Addiction and the Concept of Disorder, Part 2: Is every Mental Disorder a Brain Disorder?

Are mental dysfunctions autonomous from brain dysfunctions? A perspective from the personal/subpersonal distinction

Despite many authors in psychiatry endorsing a naturalist view of the mind, many still consider that mental dysfunctions cannot be reduced to brain dysfunctions. This paper investigates the main reasons for this view. Some arguments rely on the analogy that the mind is like software while the brain is like hardware. The analogy suggests that just as software can malfunction independently of hardware malfunctions, similarly the mind can malfunction independently of any brain malfunction. This view has been critically examined in recent literature. However, other less discussed reasons suggest that mental dysfunctions cannot be reduced to brain dysfunctions because mental dysfunctions are appropriately ascribed at the level of intentional mental states, while brain dysfunctions are solely related to abnormalities in anatomy and physiological processes. This paper questions why such a view would be upheld. The discussion is framed within the interface problem in the philosophy of cognitive science, which concerns the relationship between personal and subpersonal levels of explanation. The paper examines the view that an autonomist perspective on the personal/subpersonal distinction could justify the separation of mental dysfunctions, described in intentional terms, from brain dysfunctions, described in anatomical or physiological terms. Ultimately, the paper argues that the autonomist view cannot be upheld in psychiatry and, consequently, does not provide a principled justification for rejecting the reduction of mental dysfunctions to brain dysfunctions.

Klerman's "credo" reconsidered: neo-Kraepelinianism, Spitzer's views, and what we can learn from the past

In 1978, G. Klerman published an essay in which he named the then-nascent "neo-Kraepelinian" movement and formulated a "credo" of nine propositions expressing the movement's essential claims and aspirations. Klerman's essay appeared on the eve of the triumph of neo-Kraepelinian ideas in the DSM-III. However, this diagnostic system has subsequently come under attack, opening the way for competing proposals for the future of psychiatric nosology. To better understand what is at stake, in this paper I provide a close reading and consideration of Klerman's credo in light of the past forty years of research and reflection. The credo is placed in the context of two equally seminal publications in the same year, one by S. Guze, the leading neo-Kraepelinian theorist, and the other by R. Spitzer and J. Endicott, defining mental disorder. The divergences between Spitzer and standard neo-Kraepelinianism are highlighted and argued to be much more important than is generally realized. The analysis of Klerman's credo is also argued to have implications for how to satisfactorily resolve the current nosological ferment in psychiatry. In addition to issues such as creating descriptive syndromal diagnostic criteria, overthrowing psychoanalytic dominance of psychiatry, and making psychiatry more scientific, neo-Kraepelinians were deeply concerned with the conceptual issue of the nature of mental disorder and the defense of psychiatry's medical legitimacy in response to antipsychiatric criticisms. These issues cannot be ignored, and I argue that proposals currently on offer to replace the neo-Kraepelinian system, especially popular proposals to replace it with dimensional measures, fail to adequately address them.

Addiction from the harmful dysfunction perspective: How there can be a mental disorder in a normal brain

Is addiction a medical disorder, and if so, what kind of disorder is it? Addiction is considered a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Critics argue that the brain changes result instead from normal neuroplasticity and learning in response to the intense rewards provided by addictive substances, thus addiction is not a disorder but rather a series of normal-range if problematic choices. Relying on the harmful dysfunction analysis of medical disorder to evaluate disorder versus nondisorder status, I argue that even if one accepts the critics' reinterpretation of NIDA's brain evidence and rejects the brain disease account, the critics' conclusion that addiction is not a medical disorder but is rather a matter of problematic nondisordered choice does not follow. This is because there is a further possible account of addiction, the evolutionary "hijack" view, that holds that addiction is due to the availability of substances and stimuli that were unavailable during human species evolution and that coopt certain brain areas concerned with human motivation, creating biologically undesigned peremptory desires. I argue that if the hijack theory is correct, then it opens up the possibility that addiction could be a true motivational medical disorder for which there is no underlying neurological-level dysfunction. Finally, I explore the implications of this account for how we see the social responsibility for addiction and how we attempt to control it.

Determinism and Destigmatization: Mitigating Blame for Addiction

The brain disease model of addiction is widely endorsed by agencies concerned with treating behavioral disorders and combatting the stigma often associated with addiction. However, both its accuracy and its effectiveness in reducing stigma have been challenged. A proposed alternative, the “choice” model, recognizes the residual rational behavior control capacities of addicted individuals and their ability to make choices, some of which may cause harm. Since harmful choices are ordinarily perceived as blameworthy, the choice model may inadvertently help justify stigma. This paper seeks to fully naturalize the choice model by highlighting the determinants of voluntary action and thus increase its potential for destigmatizing addiction. In light of a deterministic understanding of behavior, it is unreasonable to suppose that addicted individuals could have made different choices in becoming addicted and in subsequent situations. To the extent that stigma is motivated by the supposition that addicted individuals could have chosen otherwise in actual situations, a deterministic understanding of addictive behavior promises to mitigate blame and stigma.

Trying to make sense of rodents' drug choice behavior

Since the first experimental hint for the existence of "an actual desire or striving for the drug" in nonhuman animals by Sidney Spragg in the late 1930s, much effort has been expended by lab researchers to try to model in a valid manner the key behavioral aspects and signs of addiction in animals, typically in rodents (i.e., mainly rats and, to a lesser extent, mice). Despite much advances, there still remains a lingering doubt about the disordered status of drug use in rodents. This is mainly because drug use occurs in a particular setting where animals have access to a drug for self-administration but without access to other valuable behavioral options that could compete with and divert from drug use. Here I review evidence showing that enriching the drug setting with other behavioral options can dramatically influence the pattern of drug choices in rodents. Overall, access to other options during drug access can divert the vast majority of rats from continued drug use. Only few individuals continue to engage in drug use despite access to and at the expense of other options. However, there exist certain high-risk settings in which virtually all animals are vulnerable to develop a harmful pattern of exclusive drug use that can even become fatal in the long run if not discontinued by an outside intervention. Paradoxically, it appears that the behavioral trait that is hypothesized to uniquely render rodents vulnerable to the latter settings (i.e., a narrow focus on the local, current choice, with no consideration of the global pattern of choice) would also protect most of them from using drugs in other choice settings. I conclude with an attempt to make sense of this peculiar setting-specific behavior and with some general propositions for future research.

Introduction: Testing and Refining Marc Lewis's Critique of the Brain Disease Model of Addiction

In this introduction we set out some salient themes that will help structure understanding of a complex set of intersecting issues discussed in this special issue on the work of Marc Lewis: (1) conceptual foundations of the disease model, (2) tolerating the disease model given socio-political environments, and (3) A third wave: refining conceptualization of addiction in the light of Lewis's model.