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  • Degeneracy of Categorical Disease Paradigms
  • C. Robert Cloninger (bio)
Keywords

diagnosis, neurobiology, nonlinear dynamics, health promotion

The optimistic tinkering with the categorical approaches to psychiatry suggested by Stoyanov, Machamer, and Schaffner (SMS; 2013) is ingenious, but in my opinion is fatally flawed. I admit to having made the same errors in advocating linear deconstruction of putatively categorical entities (Cloninger et al. 1983, 1985), but subsequently recognized the inadequacy of the assumptions of such paradigms. I now regard all categorical approaches to understanding common diseases in medicine to be outmoded and degenerate. Categorical labels have a limited utility as rough approximations for brief communication among colleagues, for billing, or for epidemiological counts as required by treaties regarding the International Classification of Diseases (Kendell and Jablensky 2003), but they are not useful for understanding and treating the complex adaptive systems that cause common diseases (Cloninger et al. 2012a).

A paradigm is scientifically degenerate if it does not provide a way to test and modify its basic assumptions or if it cannot make predictions that go beyond observed data (Cloninger 2004). The term degeneratewas initially used as I am defining it in a critical analysis of research on the inheritance of IQ (Urbach 1974). Elaborate categorical systems like the International Classification of Diseases and Diagnostic and Statistical Manual of Mental Disorders are based on the specious assumption that progressive splitting will lead to increased homogeneity and comprehensiveness, but evidence in psychiatry shows that increasing the number of specific syndromes considered valid from 14 to more than 300 has not reduced the proportion of individuals (about 20%) assigned to ‘undiag-nosed but ill’ or ‘not otherwise specified’ residual categories (Cloninger 1989; Clayton et al. 1992). Severity of dysfunction is strongly related to the simultaneous diagnosis of increasing numbers of comorbid categories, each of which remains heterogeneous and complex, as I have described in more detail elsewhere (Cloninger 2002; Cloninger et al. 2012b).

Stoyanov, Machamer, and Schaffner (2013) wrongly attribute specificity to Minnesota Multi-phasic Personality Inventory scores for depression when in actual fact the Minnesota Multiphasic Personality Inventory can only be meaningfully interpreted in any given person as a multidimensional profile of scores. This error illustrates the way that contemporary diagnostic systems tend to reify categories as discrete entities despite the fact that there is no justification for doing so (Kendell and Jablensky 2003). [End Page 275]

The Complexity of Common Medical Disorders

The leading causes of death and disease burden are common chronic diseases, such as cardiovascular diseases, obstructive lung diseases, diabetes mellitus, and depression (Murray and Lopez 1996). To make progress in the diagnosis and treatment of medical disorders, we must face and accept the fundamental fact that these common disorders are metastable syndromes produced by complex adaptive systems of multiple genetic and environmental variables that interact through multiple reciprocal feedback mechanisms. These reciprocal feedback systems evolved through phylogeny to maintain relative homeostasis (i.e., metastable states) while preserving plasticity to change in response to variation in the context of a person’s environment, goals, and values (Cloninger 2009; Cloninger and Kedia 2011).

We also need to recognize that people have evolved to have a ternary nature composed of body, thoughts, and psyche. The distinction I am making between thoughts and psyche is close to that of Chalmer’s ‘mind 1,’ which is logical and deterministic but not self-aware, and ‘mind 2,’ which is self-aware, creative, and free to assign values (Chalmers 1996; Cloninger 2004). The three aspects of a person are regulated by three systems of learning and memory with qualitatively distinct brain networks and functional properties (Cloninger 2004; Cloninger et al. 2011). Only values that are self-transcendent lead to flourishing of the ‘good life,’ that is, a life of well-being characterized by happy functioning, healthy plasticity, and virtue (Cloninger and Cloninger 2011; Cloninger et al. 2012a). Where is the basis for values and virtues in the SMS (2013) paradigm of health? How can we have an adequate model of health and disease without a role for values and virtue?

Heart Disease as a Research Exemplar

The degeneracy of the SMS (2013) approach is fully exposed in their choice of myocardial infarction as an ideal exemplar...

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