Philosophical Issues in Psychiatry

I vividly recall the coy smile of one of the senior inpatient attending psychiatrists during a morning report as one of the junior residents, presenting a newly admitted patient diagnosed with schizophrenia, was asked to discuss the disorder’s etiology and began to recite the latest neuroimaging findings and candidate gene linkage studies. “You know,” he said, “they still have not found the ‘schizochete,’ and they have been looking for it since I was a resident.”

Meaningful analyses of the complexities involved in psychiatric epistemology are hard to come by. Typically, explorations into important issues in psychiatry that might help the discipline refine its understanding, explanations, and ultimately its clinical utility tend to deteriorate into either dichotomized nature versus nurture debates or adoptions of bland “biopsychosocial” models, which essentially posit that it’s all just really complicated, so why bother?

As a result, fundamental questions about psychiatry’s philosophical underpinnings remain largely unexamined. Kendler and Parnas undertake this exploration in a readable, cogent manner in Philosophical Issues in Psychiatry . The book grew out of a conference held in Denmark in 2006, and each chapter is preceded and followed by a brief commentary by either an author or an editor in an effort to both summarize the major points and capture the interactive spirit of the original presentation. The chapters are further arranged into three major sections—causation, phenomenology, nosology—each of which focuses on a subject at the interface of psychiatry and philosophy.

Upon learning that I would be reviewing a philosophy book, I was not thrilled. Thoughts of dense, inaccessible text and irrelevant topics materialized. However, after reading a few chapters those thoughts quickly dissipated. The authors go to great lengths to ensure that the book is accessible for those with a limited background in philosophy.

Many clinicians might find themselves asking the question that the authors pose in the introduction of the book: Why does a busy clinician with loads of patients need to understand anything about philosophy? The answer is that practitioners will get not only an increased appreciation of the factors implicated in complex behaviors like depression but also an enhanced understanding of causality in complex systems and the problems this poses for reductionist understandings of psychiatric disorders. Additionally, with DSM-V on the horizon and increased attention focused on psychiatry’s grouping of disorders, one of the book’s most interesting chapters centers on “Psychiatric Systematics” and offers insightful comparisons between psychiatric nosology and its counterparts in chemical taxonomy (the periodic table) and biological taxonomy (genus/species).

In the Mishna, Rabbi Tarfon taught, “You are not obligated to finish the task, neither are you free to neglect it.” In this spirit, Drs. Kendler and Parnas’s book is an invitation into an oft-neglected area of psychiatry, an exploration of the philosophical underpinnings and its attendant complicated and multifaceted issues.