Psychopathology Beyond Psychiatric Symptomatology

It is important for a field to occasionally take stock of where it is, which Annemarie Köhne has done with her exploration of different frames of thought on psychopathology currently in play. As an advocate for thinking of psychiatric constructs as practical kinds that are often calibrated to serve different, even competing purposes (Zachar, 2002, 2015), I am in agreement with her concerns about relying on a one-size-fits-all model. Between her and I there are slight differences of emphasis with respect to essentialism and the role and scope of symptom-based descriptive psychopathology. In what follows I explicate these differences.

Köhne competently elucidates how a categorical, disease-based model of disorder readily activates essentialist assumptions, but for an audience of psychiatrists and psychologists, I would be inclined to also emphasize that essentialism is more elaborate than the search for underlying causal properties. In its most metaphysical sense, it is about kinds having fixed, knowable natures that make them be what they are. Under Plato, these natures (or essences) were considered more real than the particular individuals in which they were implemented, but with Aristotle the individuals became real and the essences (or substantial forms) became conceptual abstractions.

Essentialism did not survive the scientific revolution unchanged, most readily seen in Locke's distinction between real versus nominal essences. For material objects, a real essence refers to the underlying properties (constitution) on which the identifying properties (nominal essences) of a kind depend. Locke's notion of an underlying real essence was inspired by Boyle's corpuscular philosophy which replaced Aristotelian substantial forms with matter (atoms) in motion. In Locke, material essences were transformed into a) underlying casual properties that are b) identity-determining. Interestingly, Locke held that only kind concepts have essences. Individuals have essences only as members of a kind.

Underlying causal properties are only an ingredient of essentialism. Without adding into the stew the notion of the underlying properties doing most of the causal work, of being identity determining, and being what is really real in contrast to surface features, underlying causal properties are not essences.

Let me make one additional point about essentialism. Many would consider the ur-metaphor of essentialism to be the imploration for our theories and classifications to carve nature at the joints, so it was surprising to see an article that warns against adopting an uncritical essentialism to end with a plea for our classifications to carve nature at the joints. This seems to be part and parcel of Köhne's notion that we should try to observe psychiatric phenomena without preconceptions and as they are (i.e., "bottom-up" in her words), which to my mind recalls the notion of bracketing as espoused by the more essentialist versions of phenomenology. Following Hillary Putnam, I am skeptical that we can ever observe psychiatric phenomena from such a neutral, God's eye view perspective.

On descriptive psychopathology, Köhne's discussion of transcending diagnosis is important for how we think about psychopathology, but I would not pair it with the trendy critique of symptom-based descriptive psychopathology by various and sundry groups who argue that that the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) systems are broken. An alternative view would be that professionals do not receive enough training in psychopathology to understand the nature and limits of diagnostic kinds. Blaming the inherent complexity of psychopathology on the classification system is focusing on the wrong problem.

Typically, when psychiatrists and psychologists use the term transdiagnostic they are referring to constructs that cut across traditional diagnostic kinds. The article that Kohne sites by Fairburn, Cooper, and Shafran (2003) used transdiagnostic in its standard sense—referring to mechanisms that cut across the major kinds of eating disorder.

Defining transdiagnostic as "transcending diagnosis" and associating it with symptom-transcending factors is a creative innovation that calls attention to the importance of going beyond psychiatric symptoms in understanding psychopathology. As I have argued elsewhere, the DSM and the ICD are classification systems and it is a mistake to treat them as textbooks of psychopathology (Zachar, 2019...