Conceptual analysis of psychiatric approaches: phenomenology, psychopathology, and classification Aaron L. Mishara and Michael A. Schwartz Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio, USA Current Opinion in Psychiatry 1995, 8:312-316 Philosophic approaches to psychopathology and nosology show diversity but also a need for a conceptual framework. Anglo-American and Continental phenomenological approaches contribute diversely to a common framework without definitive results. The dilemmas of c lassification and diagnosis may, in part, be overcome if we adopt an approach that goes beyond the common-sense assumptions. Introduction The past year has been marked by numerous and rich developments in the field of philosophical psychopathology, as well as philosophical approaches to the problems of classification and diagnosis. These suggest that a new discipline (with ancient roots) is developing that, nevertheless, has its internal problems. Philosophy is itself in a pluralistic phase and we are seeing an unprecedented willingness of Anglo-American and Continental approaches to work together in applying philosophy to the realms of psychopathology and diagnostic classification. However, the symptom to symptom (or disorder to disorder) approach in vogue at present begs systematization. Certain disorders and symptoms lend themselves more easily to philosophic analysis, but the task of philosophical approaches to psychopathology and classification should be to determine the basic structures in the various mental disorders, and then find some basis for comparing disorders and how we conceptualize and classify them. In this review, we shall present some of these new efforts. Philosophical approaches to psychopathology Two book collections [1**,2*], as well as numerous contributions to the new journal Philosophy, Psychiatry, and Psychology, and elsewhere suggest that the collaborative effort of philosophy and psychopathology has a promising beginning. Philosophy, Psychiatry, and Psychology may be the first English language journal devoted to establishing the link between philosophy and abnormal psychological phenomena; it is also one of the few journals to employ both Anglo-American and Continental approaches. Fulford [3*,4] argues that psychiatry has conceptual problems at the heart of the discipline. Philosophy provides tools to understand these problems better. It can offer positive ways of characterizing symptoms in differential diagnosis that are otherwise framed negatively or

based on unclarified (value) assumptions. Delusions of thought insertion, for example, require a distinction of levels: first, the patient's actual experience of inserted thoughts; and second, the patient's structure of beliefs about the experience. The latter has been negatively characterized as 'lack of insight'. This differentiates it from other disorders that may involve similar experiences, but does not embed them in the belief that another person is the agency of the thoughts. Fulford argues that such symptoms can be understood positively in terms of failed action rather than a disturbance of cognitive functioning. Stephens and Graham [5*,6] take a similar approach to the symptom of thought insertion by stressing a disturbance of a sense of agency. They argue that psychopathological data compel us to question basic philosophical assumptions. Thought insertion involves a disturbance of self-consciousness, in which self-consciousness can be broken down into two components: first, the data given by introspection or inner perception are given as belonging to an individual; they are 'mine'; and second, mental phenomena have an agency character beyond their mineness; in thought insertion, the source of the thoughts is experienced as alien, as due to someone else's agency. Attributions of agency are added onto the self-attributions, for example, the person experiencing thought insertion acknowledges that they are experiencing the thought but not that they are Its agent or source. The conversational, communicative character of the patients' thoughts may provide an experiential basis for their attributing their thoughts to other agents. The data of thought insertion, therefore, enables us to make a philosophical distinction that would be otherwise overlooked if we descriptively began with 'normal' consciousness. Addressing the problem of thought insertion, Chadwick [7*] questions whether the identification of a thought as alien results from the content, the quality, or simply the experience of lack of agency. She argues from a cognitivist reading of Kant that thought insertion can, in part, be explained in terms of a discontinuity of content apart from the formal condition of an 'I think' that only accompanies thinking experiences in principle. Wiggins' commentary [8] on the article by Stephens and Graham [5*] points to similarities and differences with the Continental phenomenological approach that he proposes. Husserl's phenomenological philosophy reveals that inner mental life comprises both active and passive, or 'automatic' mental processes. It would seem that thought insertion does not occur as a disturbance of the active processes that I attribute to myself or others, but to passive occurrences that also belong to my subjective experience but have an automatic character. Delusions of thought insertion may occur at much earlier phases of passive, automatic processing than attributions of agency or ownership as the locus of mental acts. Graham and Stephens [6] argue that delusions of thought insertion and hearing voices are structurally similar in that patients recognize that the event does belong to them but think that it is due to an external agency. We agree and feel that this is a basis for phenomenological variation to find common structures in symptoms of mental disorders, but disagree with Graham and Stephens' further claim that such delusions resemble the disassociation of dissociative identity disorder. Philosophical approaches have been applied to clarify other symptoms and disorders. For

Flanagan [9], ourselves are 'multiply authored', but because of the influence of these same caretakers, we adhere to the cultural rule of 'one self per customer'. Selves become 'multiplex' without becoming multiple. Dissociative identity disorder arises when the 'authorial work' does not grasp connections between various narrative segments. Flanagan's metaphor of self-authorship converges with postmodern approaches to the self. They share several assumptions that we feel need to be further investigated: (1) continuity of human experience is authored in a manner similar to the authorship of a text; (2) singularity of the self is conventional; its representation (in cognitive systems) has no basis or ground beyond a cultural modeling process (i.e. one self per customer); and (3) conscious representation is secondary to a complex dispositional brain structure (for poststructuralists, a cultural 'writing' process) and needs only intermittent occurrence. We believe that there is no fundamental reason to identify human life with the metaphor of narrative or authorship. Narration (telling stories that make meaningful connections between events) is a process secondary to the experience of continuity in time of an embodied individual, in which continuities and discontinuities have already been registered. Life is not a text, but rather embodiment is the pre-condition for texts and self-reflection [10*]. Analytic and post-structuralist approaches to problems of self and mind fall into similar quandaries because they base their ontologies on language or linguistic structure rather than a phenomenology of preconceptual embodied experience as the source of structural meaning. Boden [11] approaches dissociative identity disorder in terms of computational theory. She presents a computational model of mind as a set or 'society' of mini-agents, in which one integrative subsystem constructs a self-model. The latter is able to generate biographical narratives that unify the person's actions. The giving of post-hoc accounts of one's actions according to a story need only approximate real circumstances. Therefore, the 'normal' mind copes by living in part illusions. Psychodynamic defenses, such as rationalization, denial and splitting, occur as semantic shifts to reduce anxiety. The mental disassociation in dissociative identity disorder results from various types of compromise or breakdown in the control system that unifies the mini-agents in the less than perfect narrative structure; competing motivations may behave independently and alternately with differential access to memories. She proposes that these may even support their own distinct narratives. Computational theories, however, Boden admits, are still unable to explain the sudden changes in physiognomy, body language or even sensitivity to drugs of the different 'alters'. In this issue, Jennifer Radden (pp 343-345) reviews the recent controversy concerning dissociative identity disorder as social construct or actual disorder. Other philosophic computational accounts of disorders or symptoms have been proposed for delusions [12*], and hysteria [13], or modeled by means of damaged connectionist networks (brain damage or in dyslexia [14*]) . Phenomenology and psychopathology Despite recent possibilities for rapprochement and cross fertilization between Anglo-American

and Continental phenomenological approaches, Walker, following Berrios' lead [15*] and his own earlier efforts, has devoted four consecutive articles in Philosophy, Psychiatry, and Psychology [16, 17] (two of which are still not published) to divorcing once and for all Husserl's philosophic phenomenology from psychopathology, or at least from Jaspers' psychopathology. Far from closing the argument, however, these ambitious articles invite new reflection on the topic. We wonder whether Walker, in his desire to bring the argument to a conclusion, is not overemphasizing several points and thereby overlooking others. We mention only three here: (1) Jaspers’ 'selectively' appropriated concepts from Husserl's phenomenology that he found relevant to his own project; Walker, therefore, minimizes the convergence between Jaspers and Husser!; (2) Walker one-sidedly emphasizes the transcendental idealism of phenomenology and neglects its empirical, mundane developments both by Husserl and those who modified his approach (e.g. Gurwitsch, Merleau-Ponty, and Schutz); and (3) there is an entire tradition of thought and research in psychiatry that has relied on Husserl's work; Walker, therefore, minimizes the usefulness of phenomenology for psychiatry. With regard to the first two points, Wiggins and Schwartz are preparing a rejoinder to Walker that will also appear in Philosophy, Psychiatry, and Psychology. With regard to the third, many international psychiatrists (Binswanger [ 18**], Blankenburg [19*], Doerr, Ey, Kraus [20*,21*], Kuhn [22*], Lopez-Ibor Sr., Kimura, Kisker, Matussek Sr., Mayer-Gross, Minksowski, Mueller-Suur, Scharfetter. Schneider, Schotte, Straus, Tatossian, Tellenbach, Gebsattel and many others) have been influenced by Husserl's phenomenology or a variation of it. Walker makes the following objections to Husserlian phenomenology: first, that phenomenology has nothing to do with facts or real experience; and second, that phenomenology concerns itself with trivial examples. We are, therefore, led to make the conclusion that Husserl's phenomenology has little to offer psychopathology. Rather than arguing these points here, we feel that a lively debate concerning the relevance of phenomenology has been opened and anticipate a constructive outcome. One exception to this conclusion is the approach of Ludwig Binswanger (1881-1966), whose four-volume selected works have been newly edited [18**]. Binswanger sent Jaspers a review of one of the latter's early phenomenological psychopathological writings in 1913. As Mishara [23*] indicates, their subsequent correspondence tended to focus on, among other points, the role of Husserl's phenomenology in psychopathology. In his search for the foundations of psychiatry as a science, Binswanger himself went through several phases: psychoanalysis, Neo-Kantianism, Husserl's phenomenology, and Heidegger's analysis of existence. In a final phase, he returned to Husserl's phenomenology to study disturbances of time perception, interpersonal relationship, and levels of structural meaning in manic-depressive psychoses and schizophrenic delusions. He called this final phase of his work 'empirical phenomenology'. Delusional 'objects', for example, are neither cognitions nor perceptions, but rather a disturbance in the ‘passive’ automatic processes, in which the patient's experience first comes to unity. (Because this 'belief' makes up the very fabric of his reality, and therefore his relatedness to others, the patient is thereby unable to distance himself

from the claims of the delusions [23*]). Other psychiatrists have used Husserl's phenomenology to make distinctive gains for psychiatry. Following Binswanger, Blankenburg [24] applied Husserl's methodology to developing a psychopathology of 'common sense' in different disorders. Such differences in access to common sense could furnish criteria for differential diagnosis. Premorbid unipolar depressive patients are overly attached to common sense, which persists during episodes Patients with schizophrenia, on the other hand, lose a sense for things that are evident in everyday common sense. They no longer have a sense for what is sociably suitable in a manner different from the loss of tact in organic patients. Tellenbach [25] found that the premorbid personality of a subgroup of patients with endogenous depression, which he called the typus melancholicus, displayed rigidity, extreme orderliness, exacting perfectionism, and overattachment to social ideals. Interestingly, Shimoda [26] in Japan independently discovered the same premorbid structure. Kraus [20*] elaborated that such patients are overly identified with social roles and demonstrate intolerance of ambiguity. Empirical studies, primarily by von Zerrsen [ 27] have corroborated Tellenbach 's [25], Shimada's [26] and Kraus' [20*] investigations. A recent effort to apply Husserl's phenomenology to psychiatry and psychotherapy has been made in a special section of the American Journal of Psychotherapy, edited by Chessick [28*]. This includes articles that concern the phenomenology of empathy, postoperative psychosis, and narrative in the healing process; typus melancholichus and social role; and the hermeneutic approach to psychotherapy [10*,20*,29-31]. A recent monograph relates Husserl's phenomenology to Jaspers' psychopathology and cognitive science [32]. Other authors have recently applied continental phenomenology to problems of psychiatry and psychopathology (19*,21*,22*]. Philosophic and phenomenological approaches to psychiatric diagnosis and classification: are the dilemmas surmountable? Fabrega [33*,34] defines diagnosis as psychiatry's most basic and important task . Most clinicians and researchers, however, he notes, take the concept of psychiatric disorder for granted as a primitive given. The very questioning of the nature of psychiatric disorder brings us into a quagmire of questions that ultimately involve philosophy and history: On the one hand, a universal and standardized system of psychiatric diagnosis is desired. Therefore, the tendency to view disorders as naturalistic, reified objects evolved in the 19th century. On the other hand, disorders (and their classification) are rooted in social contexts (and problems) with historical, cultural, and political economic frameworks. They are also integrally connected to the individuals experiencing them. Fabrega argues that the fundamental ideas employed in psychiatric diagnosis have their own history and culturally bound meanings. How, for example, we have come to value the self - that is, the individual as autonomous and responsible for acts, as behaving purposely and supplying rationales - as well as our views

concerning medicine and treatment would not be possible without our cultural upbringings and traditions. The universalist agenda of an international classification of psychiatric diagnosis is itself a Western European cultural idea and highly culture bound. We do feel that there is a way out of this dilemma, but it requires that we leave behind our metaphysical prejudices about the way things should be organized according to sharply defined categories or oppositions. The oppositions, mind-body, inner-outer (as in inner experience-behavior), self-other, for example, are supposed to neatly divide the biological, psychological, and cultural realms when we think about and treat mental disorders. These categories are so engrained in how we approach problems and build models that it is hard for us to imagine a reality without them. They are culturally formed (and handed down to us) as metaphysical prejudices and yet we take them to be timeless because they are given to us in common sense. Because phenomenology methodically suspends common sense to study the structures of meaning informing our prejudices, it provides an arduous (but nevertheless manageable) path out of our own cultural prejudices in the development of diagnostic classificational systems that take into account the whole person in cultural content [10*,35]. Further dilemmas regarding the classification of mental disorders have been presented in a historical overview (36*]. In the meanwhile, Wiggins and Schwartz [37*] argue for the appreciation of these disorders as 'ideal types'. Ideal types, taken from Weber and Jaspers, are flexible concepts that systematically enumerate the qualities of mental disorders without prematurely committing investigators to conventionalist (nominalist), or naturalist approaches. Ideal types enable us to concede our partial ignorance and partial knowledge of mental disorders and help us appreciate the wide variety of approaches available to current investigators. Radden [38*] has reviewed this and other recent discussions of psychiatric classification, including the book Philosophical perspectives on psychiatric diagnosis [39**]. She affirms the diversity of recent criticism, the focus on evaluative elements as well as clinical facts, and the willingness to offer alternative taxonomic principles. Conclusion This review is meant to indicate the breadth and depth of recent work on philosophical approaches to the psychopathology and nosology of mental disorders. At present, there is diversity but also an effort to find a common conceptual framework. Anglo-American and Continental phenomenological approaches are able to contribute diversely to this framework without, as yet, providing definitive solutions. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: · *of special interest ** of outstanding interest

1. Griffiths AD (Ed): Philosophy, psychology and psychiatry. Cambridge: Cambridge

University Press; 1994. **An anthology of well-argued and innovative essays concerning the application of philosophy to basic themes in psychiatry and psychology.

2. Graham G, Stephens GL (Eds): Philosophical psychopathology. Cambridge: MIT Press;

1994. *A serious effort to approach various problems of psychopathology from an Anglo-

American perspective. 3. Fulford KWM: Minds and madness: New directions in the philosophy of psychiatry.

In Philosophy, psychology and psychiatry. Edited by Griffiths AP. Cambridge: Cambridge University Press; 1994:5-25. *Philosophy can help clarify the concepts at the heart of psychiatry, and thus has practical relevance. Philosophic thinking and a more patient-centered approach to medicine should be integrated into the training and research of psychiatrists. Philosophy can benefit from the rich array of psychopathological phenomena by adopting a model of rationality, in which its affective, intentional, and other noncognitive aspects are as important as the cognitive

4. Fulford KWM: Value, illness and action failure: framework for a psychopathology of delusions. In Philosophical psychopathology. Edited by Graham. G, Stephens GL. Cambridge: MIT Press;1994:205-233. .

5. Stephens GL, Graham G: Self-consciousness, mental agency, and the clinical

psychopathology of thought-insertion. Philos Psychiatr Psychol 1994,1:1 -10. *Tools of philosophical analysis are employed to carefully examine and clarify the patient's experience of the symptom of thought insertion.

6. Graham G, Stephens GL: Mind and mine. In Philosophical psychopathology. Edited

by Graham G, Stephens GL. Cambridge: MIT Press; 1994:91 -109.

7. Chadwick R: Kant, thought insertion, and mental unity. Philos Psychiatr Psychol 1994, 2:105-113. *Kant's transcendental psychology gives an abstract description of mechanisms of mental processes that can be investigated empirically. Delusions of thought insertion involve a discontinuity of contents as thoughts are related in time within one consciousness and yet not acknowledged as being thought or produced by that consciousness. In this way, Chadwick separates an objectified unified self as owner of mental states from its formal, transcendental possibility. She argues that such a view could have implications for psychiatric notions of self.

8. Wiggins OP: Commentary on 'self-consciousness, mental agency, and the clinical psychopathology of thought insertion. Philos Psychiatr Psychol 1994, 1:11-12

9. Flanagan 0: Multiple identity, character transformation, and self-reclamation. In Philosophical psychopathology. Edited by Graham G, Stephens GL. Cambridge: MIT Press; 1994.

10. Mishara AL: Narrative and psychotherapy: the phenomenology of healing. Am J

Psychother 1995, 49:180--195. *Patients with certain disorders are unable to benefit from the healing that comes with the passage of time. Their narrative efforts are sometimes able to restore time's effectiveness in healing, first by allowing for distance between self and traumatic experience, and second by structuring a new meaning and relationship to the experience (including a new role for narrating self). Phenomenology provides an alternative account (of healing, time, and embodiment) to the cognitive theory in which a painful feeling is 'translated' into a cognitive-linguistic representation that organizes it. (Patients with psychosis are often unable to benefit from narrative because they are unable to distance themselves from their immediate experience).

11 . Boden MA: Multiple personality and computational models. In Philosophy, psychology and psychiatry. Edited by Grifiiths AP. Cambridge: Cambridge University Press; 1994:103-114.

12 . Spitzer M: A neurocomputational approach to delusions. Compr Psychiatr 1995,

36:83-105. *Acute delusions are linked to neuromodulation which might be modeled in the fine tuning of the signal to noise ratio in the activation of neuronal networks. An increased ratio could lead to the attaching of spurious significance to otherwise harmless events during prodromal delusional moods and delusions.

13 . Lloyd D: Connectionist hysteria: reducing a Freudian case study to a network model. Philos Psychiatr Psychol 1994, 2:69-88.

14. Plaut D, Shallice T: Connectionist modelling in cognitive neuropsychology: a case

study. Hove: Lawrence Erlbaum Associates; 1994. *The authors demonstrate how damaging networks - by removing units, or their connections, or adding random noise - can model cognitive errors resulting from brain damage in dyslexia. The approach suggests how psychiatric symptoms could be similarly modeled.

15. Berrios GE: Phenomenology and psychopathology: was there ever a relationship?

Compr Psychiatr 1993, 34:213-220.

*An erudite treatment which is nevertheless one-sided in its evaluation. 16. Walker C: Karl Jaspers, Edmund Husserl I: The perceived convergence. Philos Psychiatr

Psychol 1994, 1:117-134.

17. Walker C: Karl Jaspers, Edmund Husserl II: The divergence. Philos Psychiatr Psychol 1994, 4:245-265

18. Binswanger L: Ausgewaehtle Werke. (4 Volumes). Edited by Braun HJ, Fichtner G,

Herzog M, Holzhey-Kunz A, Holzhey H, Juenemann G. Heidelberg: Roland Asanger Verlag; 1992-1994.

**A newly edited collection of many of Binswanger 's most important writings. Some previously unpublished fragments and letters are included. The editors' introductions approach Binswanger 's work conceptually and historically; however, insufficient attention is given to the relevance of his work to current psychiatric concerns.

19. Blankenburg W: Die Geschichtlichkeit des Daseins und die konzeption einer

'Historologie' durch Erwin Straus. In Zeit und Welt in den Psychosen. Edited by Kraus A. Wuerzburg: Koenigshausen und Neumann (in press).

*A difficult but thoughtfully performed study of psychosomatic, psychoanalytic and phenomenological approaches to shame as it occurs in different disorders. Shame I shown to relate to the historical development of the individual and to originally have a protective function

20. Kraus A: Psychotherapy based on identity problems of depressives. Am J Psychother

1995, 49:197-212. *The hypernomic behavior and loss of autonomy of the typus melancholicus,is described

in terms of an overidentification with social roles. It is distinguished from anancastic compulsive behavior in its orientation to social normative expectations and its being ego-syntonic.

21. Kraus A: Phenomenology of the technical delusion in schizophrenics. Phenomenal

Psychol 1994, 25:51-69. *A phenomenological study of technical gadgets in the delusions of patients with

schizophrenia. 22. Kuhn R: Psychopathologie der Angsterkrankungen. In Angsterkrankungen. Edited by

Niessen G. Bern: Huber Verlag; 1995, 19-27. *A phenomenological approach to anxiety (as opposed to fear) in different disorders is

presented by an eminent psychiatrist. 23. Mishara AL: Binswanger and phenomenology. In Encyclopedia of phenomenology. Edited

by Embree L, Carr D, Evans JC, Huertas-Jourda L, Kockelmans JL, McKenna W, Mickunas A, Mohanty JN, Seebohm TM, Zaner RM. The Hague: Kluwer Academic Publishers; 1995. *Binswanger debates with Jaspers about the role of intuition and phenomenologic

method in psychopathology. In his late works, he returns to a Husserlian approach of genetic phenomenology to uncover automatic, passive processes in the formation of delusions.

24. Blankenburg W: Ansaetze zu einer Pyschopathologie des common sense. Confinia

Pschiatrica 1969, 12:144-163.

25. Tellenbach H: Melancholie, Problemgschichte, Endogeneitaet, Typologie, Pathogenese, Klnik, edn 4. Heidelberg: Springer; 1983.

26. Shimada M: Ueber den praemorbiden Charakter des manisch depressiven lrreseins.

Psychiatrica et Neurologica }aponica 1941, 45:62.

27. von Zerrsen D, Poessl J: The premorbid personality of patients with different subtypes of affective illness. J Affective Disord 1990, 21:39-50.

28. Chessick RD: The application of phenomenology to psychiatry and psychotherapy. Am J

Psychother 1995, 49:159-162. *Husseri's philosophy is described with special emphasis on how it may be helpful for the psychotherapist. Treatment is concentrated on the whole patient by focusing on the emotional interchange that stays strictly with the phenomena presented.

29. Nissim-Sabat M: Towards a phenomenology of empathy. Am J Psychother 1995, 49:163-170.

30. Chessick RD: Psychosis after open heart surgery: a phenomenological study. Am J

Psychother 1995, 49:171-179. 31. Lang H: Hermeneutics and psychoanalytically oriented therapy. Am J Psychother 1995,

49:215-224. 32. Fewtrell D, O'Connor K: Clinical phenomenology and cognitive psychology. London :

Routledge; 1995. 33. Fabrega H: Epilogue: a universal approach to psychiatric diagnosis. In Psychiatric

diagnosis, a world perspective. Edited by Mezzich JE, Honda Y, Kastrup MC. New York: Springer; 1994:317-329. *With considerable background experience in cross-cultural psychiatry, the author offers an impressive critique of present nosological trends

34. Fabrega H: Personality disorders as medical entities: a cultural interpretation. J Pers

Disord 1994, 8:149-167. 35. Mishara AL: A phenomenological critique of commonsensical assumptions in DSM-III-R:

the avoidance of the patient's subjectivity. In Philosophic perspectives on psychiatric diagnostic classification. Edited by Sadler JZ, Wiggins OP, Schwartz MA. Baltimore: Johns Hopkins University Press; 1994:129-147

36. Mack AH, Forman L , Brown R, Frances A: A brief history of psychiatric classification.

From the ancients to DSM-IV. Psychiatr Clin North Am 1994, 17:515-523. *A concise overview of the history of efforts to bring classificatory order in the universe of human behavior. DSM-IV is viewed in terms of the perennial nosological themes: etiology versus description, lumping versus splitting, categorica l versus dimensional systems, and extremes versus boundary cases.

37. Wiggins OP, Schwartz MA: The limits of psychiatric knowledge and the

problem of classification. In Philosophical perspectives on psychiatric diagnostic classification. Edited by Sadler JZ, Wiggins OP, Schwartz MA. Baltimore: Johns Hopkins University Press; 1994:89-103. *The approaches afforded by prototypes, dimensions and polythetic concepts implicitly acknowledge intractable limits to the present psychiatric knowledge of mental disorders. The concept of ideal types integrates·these views by enabling the delineation of patterns that may not actually exist in reality but which can, nevertheless, orient and structure scientific enquiry.

38. Radden J: Recent criticism of psychiatric nosology. Philos Psychiatr Psychol

1994, 2:193-200. *A lucid and concise review of recent criticisms of contemporary psychiatric classification. Previous questions of reliability and validity have been superceded by more fundamental concerns confronting our present systems: the unavoidable metaphysical alliances, theoretical underpinnings, normative tenets of such systems, the possible social and contextual sources of mental disorder, gender issues, and the problem of acknowledging and taking into account the patient's subjectivity

39. Sadler JZ, Wiggins OP, Schwartz MA (Eds): Philosophic perspectives on

psychiatric diagnostic classification. Baltimore: Johns Hopkins University Press; 1994:89-103. **Philosophical problems of nosology are approached from both Anglo- American and Continental perspectives. The authors criticize numerous aspects of existing nosologies, but, beyond this, offer constructive solutions to many of the problems raised. It is the first anthology produced under the sponsorship of the Association for the Advancement of Philosophy and Psychiatry (AAPP).