Ontological Assumptions, a Biopsychosocial Approach, and Patient Participation: Moving Toward an Ethically Legitimate Science of Psychiatric Nosology

Important philosophical work has gone into debunking thoroughly entrenched positivist notions that objective science proceeds in a value neutral manner. Dr. Tamara Kayali Browne's (2017) article "A Role for Philosophers, Sociologists, and Bioethicists in Revising the DSM" admirably takes the next step. Given the evaluative elements that permeate, in this case, the science of nosology—how do we deal responsibly with those evaluative elements? She correctly, in my opinion, concludes that dealing with evaluative issues responsibly is tantamount to dealing with them ethically. But, as her concrete example of the ethics of premenstrual dysphoric disorder (PMDD) demonstrates, dealing with the ethics of the science of nosology is a complex matter. The ethical dimensions of the science run deep, all the way down to the way we conceptualize the nature and meaning of mental disorder. I think that clarifying the implicit ontological assumptions that guide the science of nosology confirms Dr. Browne's premise that philosophers and social scientists have an important role to play in the development of an ethical science of nosology. But, I would add that the ethical legitimacy of the science of nosology also hinges on patient or mental health service user participation.

Dr. Browne reveals several negative consequences that could result from characterizing PMDD as a mental disorder. But, I think at least some of the potential harms she discusses can more clearly be traced to the results of interpreting the meaning of disorder in a certain way or, to the same point, of conceptualizing disorders as a certain type of thing. Dr. Browne points out that regarding PMDD as a mental disorder could result in concluding that the problem is inside the biology of the patient. Indeed, the belief that PMDD is biologically based played an important role in Diagnostic and Statistical Manual of Mental Disorders (DSM) workgroup arguments that PMDD is a valid 'biomedical' psychiatric disorder (Zachar & Kendler, 2014). Dr. Brown notes that regarding PMDD as a biological problem inside the patient could result in a failure to address underlying social determinants of the mental distress, and treatment could devolve into facilitating 'successful' adaptation to oppressive and unjust circumstances. I think this is exactly what will result if we hold the belief that, if mental distress is in some sense biological, then it is biological all the way through. In other words, if it is a biological problem it must have a biological cause and a biological cure. But, it is possible, and I would argue more helpful to those in distress, to take a more 'biopsychosocial' view of the nature, cause, and treatment of mental distress.

The epistemological divide between the social and biological sciences does not necessarily translate into an ontological divide between the social and the biological in a person with mental distress. Dr. Browne notes that patients labeled as having PMDD may be experiencing normal reactions to extremely stressful conditions, such as being a victim of abuse. But it is important to recognize that severe stress can be translated quickly to a biological level. For example, a normal reaction to extreme stress results in the release of the stress hormone cortisol that in turn has an impact on neuroplastic developments in the circuitry of the brain (Schore, 2003). We should not be entirely surprised when mental distress with social antecedents is at least partially mediated by biological interventions. A history of abuse increases the risk of developing many different kinds of mental disorder in a non-specific manner, and, for some of those people, medication mitigates the distress and dysfunction associated with disorder.

Problems occur when we interpret evidence that psychopharmacological treatment benefits some people with distress to mean that that distress is really biological and not social. Then the social antecedents of the distress will be swept under the carpet. Dr. Browne points out a potential solution to that problem; even if medication were helpful to some people suffering severe premenstrual distress, it should not be necessary to be diagnosed with a pathological syndrome to receive...