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SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of East Anglia

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Page 1: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 2: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Meyer’s psychobiology

Adolf Meyer

(1866-1950)

Page 3: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Meyer’s psychobiology

Adolf Meyer

(1866-1950)

Professor, Johns Hopkins 1908-1941

Page 4: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Meyer’s psychobiology

Adolf Meyer

(1866-1950)

Professor, Johns Hopkins 1908-1941

“Dean of American psychiatry” first half of 20th century

Page 5: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Meyer’s psychobiologyDistinctively pragmatic and instrumental approach

Page 6: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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)

Page 7: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Commonsense psychiatry of Adolf Meyer

Mental disorders as disturbances of adaptation

Page 8: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Commonsense psychiatry of Adolf Meyer

Mental disorders as disturbances of adaptation

Less concerned with symptoms and disease than understanding the conditions of mental reactions

Page 9: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 10: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Commonsense psychiatry of Adolf Meyer

Recognition of inherent uncertainty in psychiatric and medical practice

Page 11: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 12: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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”

Page 13: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Meyer’s views on psychiatric classification

Statistical manual for the use of institutions for the insane (1918), American Medico-Psychological Association

Page 14: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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”

Page 15: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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”

Page 16: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Neo-Kraepelinian approach

Disease entities in psychiatry - single morbid process

Page 17: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Neo-Kraepelinian approach

Disease entities in psychiatry - single morbid process

Dementia praecox and manic depressive illness

Page 18: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Neo-Kraepelinian approach

DSM-III introduced operational criteria to replace so-called vague, imprecise concepts

Page 19: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 20: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 21: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

A neo-Meyerian approach to diagnosis

(1) Psychiatry should not abandon diagnosis, but recognise it for what it is

Page 22: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 23: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 24: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(1) Psychiatry should not abandon

diagnosis, but recognise it for what it is Classification is justified as essential for scientific communication

Page 25: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 26: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(1) Psychiatry should not abandon

diagnosis, but recognise it for what it is Diagnosis as a means of attempting to manage individual clinical complexity

Page 27: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 28: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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”

Page 29: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 30: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(2) Psychiatry should not be panicked by the

unreliability of psychiatric diagnosis "… assuredly an unreliable system must be invalid” (Robert Spitzer)

Page 31: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 32: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(2) Psychiatry should not be panicked by the

unreliability of psychiatric diagnosis "…Reliability is paradoxical – attenuation paradox

Page 33: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 34: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(2) Psychiatry should not be panicked by the

unreliability of psychiatric diagnosis Diagnostic concepts are simply categories justified by clinical utility

Page 35: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 36: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 37: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(3) Psychiatry should avoid the reification of

diagnostic concepts Too easily assume a concept is an entity of some kind

Page 38: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 39: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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"

Page 40: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(3) Psychiatry should avoid the reification of

diagnostic concepts Unobservable hypothetical construct

Page 41: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(3) Psychiatry should avoid the reification of

diagnostic concepts Unobservable hypothetical construct

Prototype or ideal type

Page 42: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

(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

Page 43: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Psychiatric diagnosis as a contested area

Neo-Kraepelinian vs. Neo-Meyerian

Page 44: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Psychiatric diagnosis as a contested area

Neo-Kraepelinian vs. Neo-Meyerian

WPA Institutional Program on Psychiatry for the Person

Page 45: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

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

Page 46: SOME ASPECTS OF THE MORAL BASIS OF DIAGNOSIS: The challenge of Meyer’s Psychobiology D B Double Norfolk & Waveney Mental Health NHS FT & University of

Psychiatric diagnosis as a contested area

There is as much consensus for the neo-Meyerian paradigm as there is the neo-Kraepelinian orthodoxy


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