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Bipolar, Borderline or Both? Diagnostic/Formulation Issues in Mood and Personality Disorders

Unmute enhancedmedical Mute enhancedmedical Follow Follow enhancedmedical Following Following enhancedmedical Unfollow Unfollow enhancedmedical Blocked Blocked enhancedmedical Unblock Unblock enhancedmedical Pending Pending follow request from enhancedmedical Cancel Cancel your follow request to enhancedmedical. Joined March Tweets Tweets Tweets, current page. You blocked enhancedmedical Are you sure you want to view these Tweets? Viewing Tweets won't unblock enhancedmedical Yes, view profile. Close EnhancedMedicalCare followed. Offering an account of the harmonious soul, whose rational and non-rational elements achieve a unified whole, Aristotle leaves us a picture of the warring and fractured state of an unhealthy soul, for example.

And, while they adhere to a different account of the passions and a more knowledge-based and Platonic analysis of vice, this link with the vices and virtues is also characteristic of the subsequent Stoic analyses Irwin A conception of mental illness as psychic disunity as well as an association between health, rationality and virtue reoccurs in later philosophy Spinoza, for example , and in psychoanalytic traditions.

Yet disturbed or disabled doxastic states and capabilities remain core exemplars of disorder, over which intuitive agreement is consistent. Characterized by incomprehensibly disordered thought, failure to adjust beliefs in response to new evidence, inconsistencies between thought and action, and delusional convictions, psychosis and psychotic thought patterns are regularly judged prototypical features of mental disorder. So the rationalistic analysis of disorder may yet correspond—but to a reduced version of the presently sprawling overall category.

Forms of doxastic irrationality are still the mainstay of much policy and legal analysis about mental disorder. Ostensibly, construing mental disorder as a want of rationality has been weakened in the face of evidence from behavioral economics showing that holding and acting on well-grounded and reasons-responsive beliefs occurs rarely in the general population, and common prejudices and superstitions seem to be indistinguishable from clinical delusions with respect not only to their prevalence but to the way they are adopted and maintained Bortolotti , Along these lines, some illusions, delusions, and hallucinations have recently been acknowledged.

But as this indicates, whether disorder is usefully characterized as a want of reason depends, finally, on guiding, normative conceptions of mental health or eudaimonia , and of the role of reason in those conceptions—not on facts of the matter, or consequentialist reasoning. Other depictions of disorder rely on one or both of the groups of traits around suffering, distress and psychic pain, on the one hand, and, on the other hand, disability, incapacity and personal or behavioral dysfunction. These are the features noted in a series of influential prefatory remarks in the diagnostic and statistical manuals the DSMs and ICDs.

The wording of the fifth edition of the DSM introduces a disjunction:. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. WHO 5, emphasis added. Because distress, psychic pain, and suffering form a part of normal human experience, and the presence of distress is also used to separate disorder from social deviance, further qualifications follow each of these statements WHO 5. In addition, as the disjunction in the DSM formulation apparently recognizes, many disorders fail to exhibit evidence of distress or suffering.

Psychodynamic or psychoanalytic presuppositions may posit underlying distresses that are masked, or submerged, within the psyche; and the elusive phenomenology of some conditions suggests the presence of nameless existential anxieties hidden from awareness Ratcliffe , But such explanations aside, distress has been widely regarded as a ubiquitous, if not unfailing, feature of disorder.

In symptom-focused accounts laying stress on the consequences of the syndrome, distress becomes prominent as a form of disabling dysfunction Stein et. But risk of disorder is not disorder, and risk language invites troubling issues around over-diagnosis and false positives Schwartz ; Stein et al. We might expect the separation of normal from pathological distress and, more broadly, the characterization of mental disorder in terms of distress, to be indicated by distress emanating from the disorder itself, rather than from other contingencies.

But equally outcomes of the disorder itself are the distresses resulting from the stigma and discrimination that follow diagnosis and treatment, as well as a host of other, frequently negative, consequences in jarring and alarming disruptions to personal lives, selves, and relationships Tekin In serving to shrink the margins of disorder, such biomarkers may be welcomed by those decrying over-diagnosis, even if an evaluative interpretation as to whether, and when, such biomarkers occur in healthy and unhealthy form is still required.

Similarly stressing intrinsic properties, others have emphasized that psychological symptoms may constitute a mental disorder, even as it is caused by biological or social factors. Thus, in the case of depression without evidence of known biomarkers, our intuitions suggest disorder would be attributed on the basis of psychological symptoms alone. Were known biomarkers present without evidence of any psychological symptoms, on the other hand, no attribution would be made. But today at least, disorder would be attributed on the basis of the symptoms of depression with or without known biomarkers.

Analyses characterizing felt distress as a property constitutive of some given psychiatric condition such as depression , are also compatible with recent models focused on the causally interconnected statistical networks making up symptom clusters. These clusters are depicted as reinforced through feedback loops that serve to rope together assorted symptoms independent of any underlying, antecedent, common, cause. Symptom-focused accounts sometimes combine suffering with disability, as was noted.

But standing alone, something the affected person is prevented from doing, or unable to do as well as others, captured in the ideas of disability, impairment, incapacity and personal or behavioral dysfunction, offers an alternative characterization that can acknowledge disorders without apparent personal suffering notably mania, some personality disorders, and some addictions. Dysfunction and disability have been allied, or treated as rough equivalents, but disability is also placed in opposition to dysfunction.

Instead of construed as internal to the person, disabilities are often represented as conditional impairments, dependent on context including physical and social arrangements. Dysfunction forms a central element of the most widely discussed analytic definition of mental disorder, introduced in Section 3. In the first, dysfunction occurs in some part or parts of a bodily or neural system. Only the first kind of dysfunction is claimed to permit non-evaluative description. The characteristic dysfunction of mental disorder is here part of a standard, idiopathic model, as we saw, with these disabling traits understood as the symptomatic, causal manifestations of an underlying, pathological process.

Others are more ambitious, proposing analytic definitions in terms of necessary and sufficient conditions. Some are intended to cover other medical conditions as well as mental disorders. The symptoms of mental disorder are primarily, if not exclusively, states about which their subject can claim a sort of authority.

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Psychology can provide reliable behavioral assessments of disorder, and indicate its presence through laboratory performance tests. But no mental disorder is thus far independently verifiable though blood tests or scans, for example. So first person reports play a special part in understanding such disorder for the clinician, and those establishing philosophical analyses are similarly beholden Flanagan ; Varga In these traditions neither psychology nor psychopathology are empirical sciences in the usual sense because they involve distinctive forms of explanation.

Arising within nineteenth century social science, the hermeneutical approach involving meanings calls for Verstehen understanding , a distinctive, interpretive way of apprehending human action. These differences bring contrasting theories about psychology as science. But psychopathology likely offers a challenge so great as to call for a range of approaches Ratcliffe ; Wiggins and Schwartz ; Gallagher And efforts to tie in phenomenological theorizing with findings in neuroscience have yielded the hybrid methodology of phenomenological clinical neuroscience advocating an initial study of subjective experience to only then be probed for its underlying neurobiology Mishara The merging of empirical and phenomenological methodologies is also readily supported by the tenets of some accounts of embodied and enactive cognition.

Applied to mental disorder, this departure from classical cognitivist assumptions and analogies suggests that in at least some, and perhaps all cases, disorder grows out of disturbances in embodied interaction with the environment, and not from dysfunctions occurring in high-level cognitive mechanisms Drayson ; Stanghellini ; Maiese While Section 3 focused on what might separate mental from non-mental disorders, and Section 4 was concerned with how to separate disordered from non-disordered states, Section 6 addresses another aspect of classification: controversies over how different types of putative mental disorders should be distinguished from one another.

These controversies, like so many about psychiatry, span the disciplines of medicine, science including neuroscience and psychology and philosophy. Aside from serving the institutions providing services, their uniformity is aimed to enhance inter-diagnostician reliability; and research based on these reliable classifications, it has been hoped, should eventually allow validation of the categories APA Failure of this hope to achieve its promised yield in research findings partly motivated the revised research domain criteria RDoC , described later in this section.

Philosophical discussions of psychiatric classification can be arranged according to their allegiance to the DSMs and ICDs, and their accompanying presuppositions. Others have accepted the entities so classified Sass, Zahavi, Frith and colleagues, for example. Criticisms of DSM and ICD classifications have addressed their research purposes and usefulness, categorical approaches and supposed value-neutrality. The claim to value neutrality is discussed in Section 8.

These classifications recognize the presence of many overarching values, including the methodological ones implicit in their goals of achieving validity and reliability. But further, unsupportable values such as homophobia and misogyny have been identified as well.

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Research-related concerns such as these have led to upheavals within psychiatry, issuing in new, dimensional criteria by which the research domain is to be approached Revised Domain Criteria, or RDoC. Separate units of analysis genes, cells, circuits, self reports, etc. In partial defense against objections to DSM-type classifications, Elizabeth Lalumera employs the contrast between conceptions procedures of identifications and concepts reference fixing representations.

Mental disorders may still correspond to theoretically informed concepts , thus far incompletely understood, and presently known only through descriptive conceptions enabling identification practices in diagnosis and care Lalumera DSM-type classification adheres to a classical nineteenth century disease model, whereby each disease is a discretely bounded entity, made up of a symptom cluster emanating from underlying organic states or processes within the individual patient. The applicability of each aspect of this model to mental disorder has been challenged.

Some would replace its idea of validity involving a relation between classificatory name and underlying disease with the statistical concept of predictive or prognostic validity, which proceeds without reference to underlying causes. Rather than discretely bounded, many disorders appear to be continuous with normal states. In an interpretive and definitional choice, over which the data remains ambiguous, mental disorders arguably represent no more than tails of normal distributions of particular traits in the general population Machery Solely internal, organic states and processes, and genes, cannot alone explain any, and probably all, diagnostic disorders.

Expanding with each new addition, the collection of disorders enumerated and described in these classifications has prompted alarm over the boundaries of mental disorder, the erosion of normal, mentally healthy states and variations, and the inappropriate role played by medical psychiatry and, finally, science, in dictating norms of healthy psychic functioning.

In contrast to these commonly-voiced apprehensions about over-medicalization, there remains the persistent charge of under- diagnosis and under -treatment of those with diagnosable mental disorder, often attributed to stigma, and to the socioeconomic status of under-served communities. The actual epidemiological data remains opaque and equivocal, leaving these contrary speculations unresolved and likely unresolvable. The DSM and ICD diagnostic classifications have been remarkably influential worldwide: today, they appear almost immovably permanent. Philosophers of science have explored whether mental illnesses might be classified as natural kinds, the claim made about particular diagnostic categories or symptom clusters depression, schizophrenic disorder, and autism, for example , as well as about separate symptoms Cooper ; Samuels See entry on Species.

The expectation here is merely that a natural kind must be able to ground explanations and inductive inferences, and enable effective human intervention. Linked by shared causal properties such as genes, on this view, their homeostatic aspect ensures that property clusters making up separate disorders or symptoms will remain stable enough to behave the same way in response to the same conditions, due to a similarity-generating mechanism explaining their co-occurrence. That comparable stability and consequent predictive properties could arise not from shared causal properties such as genes, but as the result of feedback loops binding symptoms together in stable clusters has also been proposed.

See essays in Kincaid and Sullivan Granted, psychological categories seem to be more like biological species than like gold, magnesium or atomic particles, for instance, in possessing fuzzy boundaries and seeming to rest on continua, rather than forming discrete categorical entities. But the differences have often been seen as profound, as three examples will demonstrate.

Indeed, mental disorders have been denied the status of natural kinds on precisely the grounds that instability in their properties results when they have been classified and labeled Hacking None of these differences has gone un-criticized. A thoroughgoing mind to brain reductionism would reject i. About ii , it has been pointed out that the classification of biological species is also subject to the instability wrought by looping effects. And similarly, it has been argued in response to iii both that values also enter into the classification of biological species, and that once we reach the categories of interest in this analysis, non-evaluative traits form the observable taxa of such species Cooper By adopting a thoroughgoing biological reductionism it will be possible although not necessary , to accept as dispositive the parallel between psychiatric categories and other categories recognized as natural kinds on non-essentialist definitions.

But, although the diverse ends to which disease taxonomies can be put argue against finding a single answer about the kind status of mental disorders, focus on the purposes served by disorder language and categories has proven fruitful, here.

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Along with practical kinds, moreover, mental disorders may be further classified according to their status as dimensional, discrete, and fuzzy kinds, and there is little reason to suppose mental disorders are all of one kind Haslam , A settled self-conception that involves being mistakenly seen as ill can be effectively treated using trust-building strategies that avoid medical language forcing the subject to explicitly acknowledge illness Reimer ; Tekin Values have unfailingly played a part in the way mental disorders are classified, conceptualized, experienced as personal diagnosis, and treated.

Unacceptable bias has been repeatedly identified, exemplified in categories such as homosexuality with its homophobia , pre-menstrual syndrome unwarrantedly assigning disorder status to normal function , masochistic personality disorder pathologizing misogynist gender roles , and oppositional defiant conduct disorders exhibiting racial bias. Sadler , ; Potter ; Poland There is no question that values have played a role in discourse on mental disorder.

The question remaining is whether moral values are inescapably attached to the conceptualization and classification of mental disorders at the level of theorizing, forming an inherent part of their definition. Objectivist or naturalist conceptions have implications well beyond these academic debates, it should be added.

For example, a related societal issue with practical consequences concerns the expectations around a value-free medicine in those assigning, and subject to, diagnoses, regardless of the facts of the matter. The contrast between evaluativism and objectivism reveals nothing distinctive about mental disorder in this respect. But the theory of values based medicine VBM emphasizes that, because they are shared, values in the rest of medicine are not usually contentious. When VBM is adopted as a treatment approach, these contested values can be acknowledged, and the different perspectives supported, and subjected to negotiation Fulford , Discerning what would be the maximal response in terms of perpetuating the species represents another of these objections, since no agreed-upon conclusion about this can be drawn in a value-neutral, or perhaps any, way.

The broad contrast between evaluativism and objectivism has also been resisted for other reasons. In this relaxed naturalism, objectivism merely means requiring no special subject for the disciplining, conception, and framing of judgments, and providing a contrast between correct and incorrect, or truth and falsity, for the relevant judgments Thornton The present discussion concerns evaluations that are primarily negative, although as we saw earlier, positive evaluations arise in traditions valorizing madness and many in the neuro-diversity movement insist that autism spectrum and other mental disorders are human variations analogous to differences of gender, which ought to be granted respectful accommodation, not clinical treatment.

Negative social attitudes towards observable disorder have led to stigma, self-stigma, and discrimination Hinshaw The madman and madwoman have been the subject of fear, misunderstanding, disparagement and condemnation, their failings exaggerated and humanity denied Gilman With modernity, care and protection apparently replaced earlier, moralistic and neglectful arrangements. Despite such attitudinal change, however, these issues around responsibility remain contentious and unresolved C. Edwards The effect of diagnoses on those so distinguished has been demonstrated to be extensive, often personally transformative, and rarely consistently benign.

The extent of these effects has drawn research attention to first-person report, and to the eloquent madness memoirs increasingly available for study. The Recovery movement, for example, stresses the way the self and identity are diminished by diagnosis, eroding and occluding other, more positive, attributes making up the whole person.

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Not only the social and personal effects of diagnosis in individual lives and within mental health care, but also the societal face of psychiatric care, are achieving belated recognition. The social attitudes and values adopted towards mental disorders, added to features associated with such disorders themselves, have given rise to a bioethics differing in emphasis from that which addresses ethical issues in most of general medicine.

Widespread stigma about such disorder raises extra privacy and confidentiality issues, for example. Because of the powerful and disruptive effects of the experience of disorder, conceptions of disorder, and of its treatment, are often linked to the self and identity of the subject in distinctive ways Tekin , forthcoming. The perceptual, affective, and reasoning disabilities that at least temporarily mark severe disorder are seen to jeopardize the widely-valued traits of rational autonomy, responsibility, and coherent and unified personhood, leading to challenges over autonomy and decisional capacity R.

And most significant, treatment raises fundamental ethical issues because it regularly employs coercive methods. These coercive practices are judged of serious moral concern in recent policy documents. For example, coercive treatment apparently violates rights proclaimed by the United Nations Convention on the Rights of Persons with Disabilities Looking toward the future, the related field of neuroethics explores developments and prospects in neuroscience possessing increased urgency, or distinctive relevance, for psychopathology.

See entries on Philosophy of Neuroscience, and Neuroethics. Responsibility concepts, together with those around personhood, autonomy, diminished capacity, treatment responses, and individual rights, make up an inescapable aspect of the broad field of psychiatric ethics that includes neuroethics. Two areas of recent research will serve to illustrate, the first concerning responsibility and blame.

Attitudes of blame are customarily treated as an appropriate sequel to assigning responsibility Watson By emphasizing the tie between responsibility and morally-neutral agency, Hanna Pickard uncouples responsibility from blame. At least for the apparently willful behavior of those diagnosed with disorders affecting agency, she argues, the proper stance for the care-giver is grounded in an empathic attitude that assigns responsibility without blaming, because it is one most conducive to improvement and recovery Pickard Closely related to these philosophical concerns about responsibility are issues involving the personality disorders, which, due to their long-recognized relationship to more normal character weaknesses, and their evidently dimensional nature, sit uneasily within psychiatric classifications Sinnott-Armstrong ; Radden ; Pickard Among one DSM grouping cluster B personality disorders, including borderline, narcissistic and antisocial , additional distinguishing features have been observed: their symptoms are described using moralistic language.

Philosophical challenges to customary moral, ethical, and medical presuppositions introduced in this section have been influenced by, and are difficult to separate from, critiques of medical psychiatry during the second half of the twentieth century that have taken place not only within academe, but also beyond it. These are discussed in Section The category of psychosis, employed for extreme states of disorder affecting perceptual capabilities in hallucinations and reasoning in delusions , are introduced here, followed by a sample of particular disorders among the many that have received philosophical attention: addiction, anorexia, psychopathy anti-social personality disorder , and depression.

The severity of hallucinations and delusions, with almost unfailing consequences for the fate of their subject in clinical, legal, social, and personal settings, serves to distinguish them from many of the general controversies about disorder noted thus far. They have also been the impetus for important collaborative work between several sciences: in addition to being psychiatric disorders delusions occur as symptoms of neurological diseases of and injury to the brain, and as such have been subject to considerable empirical study. Philosophical research on delusions primarily addresses issues about their intelligibility; about their status in relation to more normal doxastic states; and about explanatory models.

The intelligibility of delusions remains contested. Delusions are expressed using unexceptional syntax, and some involve content that, while inaccurate or implausible, is entirely comprehensible. These, Jaspers insisted, are secondary delusions; primary delusions, in contrast, are distinguished by their meaninglessness: attributing meaning to them is a misapplication of the hermeneutic approach Jaspers []; Gorski Influenced by Wittgenstein, others have adopted the position that all delusions are meaningless utterances Berrios Findings in brain science have been employed to confirm the latter view.

Delusions are hypothesized to reflect thought and narrative fragments trapped in the off-line, default cognitive mode, due to brain activity that prevents processes of critical evaluation Gerrans Delusions are belief-like, but disagreements arise over whether they are beliefs, imaginings, some formes frustes of one of these two, or a distinct hybrid form.

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The doxastic position delusions are beliefs must somehow accommodate that compared to typical beliefs, delusions are not responsive to countervailing evidence, and are only weakly behavior guiding. See entry for Delusions. Increasingly, explanations of delusions are multi-factorial. Added to these difficulties, the phenomenology of addiction is not uniform Kennett Similarly, addicts have been characterized as engaging in a misevaluation that, serving to explain their resistance to contrary evidence, is further reinforced by unthinking and impulsive behavior Summers ; Lewis Among eating disorders, the apparently voluntary self-starvation known as anorexia nervosa has been a subject of intense speculation and theorizing.

Because of its strong gender link, this behavior has been interpreted as an attempt to exert power by a group adolescent girls and young women marked by powerlessness, in a form of extreme, perfectionistic self control, creating an alienated, unheimlich body Svenaeus The disorder apparently occurs more frequently in settings of Western or Westernized, influence and affluence. So the motivation of the anorexic individual deserves attention, especially her beliefs, attitudes and feelings Giordano ; Svenaeus ; Morris See Morris ; Gadsby In their apparent failure to recognize the difference between moral and merely conventional transgressions, it has been questioned whether so-called psychopaths those diagnosed with antisocial personality disorder are appropriately held responsible for their attitudes and actions Sinnott-Armstrong ; Adshead ; whether, in seeming to hold normal moral beliefs without being motivated by them, they provide a counterexample to motivational internalism; and whether their observed amygdala dysfunction serves to excuse Levy Treatment approaches critically rest on how these traits are understood Maibom For further discussion of psychopathy, see entry on Philosophy of Psychiatry.

Since the humoral theories of earlier eras, mood disorders have been strongly associated with bodily states. Laing, and Michel Foucault. Many of these involved social and political critiques and calls to action, with real-world consequences that have been linked to deinstitutionalization, human rights movements, and a shift towards more autonomy-focused mental health care. Interwoven with these ideas from the start have been relentless critiques from feminist theory.

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Lloyd ; Potter