Wakefield’s harmful dysfunction analysis asserts that the concept of medical disorder includes a naturalistic component of dysfunction and a value component, both of which are required for disorder attributions. Muckler and Taylor, defending a purely naturalist, value-free understanding of disorder, argue that harm is not necessary for disorder. They provide three examples of dysfunctions that, they claim, are considered disorders but are entirely harmless: mild mononucleosis, cowpox that prevents smallpox, and minor perceptual deficits. They also reject the proposal that dysfunctions (...) need only be typically harmful to qualify as disorders. We argue that the proposed counterexamples are, in fact, considered harmful; thus, they fail to disconfirm the harm requirement: incapacity for exertion is inherently harmful, whether or not exertion occurs, cowpox is directly harmful irrespective of indirect benefits, and colorblindness and anosmia are considered harmful by those who consider them disorders. We also defend the typicality qualifier as viably addressing some apparently harmless disorders and argue that a dysfunction’s harmfulness is best understood in dispositional terms. (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)

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)

In the first part of this article, I argue that Christopher Megone's natural-kind interpretation of Aristotle's argument that "the function of a human being is reason" does not resolve major puzzles about the argument, specifically the puzzles of why a human being has a function and why reason is that function. I attempt to resolve these puzzles by supplementing the natural-kind account with the doctrine that reason is the master regulatory natural function by which individuals enter into social life. In (...) the second half, I critique Megone's value account of function and argue for a nonevaluative, causal-explanatory account of function and teleological explanation. (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)

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)

The harmful dysfunction (HD) analysis of "disorder" holds that disorders are harmful failures of "designed" (that is, naturally selected) functions. Murphy and Woolfolk (2000) present a series of proposed counterexamples to the HD analysis to support their claim that it fails to provide a necessary condition for disorder. They argue that disorder can exist where there is no failed function, as in failed spandrels and inflamed vestigial organs, and that there can be disorders when everything is working as designed, as (...) in environment--design mismatches and disorders acquired through normal learning processes. They also argue that the HD analysis suffers from methodological problems, including value-ladenness of dysfunction judgments and unwarranted assumptions about the nature of internal mechanisms and their functions. -/- In this paper, each of these objections is critically evaluated. Reanalysis of the proposed counterexamples is argued to reveal strong support for the HD analysis. For example, failed spandrels are considered disorders when and only when they imply failures of designed functions; dysfunctions of vestigial organs involve failures of function at the tissue level, not the organ level; mechanism-environment mismatches are not considered disorders; and conditions acquired through normal learning processes can involve dysfunctions and are considered disordered only when they do. Murphy and Woolfolk's methodological objections are found to be based on a misinterpretation of the HD analysis. It is concluded that Murphy and Woolfolk fail to offer a cogent objection to the HD analysis. (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)

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 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)

In ‘Rethinking Disease’, Powell and Scarffe1 propose what in effect is a modification of Jerome Wakefield’s2 3 harmful dysfunction analysis of medical disorder. The HDA maintains that ‘disorder’ is a hybrid factual and value concept requiring that a biological dysfunction, understood as a failure of some feature to perform a naturally selected function, causes harm to the individual as evaluated by social values. Powell and Scarffe accept both the HDA’s evolutionary biological function component and its incorporation of a value component. (...) Their proposed ‘new twist’ is to revise the value component: ‘Our proposed definition of disease is as follows: a biomedical state is a disease only if it implicates a biological dysfunction that is, or would be, properly disvalued’. So, they propose that a disorder is a ‘properly disvalued dysfunction’ rather than a ‘harmful dysfunction’, an approach they term ‘thickly normative’ in contrast to the thin normative approach of the HDA. There has been a surge of interest recently in better understanding the ‘harm’ component of the HDA. Powell and Scarffe’s analysis is a helpful contribution to this discussion. We focus here exclusively on their proposal regarding the analysis of the concept of disorder and ignore many important related issues that the authors address, ranging from prioritising resource allocation between disorders and non-disorders to whether the concept of disorder should be replaced by a generic welfarist concept. The resolution of these additional issues depends on first understanding ‘disorder’. The authors’ proposed changes to the HDA also deserve evaluation because the HDA, which has been endorsed by leading nosologists,4 plays an influential role in nosological debate across categories of disorder ranging, for example, from sexual paraphilias5 to psychopathy.6 A basic problem is that Powell and Scarffe misinterpret …. (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)

: 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)

In psychiatry's transformation from an asylum-based to a community-oriented profession, false positive diagnoses became a major challenge to the validity of the diagnostic system. The shift to descriptive, symptom-based operationalized diagnostic criteria of DSM-III further exacerbated this difficulty because of the contextually based nature of the distinction between normal distress and mental disorder. Through selected examples, the degree of success with which DSM-III and DSM-IV have attended to the challenge of avoiding false positive diagnoses is examined. Conceptual analysis of selected (...) criteria sets, with a focus on counterexamples to the claim that DSM criteria imply disorder, is performed. Psychiatry has so far failed to systematically confront the problem of false positives. Flaws in criteria, which can be recognized even by lay people, remain unaddressed, despite the fact that the issue is purely conceptual and is not sensitive to any new research information. (shrink)

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.

: 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).