Philosophers Challenge Psychiatry and its Search for Mechanisms of Disorder

Dr. Hartner and Dr. Theurer, researchers in philosophy and the social sciences, published a new paper that conscientiously articulates the philosophical problems and taken-for-granted assumptions in psychiatry. They call into question psychiatry’s ongoing attempt to identify the mechanisms that underlie psychiatric “disorders,” for example, by searching for biomarkers of “depression.”

Central to their analysis, Hartner and Theurer examine the question that has surfaced time and time again in the field: “What kind of thing is a psychiatric disorder?” They review the meaning behind the question itself and the different positions taken in response. Ultimately, their philosophical assessment leads them to conclude that psychiatry should not continue to seek biomarkers or other mechanisms believed to be the origin of “disorders.”

“Psychiatry should not attempt to map its categories to underlying multilevel mechanisms, no matter how complicated, because psychiatry is uniquely and precariously situated at the border of empirical facts and social values, and no mechanism can coherently purport to account for both,” they write.

In addition to the fallacies that they argue are embedded in the notion that mechanisms of disorders can be identified, Hartner and Theurer express concerns that uncritically promoting this endeavor is misleading and provides circular support for a flawed diagnostic system. They write:

“Moreover, the instability of our existing psychiatric taxonomy gives us reason to worry that a search for mechanisms of disorder, which presumably always has to work backward from diagnostic and classificatory procedures to the biological considerations that justify them, will lend the appearance of scientific validity and empirical respectability to a procedure that is bound to be rife with nonempirical social and value judgments.”

To demonstrate their argument, the authors begin by addressing the central question of “what kind of a thing is a psychiatric disorder?” People within and outside of the psy-disciplines have taken different positions to understand the nature of psychiatric disorders. For example, for some, psychiatric disorders represent what would be referred to as “natural kinds.” Those who align with this belief are considered to be “realists,” and they understand psychiatric disorders to be natural and biological, existing “independent of human interests.”

The other side of the debate features the belief that psychiatric disorders are concepts constructed in a way that is dependent on human interests. This argument, referred to as the “constructivist” argument, asserts that mental disorders do not represent naturally existing entities with real boundaries because it is humans who have classified them. Therefore, psychiatric research cannot aim to discover the mechanisms of disorder or the boundaries that exist between different disorders. The authors further explain the constructivist position on the nature of psychiatric disorders. They write:

“At the other end of the spectrum, the constructivist answers these questions by pointing out that psychiatric kinds are just labels designating clusters of behaviors that society would prefer to reform, treat, or isolate.”

The field has consistently come up short in locating biomarkers for disorders. Yet, the constructivist argument risks minimizing experiences of distress that are felt to be very real and salient to those who suffer and to those who are hoping to provide care and treatment for suffering. The authors point out that psychiatric symptoms for disorders do seem to cluster together and evidence exists that specific traits may be heritable.

Based on these arguments, Hartner and Theurer engage additional questions that suggest the realist vs. constructivist debate does not adequately capture the truth within the experience of psychiatric disorders. They ask, “How are these things possible if disorders are mere reflections of social values? It is tempting to think, then, that the right answer lies somewhere in between.”

Indeed, some have theorized that psychiatric disorders are “neither natural, biological kinds nor arbitrary socially constructed kinds that are unaffected by empirical facts in the real world.” Rather, they can be seen as having practical utility in the real world. Through this lens, psychiatric disorders can have practical value. Zachar (2000), the pioneer of this approach, argues that psychiatric disorders are “more than names but less than inherent essences.” The authors explain:

“On this view, both the realist and the constructivist are asking the wrong question: The practical kinds account holds that psychiatric kinds should be judged in terms of their usefulness, not in terms of whether they ‘really exist.’ The goal of constructing a psychiatric taxonomy should be to diagnose and treat patients, not to determine whether psychiatric disorders like autism are real.”

However, those who adopt this argument are faced with the daunting task of explaining what makes practical “kinds” practical? In other words, what distinguishes and defines things that are practical from things that are impractical?

Hartner and Theurer continue to engage this debate, pointing out the limitations of different positions as well as the responses taken to address these limitations that grow increasingly more complex. For example, they explain that two separate arguments tend to be conflated in these discussions. The question of whether psychiatric disorders are real or constructed ought to remain distinct from whether certain properties or essences account for the coherence of a construct, as the latter cannot necessarily be used to support the former.

In addition to disentangling the nuances inherent in these positions, Hartner and Theurer attempt to incorporate philosophy into questioning the nature of psychiatry and psychiatric methods. They write:

“We argue that, despite their appeal, these views ultimately stumble on confusion about the nature of psychiatric science, the aims and limitations of scientific inquiry and mechanistic explanations, and the role of values in psychiatry. Exposing these difficulties is a helpful step toward showing why understanding the nature of psychiatric disorder requires first clarifying the nature of psychiatry itself, its status as a science-based form of medicine, and the limitations on what its methods can teach us about the nature of psychiatric disorder.”

One primary consideration that surfaces is whether or not the question central to the debate about mental disorders or “kinds” ought to be the primary focus. To ask, “what kind of thing is a psychiatric disorder?” recasts focus from the legitimacy of psychiatric practice, methods, and approaches, toward a focus on the nature of disorders instead. Hartner and Theurer explain:

“But there is something disconcerting about this as the central question in the philosophy of psychiatry, for it encourages us to characterize psychiatry by focusing not on psychiatric practice itself—the methodology, techniques, and philosophical commitments of its practitioners, and the taxonomy of disorders that results— but rather on the status of the disorders it countenances.”

They continue:

“Perhaps it is time to reverse that. As currently posed, the central question seems to lead us back to the same stagnant well of choices: Psychiatric disorders are either real parts of the natural world or they are mere products of human classificatory conventions.”

To their first point, the authors deliver a philosophical questioning of psychiatric practice. They point out that psychiatry operates from the vantage point that a mental disorder is a legitimate kind of thing, with a set of features that make up its classification, and an issue that falls within the purview of psychiatric expertise. All of these assumptions tend to go unquestioned and, for the most part, evade any major critical reconsideration.

“Meanwhile, the psychiatric community seems to have relatively little interest in these philosophical matters. It seems now to be much more concerned with putatively practical disputes, such as which big book of mental disorders to adopt, which branch of science will ultimately furnish the mechanisms of psychiatric disorders, and which professional degrees qualify one to treat psychiatric disorders with prescription drugs.”

Moreover, providers appear to be comfortable staying within the confines of this myopic approach, the authors contend.

“Clinicians and researchers in psychiatry appear increasingly comfortable with or indifferent to unresolved philosophical questions about the nature of psychiatry’s subject matter.”

These observations drive the authors to contribute their philosophical lens to this debate. They articulate their primary purpose:

“Our goal in this article is to refocus the primary target of philosophical attention—for philosophers and psychiatrists alike—on the nature and subject matter of psychiatry and the scope and limits of psychiatric expertise. We propose to do this by challenging the central question in the philosophy of psychiatry with its focus on the nature of psychiatric disorders.”

Hartner and Theurer immerse themselves into the different positions that comprise the discussion, outlining how this central question has evolved into psychiatry’s search for mechanisms of psychiatric disorder.  Responses have developed that attempt to explain the mechanisms of disorder in a way that captures the idea that mental disorders may not be real or constructed, but rather, are practical.

In an effort to explain “practical,” the researchers attempt to identify complex interactions between behavior, environment, and physiology as they manifest through development, evolution, and interaction with the environment. However, even if these mechanisms are identified, the authors explain, “it is not obvious how the existence of any such mechanism is possible or what such a mechanism would be a mechanism of.”

To clarify this point, the authors distinguish between what it means to ask “how?” versus “why?” To question the mechanism of a “disorder,” such as a state of hyper-alertness, is to arrive at an explanation of “how hyper-alertness comes to be vs. why hyper-alertness is problematic.” Therefore, to frame a person’s distress as problematic can only come about if one is discussing the person in relation to their environment.

They apply this dilemma in another example, using anxiety as the psychiatric disorder in question:

“Understanding the neurological mechanisms of the symptoms of anxiety, for example, is surely a crucial task for a psychiatrist hoping to intervene on that mechanism. But the question of whether such intervention is the appropriate course of treatment in the first place, or whether it is the symptoms rather than the organism’s circumstances that really need treatment, cannot be settled by neurological mechanisms.”

Ultimately, Hartner and Theurer argue that the quest for mechanisms cannot result in the information needed to inform understanding of distress or approaches to ameliorate it sufficiently.

“The focus on mechanisms,” the authors write, “risks conveying the simplistic and misleading impression that psychiatric disorders are simply discovered by exploring the empirical world, that such discoveries can and should shed light on what is wrong with the patients who present with symptoms, and that such discoveries can and should yield medical interventions that should be used to alleviate symptoms.”

This search is likely to result in approaches that have the potential to be dangerous, they assert. Hartner and Theurer illustrate this by reasoning that “intervening directly into, say, neurotransmitter systems may be a rather dangerous and unjustifiably sledgehammer-like intervention for undoing the effects of bullying or loneliness, for increasing one’s satisfaction with a genuinely unfulfilling and pointless job, or for helping children focus at hours of the day that their circadian rhythms dictate they ought to be sleeping.”

The authors reiterate their argument that psychiatry should not seek mechanisms of disorder numerous times throughout the paper. They are adamant in their position that to understand clusters of symptoms that are perceived to be “disorder,” the person must be understood within their environment.

Examining the person and their biology, or empirical facts believed to explain their symptoms, even if the methods used are complex, will not provide an answer as to why these symptoms of distress are occurring. Therefore, they cannot sufficiently inform an appropriate response. Instead, considerations that attend to societal structures, collective values within cultures and subcultures of humanity, and expectations of what it means to be problematic or live well are essential components.

Although Hartner and Theurer meticulously trace through complex philosophical positions regarding these debates, they do so in a way that is applicable, citing real-world examples throughout their paper and articulating radical stances on psychiatry and its approaches.

For example, they specifically discuss the recent NIMH initiative, the Research Domain Criteria (RDoC) approach. They explicit write that this initiative represents “a step in the wrong direction.” It endeavors to reconfigure a new diagnostic taxonomy from the ground up by understanding psychiatric disorders as brain disorders.

RDoC is positioned as an alternative to the DSM which was designed by defining clusters of symptoms first and then working backward to identify diagnoses. Contrary to this, the RDoC initiative is set to begin by identifying the mechanisms of disorders, operationalized as evidence of brain dysfunction, to then explain clusters of symptoms. The authors describe how the RDoC approach is fundamentally flawed.

“This is because, again, it is symptoms rather than disorders that we may explain by elucidating underlying biological mechanisms. The disorder labels and the decisions about which symptoms belong underneath them are always determined in part by social and evaluative considerations. Perhaps for this very reason, no commitment to disorders as natural kinds is implicit in the DSM itself. It is, however, implicit in research projects that attempt to ground those kinds in underlying mechanisms. And this, we argue, is the fundamental mistake and the one that the RDoC initiative threatens to entrench even further.”

Hartner and Theurer recommend that the field of psychiatry recognize the lack of solid ground that underlies any attempt to provide care for persons in distress. Incorporating philosophy can facilitate a more ethical and humane approach. However, they make it clear that distress can be real and burdensome and that it is possible for individual “symptoms” and accompanying mechanisms be fully explained. They write:

“We do not deny that individual symptoms can be fully explained mechanistically. Nor do we deny that the very real—and sometimes very burdensome— experience of depression can and does manifest itself in many different ways for different people. That is a good reason for exploring the mechanisms that generate depressive symptoms. What we deny is that the mechanisms that generate psychiatric symptoms can thereby tell you that the patient is disordered. That is because, unlike identifying the mechanisms that generate symptoms (e.g., feeling anxious or depressed), the decision to group symptoms together as a disorder depends on social considerations and evaluative judgments. Mechanistic explanations cannot, in principle, explain why symptoms and behaviors are dysfunctional or harmful.”

In their conclusion, Hartner and Theurer explain that initiatives to identify mechanisms of a disorder are concerning because numerous, unjustified assumptions support the search. In turn, the results of such endeavors appear to lend “scientific validity to a classification scheme that has too little empirical evidence to support it.” Moreover, the surrounding environment and the potentially unjust social order that contributes to one’s distress go unexamined and unchallenged. These concerns are powerfully illustrated in the following example:

“If a patient is depressed because she spends 40 or more hours a week engaged in alienating labor for exploitative pay, the decision to help her dampen those feelings with drugs seems to assume that it is her response rather than her culture that is dysfunctional. But psychiatrists have no special expertise on these matters.”

They continue:

“We sympathize with the rebuttal that in such cases psychiatry involves helping patients cope with circumstances they cannot change. Nevertheless, such practices are potentially dangerous, to both patients and society, because they involve manipulating complex chemical systems that we do not fully understand and also because they contribute to the normalization of social practices that need to be justified by rational argumentation.”

Building on this example, the authors attend to the question of what it means to behave in problematic or abnormal ways by deliberating the nexus of a person’s behavior and their surrounding social values.

“Whether depression or cheerful acceptance is the more ‘dysfunctional’ or ‘abnormal’ response to exploitative labor needs to be settled by arguments about our social values, not by appeal to empirical evidence about whether feelings of depression and despair are a product of neurotransmitter systems.”

Finally, the stance the authors take is made clear as they delineate the dangers associated with the search for mechanisms of disorders. Hartner and Theurer conclude with the following two remarks.

First, “…it is important to emphasize that among the ethical obligations of professionals is the obligation to recognize the limits of one’s own expertise.”

“Second, and finally, we must always bear in mind that psychiatry has a rather checkered history of overstepping its expertise and dictating poorly justified values disguised as scientific facts to the public and the patients it treats.

 

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Hartner, D. F., & Theurer, K. L. (2018). Psychiatry should not seek mechanisms of disorder. Journal of Theoretical and Philosophical Psychology. http://dx.doi.org/10.1037/teo0000095 (Link)