Kendler Kenneth S
Virginia Institute of Psychiatric and Behavioral Genetics, and Departments of Psychiatry, and Human and Molecular Genetics, Medical College of Virginia/Virginia Commonwealth University, Richmond, VA, USA.
World Psychiatry. 2016 Feb;15(1):5-12. doi: 10.1002/wps.20292.
A foundational question for the discipline of psychiatry is the nature of psychiatric disorders. What kinds of things are they? In this paper, I review and critique three major relevant theories: realism, pragmatism and constructivism. Realism assumes that the content of science is real and independent of human activities. I distinguish two "flavors" of realism: chemistry-based, for which the paradigmatic example is elements of the periodic table, and biology-based, for which the paradigm is species. The latter is a much better fit for psychiatry. Pragmatism articulates a sensible approach to psychiatric disorders just seeking categories that perform well in the world. But it makes no claim about the reality of those disorders. This is problematic, because we have a duty to advocate for our profession and our patients against other physicians who never doubt the reality of the disorders they treat. Constructivism has been associated with anti-psychiatry activists, but we should admit that social forces play a role in the creation of our diagnoses, as they do in many sciences. However, truly socially constructed psychiatric disorders are rare. I then describe powerful arguments against a realist theory of psychiatric disorders. Because so many prior psychiatric diagnoses have been proposed and then abandoned, can we really claim that our current nosologies have it right? Much of our current nosology arose from a series of historical figures and events which could have gone differently. If we re-run the tape of history over and over again, the DSM and ICD would not likely have the same categories on every iteration. Therefore, we should argue more confidently for the reality of broader constructs of psychiatric illness rather than our current diagnostic categories, which remain tentative. Finally, instead of thinking that our disorders are true because they correspond to clear entities in the world, we should consider a coherence theory of truth by which disorders become more true when they fit better into what else we know about the world. In our ongoing project to study and justify the nature of psychiatric disorders, we ought to be broadly pragmatic but not lose sight of an underlying commitment, despite the associated difficulties, to the reality of psychiatric illness.
精神病学学科的一个基本问题是精神障碍的本质。它们是什么样的事物？在本文中，我回顾并批判三种主要的相关理论：实在论、实用主义和建构主义。实在论假定科学的内容是真实的且独立于人类活动。我区分了实在论的两种“类型”：基于化学的，其典型例子是元素周期表中的元素；基于生物学的，其范例是物种。后者更适合精神病学。实用主义阐述了一种处理精神障碍的明智方法，即只寻求在现实世界中表现良好的类别。但它并未对这些障碍的真实性提出主张。这是个问题，因为我们有责任代表我们这个专业以及我们的患者，去反对那些从不怀疑他们所治疗疾病真实性的其他医生。建构主义一直与反精神病学活动家联系在一起，但我们应该承认社会力量在我们诊断的形成过程中发挥了作用，就像在许多科学领域中一样。然而，真正由社会建构的精神障碍很少见。然后我描述了反对精神障碍实在论理论的有力论据。鉴于如此多先前提出的精神病诊断后来都被摒弃了，我们真的能声称我们当前的疾病分类法是正确的吗？我们当前的许多疾病分类法源自一系列历史人物和事件，而这些事件本可能有不同的发展走向。如果我们一遍又一遍地重放历史录像带，《精神疾病诊断与统计手册》（DSM）和《国际疾病分类》（ICD）每次迭代时不太可能有相同的类别。因此，我们应该更有信心地为更广泛的精神疾病建构的真实性进行论证，而不是为我们当前仍属暂定的诊断类别。最后，与其认为我们的疾病是真实的，因为它们与世界上清晰的实体相对应，我们应该考虑一种融贯论的真理观，即当疾病与我们对世界的其他认知更契合时，它们就变得更真实。在我们正在进行的研究和论证精神障碍本质的项目中，我们应该在总体上保持实用主义，但尽管存在相关困难，也不能忽视对精神疾病真实性的根本承诺。
