SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double...

SOME ASPECTS OF THE MORAL BASIS OF

DIAGNOSIS: The challenge of

Meyer’s Psychobiology

D B DoubleNorfolk & Waveney Mental Health NHS FT

& University of East Anglia

Meyer’s psychobiology

Adolf Meyer

(1866-1950)

Meyer’s psychobiology

Adolf Meyer

(1866-1950)

Professor, Johns Hopkins 1908-1941

Meyer’s psychobiology

Adolf Meyer

(1866-1950)

Professor, Johns Hopkins 1908-1941

“Dean of American psychiatry” first half of 20th century

Meyer’s psychobiologyDistinctively pragmatic and instrumental approach

Meyer’s psychobiologyDistinctively 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