People hold wildly opposing and very strong views on the question whether mental disorders are brain disorders, and the disagreement is primarily a conceptual one, not one about whether there are,...

This contribution focuses on what type of question “Are mental disorders brain disorders?” is and what task Anneli Jefferson performs in her book with the same title. I distinguish between conceptual engineering and conceptual choice, the former involving the individuation of an adequate concept for a specific goal, and the latter involving the normative problem of whether we should employ the concept at hand. I contend that Anneli Jefferson’s book is a work of conceptual engineering, which is (...) valuable in and of itself, but that this is insufficient to answer an equally essential version of the question, “Are mental disorders brain disorders?”, namely, whether we should adopt the newly engineered concept or not, considering a broader range of goals for mental health research and practice. (shrink)

The effects of mental disorder are apparent and pervasive, in suffering, loss of freedom and life opportunities, negative impacts on education, work satisfaction and productivity, complications in law, institutions of healthcare, and more. With a new edition of the 'bible' of psychiatric diagnosis - the DSM - under developmental, it is timely to take a step back and re-evalutate exactly how we diagnose and define mental disorder. This new book by Derek Bolton tackles the problems involved in the (...) definition and boundaries of mental disorder. It addresses two main questions regarding mental illness. Firstly, what is the basis of the standards or norms by which we judge that a person has a mental disorder - that the person's mind is not working as it should, that their mental functioning is abnormal? Controversies about these questions have been dominated by the contrast between norms that are medical, scientific or natural, on the one hand, and social norms on the other. The norms that define mental disorder seem to belong to psychiatry, to be medical and scientific, but are they really social norms, hijacked and disguised by the medical profession? Secondly, what is the validity of the distinction between mental disorder and order, between abnormal and normal mental functioning? To what extent, notwithstanding appearances, does mental disorder involve meaningful reactions and problem-solving? These responses may be to normal problems of living, or to not so normal problems - to severe psycho-social challenges. Is there after all order in mental disorder? With the closing of asylums and the appearance of care in the community, mental disorder is now in our midst. While attempts have been made to define clearly a concept of mental disorder that is truly medical as opposed to social, there is increasing evidence that such a distinction is unviable - there is no clear line between what is normal in the population and what is abnormal. 'What is Mental Disorder?' reviews these various crucial developments and their profound impact for the concept and its boundaries in a provocative and timely book. (shrink)

This book offers a comprehensive study of the views of ancient philosophers on mental disorders. Relying on the original Greek and Latin textual sources, the author describes and analyses how the ancient philosophers explained mental illness and its symptoms, including hallucinations, delusions, strange fears and inappropriate moods and how they accounted for the respective roles of body and mind in such disorders. Also considered are ethical questions relating to mental illness, approaches to treatment and the (...) position of mentally ill people in societies of the times. The volume opens with a historical overview that examines ancient medical accounts of mental illness, from Hippocrates' famous Sacred Disease to late antiquity medical authors. Separate chapters interpret in detail the writings of Plato, Aristotle, Galen and the Stoics and a final chapter summarises the views of various strains of Scepticism, the Epicurean school and the Middle and Neo-Platonists. Offering an important and useful contribution to the study of ancient philosophy, psychology and medicine. This volume sheds new light on the history of mental illness and presents a new angle on ancient philosophical psychology. (shrink)

This new edition of Mind, Meaning, and Mental Disorder addresses key issues in the philosophy of psychiatry, drawing on both philosophical and scientific theory. The main idea of the book is that causal models of mental disorders have to include meaningful processes as well as any possible lower-level physical causes, and this propsoal is illustrated with detailed discussion of current models of common mental health problems. First published in 1996, this volume played an important role in (...) bridging the gap between philosophy and psychiatry, and introducing those in psychiatry to philosophical ideas somewhat neglected in their field. Completely updated, the new edition of this acclaimed volume draws on the strengths of the first edition, and will be a central text in the burgeoning field of philosophy of psychiatry. (shrink)

In this commentary on Anneli Jefferson’s book “Are Mental Disorders Brain Disorders?,” I offer an overview of her central thesis, and then propose my own modified account of when we are justified in calling mental disorders as “brain disorders.” In doing so, I draw on recent work in neuroscience that understands the relationship between brain and behavior in complex, dynamic, and computational terms. In particular, I disagree with Jefferson’s criterion of sufficiency, that a particular (...) brain process should always realize a psychological dysfunction. I propose that a psychiatric disorder can be said to be a brain disorder if there are empirically identifiable systematic brain differences associated with it and if these associations are contextualized within a scientifically robust theoretical understanding of the relationship between brain and behavior. I conclude by preliminary reflections on whether the issue of “mental disorder” versus “brain disorder” comes down to “the language of psychology” versus “the language of neuroscience,” and the degree to which the former can be expressed in the latter. (shrink)

This issue contains a book symposium on Anneli Jefferson’s book, Are mental disorders brain disorders?. It is a delight that the symposium brings together a variety of perspectives from philosopher...

Authenticity has recently emerged as an important issue in discussions of mental disorder. We show, on the basis of personal accounts and empirical studies, that many people with psychological disorders are preoccupied with questions of authenticity. Most of the data considered in this paper are from studies of people with bipolar disorder and anorexia nervosa. We distinguish the various ways in which these people view the relationship between the disorder and their sense of their authentic self. We discuss (...) the principal modern ac-counts of authenticity within the analytic philosophical tradition. We argue that accounts based on autonomous, or wholehearted, endorsement of personal characteris-tics fail to provide an adequate analysis of authenticity in the context of mental disorder. Significant elements of true self accounts of authenticity are required. The concept of authenticity is a basic one that can be of particular value, in the context of self-development, to people with mental disorder and to others experiencing substantial inner conflict. (shrink)

The question of whether mental disorders are disorders of the brain has led to a long- running and controversial dispute within psychiatry, psychology and philosophy of mind and psychology. While recent work in neuroscience frequently tries to identify underlying brain dysfunction in mental disorders, detractors argue that labelling mental disorders as brain disorders is reductive and can result in harmful social effects. This book brings a much- needed philosophical perspective to (...) bear on this important question. (shrink)

This book offers a broad, systematic philosophical approach to mental disorder. The authors spend the first half of the book presenting their basic philosophical allegiances, and they go on to apply their philosophical approach to mental disorder. As the authors note, psychiatry has been largely neglected by contemporary philosophy of mind, and this book is a laudable attempt to rectify the situation by producing a sustained and clinically well-informed philosophical treatment of mental disorder.

Mental disorder is an urgent and growing public health problem.1 Scientific investigation of this problem has the pragmatic goals of identifying the causes of mental disorders and developing strategies to effectively treat them. Philosophers of psychiatry have participated in the inquiry into the empirical examination of mental disorders, predominantly by debating whether psychopathology is a legitimate target of scientific inquiry and, if so, how mental disorders should be explained, predicted, and intervened on. However, (...) as I show in this paper, these philosophical discussions have mostly neglected the actual state of inquiry in psychiatry and relevant disciplines, as well as the first-person experiences... (shrink)

This is a reply to Gipps' commentary on my 'The Concept of Mental Disorder'.

What mental disorder means is controversial. I attempt to solve that controversy by applying the method of defining a phenomenon in terms of the goals we have for demarcating that phenomenon from other phenomena to the case of mental disorder. I thus address the question about the nature of mental disorder by paying attention to the goals we have for demarcating mental disorder. I maintain that these goals, which embody the reasons why we consider mental (...) disorder a significant phenomenon for us, have a common denominator: they refer to psychological capacity for autonomy. I present a conceptual foundation for defining mental disorder on the basis of that psychological capacity and argue that this way of understanding the nature of mental disorder avoids the main problems of the central contemporary theories of mental disorder. Then I explain why this conception of the nature of mental disorder is not undermined by anti-psychiatric criticisms to the effect that mental illness does not exist, that the mentally ill should not be treated differently from others, and that seeing problems of the mentally disordered as psychiatric problems is unjustified medicalization. I conclude by suggesting that the presented conceptual foundation for defining mental disorder would benefit from being complemented by results of empirical psychology. (shrink)

It is now generally agreed that we have to rely on value judgments to distinguish mental disorders from other conditions, but it is not quite clear how. To clarify this, we need to know more than to what extent attributions of disorder are dependent on values. We also have to know (1) what kind of evaluations we have to rely on to identify the class of mental disorder; (2) whether attributions of disorder contain any implicit reference to (...) some specific evaluative standard; and (3) whether the concept of mental disorder is value laden in the definitional or in the epistemic sense. I will argue that the evaluations we have to rely on are mainly considerations of harm, but that we also need to rely on other evaluations; that there should be no references to specific evaluative standards; and that even though mental disorders are necessarily undesirable, "mental disorder" may well be a descriptive phrase. (shrink)

The current experiments examine mental health clinicians’ beliefs about biological, psychological, and environmental bases of the DSM‐IV‐TR mental disorders and the consequences of those causal beliefs for judging treatment effectiveness. Study 1 found a large negative correlation between clinicians’ beliefs about biological bases and environmental/psychological bases, suggesting that clinicians conceptualize mental disorders along a single continuum spanning from highly biological disorders (e.g., autistic disorder) to highly nonbiological disorders (e.g., adjustment disorders). Study 2 (...) replicated this finding by having clinicians list what they thought were the specific causes of nine familiar mental disorders and rate their bio–psycho–environmental bases. Study 3 further found that clinicians believe medication to be more effective for biologically based mental disorders and psychotherapy to be more effective for psychosocially based mental disorders. These results demonstrate that even expert mental health clinicians make strong distinctions between psychological and biological phenomena. (shrink)

In this paper I argue that thinking in terms of process metaphysics and seeing the mind and mental disorders as processual in nature allows for a more complete understanding of mental disorders than is allowed by non-processual frameworks, while it also allows us to incorporate what we currently know about them. In addition, it can address problems in psychiatry that arise when we ask the wrong kinds of questions that naturally arise within a non-processual metaphysical framework. (...) In this paper I address the problems of reductionism, essentialism and dualism. -/- . (shrink)

The concept of mental disorder is often defined by reference to the notion of mental dysfunction, which is in line with how the concept of disease in somatic medicine is often defined. However, the notions of mental function and dysfunction seem to suffer from some problems that do not affect models of physiological function. Functions in general have a teleological structure; they are effects of traits that are supposed to have a particular purpose, such that, for example, (...) the heart serves the goal of pumping blood. But can we single out mental functions in the same way? Can we identify mental functions scientifically, for instance, by applying evolutionary theory? Or are models of mental functions necessarily value-laden? I want to identify several philosophical problems regarding the notion of mental function and dysfunction and point out some possible solutions. As long as these questions remain unanswered, definitions of mental disorder that rest upon the concept of mental dysfunction will lack a secure foundation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice, Mental Disorder, and the Role of Underlying Pathological ProcessesNancy Nyquist Potter (bio) and Peter Zachar (bio)Keywordsresponsibility, virtue theory, cultural norms, psychopathologyThe issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an (...) article on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy... (shrink)

Essentialism is one of the most pervasive problems in mental health research. Many psychiatrists still hold the view that their nosologies will enable them, sooner or later, to carve nature at its joints and to identify and chart the essence of mental disorders. Moreover, according to recent research in social psychology, some laypeople tend to think along similar essentialist lines. The main aim of this article is to highlight a number of processes that possibly explain the (...) persistent presence and popularity of essentialist conceptions of mental disorders. One such process is the general tendency of laypeople to essentialize conceptual structures, including biological, social, and psychiatric categories. Another process involves the allure of biological psychiatry. Advocating a categorical and biological approach, this strand of psychiatry probably reinforced the already existing lay essentialism about mental disorders. As such, the question regarding why we essentialize mental disorders is a salient example of how cultural trends zero in on natural tendencies, and vice versa, and how both can boost each other. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Intentional OrderRichard Gipps (bio)Bengt Brülde and Filip Radovic inform the reader that they will assume "there is such a thing as a general category of disorder, of which mental and somatic disorders can be regarded as subcategories" (2006, 100). With this assumption in place, they take up a fascinating discussion of what warrants our categorizations of certain disorders as mental as (...) opposed to physical. The answers they then canvass include the possibilities that it is the mentality of the internal causes, or of the symptomatic effects, of these disorders which renders them mental, or that there is no single answer, or that there is no valid distinction to be drawn.In what follows I wish to question the initial assumption, and then offer an understanding of the nature of mentality that I hope will lead to a different way of answering the question, what is mental about mental disorder? It worries me that the views I develop here may share too little by way of common framework assumptions with the views developed in Brülde and Radovic's paper. I hope that this does not render dialogue impossible, or make the thoughts that were inspired by their thoughtful paper appear just too off field to be seriously entertained.The Concept of DisorderBrülde and Radovic assume that "mental disorders" and "physical disorders" are subtypes of a general category of disorder. (In what follows I describe this as the assumption.) They also distinguish between two questions: (1) What is mental about mental disorder? (in what follows I describe this as the question) and (2) What does it take for a condition to be a disorder? This latter question is, they acknowledge, certainly important, but is set aside for the time being.Mental disorder, physical disorder, and we might perhaps also add social disorder, are then subcategories of disorder. They are perhaps not natural kinds, but nevertheless they are subcategories within a general category. With their assumption in place it makes good sense to reject accounts of the mentality of mental disorders that seem to simply presuppose the concepts of mind and body when they address the question.There is of course a trivial sense in which everyone must agree that mental disorders and physical disorders are to be considered subcategories of disorder. There is what could be described as a logical sense of category and subcategory, in which any noun is said to designate a category and any adjectival qualification of it to introduce a subcategory. However, we can also distinguish what I call a "semantic" sense, in which talk of categories and subcategories is more restricted. Here we rely on there being a unitary sense to the putative category if we are to talk meaningfully of subcategories of this single category. [End Page 117]The philosophy of the individuation of senses is not within my expertise, but I am relying on an intuitive notion spelled out by the following. First, that a good dictionary would elaborate these senses by providing different definitions of the putative category rather than a single definition followed by examples. Second, that when we do not have to do with categories in the semantic sense, we would find ourselves more in want of true understanding of what was being said, and not so much in want of mere further knowledge, if we are offered a description that included the noun (disorder) without the qualifier (mental). Third, that we are less likely to be dealing with subcategories within a general semantic category if we easily can turn the adjective–noun pair (e.g., mental disorder) around to provide two nouns in a short phrase (e.g., disorder of the mind), or if there are verbal and adjectival forms of the second noun that can also be used in conjunction with the first noun (e.g., disordered mind).An example serves to make things clearer. Consider a chemist who has a reaction in her laboratory. What is referred to may be an emotional reaction (to her sudden scientific breakthrough), or a chemical reaction. In this case, I suggest, we do not have to do with a semantic category of "reaction," which... (shrink)

Certain things should never be taken for granted, among them... the precise meaning of words that are at the heart of your discipline.For a large class of cases - though not for all - in which we employ the word ‘‘meaning’’ it can be defined thus: the meaning of a word is its use in the language.The prevailing state of affairs in the mental health field is one in which we have been unable to agree on a definition of (...) our central concept, that of ‘mental disorder’. That is to say, we have not achieved consensus in the matter of what criteria constitute the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Moral Responsibility:Disorders of Personhood as Harmful Dysfunctions, With Special Reference to AlcoholismJerome C. Wakefield (bio)Keywordsalcohol dependence, philosophy of psychiatry, mental disorder, harmful dysfunction, psychiatric diagnosis, person, moral responsibilityIn his paper, Ethical Decisions in the Classification of Mental Conditions as Mental Illness, Craig Edwards grapples with a profound problem: why is it that when we classify a mental condition as a (...) mental disorder, that tends to take the condition out of the sphere of moral responsibility or virtuousness of character? For example, it is not uncommon when someone commits suicide and the question is raised as to why he or she did it, that instead of a reason or character trait that would place the act within a moral calculus, one is offered the explanation "she was clinically depressed" or "he was bipolar," and this tends to terminate discussion and make reasons and moral evaluation superfluous. Why does such a comment have that effect?As Edwards notes, this can get complicated as the moral and the disordered interact. Certainly people are sometimes morally responsible for acting on their disordered impulses (as in pedophilia), and they are responsible for putting themselves in the way of disorder, as when someone imbibes in a way likely to lead to alcoholism. But at the normal/disorder divide, there seems to be a consistent lifting of some responsibility, reflecting the application of the sick role. For example, the rough equivalent of our current category of post-traumatic stress disorder (PTSD) was recognized as a disorder in earlier wars ("shell shock," "war neurosis"), but often considered an expression of cowardice; the cowardice was morally evaluable as a failure of virtue (even if, like many personality traits, being a coward is not within the person's direct voluntary control) and led to contempt for those with PTSD, but nonetheless—except in cases thought to be malingering—the PTSD that resulted constituted a disorder for which the individual was [End Page 91] not in the same direct sense blameworthy. This moral shift requires explanation.This topic also has important social ramifications. Relief from responsibility may sound like a good thing, and it is trumpeted by mental health advocates as a reason for supporting the classification of many conditions as disorders. But as Edwards is aware, it is a two-edged sword. Disordered status may allow escape from censure and offer the protections of the sick role, but it also changes the relationship of the agent to his or her own actions and imposes the responsibility of the sick role on the individual to attempt to change ("get better"). The sick role allows for no defense of an idiosyncrasy based on normal variation ("It takes all kinds…") or the individual's eccentric vision or steadfast integrity, for that vision or sense of integrity are now seen as pathological and not morally legitimate. The individual is subjected to endless entreaties to seek help and it is implied that not to do so is irresponsible, so that a decision to embrace one's nature and remain as one is becomes illegitimate. Moreover, the sick role allows for no explanation in terms of the individual's normal defensive response to unjust, deprived, or challenging social or environmental circumstances, thus weakening the motives for social change rather than individual intervention.In sum, there is an inevitable sense in which being placed in the sick role inherently stigmatizes the "sick" condition in virtue of the special moral attitudes extended to the disordered. Cultures can thus easily exploit the sick role and its much-touted relief from responsibility to extend the reach of social control processes. This is one reason why the distinction between disorder and non-disorder is so important, and why it is crucial to identify when non-disordered conditions are mislabeled as disorders—as when, for example, psychiatry gets it wrong about the distinction between normal and disordered sadness (Horwitz and Wakefield, 2007). Such overpathologization can redefine the boundaries of our moral universe on mistaken grounds.Edwards offers two provocative answers—not entirely at ease with each other—to the question of why mental disorders relieve the patient from moral responsibility: (1) mental disorders are... (shrink)

In this brief commentary, I would like to discuss two reservations I have about the article by Bergner and Bunford. Before doing so let me make some preliminary remarks.Their hypothesis that the concept of disability unites the various mental disorder constructs that have been proposed over the centuries and across cultures is reasonable and accords well with common sense. The concept of disability does a lot of good work in helping us to understand mental disorders.With respect to (...) the authors’ contrast between the disability conception versus the behavioral conception of mental disorder, the notion that counting behaviors alone justifies diagnosing a psychiatric disorder is worth critiquing. Claiming that everyone... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice, Mental Disorder, and the Role of Underlying Pathological ProcessesNancy Nyquist Potter (bio) and Peter Zachar (bio)Keywordsresponsibility, virtue theory, cultural norms, psychopathologyThe issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an (...) article on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy... (shrink)

There are different ways of responding to the absence of a shared physical causal core among the range of mental disorders currently recognized by the International Statistical Classification of Diseases and Related Health Problems and the Diagnostic and Statistical Manual of Mental Disorders. Obviously enough, some of the listed disorders are not physically explicable in principle, while others are merely likely to be biological in origin. Only a minority of disorders can be explained as (...) the outcomes of impaired biological function, and in some of those cases biological explanations capture their phenomena little more than partially. Psychiatry nevertheless is perceived as and understands itself... (shrink)

During the last years, there has been an important discussion on the concept of mental disorder. Several accounts of such a concept have been offered by theorists, although neither of these accounts seems to have successfully answered both the question of what it means for a certain mental condition to be a disorder and the question of what it means for a certain disorder to be mental. In this paper, I propose an account of the concept of (...) mental disorder that, if I am right, provides satisfactory answers to both of these questions. Furthermore, this account (unlike other accounts presented in the literature on the subject) meets the requirements for achieving a crucial goal underlying the project of sorting out the concept of mental disorder, namely the goal of allowing the existence of a dialogue between mental health professionals of different theoretical orientations. To achieve this goal, the account herein proposed is not based in any particular theoretical framework, but in both ordinary and technical theory-neutral concepts. In the last part of the paper, I argue that it follows from most accounts of the concept of mental disorder that the disciplines concerned with explaining some mental disorders are not branches of medicine, and that the treatment of some mental disorders is not a matter of medical intervention. (shrink)

Although generally supportive of our overall position, both Zachar and Gala and Laughon raise questions about our research design. Herein, we respond to these questions by presenting counterarguments that support the soundness of this design.Subsequent to stating some broad agreement with our central thesis that mental disorder is best viewed as a disability concept and not a behavioral one, Dr. Zachar expresses a number of reservations about our work. We focus on the following discussion on what seem to be (...) the most significant of these.Dr. Zachar states the following : “In 8 of their 12 conditions, the dependent variable is evaluation of problematic behavior and the independent variable is disability... (shrink)

In this commentary on Anneli Jefferson’s Are Mental Disorders Brain Disorders? I endorse her capacitarian approach to responsibility but suggest that the effects of at least some mental/brain disorders on the agent’s psychology show that we cannot neatly separate the epistemic condition from the control condition when assessing agential capacity. I then discuss the labeling issue in the context of rival attributionist accounts of responsibility which hold that agents are responsible if their actions are (...) attributable to them. The incorporation of mental disorders into identity through social processes may open agents with mental or brain disorders open to unfair blame. However, we cannot fully understand the effects of the disorders on agential capacity without closely attending to the social environment that shapes the way the disorder is conceived, enacted, perceived, and responded to over time. (shrink)

The recent discussion of the concept of mental disorder has focused on what makes a mental disorder a disorder. A question that has received less attention is what makes a mental disorder mental rather than somatic. We examine three views on this issue -- namely, the internal cause view, the symptom view, and the pluralist view -- and assess to what extent these accounts are plausible. Three strategies used to pinpoint the mental in psychiatry are (...) identified, namely negative characterizations, exemplification of paradigmatic mental features, and an appeal to intentional content. We also examine different versions of nihilism. Finally, it is observed that the discussion of what makes a mental disorder mental has largely been unaffected by conceptions of the mental in the philosophy of mind. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Close Enemies: The Relationship of Psychiatry and Psychology in the Assessment of Mental DisordersPhilippe Le Moigne, PhDAs Peter Zachar rightly points out in his comment, the assessment of mental disorders underwent new developments with the release of the Diagnostic and Statistical Manual of Mental Disorders-V in 2013 (American Psychiatric Association, 2013). Whereas in 1980, the manual had been thought of in a rigorously (...) categorical way, on the basis of distinct and closed syndromic entities, this new version advocated the development of a radically dimensionalist approach, with the diagnosis aiming this time to restore the whole symptomatological picture of the patient on a spectrum of ratings are supposed to cover the entirety of psychiatric semiology (American Psychiatric Association, 2013).For its part, my article aimed to show how standardized assessment, guided by the return of psychiatry’s authority and the assertion of its legitimacy in the diagnostic field, gave the ascendancy in the 1980s to the classificatory tradition and thus to the categorical model, to the detriment of personality approach and test psychology which offered a competing solution here. This perspective, historically dated, may have led the reader to think that there is an antagonism that cannot be overcome here. Rather, it should be seen as a form of structuring opposition, or even a “complementarity inscribed in rivalry,” between psychiatry and psychology, which is naturally susceptible to change over time.Indeed, the reversal operated by the Diagnostic and Statistical Manual of Mental Disorders-V is not total because it cannot be total. The defense of the dimensionalist approach, dear to the psychological testing tradition, was intended here to allow the identification of co-morbidities, present in most patients but poorly apprehended by the categorical approach, and to open up diagnosis to prevention by screening for minor manifestations of psychopathology when they suggest the [End Page 259] development of a manifest episode of the disease in the more or less long term. The risk here is that we end up with overdiagnosis and thus an over-representation of false positives (Wakefield, 2015). In other words, this type of approach does not escape the obligation to determine threshold scores, likely to indicate the lower limit of the disorder, and thus to resort to a categorical approach. There is a first affinity between the two perspectives which obeys, beyond the divergences in principle, a technical requirement.But the two approaches have even more in common when we look at their epistemological background: they share the idea that the representation and the intervention on mental disorder, to use Ian Hacking’s expression (1983), must be based on the model proposed by the physical and natural sciences. And as Greta Kaluzeviciute aptly points out in her comment, this orientation leads to the idea of measuring mental disorder in particular to conduct elaborate quantification operations to determine, for example, whether two entities are statistically distinct or whether a drug has a significant effect on the evolution of a pathology.This is in fact an old question that can be formulated as follows, to use the expression of the psychometrician Joel Michell (1999): are psychological dimensions metric? In other words, if we want to apply the language of numbers to mental disorders, they must share its properties, two of which seem essential: it must be possible to establish that each mental disorder, in the same way as qualities attributable to length for example, has a zero and can be divided by means of gradients (or degrees of intensity) whose interval is constant (Le Moigne, 2018; Michell, 1999). For lack of space, let us only address the second condition. This one has already been denied by many, starting with Bergson at the end of the nineteenth century (1889). He does not believe in the quantification of psychological expressions, starting with sensations. What is the common point, he wrote, between the feeling of a mild pain, as one feels a stiffness, and the sensation of a needle being hammered into your flesh? For him, one and the other of these intensities are incomparable, so that they do not belong to a similar register of sensations that one could stage from a 0 toward a... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Still Defining Mental Disorder in Terms of Our Goals for Demarcating Mental DisorderJukka Varelius (bio)Keywordsmental disorder, definition, psychological capacity for autonomy, Matthews, SavulescuI thank Eric Matthews and Julian Savulescu for their thought-provoking comments. Unfortunately, I am not here able to discuss all the important points they raise, but must settle for briefly addressing their main criticisms of my view.Reply to MatthewsI believe that some arguments are rationally (...) irresolvable, but do not think that about all philosophical arguments. In terms of moral philosophical argumentation, though not only that, I share the rather common belief that we should proceed by seeking reflective equilibrium between requirements of logic, the best factual knowledge about ourselves and our environment, and our strongly held evaluative intuitions. (This is not to say that there would always be a clear distinction between facts and values.) By such intuitions I refer, for example, to the intuition that it is morally wrong to torture babies for fun. If we are considering whether it is morally permissible to act in a particular way and realize that acting in that way is in the morally relevant respects similar to torturing babies for fun, we conclude that it is not morally permissible to act in that way. That question is solved for persons who accept the moral intuition that it is wrong to torture babies for fun and wish to take facts and logic into account. This method is useful in the context of defining mental disorder, too.Although we have some strongly held intuitions as to what mental disorder is about, such as that person A is a paradigm case of a mentally disordered person, referring to them has not sufficed to solve the controversy concerning the demarcation of mental disorder. Therefore, I want to consider the possibility that referring also to the goals we have for demarcating mental disorder could help us in solving it. At this stage of enquiry at least, I thus believe that the controversy is solvable, but only among persons who share certain points of departure. Accordingly, the "our" in expressions like 'our goals for demarcating mental disorder,' whose reference Matthews enquires about, refer to those who share the intuition that A is a paradigm example of a mentally disordered person, consider the demarcation goals significant, want to take [End Page 67] facts into account, and wish to make logically valid inferences.If one cares about the other things but does not want to consider A's case, one can focus on some other case of a person whose psychological capacity for autonomy is diminished. (Unless, of course, one thinks that no such persons exist and all whom we believe to lack psychological capacity for autonomy are really playacting, malingering, etc.) I, however, now continue with A's case. We have, ex hypothesi, sufficient reason to believe that A lacks not merely relevant information, but also the psychological capacity that understanding it and making use of it in assessing her beliefs and desires presupposes. If someone who knows this about A still insists that A is in perfect mental health and wants, say, to treat her as an object of entertainment in a human zoo, my argument is unlikely to reach him. But who is he to say that we should not care about A's loss of capacity for autonomy and the misfortunes it involves?And of course, also rationally establishing that a person who lacks such capacity is mentally healthy or that the controversy on the nature of mental disorder is not rationally resolvable presupposes that the discussants share some points of departure, including evaluative intuitions. Instead of the intuitions that to be ill is essentially to suffer harm, that behavior governed by one's feelings is always autonomous, and so on, that Matthews refers to, proponents of such views are, however, well advised to resort to less obscure and less controversial intuitions. What, for example, is meant by 'harm'? Is a person who is so overwhelmed by emotions that she is unable to think clearly always autonomous with respect to the actions she performs while in that state? If one takes that all intuitions are useless... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clarifying the Relationship Between Vice and Mental Disorder: Vice as Manifestation of a Psychological DysfunctionMichael B. First (bio)KeywordsDSM-IV, psychiatric diagnosis, impulse control disorders, sexually violent predator commitmentIndividuals generally present for psychiatric evaluation for one of two reasons: either because they themselves are suffering from a psychiatric symptom that causes distress (e.g., severe panic) or impairs their ability to function effectively (e.g., memory loss), or else they are (...) brought to clinical attention because their behavior or attitudes are considered by others to be problematic. There are a wide range of behaviors that fall into this second category. In some cases, the individual is pressured to seek treatment because of the negative impact that a behavior has on a relationship partner (e.g., sexual dysfunction, anger outbursts) or an employer (e.g., excessive alcohol use). Often, however, the external trigger for a clinical evaluation falls under Sadler’s definition of vice, that is, criminal (illegal) behaviors or attitudes that could be considered “wrongful” or “immoral” in the social arena because the behavior violates the law or an important social more.Given that one of the most important goals of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is to facilitate clinical practice (First et al. 2004) and in doing so provide a diagnostic code to cover any patient that might present himself or herself to a mental health professional, the DSM has evolved over its various editions to become a veritable laundry list of psychological and behavioral ills, some of which may constitute a violation of the rights of others or society. The DSM-III (and its successors) have adopted a descriptive approach wherein disorders are defined in terms of their presenting surface symptomatology, which was necessitated by the field’s lack of knowledge about the underlying etiology of mental disorders. Given this reliance on presenting symptoms, it is therefore inevitable that some disorders are defined in terms of behaviors that can be considered vices. For example, impaired impulse [End Page 35] control often leads to acting out behavior that, at its mildest is inappropriate, and at its most severe is destructive to self and others. Many of the disorders cited by Sadler as being vice-laden fall into this category, namely, pyromania (failure to resist impulses to set fires), kleptomania (failure to resist impulses to steal), intermittent explosive disorder (failure to resist aggressive impulses), certain forms of substance abuse (i.e., those involving possession and use of illegal substances) and paraphilias (i.e., those involving nonconsenting victims).It is important to clarify from the outset that the criteria for determining whether a behavior is a “vice” (i.e., whether it is illegal or immoral) is not equivalent to the criteria for determining whether a behavior is indicative of a mental disorder. According to the DSM-IV-TR definition, a mental disorder is conceptualized as a “clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (American Psychiatric Association [APA] 2000, xxxi). The definition warns against considering “deviant behavior[s] (e.g., political, religious, or sexual)” and “conflicts that are primarily between the individual and society” to be evidence of mental disorder except in those cases in which the “deviance or conflict is a symptom of a dysfunction in the individual.” Thus, when considering whether a particular “vice” behavior is a component of a mental disorder, it is crucial to determine whether the behavior is a manifestation of an underlying psychological dysfunction, such as a dysfunction in impulse control. If so, it may potentially be appropriate for that individual to be treated as “medically ill” in addition to, or instead of, being treated simply as a criminal.Let us examine some illustrative examples of cases that demonstrate the relationship between vice and mental disorders and the different ways in which the legal and mental health systems might deal with such cases. Consider the case of an individual who breaks... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What Makes a Mental Disorder Mental?Jerome C. Wakefield (bio)Keywordsharmful dysfunction, mental disorder, intentionality, mental dysfunction, mental functioning, phenomenality, somatic disorderWhat makes a medical disorder mental rather than (exclusively) somatic or physical? Psychiatry to some extent depends for its existence as a medical specialty on the distinction between mental and somatic disorders, yet the history of this distinction presents a bewildering array (...) of puzzling judgments, radical shifts, and seemingly arbitrary distinctions. The historical observation that putative mental disorders are often reclassified as physical disorders as soon as their physiologic basis is understood further confuses matters. Moreover, recent debates about such classifications often seem to reflect desires to protect professional turf or obtain optimal reimbursement for treatment more than they do the application of a coherent conceptual distinction. No wonder that Brülde and Radovic (2006) disarmingly admit at the outset of their exploration of this question that there is a case to be made that their topic is relatively unimportant or even meaningless intellectually, a rare way to start an inquiry!Could there nonetheless be a cogent conceptual distinction lurking here? Brülde and Radovic usefully invite us to reframe the question, in effect as follows: Suppose we pay attention to professional and lay judgments as evidence but at the same time try to avoid being ensnared by the distortions resulting from turf issues and other pragmatic motives and constraints. Can we then identify some principled distinction in this domain that is worth making and that interestingly corresponds to the distinction generally made between mental disorders and strictly somatic disorders? Brülde and Radovic do not come to any confident or compelling conclusion about this.My answer, based on my harmful dysfunction analysis of disorder (Wakefield, 1992a, 1992b, 1999a, 1999b), is that a mental disorder is a harmful mental dysfunction, where a mental dysfunction is a failure of the capacity of some mental mechanism to perform a function for which it was biologically designed. I argue that, owing to a series of logical missteps, Brülde and Radovic needlessly reject this view. After some preliminary comments and clarifications, I defend the internal dysfunction approach from the objections posed by Brülde and Radovic, and then conclude by elaborating this view in some new ways. Note that Brülde and Radovic critique something they call the "internal cause view" of what makes a disorder mental, and they name others who hold that view. However, my work figures prominently in their discussion, and for expository simplicity, I will presume to simply construe their arguments as aimed at the harmful dysfunction analysis. [End Page 123]Clarifying the QuestionIt is easy to misconstrue the question "What makes a mental disorder mental" as demanding a precise account of the mental, an error to which Brülde and Radovic succumb in their repeated complaints that various writers do not present principled accounts of the mental but rely on lists of prototypical mental states or tentative guidelines to fix the reference of mental. We would need a precise definition of mental if the problem were how to classify cases in which it is ambiguous whether some phenomenon is mental or physical. We might imagine, for example, someone being genuinely puzzled as to whether inability to sleep is failure of a mental function or process. But this sort of puzzle about the boundaries of the mental is not the problem with which Brülde and Radovic are concerned; anyway, ambiguous cases may just be inherently ambiguous. The problem, which a crisp definition of mental will not resolve, is what relation mental states or mechanisms must have to a disorder to make it a mental disorder; must there be mental symptoms, or mental dysfunctions, or either one, and so on? But, even if a precise resolution of the nature of the mental is not needed, some notion of the mental domain is essential in pursuing this discussion. We can pick out the mental ostensively, by pointing to lots of examples (e.g., perception, motivation, emotion, thought, and sensation) much more confidently than we can define it in a principled way. But because Brülde and Radovic find fault in such ostensive reference fixing, let me... (shrink)

How do people detect mental dysfunction? What is the influence of cultural models of dysfunction on this detection process? The detection process as such is not usually researched as it falls between the domains of cross-cultural psychiatry and anthropological ethno-psychiatry . I provide a general model for this “missing link” between behavior and cultural models, grounded in empirical evidence for intuitive psychology. Normal adult minds entertain specific intuitive expectations about mental function and behavior, and by implication they (...) infer that specific kinds of behavior are the result of underlying dysfunction. This suggests that there is a “catalogue” of possible behaviors that trigger that intuition, hence a limited catalogue of possible symptoms that feed into culturally specific folk-understandings of mental disorder. It also suggests that some mental dysfunctions, as they do not clearly violate principles of intuitive psychology, are “invisible” to folk-understandings. This perspective allows us to understand the cultural stability and spread of particular views of madness. It also suggests why certain types of mental disorder are invisible to folk-understandings. (shrink)

Several enactive-phenomenological perspectives have pointed to affectivity as a central aspect of mental disorders. Indeed, from an enactive perspective, sense-making is an inherently affective process. A question remains on the role of different forms of affective experiences (i.e., existential feelings, atmospheres, moods, and emotions) in sense-making and, consequently, in mental disorders. This work elaborates on the enactive perspective on mental disorders by attending to the primordial role of affectivity in the self-individuation process. Inspired by (...) Husserl’s genetic methodology and Simondonian philosophy of individuation, sense-making is described as the process of progressive concretization and structuration of the self-world structures that support the intentionality of conscious experiences. Accordingly, affectivity is described as the force that anticipates a partial self-world coherence in sense-making. Structurally different types of affective experiences are integrated into the genetic picture and, on this basis, a reinterpretation and classification of certain mental disorders, such as schizophrenia, depression, and the anxiety spectrum, is provided. In this way, this work contributes to a phenomenologically informed enactive account of mental disorders as disorders of affectivity. (shrink)

According to the predominant view within contemporary philosophy of psychiatry, mental disorders involve essentially personal and societal values, and thus, the concept of mental disorder cannot, even in principle, be elucidated in a thoroughly objective manner. Several arguments have been adduced in support of this impossibility thesis. My critical examination of two master arguments advanced to this effect by Derek Bolton and Jerome Wakefield, respectively, raises serious doubts about their soundness. Furthermore, I articulate an alternative, thoroughly objective, (...) though in part normative, framework for the elucidation of the concept of mental disorder. The concepts of mental dysfunction and impairment of basic psychological capacities to satisfy one’s basic needs are the building blocks of this framework. I provide an argument for the objective harmfulness of genuine mental disorders as patterns of mental dysfunctions with objectively negative biotic values, as well as a formally correct definition of the concept of mental disorder. Contrary to the received view, this objective framework allows for the possibility of genuine mental disorders due to adverse social conditions, as well as for quasi-universal mental disorders. I conclude that overall, the project of providing an objective account of the concept of mental disorder is far from impossible, and moreover, that it is, at least in principle, feasible. (shrink)

The supporters of the neurodiversity movement contend that autism is not a mental disorder, but rather a natural human variation. In a recent paper Jerome Wakefi eld, David Wasserman and Jordan Conrad (2020) argued against this view relying on Wakefi eld’s harmful dysfunction theory of mental disorder (the HD theory). Although I argue that the HD theory is problematic, I contend that arguments offered by Wakefi eld et al. (2020) against those of the neurodiversity movement are plausible, except (...) in one respect: their claim that high functioning autism in general is not a disorder is not well supported. I argue instead that the disorder status of high-functioning autistic persons should be judged on a case-by-case basis, depending on the harmfulness of the condition. In this regard, I maintain that the list of basic psychological capacities provided by George Graham (2010) provides an adequate conceptualization of harm. Moreover, I show how this framework may offer an appropriate tool for a case-by-case assessment of harm associated with high-functioning autism. (shrink)

_Psychopathology at School_ provides a timely response to concerns about the rising numbers of children whose behaviour is recognised and understood as a medicalised condition, rather than simply as poor behaviour caused by other factors. It is the first scholarly analysis of psychopathology which draws on the philosophers Foucault, Deleuze, Guattari and Arendt to examine the processes whereby children’s behaviour is pathologised. The heightened attention to mental disorders is contrasted with education practices in the early and mid-to-late twentieth (...) century, and the emergence of a new conceptualization of childhood is explored. Taking education as a central component to the contemporary experience of growing up, the book charts the ways in which mental disorders have become commonplace in childhood and youth, from birth through to college and university, but also offers examples of where professionals have refused to pathologise children’s behaviour. The book examines the extent of the influence of psychopathology on the lives of children and young people, as well as the practices that infiltrate education and the possibilities for alternative educational responses that negate the diagnosis of mental disorder. Psychopathology at School is a must read for anyone concerned about the growing influence of psychopathology in education and will be of particular interest to educated readers and to scholars, students and professionals in education, psychiatry, psychology, child studies, youth studies, nursing, social work and sociology. (shrink)

A growing number of theorists have looked to the enactivist approach in philosophy of mind or the affordance-based approach from ecological psychology to make sense of a wide variety of phenomena; some theorists believe that these theoretical accounts can offer rich insights about the nature of mental disorders, their etiology, and their characteristic symptoms. I argue that theorists who adopt such approaches also should embrace the further claim that all mental disorders are affective disorders. (...) First, enactivist accounts of mental disorder push us toward such a view insofar as they characterize such conditions in terms of disordered sense-making and conceptualize sense-making as fundamentally affective. Second, conceptions of mental disorder that emphasize affordance perception likewise motivate such a view insofar as they highlight the role that affectivity plays in the disclosure of action possibilities. What is more, both sense-making and affordance disclosure are best understood as processes of selective attention and responsiveness that rely heavily on affectivity. To illustrate and support these claims, I discuss how (a) language disturbances in schizophrenia and (b) “context blindness” in autism both result from disruptions to affectivity and selective attention that make it difficult for subjects to engage effectively with relevant affordances. (shrink)

The tendency to draw mind-brain dichotomies and evaluate mental disorders dualistically arises in both laypeople and mental health professionals, leads to biased judgments, and contributes to mental health stigmatization. This paper offers a theory identifying an underlying source of these evaluations in social practice. According to this theory, dualistic evaluations are rooted in two mechanisms by which we represent and evaluate the beliefs of others in folk psychology and theory of mind: the doxastic conception of (...) mental disorders and doxastic voluntarism. Tracing these origins contributes to our understanding of mental state representation in cognitive science and philosophy of psychiatry, the concept of belief in philosophy of mind, and may help improve patient experience and treatment in light of social stigmatization and bias toward mental illness. (shrink)