some aspects of the moral basis of diagnosis: the challenge of meyer’s psychobiology d b double...
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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
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Meyer’s psychobiology
Adolf Meyer
(1866-1950)
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Meyer’s psychobiology
Adolf Meyer
(1866-1950)
Professor, Johns Hopkins 1908-1941
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Meyer’s psychobiology
Adolf Meyer
(1866-1950)
Professor, Johns Hopkins 1908-1941
“Dean of American psychiatry” first half of 20th century
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Meyer’s psychobiologyDistinctively pragmatic and instrumental approach
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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)
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Commonsense psychiatry of Adolf Meyer
Mental disorders as disturbances of adaptation
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Commonsense psychiatry of Adolf Meyer
Mental disorders as disturbances of adaptation
Less concerned with symptoms and disease than understanding the conditions of mental reactions
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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
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Commonsense psychiatry of Adolf Meyer
Recognition of inherent uncertainty in psychiatric and medical practice
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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
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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”
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Meyer’s views on psychiatric classification
Statistical manual for the use of institutions for the insane (1918), American Medico-Psychological Association
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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”
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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”
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Neo-Kraepelinian approach
Disease entities in psychiatry - single morbid process
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Neo-Kraepelinian approach
Disease entities in psychiatry - single morbid process
Dementia praecox and manic depressive illness
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Neo-Kraepelinian approach
DSM-III introduced operational criteria to replace so-called vague, imprecise concepts
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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
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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
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A neo-Meyerian approach to diagnosis
(1) Psychiatry should not abandon diagnosis, but recognise it for what it is
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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
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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
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(1) Psychiatry should not abandon
diagnosis, but recognise it for what it is Classification is justified as essential for scientific communication
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(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
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(1) Psychiatry should not abandon
diagnosis, but recognise it for what it is Diagnosis as a means of attempting to manage individual clinical complexity
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(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
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(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”
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(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
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(2) Psychiatry should not be panicked by the
unreliability of psychiatric diagnosis "… assuredly an unreliable system must be invalid” (Robert Spitzer)
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(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
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(2) Psychiatry should not be panicked by the
unreliability of psychiatric diagnosis "…Reliability is paradoxical – attenuation paradox
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(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
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(2) Psychiatry should not be panicked by the
unreliability of psychiatric diagnosis Diagnostic concepts are simply categories justified by clinical utility
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(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
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(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
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(3) Psychiatry should avoid the reification of
diagnostic concepts Too easily assume a concept is an entity of some kind
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(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
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(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"
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(3) Psychiatry should avoid the reification of
diagnostic concepts Unobservable hypothetical construct
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(3) Psychiatry should avoid the reification of
diagnostic concepts Unobservable hypothetical construct
Prototype or ideal type
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(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
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Psychiatric diagnosis as a contested area
Neo-Kraepelinian vs. Neo-Meyerian
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Psychiatric diagnosis as a contested area
Neo-Kraepelinian vs. Neo-Meyerian
WPA Institutional Program on Psychiatry for the Person
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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
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Psychiatric diagnosis as a contested area
There is as much consensus for the neo-Meyerian paradigm as there is the neo-Kraepelinian orthodoxy