What is "truth"? Some philosophical contributions to psychiatric issues

A History of the Alexithymia Concept and Its Explanatory Models: An Epistemological Perspective

Alexithymia, as a theoretical psychotherapeutic construct, finds its origins in psychosomatic medicine, actually being quite old. However, beyond the specific observations and case studies, their characterization and systematization is relatively recent. However, from an epistemological point of view, it remains the subject of debate and therefore remains outside the conventional diagnostic guidelines. Possibly, its history, closely linked to psychoanalysis, as well as the lack of clear empirical references, has turned the alexithymia construct before into a good descriptive and comprehensive framework than in a precise diagnostic model. In this article it is, following the thread conduits of the historical perspective, to deepen these epistemological aspects.

Classificazione, diagnosi ed ICD-10. I - Principi generali e considerazioni critiche

Scopo- Discutere i principali problemi teorico-pratici connessi alia classificazione in campo medico e psichiatrico, e presentare la struttura generale della decima revisione della Classificazione Internazionale delle Malattie (ICD-10), entrata ufficialmente in vigore dal gennaio del 1993.Risultati- Sono dapprima discussi i fondamenti epistemologici della classificazione, le varie strategic classificatorie adottate in campo medico e psichiatrico ed i principali modelli classificatori esistenti. Sono quindi analizzati i problemi relativi alia attendibilità ed alia validità delle diagnosi psichiatriche, e vengono descritte le strategic che possono essere impiegate per migliorarle. Infine sono discussi i principi che hanno informato ia stesura dell' ICD-10 ed ifield trialseffettuati al fine di preparare il testo finale delle direttive diagnostiche.Conclusioni- La classificazione in psichiatria rappresenta un passaggio obbligato e necessario per rendere possibile la sistematizzazione delle nuove conoscenze e la comunicazione tra operatori, ricercatori ed utenti. La decima revisione dell' ICD rappresenta lo sforzo più ampio sinora compiuto in campo psichiatrico al fine di predisporre un sistema classificatorio rigoroso che, nel contempo, sintetizzi approcci e culture psichiatriche differenziate.

Intersubjectivity in Wittgenstein and Freud: other minds and the foundations of psychiatry

Intersubjectivity, the cooperation of two or more minds, is basic to human behavior, yet eludes the grasp of psychiatry. This paper traces the dilemma to the "problem of other minds" assumed with the epistemologies of modern science. It presents the solution of Wittgenstein's later philosophy, known for his treatment of other minds in terms of "human agreement in language." Unlike recent studies of "Wittgenstein's psychology," this one reviews the Philosophical Investigations' "private language argument," the crux of his mature views on mind. It reads that argument as recording his shift from the modern egocentric paradigm of mind to an intersubjective one. The paper contrasts the merits of Wittgenstein's reduction of subject and object to grammar with the problems of Freud's metapsychological reduction. It shows how Wittgenstein's intersubjective method avoids the excesses of behaviorism and phenomenology, offering a specifically human way to adapt mechanistic and interpretive means to the communicative ends of psychiatry.

Improvisation and authority in illness meaning

Using the example of psychosomatic diagnosis, I argue that the clinical context has unique epistemological constraints that limit the certainty of diagnosis and so make meaning indeterminate for sufferer and healer. As a result, forms of clinical truth are borrowed from the therapeutic context to create and authorize meanings for ambiguous or ill-defined conditions and inchoate suffering. Diagnostic interpretation is concerned with classification and legitimation through the production of authoritative truth. In contrast, therapeutic interpretation is fundamentally concerned with the pragmatic problem of "how to continue" and hence, with the improvisation of meaning. These different ends give rise to tensions and contradictions in psychosomatic theory and practice. While authority is necessary to provide a structure on which variations of meaning can be improvised, authoritative meanings may also restrict the possibilities for invention by clinician and patient. The goal of patient and physician is to create enough certainty to diminish the threat of the inchoate while preserving enough ambiguity to allow for fresh improvisation. Accounts of illness meaning must recognize the interdependence of normative rigidity and metaphoric invention.

Psychoanalysis, science and clinical practice

The question of the relationship between psychoanalysis and science, and the place of psychoanalysis in clinical practice is reviewed. A commonly held view that the central question is whether or not psychoanalysis is scientific is challenged. It is argued instead that psychoanalysis, science and clinical practice are epistemologically independent fields and attempts to subsume one within the other are unproductive. Psychoanalysis may have as much to say concerning the epistemological basis of science as science has to say concerning the epistemological basis of psychoanalysis. Only a proper appreciation of this enables the question of the relationship between psychoanalysis and clinical practice to be adequately examined.

The alexithymia construct. A potential paradigm for psychosomatic medicine

During the past decade, the alexithymia construct has undergone theoretical refinement and empirical testing and has evolved into a potential new paradigm for understanding the influence of emotions and personality on physical illness and health. Like the traditional psychosomatic medicine paradigm, the alexithymia construct links susceptibility to disease with prolonged states of emotional arousal. But whereas the traditional paradigm emphasizes intrapsychic conflicts that are presumed to generate such emotional states, the alexithymia construct focuses attention on deficits in the cognitive processing of emotions, which remain undifferentiated and poorly regulated. This paper reviews the development and validation of the construct and discusses its clinical implications for psychosomatic medicine.

Validation of the alexithymia construct: a measurement-based approach

Alexithymia is a hypothetical personality construct that has been associated with a variety of medical and psychiatric disorders. This article reviews a program of research evaluating the validity of the construct using a measurement-based, construct validation approach. For this purpose the Toronto Alexithymia Scale (TAS) was developed. In a series of studies the TAS demonstrated internal consistency, good test-retest reliability, and a stable factor structure theoretically congruent with the alexithymia construct. In separate tests of construct validity, the TAS correlated in a theoretically meaningful fashion with measures of other constructs. Criterion validity was supported by a study in which the TAS was able to discriminate between behavioural medicine outpatients designated as alexithymic and those designated as nonalexithymic on the basis of objectively rated structured interviews. In a normal adult sample, TAS scores were not related to sociodemographic variables or intelligence. These results provide considerable empirical support for the validity of the alexithymia construct. In addition, the TAS appears to be a psychometrically sound measure of alexithymia that may prove useful in testing the construct with psychiatric and medical patient populations.

Foundations of psychoanalysis reconsidered

Grünbaum's approach to psychoanalysis suffers from several difficulties. It imposes a standard of logical reductionism and methodological purity that not only violates the nature of psychoanalytic knowledge, but imposes an invalid standard of verification and scientific confirmation. It utilizes a brand of dichotomous reasoning that forces psychoanalytic propositions into artificial positions that do not reflect the actuality of analytic practice. It imposes a standard of verification that is impossible for psychoanalysis, along with all forms of psychological knowledge, to reach. It visualizes psychoanalysis as encompassing only one form of knowledge of human psychic life, forcing it into a model that eliminates other aspects of the psychoanalytic process, so that psychoanalysis is subjected to criticism only on one dimension among several--a kind of psychoanalytic straw man. The psychoanalysis that is so impaled often is difficult for the psychoanalytic practitioner to recognize. To the extent that Grünbaum's skillful and highly informed criticism of the philosophical bases of psychoanalysis encounters these difficulties, the value of his argument falls short of providing a useful basis for advancing psychoanalytic knowledge and particularly for promoting the quest for pertinent standards of validation within psychoanalysis.

Quantum metaphors in deep psychotherapy

Most psychodynamic theories are based on Freud's models of mental dynamics which were significantly influenced by Newtonian physics. Freud's attempts to use the then current scientific metaphors led to theoretical and clinical dilemmas particularly in deep psychotherapy and especially with borderline patients. The author argues that as Newtonian principles are useful for describing macroscopic reality, so Freud's Newtonian constructs are useful to a certain depth of therapy. Beyond that point, scientific metaphors can be retained but the appropriate metaphors are those of quantum physics. Quantum metaphors are used to explore duality, free will and patient-therapist interaction.

Psychotherapy research between process and effect: the need of new methodological approaches

The methodological problems and scanty results of psychotherapy research are noted and placed in a metascientific context. Efforts to attain ever greater specificity and standardization, guided by the idea of uniform methodology, are leading researchers steadily further away from the unique case. The underlying assumptions in current psychotherapy research are defined and the necessity of returning to case studies is indicated. Research methods need to be relevant and to make use of essential aspects of what is being researched (care of the research object). Psychotherapy research cannot avoid interpretations of meaning, and clinical methods should have a steering role. Case-study methods lead to specific problems of control and generalization. The scientific research strategy used in case studies is described and compared with the hermeneutic circle.

Pitfalls of a one-sided image of science: Adolf Grünbaum's Foundations of Psychoanalysis

Adolf Grünbaum's (1984) The Foundations of Psychoanalysis has received extensive attention in psychoanalytic and philosophical circles. Aspects of Grünbaum's argument are reviewed and criticized. While his volume is an important contribution to the epistemological assessment of psychoanalysis, it reflects serious shortcomings in at least four areas: its treatment of the role of suggestion in the analytic enterprise, its scrutiny of the psychoanalytic genetic method, its appreciation of analytic methodology as actually practiced, and, above all, its predication on a unidimensional, positivistic vision of science. Alternative approaches to the philosophy of psychoanalysis are suggested.