In search of a better ontology of mental disorder: From essentialism and reductionism to embracing dynamic and complex relations

Annemarie de Leeuw-Köhne

Research output: ThesisDoctoral thesis 2 (Research NOT UU / Graduation UU)


Much has been learned on mental disorder in the past decades, but this has hardly led to better treatments of mental disorder. One reason may be that our dominant ontology of mental disorder is incorrect. This formed the hypothesis from which this dissertation departed. This implicated the need to examine the grounds of the current ontology and search for innovation in order to improve the foundation that shapes our mental health care. That is what I have aimed for in this thesis, combining theoretical-philosophical analyses with network methodology and qualitative methodology.

The first part of this thesis focused on the ontological status of psychiatric ‘diagnoses’, a critical examination of the categorical frame of thought and innovation of our ontological model of mental disorder.The second part of this thesis concern debates regarding the ontology of mental disorder. The first debate is about the status of the DSM and the second debate is about the status of Precision Psychiatry. The third part of this thesis focused on relatively novel methodologies (network theory and qualitative thematic analyses) in order to innovate our ontological picture of mental disorder.

A fundamental observation from our studies is that the ontological palette is more diverse than what is taught about mental disorder in dominant scientific and educational discourse (in casu: DSM, linear medical model, bio-psycho-social-model). Two of the alternative ontologies that surfaced, stood out as they seem to open up truly new pathways. The first ontology that stood out, is the idea that mental disorder should be understood as ‘deviation from social norms’. We think this is an important finding because if we take this ontology of mental disorder seriously, we should think about solutions that transcend the individual and are directed at society and the norms that live within society: A change of cultural values or targeting stress, exclusion, social injustice, etcetera. This understanding of mental disorder necessarily places responsibility on society and politics and provides vital new directions for our policymakers that guide our research agenda’s. The second ontology that stood out, is the idea that mental disorder should be understood as an 'ecological-adaptational problem. In this ontology mental disorder is understood to be about the (im)balance of burden and strengths, skills, and recourses. With an ‘ecological-adaptational ontology’ of mental disorder we may envision a form of health care in which patients can work on either side of the balance: strengthening skills and recourses or working on burdens/problems/ pains.

These results led us to the idea that we must adjust our scientific and educational practices. This thesis shows that there are unexplored and underserved perspectives on the ontology of mental disorders. Policymakers should invest in the development, elaboration and coming of age of these other ontologies. Educational discourse should at least openly discuss the controversy around the psychiatric object and show and discuss a broader ontological palette. If these alternative ontologies will reach maturity, they may create a landscape of promising novel scientific and clinical approaches in mental health care and research.
Original languageEnglish
Awarding Institution
  • University Medical Center (UMC) Utrecht
  • van Os, Jim, Primary supervisor
Award date29 Nov 2022
Place of PublicationUtrecht
Print ISBNs978-94-6458-529-2
Publication statusPublished - 29 Nov 2022


  • Ontology
  • Psychiatric object
  • Diagnostic and Statistical Manual
  • Kinds
  • Complexity
  • Network-theory
  • Dimensional models
  • Transdiagnostic approach
  • Personalized approach
  • Relationalism


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