Christopher Boorse’s biostatistical theory of medical disorder claims that biological part-dysfunction (i.e., failure of an internal mechanism to perform its biological function), a factual criterion, is both necessary and sufficient for disorder. Jerome Wakefield’s harmful dysfunction analysis of medical disorder agrees that part-dysfunction is necessary but rejects the sufficiency claim, maintaining that disorder also requires that the part-dysfunction causes harm to the individual, a value criterion. In this paper, I present two considerations against the sufficiency claim. First, I analyze Boorse’s (...) central argument for the sufficiency claim, the “pathologist argument,” which takes pathologists’ intuitions about pathology as determinative of medical disorder and conclude that it begs the question and fails to support the sufficiency claim. Second, I present four counterexamples from the medical literature in which salient part-dysfunctions are considered nondisorders, including healthy disease carriers, HIV-positive status, benign mutations, and situs inversus totalis, thus falsifying the sufficiency claim and supporting the harm criterion. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

I argue that John Searle's (1980) influential Chinese room argument (CRA) against computationalism and strong AI survives existing objections, including Block's (1998) internalized systems reply, Fodor's (1991b) deviant causal chain reply, and Hauser's (1997) unconscious content reply. However, a new ``essentialist'' reply I construct shows that the CRA as presented by Searle is an unsound argument that relies on a question-begging appeal to intuition. My diagnosis of the CRA relies on an interpretation of computationalism as a scientific theory about the (...) essential nature of intentional content; such theories often yield non-intuitive results in non-standard cases, and so cannot be judged by such intuitions. However, I further argue that the CRA can be transformed into a potentially valid argument against computationalism simply by reinterpreting it as an indeterminacy argument that shows that computationalism cannot explain the ordinary distinction between semantic content and sheer syntactic manipulation, and thus cannot be an adequate account of content. This conclusion admittedly rests on the arguable but plausible assumption that thought content is interestingly determinate. I conclude that the viability of computationalism and strong AI depends on their addressing the indeterminacy objection, but that it is currently unclear how this objection can be successfully addressed. (shrink)

In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further (...) questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)

Current symptom-based DSM and ICD diagnostic criteria for mental disorders are prone to yielding false positives because they ignore the context of symptoms. This is often seen as a benign flaw because problems of living and emotional suffering, even if not true disorders, may benefit from support and treatment. However, diagnosis of a disorder in our society has many ramifications not only for treatment choice but for broader social reactions to the diagnosed individual. In particular, mental disorders impose a sick (...) role on individuals and place a burden upon them to change; thus, disorders decrease the level of respect and acceptance generally accorded to those with even annoying normal variations in traits and features. Thus, minimizing false positives is important to a pluralistic society. The harmful dysfunction analysis of disorder is used to diagnose the sources of likely false positives, and propose potential remedies to the current weaknesses in the validity of diagnostic criteria. (shrink)

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. In Part 1, I argued that, even if one accepts Lewis’s critique of the brain evidence presented for the brain-disease view, his arguments fail to establish that addiction is not a disorder. Relying on my harmful dysfunction analysis of disorder, I defended the view (...) that addiction is a medical disorder and a brain disorder. In Part 2, I consider some broader philosophical issues raised by Lewis’s arguments: I consider a larger puzzle, at the heart of the neo-Kraepelinian program in contemporary psychiatry, that is raised by Lewis’s argument that addiction is not a disorder because the brain displays no damage but only normal learning: must all mental disorders be brain disorders, or can mental disorders occur in normal brains? I argue that mental disorders can occur in normal brains. I critique Lewis’s response to the evolutionary “novel environment” approach to explaining why addiction is a disorder. Lewis agrees with brain-disease proponents that interpreting addiction as brain disorder relieves addicts of moral censure, but I argue that moral defect and brain disease are not exclusive. Finally, I consider Lewis’s “developmental-learning” account of addiction that encourages positive and empowering narrativizing of addiction, but I argue that the developmental-learning view is vacuous due to use of an overly broad notion of “development.”. (shrink)

A major obstacle to formulating a broad-content intentional psychology is the occurrence of ''Frege cases'' - cases in which a person apparently believes or desires Fa but not Fb and acts accordingly, even though "a" and "b" have the same broad content. Frege cases seem to demand narrow-content distinctions to explain actions by the contents of beliefs and desires. Jerry Fodor ( The elm and the expert: Mentalese and its semantics , Cambridge, MA: MIT Press, 1994) argues that an explanatorily (...) adequate broad-content psychology is nonetheless possible because Frege cases rarely occur in intentional-explanatory contexts, and they are not systematically linked to intentional laws in a way that demands intentional explanation. Thus, he claims, behaviors associated with Frege cases can be considered ceteris-paribus exceptions to broad-content intentional laws without significantly decreasing the explanatory power of intentional psychology. I argue that Frege cases are plentiful and systematically linked to intentional laws in a way that requires intentional explanation, specifically in the explanation of why certain actions are not performed. Consequently, Frege-case behaviors cannot be construed as ceteris-paribus exceptions to intentional laws without significantly eroding the explanatory power of intentional psychology and reducing the rationality of the agent. Fodor thus fails to save broad-content psychology from the prima facie objections against it based on Frege cases. (shrink)

Pierre-Henri Castel provides a short but richly argued precis of his recently published two-volume 1,000-page masterwork on the history of obsessive-compulsive disorder. Having not read the as-yet-untranslated books, I write this commentary from Plato’s cave, trying to infer the reality of Castel’s analysis from expository shadows. I am unlikely to be more successful than Plato’s poor troglodytes, so I apologize ahead of time for any misunderstandings. Moreover, I cannot assess Castel’s detailed evidential case for his substantive theses.1 I thus focus (...) on some key philosophical issues that impinge on an area of my concern, the concept of mental disorder. Castel is a rare breed of French.. (shrink)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)

: Jerry Fodor proposes a solution to Quine's inscrutability–of–reference problem for certain naturalized semantic theories, thereby defending such theories from charges that they cannot discriminate meanings finely enough. His proposal, combining elements of informational and inferential–role semantics, is to eliminate non–standard interpretations by testing predicate compatibility relations. I argue that Fodor's proposal, understood as primarily aimed at Mentalese, withstands Ray's and Gates's objections but nonetheless fails because of unwarranted assumptions about ontological homogeneity of target language predicates, and problems with Fodor's (...) reliance on predicate conjunction to resolve ambiguity. Naturalized semantics thus remains without an answer to the inscrutability objection. (shrink)

Three reservations about Keller & Miller's (K&M's) argument are explored: Serious validity problems afflict epidemiological criteria discriminating disorders from non-disorders, so high rates may be misleading. Normal variation need not be mild disorder, contrary to a possible interpretation of K&M's article. And, rather than mutation-selection balance, true disorders may result from unselected combinations of normal variants over many loci. (Published Online November 9 2006).

Andrews et al.'s analysis suffers from a series of conceptual confusions they inherit from Gould's work. Their proposal that adaptations can be distinguished from exaptations essentially by specific design criteria fails because exaptations are often maintained and secondarily adapted by natural selection and therefore, over evolutionary time, can come to have similar levels of design specificity to adaptations.