The recent suicide of comedic genius Robin Williams prompted another round of what have become the well-rehearsed pronouncements of the psychiatric establishment. Depression, the public is instructed, is “a real disease” whose diagnosis can be established reliably, whose causes are increasingly understood, and whose treatment is usually successful. If only its sufferers would bring themselves to the attention of clinicians (never mind that in Williams’s case clinical attention was hardly in short supply), a great deal of suffering and death could be avoided. Unpacking the many presumptions and misrepresentations entailed in this recurring message would require several books. In A Metaphysics of Psychopathology, Peter Zachar begins, appropriately, at the beginning: what does the word ‘real’ in “real disease” mean?

          Zachar has, over the past decade or so, become one of the brightest lights in the philosophy of psychiatry and psychology, and his wide-ranging erudition is brought to bear to great effect in the present volume. Although his subject is psychopathology, his book is perhaps more accurately characterized as a primer on the philosophical constructs that are most useful — I would argue necessary — to understand, practice, and teach psychiatry and clinical psychology with a level of sophistication commensurate with their complexities and importance. This monograph is, however, anything but a dry recitation of conceptual esoterica. Zachar’s expertise in clinical psychopathology allows him to use multiple personality disorder, bereavement and depression, narcissism, and hysteria, among other psychiatric constructs, to illustrate his philosophical lessons and insights. And although facility in psychology and philosophy would be sufficient for two successful academic careers, Zachar’s knowledge of the history of science, evolutionary biology, astronomy, and physics expand both the explanatory and entertainment value of his work. (Any book on psychopathology that includes the sentence, “For example, photons first appeared after the Higgs field broke electroweak symmetry, but they have existed for most of the history of the universe” (p. 149) deserves a wide readership!)

          Despite periodic and generally useful digressions, Zachar’s mission is clear: “Our purpose is to examine psychiatry and psychology’s use of metaphysical concepts such as real, true, and objective; to refrain from assuming that the meaning of these concepts is self-evident; and to not forbid the use of such concepts as the traditional empiricists tried to do” (p. 210). That sentence gives the impression that he steers a middle course between the scientific realists’ belief in a knowable, mind-independent reality and the empiricists’ allergy to such metaphysical elaborations. While he is respectful of the range of schools of philosophical thought, he leaves no doubt about his own. Drawing heavily on the American pragmatist tradition of William James and Charles Sanders Peirce, Zachar explains and illustrates compellingly with examples his scientifically inspired pragmatism, two major components of which are radical empiricism and instrumental nominalism.

          Philosophical categories such as those in the foregoing sentence can be forbidding to readers unacquainted with them, but in Zachar’s hands they serve to bring metaphysical constructs down to earth. Radical empiricism and instrumental nominalism seek to ground abstractions in experience and insist that they be invoked only if they serve to illuminate particular distinctions in particular contexts. Thus, the notion of ‘real’ (as in “real disease”) is only meaningful when contrasted with constructs such as ‘fictional’, ‘imaginary’, ‘artificial’, or ‘fake’, and is hopelessly obscure in the absence of such explicit contrasts brought to bear on particular questions. Through that framework, Zachar astutely diagnoses where conceptualization and classification of psychopathology can go awry. Specifically, he identifies essentialism, a construct whose enormous importance in this context he has played a major role in illustrating in recent years, as a human propensity that lies behind psychiatry’s current conceptual muddle.

          As Zachar points out, research in developmental psychology suggests that the impulse to consider taxonomy as an exercise in “carving nature at its joints” has deep roots in human cognition. We seem primed to view categories of psychopathology (among many other domains), at least aspirationally, as natural kinds, each possessing an “essence” that has been or eventually will be revealed through research. Despite the DSM’s explicit disavowal of it, an essentialist bias appears to be both instantiated in and perpetuated by psychiatry’s categorical diagnostic system. Any reader who believes otherwise need only accompany a psychiatric team on its rounds in which talk of “ruling out” particular diagnostic entities, and debates about whether this patient has a “true depression” or that one is “actually bipolar,” are certain to be heard. Moreover, as Zachar also demonstrates, the most philosophically complete definition of psychiatric disorder currently available — Wakefield’s “harmful dysfunction” model — is fundamentally essentialist and thus problematic.

          Zachar’s well-informed anecdotes regarding the process of formulating the DSM-5 are deeply revealing of a discipline in crisis. Not long ago many expected the imminent arrival of a golden age of psychiatry in which an understanding of the genetic and environmental influences on neural development and functioning would result in the advent of effective therapies tailored to specifiable psychopathologies; in which consensus about the status of psychiatric disorders would result in destigmatization of patients and cessation of internecine conflict; and in which excitement and justified optimism about the field and its accomplishments would attract the brightest and most promising students to careers in psychiatry. Perhaps less interesting in this context than the question of why that golden age has not arrived is the observation that if one were to listen to the psychiatric establishment and its allies, s/he would conclude that it has. Our highly elaborated and reified system of psychiatric diagnosis has indeed resulted in breathtaking profits for the pharmaceutical industry and a robust market for DSM desk references, diagnostic guides, casebooks, and study guides. For patients and the public, however, our age is considerably less golden. Zachar’s conceptual tools are not sufficient correctives, but they are surely necessary for the discipline to advance. His book, therefore, should be required reading for all students and trainees in psychiatry and clinical psychology and — especially — for their teachers.

          The majority of corrections to Zachar’s text I could suggest would be mere cavils. More substantive, however, is an observation about his apparent belief that metaphysical claims regarding the disease status of psychotic conditions merit less skepticism than such conceptualizations as applied to “milder” forms of psychopathology. Although such a stance is consistent with that of McHugh and Slavney and has a certain intuitive appeal, Zachar’s pragmatism suggests other possibilities. Specifically, we should take seriously the observations of some members of the “recovery” community that the disease model of psychotic states — contrary to the salutary motives of its proponents — serves to increase stigma and reduce hope, while implying (spuriously but nonetheless compellingly to some) that pharmacotherapies are indicated in all cases despite their ineffectiveness for some and adverse effects for many. After all, as Zachar so articulately reminds us, the question of whether something is “a real disease” is only meaningful in the context of the consequences of its potential answers.

© 2014 G. Scott Waterman

G. Scott Waterman, M.D., Professor of Psychiatry Emeritus, University of Vermont College of Medicine