A Metaphysics of Psychopathology

A Metaphysics of Psychopathology
by Peter Zachar

My name is Peter Zachar and I am a Professor in the Psychology Department at Auburn University Montgomery in the U.S. I have spent two decades writing about the philosophy of psychiatry, particularly in the area of psychiatric classification. About four years ago I decided it was time to systematize what I have learned in a book – which has recently been published by the MIT Press with the title A Metaphysics of Psychopathology.  

There is an ongoing tension between belief in the reality of psychiatric disorders versus the metaphysical skepticism of social constructionism and the anti-psychiatry movement. Within the mental health professions themselves, people have differing views about how much reality to attribute to conditions such as schizophrenia and post-traumatic stress disorder. For instance, some professionals consider schizophrenic psychosis to be real, others consider it to be a reified diagnostic category. 

Because psychiatrists and other mental health professionals are deeply involved in what behaviors society considers abnormal, deserving of sympathy, and even excusable, metaphysical questions such as “is PTSD a real disorder” are more than academic. Whether something such as PTSD is considered real matters – in many ways.

In the history of science, metaphysical concepts have been regarded suspiciously by thinkers inclined toward empiricism. Currently, however, the traditional empiricist skepticism that sought to expunge metaphysics from science is considered unworkable. For example, to assert that there is a categorical distinction between metaphysics and science is itself a metaphysical stance. 

In this book I re-introduce some metaphysical scrutiny into psychiatry (in the tradition of a pragmatic empiricism), but do not advocate for anti-psychiatry or its current descendants. If we examine the Science Wars of the 1990s, one of the outcomes was a more discerning use of metaphysical concepts on the part of both the participating scientists and social constructionists. This reduced the extent to which they talked past each other. The lessons learned there can also be applied to psychiatry.

One of the running themes in the book is that when metaphysical concepts such as real, true, and objective are defined with respect to each other, e.g., truth = correspondence with reality, they become lofty abstractions. People will shout out “Truth!,” wave their arms, and stamp about in defense of it, but talk about Truth is applied with equal conviction to quite opposing views in religion and science or conservatism and liberalism. This is one reason why empiricists remain skeptical about metaphysical abstractions. One of the goals of the book is to bring lofty concepts such as real, true, and objective down to earth, but not forbid their use as was done by a previous generation of empiricists.

In the second part of the book the lessons learned earlier are applied to several metaphysically-loaded issues in psychiatry. One of these issues is recent philosophical work on the concept of psychiatric disorder. I introduce a non-essentialist alternative to the essentialism of Jerome Wakefield’s harmful dysfunction model. The alternative is called the imperfect community model. Also examined in some detail are debates during the development of the DSM-5 about eliminating the bereavement exclusion for major depressive disorder and about whether narcissistic personality disorder is real.

The book concludes by reflecting on how important concepts such as real, true, and objective are in the domain of psychiatry, and how very difficult it is to get a handle on them. In part this is because of the imperfect nature of the psychiatric domain. However, in addition to thinking philosophically about psychiatric disorders, we need to also think philosophically about metaphysical concepts such as ‘real’ and not assume that we all mean the same thing when using them. That is one potential strategy for getting a handle.