Defining Mental Disease: Insights and Perspectives

1. PHI548 - Biomedical Ontology, Philosophical Aspects of Health and Disease. Defining Mental Disease. October 8, 2010; 4.00 PM - 6.00 PMDepartment of Philosophy, Buffalo NYPark Hall 148 Werner CEUSTERS1 and Barry SMITH2 1,2 Ontology Research Group, Center of Excellence in Bioinformatics and Life Sciences 1 Department of Psychiatry, University at Buffalo, NY, USA 2 Department of Philosophy, University at Buffalo, NY, USA

2. Structure of this presentation • Do mental disorders exist and if so, what are they? • Overview of relevant positions • Foundations of our work • Methodological • Representational • Towards an ontology for mental health • Utility of our work

4. Mental disordersand‘mental disorders’

5. TheAntipsychiatryCoalition This could then be a very short presentation • Their question: • Does Mental Illness Exist? • Their answer: • ‘there are no biological abnormalities responsible for so-called mental illness, mental disease, or mental disorder, therefore mental illness has no biological existence. • Perhaps more importantly, however, mental illness also has no non-biological existence, • except in the sense that the term is used to indicate disapproval of some aspect of a person's mentality.’ Lawrence Stevens, J.D, 1999

6. Their argument is based on the (narrow ?) definitions for disease. • Most attempts refer to bodily issues: • STEDMAN (27th edition): • An interruption, cessation, or disorder of body function, system, or organ. Syn: illness, morbus, sickness • A morbid entity characterized usually by at least two of these criteria: recognized etiologic agent(s), identifiable group of signs and symptoms, or consistent anatomic alterations. • DORLAND • any deviation from or interruption of the normal structure or function of a part, organ, or system of the body as manifested by characteristic symptoms and signs; the etiology, pathology, and prognosis may be known or unknown.

7. Latest WHO definition • A disease is: • an interconnected set of one or more dysfunctions in one or more body systems including: • a pattern of signs, symptoms and findings (symptomatology - manifestations) • a pattern or patterns of development over time (course and outcome) • a common underlying causal mechanism (etiology) • linking to underling genetic factors (genotypes, phenotypes and endophenotypes) and to interacting environmental factors • and possibly: to a pattern or patterns of response to interventions (treatment response).

8. WHO constitution • The State Parties to this Constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples: • Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. • …

9. What is a mental disorder ? • The social-constructivist position: • mental disorder is a value-laden social construct with no counterpart in biomedical reality. • The objectivist position: • mental disorders are natural entities that could be understood in biological terms. • The hybrid position: • Mental disorder is harmful dysfunction. • the social definition of "harm" is counterbalanced by a factual component of a malfunctioning internal mechanism causing objective dysfunction. Jablensky A: Does psychiatry need an overarching concept of "mental disorder"?World Psychiatry 2007, 6:157-158.

10. A terminological and ontological problem (1) • WHO: Lexicon of psychiatric and mental health terms. Second edn. Geneva: WHO; 1994. • ‘mental disorder’: an imprecise term designating any disorder of the mind, acquired or congenital • organic mental disorder: a range of mental disorders grouped together on the basis of their having in common a demonstrable etiology in cerebral disease, brain injury, or other insult, leading to cerebral dysfunction. • Does WHO rule out the existence of mental disorders which are not due to brain disorder?

11. The old debate on the “body-mind problem”… • Dualistic views in Philosophy of Mind: • asserts the separate existence of mind and body • comes in various flavours: • Ontological dualism • Substance dualism • Property dualism • Predicate dualism • Interaction dualism • Monistic views in Philosophy of Mind: • Behaviourism • Identity theory • Functionalism • Non-reductive physicalism • …

12. … and its impact on Psychiatry • Mental health professionalscontinue to employ a mind-brain dichotomywhen reasoning about clinicalcases. • The more a behavioral problem isseen as originating in “psychological”processes, the more a patient tends to beviewed as responsible and blameworthyfor his or her symptoms; • conversely, themore behaviors are attributed to neurobiologicalcauses, the less likely patientsare to be viewed as responsible andblameworthy. Miresco MJ, Kirmayer LJ. The Persistence of Mind-Brain Dualism in PsychiatricReasoning About Clinical Scenarios. Am J Psychiatry 2006; 163:913–918 • But: • Conducted in one institution • Based on a questionnaire with voluntary submission • Thus risk for major bias

13. A terminological and ontological problem (2) • Szasz: ‘mental illnessis a myth whose function it is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations’ • Szasz TS: The Myth of Mental Illness. American Psychologist 1960, 15:113-118.

14. The “Myth of Mental Illness” • “I maintain • that the mind is not the brain, • that mental functions are not reducible to brain functions, and • that mental diseases are not brain diseases, • indeed, that mental diseases are not diseases at all. • When I assert the latter, I do not imply that distressing personal experiences and deviant behaviors do not exist. Anxiety, depression, and conflict do exist--in fact, are intrinsic to the human condition--but they are not diseases in the pathological sense.” Thomas S. Szasz (MD), Mental Disorders Are Not Diseases. USA Today (Magazine) January 2000

15. Our interpretation of Szasz (1) • the group of persons ‘known to manifest various peculiarities or disorders of thinking and behavior’ and about which it is therefore said that they have a mental illness, consists of two subgroups: • (1) those for which there is an underlying brain disorder perhaps not yet discoverable by what the state of the art is able to offer; and • (2) those who exhibit in their behavior a ‘deviance … from certain psychosocial, ethical, or legal norms’ as judged by themselves, by clinicians, or by others.

16. Our interpretation of Szasz (2) • those for which there is an underlying brain disorder perhaps not yet discoverable by what the state of the art is able to offer • would be better described as having a brain disorder, • those who exhibit in their behavior a ‘deviance … from certain psychosocial, ethical, or legal norms’ as judged by themselves, by clinicians, or by others • while they might indeed have ‘problems of living’, and thus be suffering, are not suffering because of some disorder of a special, mental kind.

17. Our interpretation of Szasz (3) • Szasz hereby rejects as fallacious the view which regards social intercourse‘as something inherently harmonious, its disturbance being due solely to the presence of “mental illness” in many people’.

18. A terminological and ontological problem (3) • Adoption of a generic, presumably universal, definition of "mental disorder" would be premature. It may cause more harm than good to psychiatry. • Jablensky A: Does psychiatry need an overarching concept of "mental disorder"?World Psychiatry 2007, 6:157-158.

19. Jablensky’s arguments (1) • A terminological argument • Neither disease nor health has ever been strictly and unambiguously defined in terms of finite sets of observable referential phenomena. • Arguments of utility: • the medical person is least concerned with what healthy and sick mean in general ... we do not need the concept of ‘illness in general’ at all • Jaspers K. General psychopathology. Birmingham: Birmingham University Press; 1963. • doctors do not concern themselves with maximizing the evolutionary advantages of the human race as a whole, but with aiding individuals • Toon PD. Defining "disease" - classification must be distinguished from evaluation. J Med Ethics. 1981;7:197–201.

20. Jablensky’s arguments (2) • Ontological argument: • we now know that no such general and uniform concept exists. • Jaspers K. General psychopathology ,Birmingham: Birmingham University Press; 1963.. • Epistemological argument: • the emergence of molecular genetic classifications of large groups of diseases, and the concomitant availability of genetic diagnostic tests, raise the possibility that the entire taxonomy of human disease may eventually be revised.

21. Missing the nail • A definition of ‘mental disorder’ should be such • (a) that it ‘can be used as a criterion for assessing potential candidates for inclusion in the classification, and deletions from it’ and • (b) that there should be ‘at least no ambiguity about the reason that individual candidate diagnoses are included or excluded’. • Kupfer D, First M, Regier D (Eds.): A Research Agenda for DSM-V, American Psychiatric Association; 2002. • This doesn’t address at all what candidate mental disorders have in common, i.e. what differentiates them from other, non-mental disorders.

22. ICD-10 Mental disease guidelines • Two distinct ones: • The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines.Geneva: World Health Organization; 1992. • The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic criteria for research.Geneva: World Health Organization; 1993. • Yet, an individual entity, such as a mental disorder in a specific patient, does not change when looked at from distinct perspectives.

23. Goal of mental disease guidelines • Goal: to reduce the variability in coding caused by two sorts of disagreement which can arise when diagnoses are being made: • differences in opinion amongst clinicians about what type of mental disorder a patient with a certain configuration of symptoms and test results is suffering from; • in this case the disagreement is about the diagnosis independent of the diagnostic options offered by the ICD or DSM; • differences in opinion about what ICD or DSM classification code should be used in case there is agreement about a diagnosis.

24. Pies’ model • Introduces a 5-stage account of how our scientific understanding of a mental disease condition might evolve over time. The goal is a framework that is designed to allow us to determine: whether a condition represents, in the first place, dis-ease and, secondarily, whether it constitutes a specific disease, on a par with, say, bipolar I disorder. For example, how do we decide whether to consider “pathological bigotry” and “internet addiction” as specific mental disorders? Pies R: What should count as a mental disorder in DSM-V.Psychiatric Times 2009, 26.

25. The basics: existence (in a patient) criterion • ‘prolonged and severe suffering and incapacity in the affective, cognitive, or interpersonal-behavioral realms’ • Pies R: What should count as a mental disorder in DSM-V.Psychiatric Times 2009, 26. • based on: • Kendell RE: The concept of disease and its implications for psychiatry.British Journal of Psychiatry 1975, 127:305-315.

26. Pies’ 5-stage model (1) • Stage 1: patient’s acknowledgement of daily substantial and prolonged suffering and incapacity that is ‘specified in terms of social and vocational impairment, impaired vital functions, and distortions in the phenomenological realm (feeling “totally worthless,” “like I’m nothing”)’. • This must be acknowledged as an intrinsic element of the condition and not simply as a consequence of society’s punitive responses to the person’s behavior.

27. Pies’ 5-stage model (2) • Stage 2: • availability of a general syndromal description of the condition supported by evidence that the constituent signs and symptoms reliably ‘hang together’ over long periods and in geographically distant populations. • Student: ‘Does it say that the signs and symptoms endure over time and that they are (or could be) present regardless of the physical location of the patient?’

28. Pies’ 5-stage model (3) • Stage 3: • the syndrome has been characterized by authoritive sources in terms of usual course, outcome, comorbidity, familial pattern, and response to treatment; • there may also be preliminary data on pathophysiology and biomarkers, and a more specific understanding of the afflicted person’s phenomenology

29. Pies’ 5-stage model (4) • Stage 4: • known pathophysiology, cause, a specific set of biomarkers, and • in some cases an inheritance pattern for the condition (or for multiple conditions that become identified as separate entities only after Stage 2).

30. Pies’ 5-stage model (5) • Stage 5: • availability of a precise chromosomal and biomolecular etiology, and • a specification of the phenomenology, for all disease subtypes.

31. Foundations for anOntology of Mental Health

32. Foundations for our work • Methodological foundations: • Ontological Realism • Open Biomedical Ontologies Foundry • Representational foundations: • Basic Formal Ontology • Relation Ontology • Ontology of General Medical Science

33. Ontology • In philosophy: • Ontology(no plural) is the study of what entities exist and how they relate to each other; • In computer science and many biomedical informatics applications: • An ontology(plural: ontologies) is a shared and agreed upon conceptualization of a domain; • The realist view within the Ontology Research Group combines the two: • We use Ontological Realism, a specific methodology that uses ontology as the basis for building high quality ontologies, using reality as benchmark.

34. The basis of Ontological Realism • There is an external reality which is ‘objectively’ the way it is; • That reality is accessible to us; • We build in our brains cognitive representations of reality; • We communicate with others about what is there, and what we believe there is there. Smith B, Kusnierczyk W, Schober D, Ceusters W. Towards a Reference Terminology for Ontology Research and Development in the Biomedical Domain. Proceedings of KR-MED 2006, Biomedical Ontology in Action, November 8, 2006, Baltimore MD, USA

35. Ontological Realism makes three crucial distinctions • Between data and what data are about; • Between continuants and occurrents; • Between what is generic and what is specific. Smith B, Ceusters W. Ontological Realism as a Methodology for Coordinated Evolution of Scientific Ontologies. Applied Ontology, 2010. (forthcoming)

36. Ontological Realism makes crucial distinctions • Between data and what data are about: • Level 1 entities (L1): • everything what exists or existed • some are referents (‘are’ used informally) • some are L2, some are L3, none are L2 and L3 • Level 2 entities (L2): beliefs • all are L1 • some are about other L1-entities but none about themselves • Level 3 entities (L3): expressions • all are L1, none are L2 • some are about other L1-entities and some about themselves

38. L3 L2 L1

39. L3 L2 L1 OBO Foundry

40. Ontological Realism makes crucial distinctions • Between data and what data are about; • Between continuants and occurrents: • obvious differences: • a person versus his life • a disease versus its course • space versus time • more subtle differences (inexistent for flawed models e.g. HL7-RIM): • observation (data-element) versus observing • diagnosis versus making a diagnosis • message versus transmitting a message

41. Is depression considered a continuant or occurrent? • What do we mean by ‘depression’ ? • The name of some disease ? •  continuant • A bout of feelings of being worth nothing, sobbing, appearance of suicidal thoughts, … •  occurrent

42. Representational units in various • forms about (1), (2) or (3) (2) Cognitive entities which are our beliefs about (1) (1) Entities with objective existence which are not about anything Three levels of reality in Ontological Realism Representation and Reference representational units cognitive units communicative units universals particulars First Order Reality

43. No putative negative entities • DSM-IV criteria for autistic disorder: • failure to develop peer relationships appropriate to developmental level • a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people • lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. • How to represent this ?

44. How to represent this ‘negative findings’ • Lack of spontaneous make-believe play in some child (John) would thus be described in roughly this way: • Not (Jim participant_of some instance of make-believe play).

45. Basic Formal Ontology

46. ‘person’ ‘drug’ ‘insulin’ ‘W. Ceusters’ ‘my sugar’ DIAGNOSIS my doctor’s work plan my doctor’s diagnosis INDICATION my doctor’s computer my doctor PATHOLOGICAL STRUCTURE PERSON me my NIDDM DISEASE DRUG my blood glucose level PORTION OF INSULIN MOLECULE Basic Formal Ontology Referent Tracking The representational square Generic Generic Specific Specific L3. Representation L2. Beliefs (knowledge) L1. First-order reality

47. Disposition • A disposition is a realizable entity which is such that (1) if it ceases to exist, then its bearer is physically changed, (2) whose realization occurs, in virtue of the bearer’s physical make-up, when this bearer is in some special physical circumstances

48. The essential pieces dependent continuant material object spacetime region spatial region temporal region history instanceOf t t t participantOf at t occupies some temporal region some quality my 4D STR my life projectsOn me … at t projectsOn at t some spatial region located-in at t

49. OBO Foundry ontologies in BFO-dress 49

50. Ontology of General Medical Science First ontology in which the L1/L2/L3 distinction is used Scheuermann R, Ceusters W, Smith B. Toward an Ontological Treatment of Disease and Diagnosis. 2009 AMIA Summit on Translational Bioinformatics, San Francisco, California, March 15-17, 2009;: 116-120. Omnipress ISBN:0-9647743-7-2