Cet article explore la classification des troubles psychiatriques dans la perspective du modèle des espèces pratiques. En nous basant sur certains travaux en philosophie des sciences qui soutiennent que les éléments chimiques et les espèces biologiques ne possèdent pas de véritables essences, nous affirmons que les troubles psychiatriques ne devraient pas être compris, eux non plus, de façon essentialiste. Les troubles psychiatriques sont des « espèces pratiques », non des « espèces naturelles ». Ce modèle représente une approche pragmatiste de (...) la classification qui pose, compte tenu de l’infinie complexité du monde, qu’une multitude de décisions peuvent jouer un rôle légitime dans la définition des limites des catégories. Il s’agit d’une approche nominaliste contemporaine qui considère les concepts et les catégories comme provisoires et partiels, sans toutefois rejeter l’idée qu’ils sont des espèces légitimes. Ce modèle rejette ce que Ian Hacking a nommé le structurisme inhérent, sans pour autant rejeter les espèces. Le modèle des espèces pratiques rejette aussi l’éliminativisme. Il est en accord avec les arguments non essentialistes offerts par les éliminativistes, mais il n’accepte pas leurs conclusions austères. Je discute finalement les complications et les imperfections du modèle.This article explores the classification of psychiatric disorders from the perspective of the practical kinds model. Based on work in the philosophy of science which argues that chemical elements and biological species do not have real essences, it is argued that psychiatric disorders should not be understood essentialistically either. Psychiatric disorders are practical, not natural kinds. This model represents a pragmatist approach to classification which holds that, because the world is so complex, a multitude of decisions can play legitimate roles in defining category boundaries. It is a contemporary nominalistic approach that views concepts and categories as provisional and partial, but does not reject the notion that there are legitimate kinds. It rejects what Ian Hacking has called inherent structurism, but not kinds. The practical kinds model is also anti-eliminativist. It agrees with the non-essentialistic arguments offered by eliminativists, but does not accept their austere conclusions. Complications and shortcomings of the model are discussed. (shrink)

A satisfactory account of the nature of health is important for a wide range of theoretical and practical reasons. No theory offered in the literature thus far has been able to meet all the desiderata for an adequate theory of health. This article introduces a new theory of health, according to which health is best defined in terms of dispositions at the level of the organism as a whole. After outlining the main features of the account and providing formal definitions (...) of ‘health’, ‘healthy’, and ‘healthier than’, I present the main strengths of the proposed account. I argue that the proposed dispositional theory accounts for all paradigm cases of health and pathology, that it circumvents a number of problems faced by rival theories, and that it makes for a naturalistic theory of health with a rigorous metaphysical underpinning. 1Introduction 2The Dispositional Account 3Further Specification of the Dispositional Account 3.1Reference classes 3.2Comparison classes 3.3Which dispositions? 4Advantages of the Dispositional view 5Three Objections and Replies 5.1Objection 1: Counter-examples 5.2Objection 2: Issues with holism 5.3Objection 3: Expediting medicalization 6Final Remarks. (shrink)

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)

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)

Les critiques actuelles des diagnostics psychiatriques, qu’elles viennent des antipsychiatres, des béhavioristes, des constructionnistes sociaux, des szasziens et des foucaldiens, rejettent généralement l’idée que le concept de trouble mental est légitime du point de vue médical, ne laissant donc aucun argument solide à partir duquel il soit possible de mener une critique constructive et d’établir un dialogue avec la psychiatrie. Ces positions ne réussissent également pas à expliquer les fortes intuitions populaires qui permettent aux gens de distinguer les troubles psychologiques (...) des autres conditions psychologiques négatives. Selon l’analyse de la dysfonction préjudiciable présentée dans cet article, un trouble mental est une condition : 1) préjudiciable, un concept évaluatif basé sur des valeurs sociales ; et 2) causée par une dysfonction psychologique, un concept factuel se rapportant à un mécanisme psychologique qui accomplit une fonction pour laquelle il a été biologiquement conçu . L’analyse DP est ainsi une position hybride qui requiert à la fois que des critères évaluatifs et factuels soient satisfaits pour garantir l’attribution d’un trouble. Nous argumentons que l’analyse DP réussit admirablement à expliquer les jugements intuitifs quant à ce qui est un trouble et à ce qui en n’est pas. La composante factuelle permet également de critiquer le critère diagnostique du DSM, ce que nous ferons à l’aide de plusieurs exemples . Ces critiques déterminent où le DSM a dévié de ses propres hypothèses et ainsi considéré comme des troubles ce qui n’en est pas. Elles expliquent également pourquoi les tentatives du DSM de remédier au problème en introduisant le critère du « cliniquement significatif » échouent.Current antipsychiatric, behaviorist, social-constructivist, Szaszian, and Foucauldian critiques of psychiatric diagnosis generally reject mental disorder as a medically legitimate concept, thus allowing no place to stand from which to mount a constructive critique and dialogue with psychiatry. These views also fail to explain the robust folk intuitions by which people distinguish psychological disorders from other negative psychological conditions. According to the harmful dysfunction analysis presented in this paper, a mental disorder is condition that is harmful, a value concept judged by social values ; and caused by a psychological dysfunction, a factual concept referring to failure of a psychological mechanism to perform a function for which it is biologically designed . The HD analysis is thus a hybrid account that requires both value and factual criteria to be satisfied before attribution of disorder is warranted. It is argued that the HD analysis has considerable success in explaining intuitive judgments about disorder versus non-disorder. The factual component also allows for a critique of DSM diagnostic criteria for specific categories, with several examples discussed. These critiques identify where the DSM has deviated from its own deepest assumptions and labeled non-disorders as disorders, and why the DSM’s own attempts to fix the problem, as with the «clinical significance» criterion, do not succeed. (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. Addiction is currently classified as a medical disorder in DSM-5 and ICD-10. It is further labeled a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Lewis argues that the changes result instead from normal neuroplasticity (...) and learning in response to the intense rewards provided by addictive substances, thus that addiction is not a brain disease and by implication not a medical disorder at all. I argue that even if one accepts Lewis’s reinterpretation of the brain evidence, his conclusions do not follow. Relying on my harmful-dysfunction analysis of medical disorder, I defend the view that substance addiction is in fact a medical disorder and a brain disorder. In Part 1, I identify five arguments Lewis puts forward against the brain-disease view and evaluate them as arguments that addiction is not a disorder: Addiction is not a chronic, relapsing condition; There is no clear boundary between addiction and other strong desires; Negative consequences are not unique to disorders; The brain disease model does not account for behavioral addictions; and, Addiction is like love. I argue that Lewis’s arguments are invalid because they fail to take account of the context of addiction and its relation to biological design. (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)

This “open letter” to Christopher Boorse is a response to his influential naturalist analysis of disease from the perspective of linguistic-analytic value theory. The key linguistic-analytic point against Boorse is that, although defining disease value free, he continue to use the term with clear evaluative connotations. A descriptivist analysis of disease would allow value-free definition consistently with value-laden use: but descriptivism fails when applied to mental disorder because it depends on shared values whereas the values relevant to mental disorders are (...) highly diverse. A part-function analysis, similarly, although initially persuasive for physical disorders, fails with the psychotic mental disorders because these, characteristically, involve disturbances of the rationality of the person as a whole. The difficulties encountered in applying naturalism to mental disorders point, linguistic-analytically, to the possibility that there is, after all, an evaluative element of meaning, deeply hidden but still logically operative, in the concept of disease. (shrink)

Mental disorders are often thought to be harmful dysfunctions. Jerome Wakefield has argued that such dysfunctions should be understood as failures of naturally selected functions. This suggests, implicitly, that evolutionary biology and other Darwinian disciplines hold important information for anyone working on answering the philosophical question, ‘what is a mental disorder?’. In this article, the author argues that Darwinian theory is not only relevant to the understanding of the disrupted functions, but it also sheds light on the disruption itself, as (...) well as on the harm that attends the disruption. The arguments advanced here are partially based on the view that a core feature of Darwinism is that it stresses the environmental relativity of functions and dysfunctions. These arguments show a very close empirical connection between social judgments and dysfunctions , which is of interest for psychiatric theory. Philosophically, they lead to the conclusion that the concept of mental disorder is identical to the concept of mental dysfunction. Consequently, it is both misleading and redundant to conceptualize mental disorders as ‘harmful dysfunctions’, and not simply as ‘mental dysfunctions’. (shrink)

Mental disorders are often thought to be harmful dysfunctions. Jerome Wakefield has argued that such dysfunctions should be understood as failures of naturally selected functions. This suggests, implicitly, that evolutionary biology and other Darwinian disciplines hold important information for anyone working on answering the philosophical question, 'what is a mental disorder?'. In this article, the author argues that Darwinian theory is not only relevant to the understanding of the disrupted functions, but it also sheds light on the disruption itself, as (...) well as on the harm that attends the disruption. The arguments advanced here are partially based on the view that a core feature of Darwinism is that it stresses the environmental relativity of functions and dysfunctions. These arguments show a very close empirical connection between social judgments and dysfunctions, which is of interest for psychiatric theory. Philosophically, they lead to the conclusion that the concept of mental disorder is identical to the concept of mental dysfunction. Consequently, it is both misleading and redundant to conceptualize mental disorders as 'harmful dysfunctions', and not simply as 'mental dysfunctions'. (shrink)

All definitions of mental disorder are backed up by arguments that rely on general criteria (e.g., that a definition should be consistent with ordinary language). These desiderata are rarely explicitly stated, and there has been no systematic discussion of how different definitions should be assessed. To arrive at a well-founded list of desiderata, we need to know the purpose of a definition. I argue that this purpose must be practical; it should, for example, help us determine who is entitled to (...) publicly funded health care. I then propose eight conditions of adequacy that can be used to assess competing definitions (e.g., the ordinary language condition, the coherence condition, and the condition of normative adequacy). These conditions pull in different directions, however, and we must decide which are most important. I also suggest that there is no single definition that can help us deal with all the relevant practical issues. (shrink)

The present paper constitutes a development of the position that illness, whether bodily or mental, should be analyzed as an incapacitating failure of bodily or mental capacities, respectively, to realize their functions. The paper undertakes this development by responding to two critics. It addresses first Szasz’s continued claims that (1) physical illness is the paradigm concept of illness and (2) a philosophical analysis of mental illness does not shed any light on the social and legal role of the idea. Then, (...) in reply to Wakefield, the aim is to defend the account as an interpretation of Aristotle and to argue that this Aristotelian view of mental illness is preferable to one that rests on a supposed value free account of human function. More generally the discussion points to the fact that both Wakefield and Szasz rely on a number of metaphysical assumptions about the supposedly empirical nature of medical diagnosis, about the relation between facts and values, and about mind and body (among others), which are open to challenge. In particular the paper indicates an aristotelian approach to the fusion, in the natural world, of so-called facts and values, and the relevance of this fusion to the analysis of the concept of illness. This suggests the debate over distinct conceptions of that concept must both illumine and be illuminated by these deeper metaphysical questions. (shrink)