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2016 ; 15
(1
): 5-12
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The nature of psychiatric disorders
#MMPMID26833596
Kendler KS
World Psychiatry
2016[Feb]; 15
(1
): 5-12
PMID26833596
show ga
A foundational question for the discipline of psychiatry is the nature of
psychiatric disorders. What kinds of things are they? In this paper, I review and
critique three major relevant theories: realism, pragmatism and constructivism.
Realism assumes that the content of science is real and independent of human
activities. I distinguish two "flavors" of realism: chemistry-based, for which
the paradigmatic example is elements of the periodic table, and biology-based,
for which the paradigm is species. The latter is a much better fit for
psychiatry. Pragmatism articulates a sensible approach to psychiatric disorders
just seeking categories that perform well in the world. But it makes no claim
about the reality of those disorders. This is problematic, because we have a duty
to advocate for our profession and our patients against other physicians who
never doubt the reality of the disorders they treat. Constructivism has been
associated with anti-psychiatry activists, but we should admit that social forces
play a role in the creation of our diagnoses, as they do in many sciences.
However, truly socially constructed psychiatric disorders are rare. I then
describe powerful arguments against a realist theory of psychiatric disorders.
Because so many prior psychiatric diagnoses have been proposed and then
abandoned, can we really claim that our current nosologies have it right? Much of
our current nosology arose from a series of historical figures and events which
could have gone differently. If we re-run the tape of history over and over
again, the DSM and ICD would not likely have the same categories on every
iteration. Therefore, we should argue more confidently for the reality of broader
constructs of psychiatric illness rather than our current diagnostic categories,
which remain tentative. Finally, instead of thinking that our disorders are true
because they correspond to clear entities in the world, we should consider a
coherence theory of truth by which disorders become more true when they fit
better into what else we know about the world. In our ongoing project to study
and justify the nature of psychiatric disorders, we ought to be broadly pragmatic
but not lose sight of an underlying commitment, despite the associated
difficulties, to the reality of psychiatric illness.
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