James Phillips

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.

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.

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.

In “Whole Life Narratives and the Self” David Lumsden (2013) has provided us with a clear review of the debate over narrative and personal identity and has staked out his own position in that debate. Arguing against neo-Lockean views of an atomistic self, he defends a narrative component in personal identity. Specifically, he argues that personal identity or self involves “a bundle of narrative threads” (p. 1), but does not require the grand unity of a master narrative—a whole life narrative. It follows for him that the understanding—and treatment—of fragmented psychiatric states does not require whole life narratives. In his analysis, he is both defending a philosophical position regarding narrative and personal ..

This paper addresses the role of categories and dimensions in the classification of psychopathology. While psychopathology does not sort itself out neatly into natural categories, we do find rough, symptom-based groupings that, through refinement, become diagnostic categories. Given that these categories suffer from comorbidity, uncertain boundaries, and excessive “unspecified disorder” diagnoses, there has been a move toward refining the diagnoses with dimensional measures. The paper traces efforts both to improve the diagnostic categories with validators that allow at least partial validity and to introduce dimensional measures into the diagnostic manual. Drawing from the philosophical pragmatism of Charles Sanders Peirce, William James, and John Dewey, which emphasizes the practical, effect-sensitive consequences of a theory along with an emphasis on empirical evidence and the progressive, probabilistic character of knowledge, the paper argues that these efforts must be guided both by scientific validity and clinical utility.

The author has reviewed the history of biological theories of depression with a fascinating account of how researchers have argued backward, starting with the neurochemical effects of antidepressants on the monoamine system in the brain, and ending with etiological theories that place the biological cause of depression in disturbances of the monoamine system. He explains how further work in biological etiology has followed the same backward path. In carrying out this task, he has done such an excellent job that I have little to offer as a critique of his work. The author uses a research model developed by Lakatos, and he points out that Lakatos's approach...

In lieu of an abstract, here is a brief excerpt of the content:Commentary on “Non-Cartesian Frameworks”James Phillips (bio)Whither psychoanalytic theory and practice? This is the question raised by Louis Berger as he confronts psychoanalysis’s response to the collapse of Cartesianism that has shaken the foundations of other humanist disciplines (as well as the natural sciences) and has finally caught up with Freud’s heirs. Anyone wanting evidence of this shakeup in psychoanalysis need only consult the final 1994 issue of the International Journal of Psycho-Analysis. For the seventy-fifth anniversary edition of the journal, the editors organized a symposium on “The Conceptualization and Communication of Clinical Facts in Psychoanalysis.” In his foreword to the 300-page issue, the editor, David Tuckett (1994, 865–70), evokes the theoretical pluralism that has beset the field and asserts what is the presupposition of all the articles that follow: There are no theory-free facts, and the challenge now is to deal with this reality.I think I can assume, however, that for Berger these papers would mostly fall into his category of “not going far enough.” He invokes a Cartesian representationalism, critiqued variously by Heidegger, Wittgenstein, and Castoriadis, that continues to infect even such discussions of fact and theory in psychoanalysis as those in the landmark volume of the International Journal. Thus, though that volume may represent the official announcement of the death of positivism in psychoanalysis, it stops short of announcing the profession’s entry into the postmodern era. Indeed, it should be noted that in much contemporary discussion, an awareness of the issues of theoretical pluralism and fact/theory dilemmas rests quite comfortably with the most blatant examples of representational thinking. The object-relations tradition, for instance, remains such a dominant force that most of us would have a hard time giving up our talk of internal objects and internal representations.Berger’s presentation of the three critics of representational thought is clear and enlightening. The inclusion of Castoriadis is important because he, unlike Heidegger and Wittgenstein, is a clinician. Berger’s application of this critique of representation to psychoanalysis, and specifically to the question of the theory/practice relationship, is also developed in a meaningful way. (For a development of the critique of representational thinking that emphasizes the role of Locke in expanding the Cartesian tradition, see Nasser 1994.) Since I am in agreement with the thrust of Berger’ s presentation and have little to add to it, I will focus my comments on one area that I think does warrant further discussion—the relations between the postmodern and other postempiricist or postpositivist traditions. Although some writers (e.g., Leary 1994; Silverman 1994) tend to group movements such as postmodernism, hermeneutics, [End Page 187] and social constructionism together, Berger’s argument singles out postmodernism as the only truly nonrepresentational postempiricist movement.Of the other non-Cartesian traditions, Berger says that “their tacit retention of representationalism (including its concomitant, the theory/practice dichotomy) demonstrates their failure to identify, adequately understand, or avoid key Cartesian difficulties and limitations. They fail to appreciate the effects which accompany enframing.” He adds later: “I have been making my point with examples drawn mostly from the American Middle School, but I submit that any analytic position that invokes models or analogous logical formalisms—e.g., hermeneutic, self-psychological, constructionist, action linguistic—is subject to the identical criticisms.” I wish to take up the case of hermeneutics and question whether its differentiation from postmodernism does indeed revolve around the issue of representational thought. Sorting this issue out will bear on the final conclusions of Berger’s paper. It is true, as Berger points out, that hermeneutic discussion in psychoanalysis often involves a comparison of (representationally articulated) models; but that is not the whole story regarding hermeneutics. Remember, after all, that Heidegger—directly in Being and Time (1962, 62), and indirectly through his profound influence on Gadamer—was a pivotal figure in the development of hermeneutics. Heidegger considered his analysis of man’s precognitive enmeshment in the world to be a “hermeneutic of Dasein.” For his part, Gadamer’s analysis of man’s relations to others and to the world concludes in a relationship that is mediated through a language that is fully dialectical and...

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.1 (2002) 61-63 [Access article in PDF] Arguing from Neuroscience in Psychiatry James Phillips PHILIP GERRANS "A One-stage Explanation of the Cotard Delusion" provides an elegant example of the application of neuroscientific findings to known clinical phenomena in psychiatry. Gerrans argues that, in the cases of the Cotard and Capgras delusions, a one-stage explanation is sufficient to account for the clinical phenomena. That is, the neuroanatomic defect and the consequent anomalous experience are sufficient to produce the delusion. According to Gerrans, we do not need to postulate that the delusion will emerge only if the anomalous experience is filtered through a faulty reasoning process (a two-stage explanation). Against the argument of Young and Leafhead (1996) that Cotard and Capgras delusions stem from the same neuroanatomic deficit and differentiate only in being processed differently—thus requiring a two-stage explanation—Gerrans argues that the respective neuroanatomic defects are in fact different, and that, therefore, the two delusional syndromes differ at the first stage and do not require the two-stage explanation suggested by Young and Leafhead.I do not have an opinion as to who is right in this disagreement, and I will devote these remarks to explaining why I do not have an opinion. In developing this explanation I will touch on what I find problematic in many discussions of neuroscience, neurocognitive models, and clinical psychiatry; I will thus use this article to highlight those problems.On the face of it, one would think that the issue raised by Gerrans should admit of a simple resolution. He argues that Capgras and Cotard delusions derive from different neural defects. Young and Leafhead, on the other hand, base their two-stage argument on the argument that the two delusions derive from the same neural defect. So which is it? Neuroscientists should be able to settle the issue and end the dispute. Gerrans remarks "that we need to look more closely at the CN [cognitive neuropsychiatric] explanation of the Capgras delusion." As he describes it, face recognition involves two components, a cognitive and an affective component, with separate neuroanatomic substrates. An individual successfully recognizes the face of a friend or acquaintance when she matches the cognitive recognition (cognitive component) with the affective tone of familiarity (second component). When there is a lesion in the neural substrate of the affective component, she may recognize the face but without the tone of familiarity. In her effort to understand her affective experience of the face as alien rather than as familiar, she may conclude that her friend has been replaced by a double. Thus we have the Capgras delusion.Let us now unpack this explanation. According to Gerrans, researchers have hypothesized [End Page 61] two anatomatically distinct pathways involved in face recognition. He writes: "Initially... these separate neuroanatomic substrates were hypothesized to lie in separate dorsal and ventral processing pathways, but the most persuasive hypothesis is that of Breen et al. that face recognition is performed in the ventral visual processing pathway, whereas covert [affective] recognition effects result from the activation of pathways connecting the ventral pathway and the limbic system. It is damage to these latter pathways that gives rise to the Capgras delusion."In other words, the explanation of Capgras delusions depends on a neurocognitive model, itself based on an unspecified base of neuroanatomic data. When Gerrans writes that "[t]he Capgras delusion arises in cases where, following a neurological accident, the pathways connecting the FRU [Face Recognition Unit] to the limbic system are damaged leaving ventral pathways and hence overt recognition unimpaired...," he means that the Capgras delusion arises in that manner if the proposed model bears any relation to the reality of the living brain and if real Capgras patients have suffered the hypothesized lesion. At this point the reader is struggling with the following questions: (1) What are the hard neuroanatomic data underpinning the neurocognitive model? (2) What is the argument for developing this model (single Face Recognition Unit with independent pathways to cognitive and affective components of face recognition) out of the hard data? (3) What is the evidence...

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.4 (2001) 343-346 [Access article in PDF] Kimura Bin on Schizophrenia James Phillips With "Cogito and I: A Bio-Logical Approach," Kimura has continued his research into the core disturbance in schizophrenia. In his work, he has combined an original phenomenological approach with some fundamental concepts taken from his native Japanese and Zen culture. As in the work of others in the tradition of phenomenological psychiatry, he has focused on a basic disturbance that underlies the positive symptoms found in schizophrenic conditions. In what follows, I will attempt to relate this current effort to some of his previous work on schizophrenia. I will conclude this commentary with some remarks on what I find problematic in the treatment of Heidegger.In "Cogito and I," Kimura plunges us directly into the core ego disturbance of schizophrenic patients by quoting two patients who, each in his own words, describe a pathological split between what we may call a "subjective" and an "objective" I or self. The latter is the self that acts and is recognizable by others (and by the patient) as the agent acting in the world. The former, the subjective self, is the non-objectified sense of self or self-awareness that accompanies all our actions. The two must be integrated, and it is a failure of this integration that is at the basis of the schizophrenic's ego disturbance.We can gain further clarification of this central notion in Kimura's treatment of schizophrenia through reference to some of his other discussions of the topic. In "Reflection and Self in the Schizophrenic" (Kimura 1992b), he invokes Husserlian terminology to discuss the same polarity within the self. 1 In this study, he distinguishes "simultaneous reflection" (the subjective self) from "secondary reflection" (the objective self). In the latter, the self is a noematic object of reflection; it is the image of myself after the act, the I that has done something and can now be captured in reflection. While "Cogito and I" describes the schizophrenic split as between the noematic self and the noetic self of simultaneous reflection, "Reflection and Self in the Schizophrenic" locates the split further back within the noetic self. Kimura distinguishes in the noetic self an observing I from the I that is moving toward action, both prior to the noematic self of secondary reflection. "One could say that a subjective self here accompanies an other self no less subjective and observes it constantly 'from behind'. There is no objective, noematic self involved here; a sole noetic self splits into two simultaneous 'moments' which occupy alternitively the places of seeing and seen, and which nonetheless remain subjective-noetic" (Kimura 1992b, 118). Pélicier emphasizes this Husserlian analysis in his exposition of Kimura Bin's phenomenological treatment of schizophrenia: The Self is never grasped as an object, but rather experienced in a noetic mode. On the other hand, the representation (l'image), as an object of consciousness, and in a certain manner all representations (images), as objects of consciousness, are of the noematic [End Page 343] order in Husserl's sense. Kimura insists then on the difference between this auto-perception (jikaku) in the noetic register and its content, which, itself, is noematic. Starting from this analysis, Kimura poses to himself the question of the nature of schizophrenia.... (Pélicier 1984, 32) In still another treatment of the theme, "Pathology of the Immediate" (Kimura 1992c), Kimura Bin focuses on the role of language in the structure of the self. The circuit of simultaneous and secondary reflection described above is played out in the pre-linguistic and linguistic dimensions of the self. Simultaneous reflection is immediate and fugitive in a manner that escapes articulation but at the same time, very readily flows into a secondary reflection that exists only as a mediated, articulated, noematic self. As Kimura puts it, "As for the I, which seems apparently the most immediately given, this also, when it becomes conscious of itself as 'I,' is constituted equally as an experience mediated by a negative differentiation that inserts itself between the 'I' that is in the process of becoming...

In commenting on Hamm, Buck, and Lysaker’s “Reconciling the Ipseity-Disturbance Model with the Painful Affect in Schizophrenia”, let me first acknowledge the authors’ fine work in delineating this issue. They review very clearly the history of theoretical models of schizophrenia, including biological, psychoanalytic, and phenomenological approaches. They emphasize the need to include accounts of subjective experiences of persons with schizophrenia, and for this they underline the role of phenomenological research. In the latter, they note an emphasis on cognitive and perceptual disturbances, with an apparent neglect of painful affective experience. To demonstrate the neglect, they focus on the work of Louis..

In lieu of an abstract, here is a brief excerpt of the content:Madness of the Philosophers, Madness of the ClinicJames Phillips (bio)KeywordsPhilosophy, insanity, moral, natural, Hegel, KierkegaardDaniel Berthold's "Talking Cures: A Lacanian Reading of Hegel and Kierkegaard on Language and Madness" is an eloquent discussion of speech, silence, and the 'talking cure' in the three figures highlighted in the title. There is much to admire in this paper. The treatment of speech and silence in the thought of Hegel and Kierkegaard, with many well-chosen quotations, offers much for reflection, both with respect to these philosophers and more generally with respect to the human condition. This is a paper that deserves more than one reading. I find nothing to criticize here and intend the following as further discussion of the themes Berthold has brought to us. Taking his cue from Lacan and reading back into the nineteenth-century figures from the perspective of Lacan's emphasis on language and what he (Lacan) terms the Symbolic, Berthold explores the question of madness in Hegel and Kierkegaard. In my remarks, I connect Berthold's analysis with older traditions of madness, distinguishing what I call the madness of the philosophers and the madness of the clinic.With the phrase, madness of the philosophers, I refer to a longstanding philosophic tradition that opposes reason and passion and attributes madness to an excess of the latter. In Berthold's paper, Hegel is the representative of this position, with his description of madness as a regression into the primitive "life of feeling." As Berthold puts it:For Hegel, madness is a "reversion" or "withdrawal" or "sinking back" of the rational consciousness into the primitive world of instincts and drives, or what Hegel calls "the life of feeling" (Gufühlsleben), which he locates in "the soul," where the "mind is still in the grip of nature"... The soul is "the form of the dull stirring, the inarticulate breathing of the spirit through its unconscious individuality" (in seiner besusstlosen Individualität)... The mind becomes "mastered" by the archaic, unconscious drives of the soul: "the natural self... gains mastery over the... rational consciousness."(2009, 301)Taking off from Lacan in his interpretation of Hegel, Berthold associates reason with language—or, in Lacan's terminology—the register of the Symbolic. Hegel's "life of feeling"—or of passion—is inarticulate, primitive, and vulnerable to madness.Berthold analyzes Kierkegaard in these categories. On the one hand, Kierkegaard is driven to silence, subjectivity, and inwardness as the native [End Page 313] ground of faith. On the other hand, he recognizes something maddening in his extreme solitude, and acknowledges his need to write as a form of self-therapy: "If I stop [writing] for a few days, right away I become ill.... So powerful an urge, so ample, so inexhaustible [is my need to write], subsist[ing] day after day for... years." Kierkegaard's compromise is his "indirect communication." By Berthold's account, Kierkegaard's silence does not rate very high for Hegel and Lacan. For Hegel it represents a regression into the primitive "life of feeling." For Lacan, Kierkegaard's silent inner self is "a myth—a 'shapeless vapor,' 'absolutely nothing.'" As we shall see, Kierkegaard's ambivalence toward silence and speech (or writing) does not fit neatly into the equation of silence and madness.What, however, in contrast to this madness of the philosophers, is the madness of the clinic?1 It is madness caused by disease, whether the latter be understood in ancient terminology of humors, or more modern terminology of brain disease. For a quick review of how clinical madness has played off against the madness of the philosophers, we can turn to the philosophers themselves, invoking Plato as our first guide, because he speaks of both kinds of madness. On the one hand, with his tripartite division of the soul, he is one of the inaugurators of the philosophic vision of madness as an overcoming of the rational part of the soul by the appetitive side. On the other hand, he implicitly endorses the Hippocratic, medical view of madness with a statement like this: "A man who commits one of these crimes might be suffering from insanity, or be as good as insane either because...