Many thanks, Awais, for the elegant, analytic take-down of the critics who claim that psychiatric diagnoses are merely tautological or "circular" descriptive lists. Thanks as well for the call-out to the article Dr. Mark Ruffalo and I did for Psychiatric Times, which tracks very closely with many of your own points [see https://www.psychiatrictimes.com/view/no-psychiatric-diagnoses-do-not-reflect-circular-logic].
The key fallacy promoted by the "circularity" critics is the failure to distinguish a concept, construct, or list of diagnostic criteria from its referent. As you correctly point out:
"The diagnostic criteria in official manuals such as the DSM and ICD are simply indices, as a way of pointing towards and recognizing the existence of a state, a condition, a syndrome, a property cluster, etc. They do not constitute the condition itself (see Kendler 2017). It is not the case that “depression” is nothing more than the symptom criteria in diagnostic manuals. Rather, the criteria are a way for us to recognize the condition of depression."
There is a remarkable similarity between your observation and that of a famous Mahayana Buddhist saying; namely, "A finger pointing at the moon is not the moon." The DSM categories and their criteria are merely diagnostic "fingers" pointing to actual conditions or states of affairs in the external world (specifically, in certain patients). Thus, it is entirely fallacious to assert that psychiatric diagnosis entails the claim that "symptoms are caused by their descriptive label." (Kajanoja & Valtonen, op cit). Indeed, that assertion is a classic "red herring" (and likely, a Rylean category mistake).
The Buddhist saying puts it in more poetic but philosophically accurate language:
“Consider this example: suppose someone is pointing to the moon to show it to another person. That other person, guided by the pointing finger, should now look at the moon. But if he looks instead at the finger, taking it to be the moon, not only does he fail to see the moon, but he is mistaken, too, about the finger. He has confused the finger, with which someone is pointing to the moon, with the moon, which is being pointed to.” https://www.dharmasite.net/Surangama_new_translation.pdf
Just so! Thanks again, Awais, and I hope your readers will take a look at our article in Psychiatric Times. We anticipate a collegial rejoinder from Drs. Kajanoja and Valtonen, to which we will almost certainly respond!
Best regards,
Ron
Ronald W. Pies, MD
P.S. The volcano analogy in our article was simply meant to suggest that that we do not need to know the "deep structure" of some phenomenon--whether volcano or schizophrenia--to assert that the phenomenon has causal efficacy. Sorry for any confusion on that minor portion of our article.
'Doing justice to the clinical consensus requires an explicit recognition of the dimensional nature of symptom distribution, the prototypical nature of clinical diagnosis, the necessity of explanatory pluralism, and the complex, multilevel, multifactorial etiology wherein mental health problems (and the processes that generate them) exist in a web of temperament, psychological development, behavioral learning, genetic vulnerability, and social adversity.'
This piece does an excellent job holding the tension between diagnoses as mere labels and diagnoses as discrete disease entities. I wonder if there’s additional mileage in framing diagnoses as descriptive of processes rather than states.
The static noun form of “depression” invites the problems you’ve cataloged - it either collapses into a circular symptom list or inflates into an unwarranted hidden essence. But recognizing depression as a process - a pattern of how certain phenomena unfold, reinforce each other, and sustain themselves over time - seems to offer explanatory traction without the metaphysical overclaiming.
This also maps better onto clinical reasoning as I experience it. In practice, I’m not checking boxes on a symptom list. I’m recognizing a trajectory, a dynamic. “This has the shape of a depressive process”. The name points toward how things are moving, not just what’s present.
The process framing makes treatment logic more transparent as well. We’re not eliminating a disease entity - we’re interrupting, redirecting, moderating, shifting or resolving a process, which might involve a variety of interventions at multiple points depending on where we have leverage. That’s neither purely descriptive nor fully etiological, but it’s also explanatory.
Thank you for this! I’m working on a history of medicine piece exploring how the shift from process to substance ontology shaped medical epistemology. Now I’m adding everything Vintiadis to my reading list!
Enactivism is also very process oriented. If you haven’t seen Sanneke de Haan’s enactive psychiatry and Kristopher Nielsen’s 3E psychopathology, that’ll be worth your while
It's interesting to read your defences of "diagnosis as explanation" because I've been saying, myself, that a diagnosis can't explain anything, it's just like an abbreviation of the criteria list etc. Which I guess is too quick and dismissive, after all.
Still, many people do make a weirdly big deal out of getting a diagnosis. I get that many feel strongly that they now belong to a community, they're not a "lone freak" anymore, and that can be powerful. And obvs diagnoses can open the doors for treatments, adjustments and so on that the individual is in dire need of. But it seems to me that many people think, in addition, that they now have a CAUSAL explanation for why they think and feel and act the way they do - this reified idea of the psychiatric condition(s) as a THING that CAUSES thoughts, feelings and behaviours.
Many thanks, Awais, for the elegant, analytic take-down of the critics who claim that psychiatric diagnoses are merely tautological or "circular" descriptive lists. Thanks as well for the call-out to the article Dr. Mark Ruffalo and I did for Psychiatric Times, which tracks very closely with many of your own points [see https://www.psychiatrictimes.com/view/no-psychiatric-diagnoses-do-not-reflect-circular-logic].
The key fallacy promoted by the "circularity" critics is the failure to distinguish a concept, construct, or list of diagnostic criteria from its referent. As you correctly point out:
"The diagnostic criteria in official manuals such as the DSM and ICD are simply indices, as a way of pointing towards and recognizing the existence of a state, a condition, a syndrome, a property cluster, etc. They do not constitute the condition itself (see Kendler 2017). It is not the case that “depression” is nothing more than the symptom criteria in diagnostic manuals. Rather, the criteria are a way for us to recognize the condition of depression."
There is a remarkable similarity between your observation and that of a famous Mahayana Buddhist saying; namely, "A finger pointing at the moon is not the moon." The DSM categories and their criteria are merely diagnostic "fingers" pointing to actual conditions or states of affairs in the external world (specifically, in certain patients). Thus, it is entirely fallacious to assert that psychiatric diagnosis entails the claim that "symptoms are caused by their descriptive label." (Kajanoja & Valtonen, op cit). Indeed, that assertion is a classic "red herring" (and likely, a Rylean category mistake).
The Buddhist saying puts it in more poetic but philosophically accurate language:
“Consider this example: suppose someone is pointing to the moon to show it to another person. That other person, guided by the pointing finger, should now look at the moon. But if he looks instead at the finger, taking it to be the moon, not only does he fail to see the moon, but he is mistaken, too, about the finger. He has confused the finger, with which someone is pointing to the moon, with the moon, which is being pointed to.” https://www.dharmasite.net/Surangama_new_translation.pdf
Just so! Thanks again, Awais, and I hope your readers will take a look at our article in Psychiatric Times. We anticipate a collegial rejoinder from Drs. Kajanoja and Valtonen, to which we will almost certainly respond!
Best regards,
Ron
Ronald W. Pies, MD
P.S. The volcano analogy in our article was simply meant to suggest that that we do not need to know the "deep structure" of some phenomenon--whether volcano or schizophrenia--to assert that the phenomenon has causal efficacy. Sorry for any confusion on that minor portion of our article.
'Doing justice to the clinical consensus requires an explicit recognition of the dimensional nature of symptom distribution, the prototypical nature of clinical diagnosis, the necessity of explanatory pluralism, and the complex, multilevel, multifactorial etiology wherein mental health problems (and the processes that generate them) exist in a web of temperament, psychological development, behavioral learning, genetic vulnerability, and social adversity.'
An excellent preamble for all future discussion.
This piece does an excellent job holding the tension between diagnoses as mere labels and diagnoses as discrete disease entities. I wonder if there’s additional mileage in framing diagnoses as descriptive of processes rather than states.
The static noun form of “depression” invites the problems you’ve cataloged - it either collapses into a circular symptom list or inflates into an unwarranted hidden essence. But recognizing depression as a process - a pattern of how certain phenomena unfold, reinforce each other, and sustain themselves over time - seems to offer explanatory traction without the metaphysical overclaiming.
This also maps better onto clinical reasoning as I experience it. In practice, I’m not checking boxes on a symptom list. I’m recognizing a trajectory, a dynamic. “This has the shape of a depressive process”. The name points toward how things are moving, not just what’s present.
The process framing makes treatment logic more transparent as well. We’re not eliminating a disease entity - we’re interrupting, redirecting, moderating, shifting or resolving a process, which might involve a variety of interventions at multiple points depending on where we have leverage. That’s neither purely descriptive nor fully etiological, but it’s also explanatory.
That’s is additional mileage indeed! 😊 This is a good intro paper on this issue: https://www.tandfonline.com/doi/abs/10.1080/09515089.2022.2101443 (if you search on Google Scholar, there’s a pdf available too)
Thank you for this! I’m working on a history of medicine piece exploring how the shift from process to substance ontology shaped medical epistemology. Now I’m adding everything Vintiadis to my reading list!
Enactivism is also very process oriented. If you haven’t seen Sanneke de Haan’s enactive psychiatry and Kristopher Nielsen’s 3E psychopathology, that’ll be worth your while
Thank you for writing these descriptive and clarifying explanations Dr Aftab!
It's interesting to read your defences of "diagnosis as explanation" because I've been saying, myself, that a diagnosis can't explain anything, it's just like an abbreviation of the criteria list etc. Which I guess is too quick and dismissive, after all.
Still, many people do make a weirdly big deal out of getting a diagnosis. I get that many feel strongly that they now belong to a community, they're not a "lone freak" anymore, and that can be powerful. And obvs diagnoses can open the doors for treatments, adjustments and so on that the individual is in dire need of. But it seems to me that many people think, in addition, that they now have a CAUSAL explanation for why they think and feel and act the way they do - this reified idea of the psychiatric condition(s) as a THING that CAUSES thoughts, feelings and behaviours.