SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of East Anglia

Meyer’s psychobiology Adolf Meyer ( )

Meyer’s psychobiology Adolf Meyer ( ) Professor, Johns Hopkins

Meyer’s psychobiology Adolf Meyer ( ) Professor, Johns Hopkins “Dean of American psychiatry” first half of 20 th century

Meyer’s psychobiology Distinctively pragmatic and instrumental approach

Meyer’s psychobiology Distinctively pragmatic and instrumental approach “As a result of his efforts …, American psychiatrists began to ask, not "What is the name of this affliction?" but rather, "How is this man reacting and to what?” (Karl Menninger, The vital balance, 1963)

Commonsense psychiatry of Adolf Meyer Mental disorders as disturbances of adaptation

Commonsense psychiatry of Adolf Meyer Mental disorders as disturbances of adaptation Less concerned with symptoms and disease than understanding the conditions of mental reactions

Commonsense psychiatry of Adolf Meyer Mental disorders as disturbances of adaptation Less concerned with symptoms and disease than understanding the conditions of mental reactions The person as the essential setting for all medical thought

Commonsense psychiatry of Adolf Meyer Recognition of inherent uncertainty in psychiatric and medical practice

Commonsense psychiatry of Adolf Meyer Recognition of inherent uncertainty in psychiatric and medical practice Psychobiology never really took hold as a systematic theory of psychiatry

Commonsense psychiatry of Adolf Meyer Recognition of inherent uncertainty in psychiatric and medical practice Psychobiology never really took hold as a systematic theory of psychiatry “I should have made myself clear and in outspoken opposition, instead of a mild semblance of harmony”

Meyer’s views on psychiatric classification Statistical manual for the use of institutions for the insane (1918), American Medico-Psychological Association

Meyer’s views on psychiatric classification Statistical manual for the use of institutions for the insane (1918), American Medico-Psychological Association “I have no use for the essentially ‘one person, one disease’ view”

Meyer’s views on psychiatric classification Statistical manual for the use of institutions for the insane (1918), American Medico-Psychological Association “I have no use for the essentially ‘one person, one disease’ view” “…statistics published…are a dead loss…and an annual ceremony misdirecting the interests of staff”

Neo-Kraepelinian approach Disease entities in psychiatry - single morbid process

Neo-Kraepelinian approach Disease entities in psychiatry - single morbid process Dementia praecox and manic depressive illness

Neo-Kraepelinian approach DSM-III introduced operational criteria to replace so-called vague, imprecise concepts

Neo-Kraepelinian approach DSM-III introduced operational criteria to replace so-called vague, imprecise concepts Associated with reaffirmation of implicit “medical model” with focus on brain mechanisms

Neo-Kraepelinian approach DSM-III introduced operational criteria to replace so-called vague, imprecise concepts Associated with reaffirmation of implicit “medical model” with focus on brain mechanisms and positivistic approach to science

A neo-Meyerian approach to diagnosis (1) Psychiatry should not abandon diagnosis, but recognise it for what it is

A neo-Meyerian approach to diagnosis (1) Psychiatry should not abandon diagnosis, but recognise it for what it is (2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis

A neo-Meyerian approach to diagnosis (1) Psychiatry should not abandon diagnosis, but recognise it for what it is (2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis (3) Psychiatry should avoid the reification of diagnostic concepts

(1) Psychiatry should not abandon diagnosis, but recognise it for what it is Classification is justified as essential for scientific communication

(1) Psychiatry should not abandon diagnosis, but recognise it for what it is Classification is justified as essential for scientific communication Diagnosis is not only about identifying disease but also understanding reasons for action

(1) Psychiatry should not abandon diagnosis, but recognise it for what it is Diagnosis as a means of attempting to manage individual clinical complexity

(1) Psychiatry should not abandon diagnosis, but recognise it for what it is Diagnosis as a means of attempting to manage individual clinical complexity Fuzzy boundaries between concrete syndromes

(1) Psychiatry should not abandon diagnosis, but recognise it for what it is Diagnosis as a means of attempting to manage individual clinical complexity Fuzzy boundaries between concrete syndromes Lack of empirical evidence for “point of rarity”

(1) Psychiatry should not abandon diagnosis, but recognise it for what it is Diagnosis as a means of attempting to manage individual clinical complexity Fuzzy boundaries between concrete syndromes Lack of empirical evidence for “point of rarity” Mental disorders cannot be natural kinds

(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis "… assuredly an unreliable system must be invalid” (Robert Spitzer)

(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis "… assuredly an unreliable system must be invalid” (Robert Spitzer) Rosenhan - psychiatric diagnosis is subjective and does not reflect inherent patient characteristics

(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis "…Reliability is paradoxical – attenuation paradox

(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis "…Reliability is paradoxical – attenuation paradox Increasing internal consistency creates overly narrow measurement that will not assess construct optimally

(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis Diagnostic concepts are simply categories justified by clinical utility

(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis Diagnostic concepts are simply categories justified by clinical utility Working concepts for clinicians

(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis Diagnostic concepts are simply categories justified by clinical utility Working concepts for clinicians Value-laden nature of diagnosis is not a sign of scientific deficiency but of its meaningful nature

(3) Psychiatry should avoid the reification of diagnostic concepts Too easily assume a concept is an entity of some kind

(3) Psychiatry should avoid the reification of diagnostic concepts Too easily assume a concept is an entity of some kind Acts as justification for treatment

(3) Psychiatry should avoid the reification of diagnostic concepts Too easily assume a concept is an entity of some kind Acts as justification for treatment "Very often the supposed disease back of it all is a myth and merely a self- protective term for an insufficient knowledge of the conditions of reaction"

(3) Psychiatry should avoid the reification of diagnostic concepts Unobservable hypothetical construct

(3) Psychiatry should avoid the reification of diagnostic concepts Unobservable hypothetical construct Prototype or ideal type

(3) Psychiatry should avoid the reification of diagnostic concepts Unobservable hypothetical construct Prototype or ideal type Idealised description of those aspects of concrete reality that interest us

Psychiatric diagnosis as a contested area Neo-Kraepelinian vs. Neo-Meyerian

Psychiatric diagnosis as a contested area Neo-Kraepelinian vs. Neo-Meyerian WPA Institutional Program on Psychiatry for the Person

Psychiatric diagnosis as a contested area Neo-Kraepelinian vs. Neo-Meyerian WPA Institutional Program on Psychiatry for the Person DH Finding a shared vision of how people’s mental health problems should be understood

Psychiatric diagnosis as a contested area There is as much consensus for the neo- Meyerian paradigm as there is the neo- Kraepelinian orthodoxy