (shrink)

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. (shrink)

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. (shrink)

The mental health recovery movement promotes patient self-determination and opposes coercive psychiatric treatment. While it has made great strides towards these ends, its rhetoric impairs its political efficacy. We illustrate how psychiatry can share recovery values and yet appear to violate them. In certain criminal proceedings, for example, forensic psychiatrists routinely argue that persons with mental illness who have committed crimes are not full moral agents. Such arguments align with the recovery movement’s aim of providing appropriate treatment and services for (...) people with severe mental illness, but contradict its fundamental principle of self-determination. We suggest that this contradiction should be addressed with some urgency, and we recommend a multidisciplinary collaborative effort involving ethics, law, psychiatry, and social policy to address this and other ethical questions that arise as the United States strives to implement recovery-oriented programs. (shrink)