Gauld Christophe, Nicolle Boris, Constant Axel, Gagné-Julien Anne-Marie
Service de Psychopathologie du Développement, Hospices Civils de Lyon, 69000, Lyon, France.
Institut Des Sciences Cognitives Marc Jeannerod, UMR 5229 CNRS & Université Claude Bernard Lyon 1, 69000, Lyon, France.
Med Health Care Philos. 2025 Sep;28(3):561-576. doi: 10.1007/s11019-025-10279-2. Epub 2025 Jun 9.
The debate on whether psychiatric disorders can be studied as natural kinds has raised controversy, reviving socio-constructionist arguments about the influence of social factors on psychiatric categories. A key concept in this discussion is the "looping effect", which describes how individuals change in response to their classifications, necessitating revisions to those classifications. We argue that, until now, the broad discussions around the looping effect have greatly failed to integrate the perspectives surrounding clinicians and patients. We examine more closely the dynamic and unstable nature of psychiatric diagnoses by proposing two key hypotheses: first, that understanding the looping effect requires incorporating both clinician and patient viewpoints, and that when done adequately, such an incorporation can facilitate the work of the clinician by creating feedback loops (i.e., the iterative adjustment of clinical interpretations based on patient responses); and second, that epistemic injustices between clinicians and patients can create disruptions in these feedback loops, which we call "looping breaks", rendering them ineffective. Looping breaks can happen at the clinical level of the relationship between the patient and the clinician or at the nosological level (during the process of revising a classification). We suggest that looping breaks can be caused by a denial or minimization of credibility based on identity prejudice, or due to an epistemic disadvantage, affecting the experiential feedback of patients following the announcement of a diagnosis. To substantiate our claims, we first examine the impact of looping effects in the interaction between patients and clinicians. Second, we investigate the impact of these interactions at the nosological level, on the broader diagnostic framework. We identify epistemic injustices as critical factors that can lead to looping breaks at both levels, thus affecting the stability and validity of psychiatric diagnoses. Our findings underscore the importance of an epistemic approach to the looping effect, emphasizing both knowledge validity and justice in clinician-patient relationships and among clinicians themselves.
关于精神疾病是否可作为自然类别进行研究的争论引发了争议，使关于社会因素对精神疾病分类影响的社会建构主义论点再度兴起。这场讨论中的一个关键概念是“循环效应”，它描述了个体如何根据其分类而发生变化，进而需要对这些分类进行修订。我们认为，到目前为止，围绕循环效应展开的广泛讨论在很大程度上未能整合临床医生和患者的观点。我们通过提出两个关键假设，更深入地研究精神疾病诊断的动态和不稳定性质：其一，理解循环效应需要纳入临床医生和患者双方的观点，并且如果充分做到这一点，这种纳入可以通过创建反馈回路（即根据患者反应对临床解释进行迭代调整）来促进临床医生的工作；其二，临床医生和患者之间的认知不公正会导致这些反馈回路中断，我们称之为“循环断裂”，使其失效。循环断裂可能发生在患者与临床医生关系的临床层面，也可能发生在疾病分类层面（在修订分类的过程中）。我们认为，循环断裂可能是由于基于身份偏见对可信度的否认或轻视，或者是由于认知劣势造成的，这会影响患者在诊断宣布后的体验反馈。为了证实我们的观点，我们首先考察循环效应在患者与临床医生互动中的影响。其次，我们研究这些互动在疾病分类层面、对更广泛诊断框架的影响。我们确定认知不公正为关键因素，它可导致两个层面的循环断裂，从而影响精神疾病诊断的稳定性和有效性。我们的研究结果强调了对循环效应采用认知方法的重要性，强调临床医生与患者关系以及临床医生自身之间的知识有效性和公正性。
