Today's post is by Themistoklis Pantazakos, Assistant Professor of Psychology and Philosophy at the American College of Greece and Visiting Professor of Parenting and Special Education at KU Leuven. His research regards the philosophy of psychiatry, particularly issues of evidence based diagnosis, as well as phenomenological psychiatry and the use of client expertise in psychotherapy. In this post, he discusses the themes of his recent BJPsych editorial.
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| Themistoklis Pantazakos |
For seventy years psychiatry has hunted biological markers to anchor its diagnoses in hard science. From brain imaging to genomics, each new tool promised parity with the rest of medicine, yet no major mental disorder has a specific biomarker. This gap feeds two linked accusations: psychiatric categories don’t track real diseases, and, without biomarkers, psychiatrists wield excessive, culturally loaded authority, sometimes inflating pathology in step with pharmaceutical incentives. Critics imply that biomarkers would fix all this.
I argue the opposite. Biomarkers detect dysfunction and guide care, but they cannot decide what counts as a disorder. Pathologisation always comes before biology: oesophageal cancer was treated because patients suffered and died long before its histology was known. Conversely, conditions with clear biomarkers – hyperhidrosis, menopause, benign prostatic hyperplasia – remain disputed; biology shows change but not whether the change matters. This pattern pervades medicine, not just psychiatry, so expecting biomarkers to police the normal–pathological line is a category error.
The argument rests on two observations. First, the temporal order: we decide something is pathological when it causes suffering, debilitation, or harm; not when we discover its underlying biology. Second, the persistence of disagreement: even with biomarkers in hand, the pathological status of many conditions remains unresolved. Biological data can tell us that something in the body has changed, but not whether that change should be seen as illness or variation, as pathology or adaptation. Judging that requires a normative lens, not just a microscope.
This is clearest in psychiatry, where judgments about harm and dysfunction are more contested, but it applies across medicine. Thus, psychiatry’s lack of biomarkers is not evidence of exceptionalism; it is an intensified version of a general truth. The key difference is visibility: when consensus breaks down, the value-laden nature of diagnosis becomes undeniable. Rather than viewing this as a flaw, psychiatry should embrace it as part of its medical legitimacy.
If biomarkers cannot define disorder, what can? I suggest grounding diagnosis in the phenomenology of the patient: their lived experience of distress, impairment, and risk. This goes beyond checklist criteria or superficial symptom counts. It requires asking: how is this condition felt? How does it limit functioning? What kind of danger, if any, does it pose? And crucially, to whom and within which society?
This approach has advantages over current tools. While criteria like the ‘4 Ds’ (deviation, distress, dysfunction, danger) are useful heuristics, they often miss the interplay between individual suffering and societal context. A person may experience severe distress, not because of any inner dysfunction, but due to exclusion or stigma. In such cases, pathologising the individual obscures the real source of harm.
Ultimately, I do not, naturally, reject the role of biology in psychiatry. Biomarkers are vital for understanding mechanisms, predicting outcomes, and tailoring interventions. But they cannot, by themselves, draw the line between the normal and the pathological. That line is social, philosophical, and phenomenological. And facing that problem head-on is where philosophy of psychiatry can show its strength.