Pain assessment in 21st-century neuropsychiatry. Introducing plural, perspective, situated epistemic frames for the epidiagnostic characterisation of pain experiences

  1. Cardeña Martínez, Alejandro
Dirigida por:
  1. Ángel Peña Melián Director/a
  2. Ana Cuevas Badallo Tutor/a

Universidad de defensa: Universidad de Salamanca

Fecha de defensa: 23 de julio de 2019

Tribunal:
  1. Fermín Viejo Tirado Presidente/a
  2. María Inmaculada Perdomo Reyes Secretaria
  3. David del Río Grande Vocal

Tipo: Tesis

Resumen

Pain Assessment in 21st-Century neuropsychiatry: Introducing Plural, Perspective Situated Epistemic Frames for the Epidiagnostic Characterisation of Pain Experiences. PhD Research Plan — Logics & Philosophy of Science, ECyT - U Salamanca. Alejandro Cardeña Martínez — Direction: Dr. Ángel Peña Melián (UCM) May — 2019 The present work focuses on clinical epistemology as applied to diagnostic evaluation in neuropsychiatry: this study centres the epistemic accounts of assessing another person’s experiences of pain, seeking for describing and framing, from contemporary epistemologies, the scientific practices performed by clinicians in the process of evaluating and diagnosing neuropsychiatrically compromised pain-bearing patients. I — Introduction & Justification of the Topic of Research Pain assessment is a complex field, where many limitations of diverse origin may present methodological difficulties, altering clinical practices and blurring diagnostic and therapeutic efforts. In neuropsychiatric contexts, the assessment of a patient’s pain experiences, as reported through narratives and interpersonal measurement strategies, requires a wider attention (in comparison with non- psychiatrically compromised populations), for whom clinical models are supposed to be oriented towards rendering possible neurological dysfunctions and psychiatric pictures that could offer rather descriptive or explanatory bases for dealing with the reported pain-bearing scenario. Without a clear and meaningful understanding of patients’s experiences, undertaking further treatment (pharmacology, therapeutics) or elaborating a suitable prognosis (outlining the conditions for a plausible clinical trajectory) can be difficult tasks to attain. Patients suffering from pain reinforcing processes (by enlarging pain time-span, increasing intensity or adding a new pain-related pathology) usually acquire personal and interpersonal dysfunctions, coming down with several emotional re-attunements to their living phases, a change of attitude, of mind frame and, finally, agency and actions that, using PL Goldie’s terminology (Cf. Goldie 2000; 2002; 2003; 2004), ‘re-shape’ their overall personality. Within this context, comorbidities (further clinical entities related to a previously defined condition) can present, provoking increasingly complex and heterogeneous diagnostics that face multiple problems in characterising, identifying and dealing with neurological and psychiatric dysfunctions comorbid to a previous state of pain (van Praag 1993; Feger 2001; Maj 2005; Aragona 2009a; Jakovljević 2008; Cramer et al 2010; Klinkman & van Weel 2011; Jakovljević & Ostolić 2013). The opposite direction is also a viable development for these patients, incorporating pain as a comorbid clinical circumstance to a reinforced neuropsychiatric state. In both cases, pain assessment marks the beginning of a multifactorial heterogeneous and complex diagnostic, whose epistemological challenges must be approached should we enter a modern global practice of assessment. These scenarios introduce an epistemological worry on how accurate such assessment is able to be performed, along with several claims running procedural, ontological and deontological discussions in relation to how scientists understand patients’s values, is able to be performed, along with several claims running procedural, ontological and deontological discussions in relation to how scientists understand patients’s values, attitudes and beliefs, and how they project them in characterising an intimate and untransferable emotional experience (Cf. Goffman 1968; Haraway 1976; Dupré 1981; Thagard 1999; Schwenk 1999; Hacking 1986; 1995; 2002). This epistemic challenge comes parallel to modern increasing disagreement on the validity of systematic and categorial disease classifications, instead of wider person-centered multi-dimensional views, and the appropriateness of the current diagnostic models, their instruments for evaluation and their interpersonal practices of assessment for characterising pain experiences (Aragona 2009b; Aragona 2009c; Goldberg 2011; Hickey & Roberts 2011; Borsboom et al 2011; Anjum et al 2015). To study this landscape, the work focuses on contemporary social, naturalised epistemology: considering the renewal efforts in ethnography, anthropology, history and sociology, some modern epistemologies sprang during the 60’s-90’s, and revitalised coming the 21st Century as a new approach to identify the movements and boundaries sciences are facing. What was first programmed as a social epistemology towards general fields (Merton 1973; Goldman 1987; 1999; Fuller 1988), regenerated as a more detailed vision, marked by feminist studies, interdisciplinary research (Darden 2006), and the era of biological technology (Haraway 1991; Shiva 1995; Keller 1995; 2003a; 2003b; 2005; Weed & Rooney 2010; van Fraassen 1976; 1980; 1989; 1994; 2002; Perdomo 2003; 2011; Harding 1991; 1993; Galison & Stump 1996; Galison 2004; Weinberg 1993; 2001). The thesis follows these attitudes in epistemic pluralism, perspectivism and naturalism (Cartwright 1983; 1999; Kitcher 1984; 1992; 1993; Giere 1985a,b; 1999; 2006a; 2006b; Longino 1990; 2001; 2006) adopting a plural, perspective and situated (contextualised) view, analysing the developments in 21st-century neuropsychiatry through the theoretical instruments provided by such frameworks: the ethnographic study of scientific practices and their contexts of theory making, sounding the limits mono-lateral vs. multilateral approaches supply to diagnosis. This thesis wants to contribute to the field by proposing a multifactorial perspective that allows the creation of plural frameworks enabling interoperational research, dealing with the variegated interpretations of reported pain that particular disciplines handle. The work applies the concept of ‘epistemic frames’ as a tool for interpreting the contexts in which definitions and expectations of pain are resolved clinically; in addition, this effort would be the first application of the concept to clinical epistemology, oriented to offer useful outcomes for neuropsychiatric interoperational needs (i.e.: needs present in relationships such as patient-physician, patient-instrument, etc.). Defining and describing how the theoretical proposals develop is hoped to make clinical and research communities aware of how important a wider understanding of pain and its assessment are for delivering appropriate decisions in treatment, and forecasting prognostic scenarios involving newer technological instruments that favour patients’s recovery. II — Working Hypotheses & Main Goals The working hypothesis relates how, in applying the results of the previously referred contemporary epistemologies running plural, perspective, situated (contextualised) standpoints, the complex research and clinical scenario of pain assessment in neuropsychiatry can be exposed, its scientific practices (diagnostic practices, characterisation, instrumental assessment and therapeutical interpretation) described, and its developments and problems underlying the historical processes that the multiple fields gathered since early electrophysiology explained. The thesis introduces the concept of ‘epistemic frames’, scientific strategies of fields gathered since early electrophysiology explained. The thesis introduces the concept of ‘epistemic frames’, scientific strategies of interpretation that would work as situated contexts (in relation to the works on ‘epistemic frames’ in learning areas, mainly as exposed by Schaffer 2004; 2006; 2007; 2009; Rhode & Schaffer 2004; Crowley & Jacobs 2002), and as patterns of practicing science in a determined fashion (in relation to Kitcher 1984; 1992), that define the expectations, justifications, beliefs and predispositions installed in the subjects conforming certain epistemic community of research (Longino 1990; 2001), from which experimental designs, results, guidances of understanding, and plausible attempts at explaining phenomena emerge. Expectations play a major role, for in the development of a plural interdisciplinary research programme the focus of study and the practices involved may tend to shift amongst the original diverse disciplines: expectations would make clear that, for example, if assessment of pain is approached through an electrophysiological frame, reports, conclusions, interpretations of clinical problems and ending diagnostic values would be expected to resume, submit to and abide by the physiological terms, language and topic of research, beyond which a threshold proper to the identity of the discipline, may not give answers. This suggestion makes the case for exposing how multiple frames, which may appoint to cooperate in attending a big- picture integration of diverse origin, can be handled to explore and describe the main focuses, problems and barriers diagnostic assessment of pain in neuropsychiatry faces. These frames, schemas and enclosures of scientific interpretation, show how the scientific modelling of pain is a multifaceted problem benefited from interdisciplinary research (Cf. outlook in Darden 2006), which, at the same time, suffers from the complex circumstance of having multiple focuses of attention (especially when incorporating to discussion the problems of dysfunctional reports in assessment of neuropsychiatric conditions, more over with pain-reinforcement pictures), different definitions and theoretical orientations in the process of unifying and identifying diagnostic, adaptive and epidemiological values of patients’s bearing a pain- related condition, which is meant to be sharable through various physicians and reshaped by different clinical data systems of medical information management. This complex circumstance makes the overall concept of assessing pain an epistemological challenge that faces scientific communities with an ‘overflowing topic’, using Helmreich’s (2016) terminology, a topic of study that overflows the particular disciplines that gave origin to the concept, and now broke the incipient frame from which it was brought up to contemporary clinical diagnostics. Diversity and multilateral approaches, managed through pluralism and perspectivism standpoints in the aforementioned epistemologies, are suggested to help in better explaining what is happening with this information abundance and integrative problem, as multifactorial analysis (in diagnostic and prognostic evaluation) is also proposed to mediate in supporting the creation of modern plausible solutions responding to such overflowing challenge. The thesis suggests that such frames can be studied, through a proper bibliographical and comparative methodology observing topic literature, to fit in specific niches of scientific interest. Major Goal — The main goal of the thesis is to portray such niches (composing the body of the work) and to show how the frames clustered within said niches work, cooperate or diverge, interfering with other principles observed through incompatible or seemingly conflicting frames, exposing the epistemic consequences and problematics of interdisciplinary research through a multilateral standpoint in application to pain assessment in neuropsychiatry. Subsequent Goals — A second and quite significant goal is to attempt at integrating the different solutions, exposing the divergences and, as far as possible, informing about the plausible unfoldings and applications of a plural framework. Another goal attached the different solutions, exposing the divergences and, as far as possible, informing about the plausible unfoldings and applications of a plural framework. Another goal attached to the previous one is to be able to conjugate in one work historical accounts on electrophysiology models of pain events, with psychiatric accounts of a referred pain intervened by, say, a conversation in therapy, or the measuring strategies in diagnostic recognition, which require particular epistemological inspection. A fourth goal is to extract useful and applicable information that could be of help in defining multilateral strategies for the classification of pain-kindred dysfunctions, their measurement, and the organisation of information gathering physiological, psychiatric, prognostic and interpersonal origins, which are put to be the main concerns to the neuropsychiatric assessment of pain. A final fifth goal is to place value on the concept of ‘epidiagnostics’ as suggested to serve to define the scientific practice installed in complex diagnostic assessment: epidiagnostic practices are introduced to define diagnostic efforts fundamentally directed to determine collateral and correlational factors to better decide the detection of plausible comorbid instantiations of pathologies in a patient’s clinical picture, and primarily aligned to finding the appropriate treatment interventions, informing about prevention and prognosis of further comorbid possible scenarios. The value of epidiagnostics rests in how its being useful in a near future for focusing and modelling heterogeneous, complex, comorbid circumstances employing multi data solutions delivered through Artificial Intelligence Assisted Diagnosis for facing overflowing scenarios by (1) an attitudinal shift towards prognostic detection, prevention and accurate intervention, and (2) multifactorial assessment of the plural dimensions of stressors affecting patients’s health. III — Methodology The thesis has not changed the methodology from the original Research Plan, as also recommended and accepted by the thesis director, Dr. Ángel Luis Peña Melián, provided the topic of research and the nature of the concepts to be dealt with by it. A more detailed version of the methodology can be delivered in this version of the plan as follows. The work is installed within the framework of a bibliographical-comparative methodology (BCMf), properly designed and suitable to the topic of research, usual and recommended in dealing with overflowing interdisciplinary affairs, as the one sharpening the present thesis is taken to be. The BCMf will provide consistent information after compilation of the required data bases, and coherent with the scale and theme of the thesis. The reasons for selecting a BCMf for literature research and readings, designing the comparative approach to the matters of study, generating the interpretations achieved by this analysis, applying them to describe and put to work the hypothesis (as informed in the previous section), and to write the thesis volume, has been on account of the nature of this investigation: extracting and commenting on the epistemological aspects of neuropsychiatric evaluatory practices on pain-kindred events, with a practical, original and solvent aim. These include three major reasons: (1) Inherited from epistemological and ethnographic methodologies on describing the developments on natural sciences and biosciences, the BCMf guidance has been justified to reflect as major affairs the development of the different fields in a historical and comparative approach (Helmreich 2016; Williams 2012): the growth of the different problematics; the distinct solutions to those problem offered in a procedural account of their historical origin and variations; and the consequences brought to contemporary theory making from such previous historical accounts. These notions are to be the focus of attention of this dissertation, where BCMf organisations, in contrast to experimental and single state of the art historical accounts. These notions are to be the focus of attention of this dissertation, where BCMf organisations, in contrast to experimental and single state of the art methodologies, have been exposed to be of much use and scope coming to deal with heterogeneous interdisciplinary research (Cf. Darden 2006). (2) BCMf observes those lines of effects, as it does worry about how the definitions of scientific interesting phenomena, the required and recreated language, with its pragmatic (word usage) analysis, the decisions on classifications of scientific blocs of knowledge, the acceptance and accommodation of new theory traits, and the political, economic agendas were, have been and are currently put to work in a social interactive network (Cf. Longino 2001; Kitcher 1993; Haraway 1976; 1991; Harding 1991). Being BCMf a contextual methodology, its role in the study of contextual epistemologies using situated approaches for handling the topics of discussion comes to be more than a sheer justification, but a recommendable and almost desirable path to follow. (3) BCMf benefits conclusions with delivering on an interpretation of a wide panorama that helps to explain and describe the conceptual difficulties in characterising contemporary issues from the inside of the topics adduced through the standpoint of each discipline reviewing the research phenomena. It is to be noted that the specific dimension of this field of study requires, by natural necessity, a double perspective that maintains a certain coherence with philosophical and scientific contents together, seeking a concrete and profound revision of its theoretical bases. This methodological effort includes varied research practices: the classification and description by comparative-taxonomic method, the biological taxology in scales of complexity and organisational/clustering processes, the analysis of argumentative strategies, and the theoretical relationships of the proposed frames and niches with each other, along with field study (in dissection laboratory) including the exercise of interviews with specialists, patients and relatives of patients close to the topic of study, and finally evaluation processes of the material and contents to be analysed. BibliograpBhIyBLIOGRAPHICAL REFERENCES Anjum, R., Copeland, S., Mumford, S., & Rocca, E. (2015). CauseHealth: integrating philosophical perspectives into person centered healthcare. European Journal for Person Centered Healthcare, 3(4), 427-430. Aragona, M. (2009). About and beyond comorbidity: Does the crisis of the DSM bring on a radical rethinking of descriptive psychopathology?. 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