Psychiatric Disorders as an Imperfect Community: Peter Zachar, PhD

May 4, 2020

In this interview with Awais Aftab, MD, Dr Peter Zachar discusses how psychiatric disorders can be viewed through the lens of scientifically inspired pragmatism.

Peter Zachar, PhD, is well-known for his nuanced philosophical understanding of psychiatric concepts. In this interview with Dr Aftab, he discusses his book, A Metaphysics of Psychopathology, and how psychiatric disorders can be viewed as an "imperfect community" through the lens of scientifically inspired pragmatism.


Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.

Peter Zachar, PhD, is an Ida Belle Young Research Professor of Psychology at Auburn University Montgomery, Montgomery, AL. He graduated from Loras College in Dubuque, IA, with degrees in philosophy and psychology and from Southern Illinois University with a PhD in psychology. He has served as Department Chair, Associate Dean, and President of the Faculty Senate at Auburn University Montgomery. He is also the current President of the Association for the Advancement of Philosophy and Psychiatry. His primary area of scholarship is philosophical issues in psychiatric classification. He is the author of Psychological Concepts and Biological Psychiatry: A Philosophical Analysis (John Benjamins, 2000), and A Metaphysics of Psychopathology (MIT Press, 2014).

In the words of G. Scott Waterman, one of our previous interviewees in this series, “Zachar has, over the past decade or so, become one of the brightest lights in the philosophy of psychiatry and psychology.”1 This is by no means an overstatement. Psychiatric readers are likely to be familiar with Dr Zachar from his numerous collaborations with the psychiatric researcher Dr Kenneth Kendler on topics of conceptual and historical import; many of these articles have been published in top psychiatry journals such as American Journal of Psychiatry. It is of relevance in this context that Dr Zachar has co-edited the volume Toward a Philosophical Approach to Psychiatry (Cambridge Scholars Publishing, 2020) which is a selection of Ken Kendler’s most important philosophical papers to date.

My first foray into Zachar's intellectual world was several years ago when I came across his article “Psychiatric Disorders Are Not Natural Kinds,”2 in which he argued that conceptualizing psychiatric disorders as “natural kinds”-entities existing in nature that can be defined in terms of underlying biopathological processes or inherent statistical properties-is inadequate and unnecessary. Instead, he argued for the notion of “practical kinds”-stable patterns of phenomena that we can identify and classify in light of our scientific goals and interests.3 His critique of essentialism and defense of pragmatism is a philosophical thread that runs through his entire philosophical output and finds its most mature expression in A Metaphysics of Psychopathology.

Aftab: I want to start the interview by saying how much I loved your book A Metaphysics of Psychopathology. Your philosophical discussion is very interesting and insightful, and you talk about complex ideas with great clarity. It has given me a lot to think about and has impacted my thinking quite a bit. Can you describe as simply as you can for a general psychiatric audience what you mean by the philosophical notions of scientifically inspired pragmatism, essentialism, and the imperfect community model in your book?

Zachar: Thank you for your kind comments. I sometimes think that people writing philosophy are often attempting to impress an idealized philosophy professor whose image they keep in their head. That is not my audience. I write for people who can get engaged by philosophical ideas, and I want to rouse their intellectual excitement if I can.

How to explain scientifically inspired pragmatism? Several years ago, Louis Menand published a book called The Metaphysical Club. In it he told the story of how living through the American Civil War led some college-age men to abandon the absolute certainties they had been raised with in favor of ideas that are provisional and can be adapted to changing conditions. These young men were inspired by Darwin’s recently proposed theory of evolution and their new philosophy was called pragmatism.

Building on Menand, I emphasize the empiricist roots of pragmatism-most evident in the work of William James. Empiricism was introduced during the 17th century as a philosophy of who today would be named “scientists” as a contrast to the philosophies of Plato and Aristotle. Rather than seeking absolute truths, the empiricists sought knowledge based on experience and experiment, which is provisional and subject to correction by future experience. In using the term scientifically inspired pragmatism, I am trying to call attention to pragmatism as a new name for what one branch of empiricism developed into after Darwin introduced natural selection.

Pragmatists (as empiricists) do not favor “essences.” Traditionally, essentialism is the view that kinds have hidden natures that make them be what they are. To know an essence is to know what something is with certainty. The early empiricists were disturbed by how readily their fellow countrymen were willing to kill each other over disagreements about abstractions such as papal infallibility and the divine right of kings. They became skeptical about any claims of metaphysical certainty regarding abstractions, especially claims about essences. Someone who adopts a non-essentialist perspective does not view kinds as having identity-determining essences that all members share.

The imperfect community is a non-essentialist idea, namely, that the various members of the class of psychiatric disorders have many things in common, but there no one thing (an essence) that they all have in common and that distinguishes them as a group from non-disorders.

Aftab: Your account of the imperfect community model tells a story about how the psychiatric domain came about. Can you explain how you think that happened?

Zachar: Yes. To begin, let’s look at what the psychologist Jim van Os says about hallucinations and delusions.4 Rather than diagnostic indicators of psychosis only, van Os points out that hallucinations and delusions can occur across most of the common psychiatric disorders. The term people are using for symptoms that cut across diagnostic categories is transdiagnostic. That notion is central to the imperfect community story.

In the 19th century, the physicians who staffed the newly created asylums were exposed to large numbers of patients with psychosis. Hallucinations and delusions fell under their scope of practice, but so did the other symptoms that can occur on the psychosis spectrum-lack of impulse control, anxiousness, somatic concerns and so on. In the book I refer to these as symptoms residing in the penumbra of psychosis. In time, these penumbra symptoms would be seen as falling within the scope of practice even in the absence of psychosis. Historically this shift was represented by the introduction of constructs for non-psychotic disorders like manie sans délire. These new non-psychotic cases would have symptoms that could occur on the psychosis spectrum (like anxiousness for manie sans délire) and also their own new penumbra symptoms that did not have a strong signal on the psychosis spectrum (such as obsessions with preservation of intellect). It was therefore only a gradual shift to incorporate new penumbra symptoms under the scope of practice once they were recognized as being central for some cases and given names such as monomania-or much later obsessive-compulsive disorder.

The outcome of this gradual expansion of the scope of practice has been an imperfect community composed of disorders that are alike in many ways, but there is no one way that they are all alike. But the domain is not random or arbitrary - new constructs have been introduced for reasons. Like evolution, the process is ongoing although the rate of change varies over time. We should be open to the possibility that there may be many relevant symptoms that have not yet been recognized or perhaps “seen as” symptoms.

Aftab: In your view we can utilize that story of the imperfect community for pragmatic guidance when it comes to thorny classification issues in psychiatry. To what extent is this story grounded in actual history of psychiatry (versus it being figurative or hypothetical, akin to how philosophers sometimes talk about the “social contract” as if it were a historical event)? I imagine there are historians of psychiatry who may object to this narrative of a relatively steady expansion of psychiatric categories based on imperfect similarities of new categories to old categories.

Zachar: The imperfect community notion is not so much a guide for distinguishing between different disorders or distinguishing normal from abnormal but more like a description that illustrates why those distinctions can be hard to make.

It is important to have reasons for claiming that schizophrenia and depression are psychiatric disorders, whereas white supremacy and atheism are not disorders. In philosophy, these distinctions would typically be made by articulating necessary and sufficient conditions for membership in the class of psychiatric disorder. Developing such definitions is a good intellectual exercise but for complex classes like psychiatric disorder, such definitions create artificially precise boundaries.

The proposed necessary and sufficient conditions can also be also transformed into hidden essences, under whose guidance the history of a discipline such a psychiatry becomes a tale of how we learned to or have been attempting to discover the correct classification. I consider that approach to the history of psychiatry to be based on a metaphysical fairy tale.

In part, the imperfect community view was informed by the writings of the historian of psychiatry German Berrios.5 The imperfect community is only one way of looking at the history of psychiatry. A more comprehensive history would emphasize many more factors, including the role of conceptual models such as faculty psychology and degeneration theory. Nevertheless, the imperfect community view adopts a descriptive approach, narrating a history of how constructs such as schizophrenia evolved out of earlier constructs - such as hebephrenia - with which it shares some symptoms, building a picture of how the classification was coddled together over time based on multiple, sometimes competing considerations. It is not a tidy story.

When the psychiatrist Allen Frances talks about diagnostic inflation and the psychologists Nick Haslam and Richard McNally talk about concept creep, I see them as talking about one process by which the domain of psychiatric disorders was coddled together, but they are highlighting cases where they suspect the process is being extended too far.

In the 1960s Soviet psychiatrists tried to expand the domain to include symptoms that “manifest” in the profiles of political dissidents under the name of sluggish schizophrenia-but it did not follow the process of how the domain gradually came together and was rejected as too much of a leap. My guess is the same thing would happen if someone tried to force white supremacy or atheism into the domain.

Aftab: My concern is that there doesn’t seem to be a natural limit to the expansion of the imperfect community since much of the psychological landscape is dimensional and similarities may never end. Diagnostic entities feel forced if one can’t see the thread of similarities. Kraepelin, I imagine, might be astonished if he found out that psychiatrists a century later consider gambling and binge eating to be disorders. I sometimes wonder about the future directions our domain will take. For instance, mental health professionals, especially in forensic settings, are increasingly called upon to assess violence risk, regardless of whether there is a bona fide psychiatric disorder. We increasingly view aggression and violence in our society (think mass shootings) as products of obscure/irrational/“pathological” motivations. This is conceivably just a few steps away from creation of new psychiatric constructs surrounding violence. Are such possibilities cause for concern?

Zachar: Yes, the lack of a natural limit is very much a cause for concern-but because of some inherent vagueness in the fuzzy boundary between the normal and the abnormal, there is no magic bullet solution to this demarcation problem. It is an open ended conceptual-philosophical issue and will likely remain so. Also, there is no law dictating that the domain must always expand. It could also contract. I don’t claim that it should continually expand.

Aftab: You write: “A central motivation of the essentialist framework is to provide an explanation for why legitimate knowledge is more than something that we manufacture and construct.” And you see it as a task to provide a non-essentialist way of fulfilling that motivation. The way I understand it, your answer seems to be along the lines of: legitimate knowledge is indeed something that we manufacture and construct, but we manufacture and construct it in the context of a long-standing history of ideas and background assumptions, and we construct it in the light of available empirical evidence and in light of our pragmatic goals of our knowledge, such that a wide range of processes and outcomes are possible but they are neither arbitrary nor relativistic. Would you agree with this characterization?

Zachar: For the most part, yes. In my view our classifications are contingent on a lot of different factors, including background knowledge and goals. Once you have epistemic and evaluative commitments, however, they work together in a non-arbitrary way to constrain what counts as a good solution.

I don’t like the term manufacture even as a metaphor because it suggests the production of artificial objects such as tables and textiles. For example, I wouldn’t say that Kraepelin’s distinction between manic depression as recurrent and dementia praecox (schizophrenia) as having a deteriorating course was artificial. Recurrence and deteriorating course are actual patterns in the world. But to consider these features as essences that demarcate two different kinds of psychosis is an over-simplification. Many psychopathologists believe that recurrence remains an important feature of manic depression, but deteriorating course is a problematic way to define schizophrenia.

Our classifications are not objective enough to be considered inevitable but are more objective than being made up. For instance, once you articulate a goal such as “reliably identify schizophrenia prodromes using biomarkers,” whether you meet that goal or not isn’t something you can make up. But neither is it inevitable that we remain committed to the concepts of schizophrenia and prodrome. Viewing our knowledge as always subject to correction by future experience creates a pretty open epistemic horizon.

Aftab: Your pragmatic take on “truth” and “objectivity” was very fascinating for me. You write: “To call something a fact is to make a claim about what we are obligated to accept.” Psychiatry is certainly subject to a lot of controversy and debate, with no shortage of people holding extreme opinions. Which just makes me wonder . . . can any claims be made either about the nature of mental disorder or psychiatric classification that any “reasonable” person would be obligated to accept?

Zachar: Let me preface this answer by explaining the title of the book. It is not “The Metaphysics of Psychopathology,” but “A Metaphysics of Psychopathology.” More precisely it is a minimalist metaphysics.

Pragmatists and empiricists minimize reliance on metaphysical assumptions by articulating what they believe we are practically asserting when using metaphysical concepts such as fact, truth, and reality. When we say something is a fact, I believe we are asserting, “You are obligated to accept this no matter what you want to be the case.” A minimalist metaphysics can accommodate the idea that the world is not always the way we want it to be-the world regularly resists our wishes and preferences. Viewed this way, there is no shortage of facts in psychiatry, but which facts we should care about and what we should do with them is another matter.

Our concepts for mental disorder are too abstract and complicated for any one formulation to be obligatory. Our notions of mental disorder should continually accommodate what we understand to be the facts, but also involve norms, values, and so on-what philosophers call extra-factual considerations. One of Ken Kendler’s first philosophical articles was written after he realized that whether we should define a valid schizophrenic disorder narrowly as having a poor outcome or broadly as having many possible outcomes depends, in part, on extra-factual assumptions about “valid” disorders.6

Aftab: From Jerome Wakefield’s perspective, some cases of depression involve a failure of natural function (where “natural function” is functioning as designed in evolution) and some cases of depression don’t; the former are disorders, the latter are not. Your imperfect community model is an alternative to the harmful dysfunction model. What are the main differences?

Zachar: As an armchair exercise that articulates a working concept of psychiatric disorder, I am a fan of Jerry’s harmful dysfunction analysis. Where I disagree with Jerry is that he is offering an essentialist definition of psychiatric disorder in terms of its inner nature that he thinks closes the concept. From his perspective, once we fix a concept for psychiatric disorder, the task is to discover what properly falls under its scope. As an empiricist who believes that all our knowledge is potentially open-ended and subject to correction by future experience, I do not see abstract concepts such as psychiatric disorder as fixed and closable.

He and I also tell different stories about how the domain was built. Jerry suggests that we have a natural ability to distinguish normal from abnormal reactions to circumstances, which in the past allowed us to recognize many conditions as disorders even when we did not know their underlying nature as a unified class. Our mapping of the domain, he believes, has been an inexact and indirect process that can be improved with the harmful dysfunction analysis. From the imperfect community perspective, there is considerable consensus on some core disorders, but rather than these disorders being first clues to correctly mapping out the psychiatric domain, the domain evolved via a gradual coddling together of symptom clusters informed by a varied collection of rationales and will probably continue to do so.

Aftab: A central criticism of Wakefield's harmful dysfunction analysis is that we lack information about natural psychological functions and dysfunctions, and resultantly we are forced to use either actual or potential impairment in functioning or distress as dysfunction indicators. You seem to rely on this argument in your book as well. However, this suggests that you accept that natural psychological function and dysfunction do actually exist out there in the world, but we lack knowledge of these functions. In other words, essentialism is ontologically true but is practically unhelpful because we are epistemically limited. Is that the case?

Zachar: You ask a good question. The empiricist philosopher John Locke believed that real essences exist but are unknowable by us. My skepticism about essentialism is of a stronger variety than Locke’s. In my view, to anoint anything an “essence” is a metaphysical assertion that goes beyond what is descriptively there.

One approach to psychology divides our mental processes up into distinct faculties such as emotion, cognition, and perception. Emotion can further be divided into fear, anger, sadness, and so on. Like human hearts and lungs, the psychological faculties are said to have functions. For Wakefield, the essences of these functions have been produced by natural selection.

I accept that our psychological processes are the result of natural selection, but that does not make me a closet essentialist. In the book I claim that we are too lacking in accurate information about the selection pressures operating on the human brain during evolution to know what the natural functions are, but lack of information is not the obstacle to knowing real essences. I doubt that they are there to discover.

Rather than faculties modeled on the function of concrete physical organs like the heart, psychological functions are not features of independent structures but emerge from activities extended throughout the nervous system. Psychological functions can also accommodate more individual variation than can human heart function. There are likely thousands of psychological functions that were influenced by natural selection, big and small. If so, they are produced and maintained by interconnected mechanisms that cross-cut each other in too many ways to be divided up into a privileged taxonomy of discrete faculties with specific essences.

Aftab: In one thought experiment, Kenneth Kendler and you ask: what if we were to rewind the tape of human history to 10,000 years ago and let history unfold again from that point forward. The psychiatric classifications that emerge in these historical rewinds, how much would they resemble our current DSM? Given how historically contingent our nosology is, likely not much. However, in these historical rewinds, do you think human societies would be able to converge on to the selection of paradigmatic cases as psychiatric disorders?

Zachar: For me that thought experiment is a useful way to keep in mind that many of our current classifications are contingent on a lot of past decisions and were not inevitable. For Ken, he does not want to deny contingencies in our classification, but his primary interest is to strive for scientific progress in our understanding of disorders.

Part of the idea in the rewind notion is that the process is ongoing and future classification may look very different from what we have now. Think of all the different ways you can organize a library. By color of the book, by size of the book, by date of publication, by authors’ last names, by topic and so on. Once you pick an approach you can organize the library systematically and usefully, but there is no single correct organization.

I am skeptical of a privileged, correct psychiatric classification as well, but the ways in which symptoms empirically cluster together likely places constraints on psychiatric classification that don’t apply to organizing libraries. If we could encounter a psychiatric classification manual from a parallel historical trajectory, I suspect we would recognize something of ours in the classifications of those who lived the alternative history even if they carve things up quite differently.

Convergence on some paradigmatic cases could be a good development as long as they are not seen as having been inevitable and set in stone. Among psychologists it looks like the higher order dimensions in the quantitative approach to psychopathology might be somewhat stable. Even here the list of dimensions is not fixed, but most lists include an internalizing spectrum, an externalizing spectrum, and a thought disorder spectrum.

Aftab: Philosophers of medicine and psychiatry tend to use the general term “disorder” and often either ignore the term “disease” or just treat it synonymously with disorder, although I suspect most people would say that the connotations are quite different. This is evident from the fact that critics of medicine and psychiatry often stick with the term “disease” as their target of criticism, even when they are discussing conditions labelled as “disorders”. I feel as if there is insufficient attention given within the philosophy literature to how loaded these terms are, and maybe we need to treat these terms as conceptually distinct. Your thoughts?

Zachar: Let me first point out that one practical difference between disease and disorder is related to training histories. The term disease does not readily come to mind for me like it would had I been trained as a physician to pay primary attention to the body as opposed to primarily attending to psychological development, cognition, personality processes, social interactions and so on. Nor do I spontaneously refer to psychiatric illness. I was trained to think of depression as a psychological disorder. The term disorder readily accommodates behaviors that represent aberrant learning histories such as phobias or that represent extreme values on psychological dimensions such as impulsivity. In psychology, disorders are often thought of as hypothetical constructs measured by tests such as the Minnesota Multiphasic Personality Inventory. It is a different way of looking at things.

Thinking philosophically, it is also helpful to not be an essentialist about disease. Consider all the different things called diseases including infectious diseases, genetic diseases, diseases due to chemical exposure, injuries, inherited or acquired vulnerabilities and so on. Although not as broad as disorder, disease is potentially a broader term than critics of the disease model acknowledge.

Nor does having a biological basis make something a disease. Seventy-five years ago if psychiatrists had discovered a biological basis for same sex attraction, it would have been taken as confirming evidence that LGB orientations are diseases. They would not have reached the same conclusion, however, upon discovering a biological basis of opposite sex attraction. Now we would think of any putative biological basis of either as representing biological variation. It may be that we will only label certain biological bases as disease substrates rather than variations if we have some pre-existing notion that the associated collection of “symptoms” represent disorders. So, in psychiatry the disorder concept is prior to disease. I think of them as distinct.

Aftab: By calling something a disorder, are we necessarily implying that the problem can be located within or inside the individuals, and not in their relational context or social/structural influences? If so, does that make disorder designation problematic for a wide variety of conditions currently classified in the DSM?

Zachar: Some social psychologists argue that we have a bias to see negative behaviors as an expression of people’s inner dispositions, especially for people we consider different from us. This bias is enhanced by essentialist notions of dispositions as inherent, fixed, and stable. It takes work to overcome this essentialist bias, but in doing so you can perceive negative behaviors as developing in situations and contexts, and not as inevitable expressions of a person’s hidden nature.

One complicating factor is that in the clinic you cannot make the people in your patient’s life change or fix your patient’s horrible situation-all you usually have to work with is them. In therapy at least, this means that you need to focus on what they are contributing to the problem without blaming them. It remains useful to view individuals as autonomous and, in some sense, separate and unique. Anyone who thinks that every person’s depression is different in some way because it is their depression is, in part, viewing disorders as features of persons.

Aftab: Your discussion of the bereavement exclusion debate in DSM-5 was very illuminating. I don’t think a lot of people realize that there was agreement among the prominent figures in the debate with regards to the scientific evidence that grief-triggered depressions are clinically similar to all other stress-triggered depressions, raising the question of why one type of triggered depression was being signaled out as diagnostically different. So, there were 3 options: keep the exclusion for grief in place, eliminate the exclusion, or extend the exclusion to all other stress-triggered depressions. The first option was recognized as conceptually inconsistent, which it is, but I suppose there can be good pragmatic reasons for a classification system (any classification system) to tolerate conceptual inconsistency in the service of some practical outcome (such as concerns about medicalization of grief). What are your thoughts on tolerating conceptual inconsistencies for pragmatic reasons?

Zachar: Logical consistency is important, but what counts as adaptive and maladaptive is so sensitive to contextual factors that it is unrealistic to expect a psychiatric classification manual to have Euclidean-like logical consistency throughout. The imperfect community is not a rationally deduced system akin to geometry.

After the book was published Ken Kendler, Michael First, and I interviewed many of the participants in the bereavement and depression debate and wrote a history of it.7 So far Ken and I have written five of these interview-based histories of the DSM. Darrel Regier was a co-author on one of these articles8 and provided crucial information for several others. The psychologist Bob Krueger was a co-author on another.9 For our most recent project we were again joined by Michael First.10

The way the bereavement debate was framed for the public “should psychiatrists label grief a mental disorder” distorted what the debate was about in a way that made one side seem obviously correct. If it had been framed as “should psychiatrists decide that if you become depressed after losing a loved one or getting divorced, unless you are psychotic, you are not really depressed, but normally sad” the other side might have seemed obviously correct to even more people. One side proposed slightly expanding the boundaries of depressive disorder by incorporating grief-triggered depressive episodes (Ken Kendler’s position in the debate). The other side proposed significantly contracting the boundaries by excluding stress-triggered depressive episodes unless there are severe symptoms such as psychosis or psychomotor retardation (Jerry Wakefield’s position).

The question is: Did the evidence favor one side so convincingly that there was broad consensus among the specialists about how to proceed. With widespread disagreement (not just a small number of dissenters) about the best way to proceed, it may have been better to not force a decision and leave the bereavement exclusion as it was in DSM-IV. That was Michael First’s view and I am sympathetic to it.

But in all honesty, the debate helped psychiatrists develop a better understanding of how to distinguish between severe grief and major depressive disorder, which they articulated in the DSM-5. For example, people in severe grief alternate between having sad and happy memories of the person, while in major depressive disorder it is sadness and anhedonia most of the time. Also, in grief, the sadness is focused on the loss, while in depression, the dysphoria encompasses the self and the world in general.

Aftab: What are some emerging or unexamined areas and topics in philosophy of psychiatry that you think may be productive areas of inquiry for philosophers of psychiatry in the upcoming years? What are your hopes for the future of philosophy of psychiatry?

Zachar: Philosophy of psychiatry touches on so many different issues, let me narrow my answer to issues in classification and psychopathology. How we can best incorporate biomarkers into our descriptions will be an important topic. Conceptualizing symptoms as transdiagnostic rather than category-specific also has a lot of implications for the philosophy of psychopathology. The relationship between the quantitative approach to psychopathology, which emphasizes factor analytic derived dimensional models, and traditional clinically based constructs also raises interesting conceptual questions.

For me, I continue to work on making my empiricist, non-essentialist (nominalist), pragmatist approach to psychopathology as intuitive as I can. I also want to write more about the relationship between psychopathology and classification. They are not the same. Many people see how difficult it has been to advance our understanding of psychopathology but rather than concluding that psychopathology is really hard to figure out, they blame the lack of progress on the DSM. For example, instead of seeing how transdiagnostic symptoms complicate psychopathology, they write about comorbidity as an artifact manufactured by the DSM. I hope to articulate how important insights into the complicated nature of psychopathology have sometimes misguidedly been articulated as critiques of the DSM

I share with Ken Kendler the hope that work in the philosophy of psychiatry can contribute to the advancement of our knowledge of psychopathology in a clinically useful way. I also hope that the philosophy of psychiatry can become a more respectable subspecialty within philosophy and contribute to the advancement of our philosophical knowledge.

Aftab: Thank you!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.

Previously in Conversations in Critical Psychiatry

Relentless Warrior for Mental Health: Allen Frances, MD

The Structure of Psychiatric Revolutions: Anne Harrington, DPhil

Skepticism of the Gentle Variety: Derek Bolton, PhD

Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD

Chaos Theory with a Human Face: Niall McLaren, MBBS, FRANZCP

The Rise and Fall of Pragmatism in Psychiatry: S. Nassir Ghaemi, MD, MPH

Integrating Academic Inquiry and Reformist Activism in Psychiatry: Sandra Steingard, MD, and G. Scott Waterman, MD

Social Constructionism Meets Aging and Dementia: Peter Whitehouse, MD, PhD

50 Shades of Misdiagnosis: Susannah Cahalan

Institutional Corruption and Social Justice in Psychiatry: Lisa Cosgrove, PhD

The Impoverishment of Psychiatric Knowledge: Giovanni Fava, MD

Psychiatry and the Human Condition: Joanna Moncrieff, MD



Dr Aftab is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times Advisory Board. He can be reached at or on twitter @awaisaftab. Dr Aftab and Dr Zachar have no relevant financial disclosures or conflicts of interest concerning the subject matter of this article.


1. Waterman GS. Review, A Metaphysics of Psychopathology. Metapsychology Online Reviews. Accessed May 1, 2020.

2. Zachar P. Psychiatric disorders are not natural kinds. Philos Psychiatr Psychol. 2000;7(3):167-182.

3. Zachar P. Psychiatric disorders: natural kinds made by the world or practical kinds made by us? World Psychiatry. 2015;14:288-290.

4. van Os J, Reininghaus U. Psychosis as a transdiagnostic and extended phenotype in the general population. World Psychiatry. 2016;15(2):118-124.

5. Berrios GE. The History of Mental Symptoms. Cambridge, U.K.: Cambridge University Press; 1996.

6. Kendler KS. Toward a scientific psychiatric nosology: Strengths and limitations. Arch Gen Psychiatry. 1990;47(10):969-73.

7. Zachar P, First MB, Kendler KS. The bereavement exclusion debate in the DSM-5: A history. Clin Psychol Sci. 2017;5(5):890-906.

8. Zachar P, Regier DA, Kendler KS. The aspirations for a paradigm shift in DSM-5: an oral history. J Nerv Ment Dis. 2019;202(4):346-352.

9. Zachar P, Krueger RF, Kendler KS. Personality disorder in the DSM-5: An oral history. Psychol Med. 2016;46:1-10.

10. Zachar P, First MB, Kendler KS. The DSM-5 proposal for attenuated psychosis syndrome: a history. Psychol Med. 2020;50(6):920-926.