Posts Tagged ‘filosofia’

Psicanálise e Estética

Uma visão analítica dos efeitos da arte

com Christian Dunker

O conceito psicanalítico de sublimação tem ocupado o interesse clínico daqueles que se ocupam da experiência estética. Ao lado da leitura e interpretação de obras de arte, estes têm sido os dois principais focos do encontro entre psicanálise e o campo artístico. O curso vai retomar uma terceira incidência da estética sobre a clínica, que remonta ao conceito grego que, séculos depois, foi anexado por Freud para o tratamento da histeria, chamado de catharsis – a purificação das emoções pela via da expressão. O relativo esquecimento da catarse como dispositivo clínico pode ser atribuído à dificuldade de caracterizar exatamente como a experiência estética transforma um sujeito. Os encontros, portanto, examinam também o que viria a ser um sujeito estético compatível com a clínica de Lacan.

O curso ocorrerá sexta-feira (18/09) e sábado (19/09) das 20h às 22h.

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DSM in Philosophyland: Curiouser and Curiouser, Allen Frances *

*  é um dos organizadores da última versão do Manual Diagnóstico e Estatísticos de Transtornos Mentais (DSM-IV) .

      First off, thanks to James Phillips for inviting these stimulating commentaries. Second, a confession. My last (and only) formal training in philosophy was a freshman course in college that went well over my head. Now I have been invited to share my (probably sophomoric) speculations on the meanings that swirl below the surface of psychiatric classification. I do so without any confidence they can survive rigorous analysis by  those more expert than I in the tools of philosophic inquiry. Much of what I say below may be simple minded or simply wrong. What I do understand (perhaps better than anyone) are the practical issues of creating a psychiatric manual and the many good and bad (intended, unintended) consequences it can have. My views on deeper meanings are given, and should be taken, with a large grain of salt.

The Epistemologic Game

        First Umpire: “There are balls and there are strikes and I call them as they are.”

Second Umpire: “There are balls and there are strikes and I call them as I see them.”

Third Umpire: “There are no balls and there are no strikes until I call them.”

As I recall it, the three umpires are replaying a marathon epistemological game that: 1) began with Plato; 2) continued in the medieval joust between the realists and Occam’s nominalists; 3)was revived in the post-renaissance debate between Descartes and Vico on the power and limits of rational thought; 4)was refined by Kant; 5)churned up by Freud; and 6)finally settled by quantum physicists who have sharply downgraded the capacity of the human mind to ever fully intuit (much less understand) reality. Closer to my turf, I like to think of Bob Spitzer as umpire #1,  me as umpire #2, and Tom Szasz as umpire #3.

Spitzer’s achieved a paradigmatic revolution in psychiatric diagnosis and nosology. He introduced the method of diagnostic criteria (originally developed for research purposes) into a tool for general clinical practice. For the first time, psychiatrists could agree on diagnoses and make interpretive judgments across the research/ clinical interface. Certainly, the level of reliability achieved by DSM- III was over sold, especially when it was used by the average clinician. But DSM III was a huge leap forward from the useless and neglected guidance offered by DSM-I and DSM-II. It gave hope that psychiatry could become scientific and join in the advances that were being made in the rest of medicine.

DSM-III resulted from and promoted the victory of biological psychiatry over the psychological and social models that until then were its serious competitors. In the early dawn of its triumph, the biological model was presented with a realist, reductionist flourish that would have done umpire #1 proud. Mental disorders were real entities that existed  “out there.” The process of scientific discovery would elucidate their etiology and pathogenesis using the powerful new methods of neuroscience, imaging, and genetics.

The next section will focus on the disappointing fate of this ambitious program, but one  central point belongs here. Biological psychiatry has failed to produce quick, convincing  explanations for any of the mental disorders. This is because it has been unable to circumvent the fundamental and inherent flaw in the biological, “realist” approach – mental disorders don’t really live “out there” waiting to be explained. They are constructs we have made up – and often not very compelling ones at that. It has, for example, become clear that there is no one prototype “schizophrenia” waiting to be explained with one incisive and sweeping biological model. There is no gene, or small subset of genes, for “schizophrenia.” As Bleuler intuited, “schizophrenia” is rather a group of disorders, or perhaps better a mob. There may eventually turn out to be twenty or fifty or two hundred kinds of “schizophrenia.” As it stands now the definition and boundaries of “schizophrenia” are necessaarily arbitrary. There is no clear right way to diagnose this gang and not even much agreement on what the validators should be and how they should be applied. The first umpire was called out on strikes when the holy grail of finding the cause of “schizophrenia” turned out to be a wild goose chase.

Szasz is the third umpire. He quickly saw through the epistemological “no clothes” of umpire #1 and led the fight against simple minded biological reductionism (even well before the biologists had discovered their own voice and began making their overly ambitious and naïve claims). Szasz vigorously presented the view that mental illness is a medical “myth.”  Mental disorders were no more than social constructs that in some cases served a useful purpose, but in many others could be misused to exert a noxious social control, reducing freedom and personal responsibility. The biological “realists” reacted predictably to Szasz’ “nominalist” attack. They dismissed it. “If schizophrenia is a myth, they crowed, it is a myth that responds to medication and has a genetic pattern.” But their triumphalism was premature and based on both weak philosophic and weak scientific grounds. It turned out that the neuroscience, genetics, and treatment response of “schizophrenia” follow anything but a simple reductionist pattern. The more we learn about “schizophrenia” the more it resembles a heuristic, the less it resembles a disease.

This brings us to me (a call’um as I see’um) second umpire. In preparing DSM-IV, I had no grand illusions of seeing reality straight on or of reconstructing it whole clothe from my own pet theories. I just wanted to get the job done – i.e., produce a useful document that would make the fewest possible mistakes, and create the fewest problems for patients. Following Vico, I accepted that much in real life ( and almost everything in psychiatric classification) is overlapping, fuzzy, and heterogeneous – anything but Cartesian and amenable to overarching rationalist principles or mathematical precision. Psychiatric classification is necessarily a sloppy business. The desirable goal of having a classification consisting of mutually exhaustive, non-overlapping mental disorders is simply impossible to meet.

Instead, the second umpire follows a down-to-earth brand of Bentham utilitarian pragmatism. His umpire’s eye is fixed on the end result of getting to what works best – not distracted by biological reductionism or rationalist models of how things should be constructed. A diagnosis is a call to action with huge and unpredictable results. No decision can be right on narrow scientific grounds if it winds up hurting people.

Descriptive Psychiatry Gets Long of Tooth

The Dodo: “Everyone has run and everone has won and all must have prizes”.

      Modern descriptive psychiatry just passed its 200 birthday – if we measure it from the milestone of Pinel’s creation of the first psychiatric classification that resembles our own. His work was born from the Enlightenment belief in a rational world – some underlying order could be imposed even on the obvious irrationality of mental illness. The premise was that any domain receiving systematic observation and classification would eventually display causal patterns.

This approach was enormously successful in each of the major paradigm shifts in science. Always a careful description preceded a causal model. Kepler’s astronomical observations led toNewton’s gravity. Linnaeus’ classification of plants and animals led toDarwin’s  evolution. Mendeleyev’s periodic table led to Bohr’s structure of the atom. There have been dozens of descriptive systems vieing to describe things so brilliantly that their truth would shine forth. “All have run, but none has won prizes.” Descriptive classification in psychiatry has so far been singularly unsuccessful in promoting a breakthrough discovery of the causes of mental disorder.

This is doubly disappointing given the miraculous advances in our understanding of  normal  brain functioning. The advances in molecular biology, brain imaging, and genetics are spectacular – their impact on understanding psychopatholgy almost nil. Why the disconnect? The answer lies in a paraphrase of the opening lines of Anna Karenina. All normal brain functioning is normal in more or less the same way, but any given type of pathological functioning can have many different causes.

This is also true for all the complex diseases in medicine. A genetics company using  the Icelandic registry had tremendous success in finding gene markers for a dozen diseases, including schizophrenia. It recently went bankrupt because, in each instance, the particular candidate marker explained fewer than three per cent of the cases of the particular disease. There appear to be no common genes even for the common illnesses. Psychopathology is heterogeneous and overlapping not only in its presentation but also in its pathogenesis. There will likely be hundreds of paths to schizophrenia, not one or just a few and perhaps no final common pathway. Where does that leave the descriptive system of psychiatry? Fairly high and dry. Nature has obviously chosen to deprive us of clear joints, ripe for carving. There is little indication of any imminent and sweeping etiological breakthrough. Everything points towards a slow and painstaking retail accumulation of explanatory power. It is not even clear that the DSM categorical approach is the best research tool. The NIMH is embarking on a project to correlate an integrated exploration of neural networks with psychopathology. They chose to study dimensions of behavior (e.g. anxiety, pleasure seeking, executive functioning)  – not with the standard psychiatric disorders which are deemed too complex to have any simple relationship with a given neural network. Our DSM categories may not lead the future charge in understanding psychopathology.

Our descriptive classification of disorders is old and tired. It has worked hard for us and  continues to have many valuable and irreplaceable functions (which we will discuss in the last section). Fiddling needlessly with the labels will not advance science and may actually do more harm than good in its effect on clinical care.

The Elusive Definition of Mental Disorder

Humpty Dumpty: “When I choose a word it means just what I choose it to mean.”

      When it comes to defining the term “mental disorder” or figuring out which conditions qualify, we enter Humpty’s world of shifting, ambiguous, and idiosyncratic word usages. This is a fundamental weakness of our field. Many crucial problems would be much less problematic if only it were possible to frame an operational definition of mental disorder that really worked.

Nosologists could use it to guide decisions on which aspects of human distress and malfunction should be considered psychiatric – and which should not. Clinicians could use it when deciding whether to diagnose and treat a patient on the border with normality. A meaningful definition would clear up the great confusion in the legal system where matters of great consequence often rest on whether a mental disorder is present or absent.

Alas, I have read dozens of definitions of mental disorder (and helped to write one) and I can’t say that any have the slightest value whatever. Historically, conditions have become mental disorders by accretion and practical necessity, not because they met some independent set of operationalized definitional criteria. Indeed, the concept of mental disorder is so amorphous, protean, and heterogeneous that it inherently defies definition. This is a hole at the center of psychiatric classification.  And the specific mental disorders certainly constitute a hodge podge. Some describe short term states, others lifelong personality. Some reflect inner misery, others bad behavior. Some represent problems rarely or never seen in normals, others are just slight accentuations of the everyday. Some reflect too little control, others too much. Some are quite intrinsic to the individual, others are defined against varying and changing cultural mores and stressors. Some begin in infancy, others in old age. Some affect primarily thought, others emotions, yet others behaviors, others interpersonal relations, and there are complex combinations of all of these. Some seem more biological, others more psychological or social. If there is a common theme it is distress and disability, but these are very imprecise and nonspecific markers on which to hang a definition.

Ironically, the one definition of mental disorder that does have great and abiding practical meaning is never given formal status because it is tautological and potentially highly self serving. It would go something like “Mental disorder is what clinicians treat and researchers research and educators teach and insurance companies pay for.” In effect, this is historically how the individual mental disorders made their way into the system.

The definition of mental disorder has been elastic and follows practice rather than guides it. The greater the number of mental health clinicians, the greater the number of life conditions that work their way into becoming disorders. There were only five disorders listed in the initial census of mental patients in the mid nineteenth century, now there are close to three hundred. Society also has a seemingly insatiable capacity (even hunger) to accept and endorse newly defined mental disorders that help to define and explain away its emerging concerns. As a result, psychiatry is subject to recurring diagnostic fads. Were DSM-V to have its way we would have a wholesale medicalization of everyday incapacity (mild memory loss with aging); distress (grief, mixed anxiety depression); defects in self control (binge eating); eccentricity(psychotic risk); irresponsibility (hypersexuality); and even criminality (rape, statutory rape).

Remarkably, none of these newly proposes diagnoses even remotely pass the standard loose definition of “what clinician’s treat.” None of these “mental disorders” has an established treatment with proven efficacy. Each is so early in development as to be no more than “what researchers research” – a concoction of highly specialized research interests.

We must accept that our diagnostic classification is the result of historical accretion and accident without any real underlying system or scientific necessity. The rules for entry have varied over time and have rarely been very rigorous. Our mental disorders are no more than fallible social constructs (but nonetheless useful ones if understood and applied properly).

The Conservative/Innovation Debate or Where Have All the Normals Gone?

Alice: “But I don’t want to go among mad people

Cheshire Cat: Oh, you can’t help it,we’re all mad here”


DSM-IV would have been a very different document if I had adopted Humpty Dumpty’s confident attitude and used my authority to shape it to my personal taste. Bob Spitzer, who had led the efforts to create DSM-III and DSM-IIIR is a “splitter” whose preference is to divide the diagnostic pie into small manageable pieces. This enhances reliability, but creates many new diagnoses and artificial comorbidity (as complex syndromes are divided into their component parts). I joke that Spitzer never met a new diagnosis he didn’t like.

I am more of a lumper and also very wary of diagnostic fads and the unintended consequences of introducing new diagnoses. Given my druthers, DSM-IV would have had fewer, lumped categories and tighter criteria sets to make it harder to get a diagnosis. Instead, I chose not to impose this view on DSM-IV. We would apply a conservative standard for all changes – equally not add new things or take out old ones unless there was substantial evidence to support the change. Many decisions were thus grand-fathered  into DSM-IV that would not have had nearly enough support to meet the new higher evidentiary standard.

I am not a particularly risk averse or conservative person in my everyday life. So why the conservative tilt in setting ground rules for DSM-V?

1) The system had previously been in great flux with the rapid fire appearance within

seven years of DSM-III and DSM-IIIR. It needed a period of stability;

2) The two previous DSM’s were the product of an innovative and charismatic figure who singlehandedly moved the field by dint of his energy, determination, and grit. Now that  his accomplishments were realized, it was time for a less personalized leadership and for the field at large to reclaim responsibility for its diagnostic system;

3) My experience working on DSM-III and DSM-IIIR was that most decisions were fairly arbitrary – with plausible supporting arguments that could have gone either way. Making more arbitrary changes didn’t make much sense;

4) The scientific evidence supporting proposed changes was usually meager. Requiring that all changes be based on substantial evidence usually shut up even the most passionate advocates;

5) The literatures are not only thin but also mostly derived from highly specialized research settings that have questionable generalizability to the real world.

One’s position on the conservative/innovation continuum is influenced by reactions to the epistemological question raised previously. If you regard the categories in DSM as descriptions of “real entities,” you will be eager to change definitions in accord with evidence that they can be better described in a way that captures their real natures. On the other hand, if you believe as I do, that the DSM is necessarily more an exercise in forging a common language than in finding a truth, you need a strong reason to change the syntax. And it turns out that such strong evidence is usually lacking. This is why the reliability and utility goals are so important (and for all the discussion about it, validation is not yet particularly meaningful).

The second divide in the conservative/liberal split relates to how worried one is by real world consequences. As a pragmatist, I was acutely conscious that every change made by DSM-IV could have enormous practical consequences: 1) determining who got medicines that could greatly help or greatly harm; 2)deciding insurance and disability claims; and 3)influencing life and death forensic issues. Those of a more pure research world, innovation orientation would argue for “following the data” and damn the consequences. In my view, data sets that are thin and selective are never sufficient

support for changes that can cause considerable mischief. So there are two contrasting attitudes. Mine, the conservative view, is “Do no harm – revise the system with a light and cautious touch only when you are sure of what you are doing after a thorough risk/ benefit analysis.” The conservative approach assumes that things are there for a reason and are imbricated in a complex set of relations. I have had the painful experience of changing a word or two in a seemingly harmless way and then later learning that we had helped trigger an “epidemic” of false positives (as in Attention Deficit Disorder) or a forensic nightmare (e.g., the misuse of Paraphilia NOS in the extended civil commitment of sexual offenders).

One of the commentaries presents quite the opposite view – that the existing system is so bad that even the aggressively innovative DSM-V is suggesting far too little change, not too much. I believe this to be a naïve Cartesian rationalist view that neglects the deep roots and far flung branches of the diagnostic system. Most of the suggested DSM-V changes are such really bad ideas that they do not even represent a meaningful test of the conservative/innovator divide. I believe that most sensible people informed of their risks and benefits would veto them (this leaves out the Work Group members who are otherwise sensible but too attached to their pet suggestions to be objective about their risks).

The new suggestions all share the common problem of greatly expanding the reach of “mental disorders” at the expense of normality. Armies of millions (perhaps tens of millions) false positive “patients” would receive unnecessary and harmful treatments. I have covered this problem extensively elsewhere and won’t repeat the details here. A better, because much tougher, test case of the conservative/innovator debate comes from the DSM IV introduction of Bipolar II disorder. Here there are strong arguments on both sides and no clear right answer.

We knew that adding Bipolar II would be one of the most consequential changes in DSM-IV but went ahead (despite our conservative bias) because of what seemed to be compelling enough research evidence (descriptive, course, family history, treatment response) that it sorted better with bipolar than with unipolar mood disorders. We recognized the risks that some unipolar patients would be mislabeled and receive unnecessary and potentially harmful, mood stabilizing and antipsychotic medication. But this risk seemed more than counterbalanced by the opposing risk posed by uncovered antidepressants for those whose bipolar tendencies were previously missed by the diagnostic system.

Several facts are incontestable about trends since DSM-IV: 1) with a huge push from the pharmaceutical industry, Bipolar II has become an enormously popular diagnosis;  2) so that the ratio of bipolar to unipolar patients increased dramatically; 3) and prescriptions jumped for mood stabilizers and antipsychotics (which can cause huge and dangerous weight gains),and 4) for different reasons  rates of childhood Bipolar Disorder have increased forty fold. Some patients are undoubtedly better off for being diagnosed as Bipolar II. Others have gained a lot of weight (and risk diabetes and a potentially shortened lifespan) taking a medication that was unnecessary.

A conservative might prefer that such public health experiments be based on more evidence than was available to us when we made the decision to include Bipolar II. We also had no way of anticipating how aggressive and successful were the pharmaceutical industry marketting efforts to move product. Bipolar II also illustrates the exquisite and dangerous sensitivity of the diagnostic system to small changes. The hugely consequential decision regarding the need for potentially very harmful medication rests on the most fragile and unreliable of distinctions – the decision whether or not a hypomanic episode is present. If the minimum duration of the episode is set at a week (or even longer), people at risk for antidepressant worsening will be missed; if the requirement is 4 days (or even less), many people will receive unnecessary medication. The symptom thresholds for defining a hypomanic episode are similarly arbitrary and subject to wide swings in sensitivity and specificity, based on very minor adjustments. Making this even more complicated are the difficulties distinguishing hypomania from normal mood in someone who is chronically depressed or hypomania from substance induced mood elevation in someone using drugs.

The point here is that tiny changes in definition can (and often do) result in large, unpredictable (and usually unwarranted) swings in diagnostic and treatment habits, especially when amplified by drug companies, advocacy groups, and the media. Such potentially dangerous fads are enough to turn a lifelong, risk-taking liberal like me into a conservative nosologist. First, last, and always – DO NO HARM.


The Talmud: “We don’t see things as they are, We see things as we are”.

      Many people are troubled by the relativism implied in this penetrating insight – but I find it liberating. We will never have the perfect diagnostic system. Our classification of mental disorders will always necessarily be no more than a collection of fallible and limited constructs that seek but never find an elusive truth. But this is our best current  way of seeing and communicating about mental disorders. And despite all its epistemological, scientific, and even clinical failings, the DSM does its job reasonably well if it is applied properly and its limitations are understood.

The concern about comorbidity across disorders arises from the misconception that each is a “real” and independent psychiatric illness and that clear boundaries should or could be created to separate them. If instead, one accepts that each disorder is just a description (not a disease), then the combined descriptions  become modular building blocks each of which adds precision and information.

The concerns about heterogeneity within diagnoses also reflect a longing for well defined psychiatric “illnesses.” Instead, we are dealing with descriptive prototypes (“schizophrenia,” “panic disorder,” “mood disorder,” etc., through the manual) that are inherently heterogeneous and will hopefullly with time be divided into many true etiologically defined illnesses.

The greatest misuse of the DSM occurs in diagnosing conditions at the border of normality and criminality. Clinicians should hold themselves to the most rigorous standards when applying criteria sets in these dangerous boundary territories. The DSM incorporates a great deal of practical knowledge in a convenient and useful format.

To not know it castes one outside the community of common language speakers – the language being clinical psychiatry. But it should always be used with pragmatism and clinical common sense.

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