The concept of mental disorder: On the boundary between biological facts and social values

An Overview of the Potential Role of Nutrition in Mental Disorders in the Light of Advances in Nutripsychiatry

PURPOSE OF REVIEW

As research on the potential impact of nutrition on mental disorders, a significant component of global disability continues to grow the concepts of "nutritional psychiatry, psycho-dietetics/nutripsychiatry" have taken their place in the literature. This review is a comprehensive examination of the literature on the the potential mechanisms between common mental disorders and nutrition and evaluates the effectiveness of dietary interventions.

RECENT FINDINGS

Inflammation, oxidative stress, intestinal microbiota, mitochondrial dysfunction, and neural plasticity are shown as potential mechanisms in the relationship between mental disorders and nutrition. As a matter of fact, neurotrophic factors, which make important contributions to repair mechanisms throughout life, and neuronal plasticity, which plays a role in mental disorders, are affected by nutritional factors. In metabolism, the antioxidant defense system works with nutritional cofactors and phytochemicals. A balanced, planned diet that provides these components is more likely to provide nutrients that increase resilience against the pathogenesis of mental disorders. Nutrition can be considered a risk factor for mental disorders. Therefore, developing public health strategies focused on improving diet may help reduce the global burden of mental disorders and other related diseases.

Unshared Minds, Decaying Worlds: Towards a Pathology of Chronic Loneliness

The moment when a person's actual relationships fall short of desired relationships is commonly identified as the etiological moment of chronic loneliness, which can lead to physical and psychological effects like depression, worse recovery from illness and increased mortality. But, this etiology fails to explain the nature and severe impact of loneliness. Here, we use philosophical analysis and neuroscience to show that human beings develop and maintain our world-picture (our sense of what is true, important, and good) through joint attention and action, motivated by friendship, in the Aristotelian sense of "other selves" who share a sense of the true and the good, and desire the good for each other as much as for themselves. The true etiological event of loneliness is the moment one's world-picture becomes unshared. The pathogenesis is a resultant decay of our world-picture, with brain and behavior changes following as sequelae.

The normativist-naturalist puzzle: Functions and assumptions of health assessment tools

While there is no shortage in discussions of health assessment tools, little is known about health professionals' experience of their practical uses. However, these tools rely on assumptions that have significant impacts on the practice of health assessment. In this study, we explore health professionals' experiences with health assessment tools, that is, how they define, use, and understand these tools, and whether they take them to measure health and wellbeing. We combine a qualitative, interview-based study of the uses and understandings of health assessment tools among Danish health professionals with a philosophical analysis of these applications and perceptions. Our study shows that contrary assumptions are involved in the use of the tools, to the extent that one can speak of a normativist-naturalist puzzle: health professionals generally apply a normativist conception of health, find health assessment useful and valuable for their clinical practice, but believe that what the tools measure is basically not health proper but some proximal entity of a more naturalist kind. This result demonstrates the complexity of health assessment tools and suggests that they are used with care to ensure both that particular tools are used for the kinds of tasks they are most apt for, and that they are put to use in awareness of their limitations.

Mental health promotion and the positive concept of health: Navigating dilemmas

A prevailing view holds that the main goal of mental health promotion is to maintain and improve positive mental health, which is not merely defined by the absence of mental disorders, but by the presence of certain abilities. There are, however, challenges associated with this view that this paper aims to identify and explore. We start by highlighting three requirements for an ethically and politically justified mental health promotion scheme: (i) using a positive concept of mental health that (ii) respects the neutrality principle while (iii) not being overly permissive. Then, we argue that the WHO's positive concept of health violates (ii), and continue by exploring three philosophical accounts (i.e., Nordenfelt, 1995, 2017; Graham 2010; Wren-Lewis & Alexandrova, 2021) that could potentially provide a solution. We show that these face a dilemma of their own: they either violate (ii) or (iii), and they can rectify one issue only by violating the other. Considering the problems linked to the positive notion of health, the final section explores the alternate route of rejecting proposition (i) and instead embracing a negative concept of health. We argue that this option does not present a more advantageous solution. We conclude by highlighting the necessity for additional research to tackle the challenges we identified.

The Dynamics of Disease: Toward a Processual Theory of Health

The following article presents preliminary reflections on a processual theory of health and disease. It does this by steering the discussion more toward an ontology of organisms rather than conceptual analysis of the semantic content of the terms "health" and "disease." In the first section, four meta-theoretical assumptions of the traditional debate are identified and alternative approaches to the problems are presented. Afterwards, the view that health and disease are constituted by a dynamic relation between demands imposed on an organism and individual presuppositions for adequate response is developed. In the last section, the paper takes stock of three possible objections to and clarifies some implications of this approach to the notions of health and disease.

Psychopathology and Metaphysics: Can One Be a Realist About Mental Disorder?

Metaphysical realism about mental disorder is the thesis that mental disorder exists mind-independently. There are two ways to challenge metaphysical realism about mental disorder. The first is by denying that mental disorder exists. The second is by denying that mental disorder exists mind-independently. Or, differently put, by arguing that mental disorder is mind-dependent. The aim of this paper is three-fold: (a) to examine three ways in which mental disorder can be said to be mind-dependent (namely, by being causally dependent on the human mind, by being weakly dependent on human attitudes, and by being strongly dependent on human attitudes), (b) to clarify their differences, and (c) to discuss their implications regarding metaphysical realism about mental disorder. I argue that mental disorder being mind-dependent in the first two senses is compatible with metaphysical realism about mental disorder, whereas mental disorder being mind-dependent in the third sense is not.

What are Mental Disorders? Exploring the Role of Culture in the Harmful Dysfunction Approach

A shared problem in psychology, psychiatry, and philosophy is how to define mental disorders. Various theories have been proposed, ranging from naturalism to social constructionism. In this article, I first briefly introduce the current landscape of such theories, before concentrating on one of the most influential approaches today: The harmful dysfunction theory developed by Jerome Wakefield. It claims that mental disorders are hybrid phenomena since they have a natural basis in dysfunctional mental mechanisms, but also a cultural component in the harm experienced by human beings. Although the theory is well thought through, I will raise a critical question: Is it possible to isolate mental mechanisms as naturally evolved from cultural factors? I will argue that it is not, but that the theory could still be helpful in an understanding of mental disorders, albeit on a new footing that does not operate with a natural and a cultural component as two separate factors. I argue that we need to develop a "naturecultural" approach to psychopathology that avoids mentalism, based on the fact that human beings are irreducibly persons.

An evolutionary analysis of the applicability and utility of the clinico-pathological method in psychiatry

Unlike other medical specialties, psychiatry has not been involved in the theoretical shift that replaced the syndromal approach with the clinico-pathological method, which consists in explaining clinical manifestations by reference to morbid anatomical and physiological changes. Past and present discussions on the applicability of the clinico-pathological method in psychiatry are based on a pre-Darwinian concept of biology as the study of proximate causation. Distinguishing between mediating mechanisms and evolved functions, an evolutionary perspective offers an original contribution to the debate by overcoming the opposite views of dualism (i.e., the clinico-pathological method is not applicable to disorders of the mind) and neuroessentialism (i.e., the definitive way of explaining psychiatric disorders is by reference to the brain and its activity). An evolutionary perspective offers original insights on the utility of the clinico-pathological method to solve critical questions of psychiatric research and clinical practice, including the distinction between mental health and illness, a better understanding of the etiology and pathophysiology, the classification and differential diagnosis of psychiatric disorders, and the development of more efficacious psychiatric treatments.

Toward an improved conceptualization of emotions in patients with cancer

Cancer and its associated treatment is a major stressor, leading to emotions such as anxiety or depressive mood. Human emotions have developed through the course of evolution because they facilitate adaptation to important events, such as cancer and its associated treatment. On the other hand, emotions can be maladaptive and interfere with adaptation to cancer. Emotions are maladaptive if they are disproportionally severe or persistent, and if they interfere with functioning. We aim to expand the conceptualization of adaptive and maladaptive emotions in patients with cancer. We draw on major theories in the field of mental disorder and mental health, and apply these theories to conceptualize adaptive and maladaptive emotions in patients with cancer. (i) Maladaptive emotions have two essential features: mental dysfunction and patient harm. Maladaptive emotions are characterized by a network of strongly associated emotional symptoms, which may include cancer-related somatic symptoms. The dysfunctional symptom network is hypothesized to be the result of disturbance of life goal pursuit caused by cancer. (ii) Adaptive emotions have two essential features: ability to deal with cancer and functioning well. The ability to use emotions in an adaptive way depends on skills to recognize, express, and regulate emotions in a flexible manner. A secure attachment style facilitates adaptive emotional responses to cancer. The present conceptualization of adaptive and maladaptive emotions is expected to contribute to better understanding and management of emotions in patients with cancer.

Beyond Conceptual Analysis: Social Objectivity and Conceptual Engineering to Define Disease

In this article, I side with those who argue that the debate about the definition of "disease" should be reoriented from the question "what is disease" to the question of what it should be. However, I ground my argument on the rejection of the naturalist approach to define disease and the adoption of a normativist approach, according to which the concept of disease is normative and value-laden. Based on this normativist approach, I defend two main theses: (1) that conceptual analysis is not the right method to define disease and that conceptual engineering should be the preferred method and (2) that the method of conceptual engineering should be implemented following the principles of Alexandrova's account of social objectivity in the context of the definition of disease.

Reference-Class Problems Are Real: Health-Adjusted Reference Classes and Low Bone Mineral Density

Elselijn Kingma argues that Christopher Boorse's biostatistical theory (the BST) does not show how the reference classes it uses are objective and naturalistic. Recently, philosophers of medicine have attempted to rebut Kingma's concerns. I argue that these rebuttals are theoretically unconvincing, and that there are clear examples of physicians adjusting their reference classes according to their prior knowledge of health and disease. I focus on the use of age-adjusted reference classes to diagnose low bone mineral density in children. In addition to using the BST's age, sex, and species, physicians also choose to use other factors to define reference classes, such as pubertal status, bone age, body size, and muscle mass. I show that physicians calibrate the reference classes they use according to their prior knowledge of health and disease. Reference classes are also chosen for pragmatic reasons, such as to predict fragility fractures.

Changing perspectives on autism: Overlapping contributions of evolutionary psychiatry and the neurodiversity movement

Perspectives on autism and psychiatric conditions are affected by a mix of scientific and social influences. Evolutionary psychiatry (EP) and the neurodiversity movement are emerging paradigms that reflect these distinct influences, with the former grounded in scientific theory and the latter driven by political and social principles. Despite their separate foundations, there is a significant overlap between EP and neurodiversity that has not been explored. Specifically, both paradigms reframe disorders as natural cognitive differences rather than disease; expand the concept of "normal" beyond that implied in modern psychiatry; focus on relative strengths; recognize that modern environments disadvantage certain individuals to cause functional impairment; emphasize cognitive variation being socially accommodated and integrated rather than treated or cured; and can help reduce stigmatization. However, in other ways, they are distinct and sometimes in conflict. EP emphasizes scientific explanation, defines "dysfunction" in objective terms, and differentiates heterogenous cases based on underlying causes (e.g. autism due to de novo genetic mutations). The neurodiversity movement emphasizes social action, removes barriers to inclusion, promotes inclusive language, and allows unrestricted identification as neurodivergent. By comparing and contrasting these two approaches, we find that EP can, to some extent, support the goals of neurodiversity. In particular, EP perspectives could be convincing to groups more responsive to scientific evidence and help achieve a middle ground between neurodiversity advocates and critics of the movement.

A close look at sociality in DSM criteria

PURPOSE

The importance of sociality in psychology and psychotherapy is quite undisputed; however, this construct risks being underestimated in psychiatric nosography. The aim of the review was to assess the relevance of sociality in DSM 5 criteria.

METHOD

Sociality-laden criteria of 192 selected DSM categories have been identified through a textual grid. Second, the criteria have been classified into 6 categories, i.e., (1) Affiliation and Attachment (AA), (2) Social Communication (SC), (3) Perception and Understanding of Others (PUO), (4) Culture, (5) Clinical Significance Criterion (CSC) (6), and No Specific Construct (NSC).

RESULTS

13% of all mental disorders mention AA in their criteria. 8.8% of all mental disorders mention SC; 8.8% of all mental disorders mention PUO in their criteria. 15% of all mental disorders mention culture in their criteria (exclusively ex negativo though). 40% of mental disorders mention non-specific sociality (NSC) in their criteria. CSC is mentioned in 85% of mental disorders. Personality disorders have the highest "concentration" of sociality mentions throughout the DSM categories.

CONCLUSIONS

The overall results suggest that DSM criteria offer a confused account of sociality. We believe that the descriptive approach is the underlying reason. We suggest that in the long run a theory-laden approach to sociality, informed by evolutionary insights about motivations, could be of help.

Eco-anxiety: An adaptive behavior or a mental disorder? Results of a psychometric study

OBJECTIVE

Eco-anxiety is a complex construct that has been created to grasp the psychological impact of the consequences of global warming. The concept needs a reliably valid questionnaire to better evaluate its impact on the risk of anxiety and depressive disorders. The Eco-Anxiety Questionnaire (EAQ-22) evaluates two dimensions: 'habitual ecological anxiety' and 'distress related to eco-anxiety'. However, a version in French, one of the world's widely spoken languages, was until now lacking. We aimed to translate and validate the French EAQ-22 and to evaluate the prevalence of the level of the two dimensions of eco-anxiety and the relationship with anxiety and depressive symptoms in a representative adult sample of the French general population.

METHODS

This study was performed under the auspices of the Institut national du sommeil et de la vigilance (INSV). Participants (18-65 years) were recruited by an institute specialized in conducting online surveys of representative population samples (quota sampling). Two native French speakers and two native English speakers performed a forward-backward translation of the questionnaire. The Hospital Anxiety and Depression scale (HAD) was administered to assess anxiety (HAD-A) and depressive (HAD-D) symptoms and for external validity. Internal structural validity and external validity were analysed.

RESULTS

Evaluation was performed on 1004 participants: mean age 43.47 years (SD=13.41, range: [19-66]); 54.1% (n=543) women. Using the HAD, 312 (31.1%) patients had current clinically significant anxiety symptoms (HAD-A>10) and 150 (14.9%) had current clinically significant depressive symptoms (HAD-D>10). Cronbach's alpha coefficient was 0.934, indicating very good internal consistency. Correlation between EAQ-22 and HAD scores was low (r[1004]=0.209, P<0.001), 'habitual ecological anxiety' was correlated less with HAD-A and HAD-D than 'distress related to eco-anxiety', indicating good external validity.

CONCLUSION

This study validates the French EAQ-22 and paves the way for using the EAQ-22 as a global tool for assessing eco-anxiety. Further prospective studies are now required to better evaluate the impact of eco-anxiety on the occurrence of anxiety and depressive disorder.

Designing AI for mental health diagnosis: challenges from sub-Saharan African value-laden judgements on mental health disorders

Recently clinicians have become more reliant on technologies such as artificial intelligence (AI) and machine learning (ML) for effective and accurate diagnosis and prognosis of diseases, especially mental health disorders. These remarks, however, apply primarily to Europe, the USA, China and other technologically developed nations. Africa is yet to leverage the potential applications of AI and ML within the medical space. Sub-Saharan African countries are currently disadvantaged economically and infrastructure-wise. Yet precisely, these circumstances create significant opportunities for the deployment of medical AI, which has already been deployed in some places in the continent. However, while AI and ML have come with enormous promises in Africa, there are still challenges when it comes to successfully applying AI and ML designed elsewhere within the African context, especially in diagnosing mental health disorders. We argue, in this paper, that there ought not to be a homogeneous/generic design of AI and ML used in diagnosing mental health disorders. Our claim is grounded on the premise that mental health disorders cannot be diagnosed solely on 'factual evidence' but on both factual evidence and value-laden judgements of what constitutes mental health disorders in sub-Saharan Africa. For ML to play a successful role in diagnosing mental health disorders in sub-Saharan African medical spaces, with a precise focus on South Africa, we allude that it ought to understand what sub-Saharan Africans consider as mental health disorders, that is, the value-laden judgements of some conditions.

Disease: An ill-founded concept at odds with the principle of patient-centred medicine

BACKGROUND

Despite the at least decades long record of philosophical recognition and interest, the intricacy of the deceptively familiar appearing concepts of 'disease', 'disorder', 'disability', and so forth, has only recently begun showing itself with clarity in the popular discourse wherein its newly emerging prominence stems from the liberties and restrictions contingent upon it. Whether a person is deemed to be afflicted by a disease or a disorder governs their ability to access health care, be it free at the point of use or provided by an insurer; it also influences the treatment of individuals by the judicial system and employers; it even affects one's own perception of self.

AIMS

All existing philosophical definitions of disease struggle with coherency, causing much confusion and strife, and leading to inconsistencies in real-world practice. Hence, there is a real need for an alternative.

MATERIALS AND METHODS

In the present article I analyse the variety of contemporary views of disease, showing them all to be inadequate and lacking in firm philosophical foundations, and failing to meet the desideratum of patient-driven care.

RESULTS

Illuminated by the insights emanating from the said analysis, I introduce a novel approach with firm ethical foundations, which foundations are rooted in sentience, that is the subjective experience of sentient beings.

DISCUSSION

I argue that the notion of disease is at best superfluous, and likely even harmful in the provision of compassionate and patient-centred care.

CONCLUSION

Using a series of presently contentious cases illustrate the power of the proposed framework which is capable of providing actionable and humane solutions to problems that leave the current theories confounded.

Theoretical-Methodological Foundations for the Global Integration Method (Método de Integração Global-MIG) in the Treatment of Autism Spectrum Disorder

Currently, there is no intervention model for autism spectrum disorder (ASD) that addresses all levels and factors of the International Classification of Functioning, Disability and Health (ICF, WHO). The most researched programs focus on naturalistic, developmental and behavioral approaches to socio-communication. Less attention has been paid to motor and environmental reactivity aspects (behavior/interest restriction and sensory reactivity). The evidence rationale for the Global Integration Method (MIG, "Método de Integração Global"), a model addressing sensorimotor reactivity in addition to socio-communication, is presented. MIG is an integrative, interdisciplinary, family-oriented intervention and naturalistic program that addresses all levels and moderating factors of ASD's impact. MIG's theoretical rationale is based on the predictive coding impairment and embodied cognition hypotheses. MIG incorporates both bottom-up (flexible therapeutic suit, social-motor synchronization) and top-down (schematic social information processing, narratives, imagery) strategies to promote the building and use of accurate, flexible and context-sensitive internal predictive models. MIG is based on the premises that predictive coding improves both socio-communication and environmental reactivity, and that the postural stabilization provided by the flexible therapeutic suit frees information processing resources for socio-cognitive learning. MIG builds on interdisciplinary, professionally and parentally mediated work based on behavioral principles of intensive training in a situated environment.

An account of medical treatment, with a preliminary account of medical conditions

In this article, I present a philosophical account of medical treatment. In support of this account, I offer a suggestive account of medical conditions. The account of medical treatment uses three desiderata to demarcate treatment from non-treatment. Namely, a treatment should: (1) be describable by features that enable it to be standardized and characterized as a discrete intervention, (2) target a specific medical condition, and (3) have the possibility of being effective. The account of medical conditions underlies the second desideratum and attempts to tie medical conditions closely to biological dysfunction, while also including some conditions for which biological dysfunction is absent or its presence uncertain. I offer a simple typology of treatments and show how the accounts are relevant to treatment effectiveness, disease, placebos, contested treatments, and treatment standardization.

Discussing evidence on the components model of addiction. A commentary on Fournier et al. (2023)

Fournier and colleagues have recently examined whether the components model of addiction includes peripheral features of addiction not indicative of a disorder. The authors conducted factor analyses and network analyses of responses (N = 4,256) to the Bergen Social Media Addiction Scale. Their results showed that a bidimensional solution best fitted the data and that two items examining salience and tolerance loaded on a factor not associated with symptoms of psychopathology signifying salience and tolerance as peripherical features of addiction to social media. A reanalysis of the data (focused on the internal structure of the scale) was believed necessary considering that previous studies consistently demonstrated the one-factor solution of the scale and that four independent samples were analysed as a single sample potentially limiting the results of the original study. Findings of the reanalyses of Fournier and colleagues' data provided additional support for a one-factor solution of the scale. Potential explanations of the findings and suggestions for future research were elaborated.

Toward a Standard of Medical Care: Why Medical Professionals Can Refuse to Prescribe Puberty Blockers

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient's well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria.

Introducing the Neuroplastic Narrative: a non-pathologizing biological foundation for trauma-informed and adverse childhood experience aware approaches

Most people accessing mental health services have adverse childhood experiences (ACEs) and/or histories of complex trauma. In recognition of this, there are calls to move away from medical model approaches and move toward trauma-informed approaches which privilege the impact of life experience over underlying pathology in the etiology of emotional and psychological suffering. Trauma-informed approaches lack a biological narrative linking trauma and adversity to later suffering. In its absence, this suffering is diagnosed and treated as a mental illness. This study articulates the Neuroplastic Narrative, a neuroecological theory that fills this gap, conceptualizing emotional and psychological suffering as the cost of surviving and adapting to the impinging environments of trauma and adversity. The Neuroplastic Narrative privileges lived experience and recognizes that our experiences become embedded in our biology through evolved mechanisms that ultimately act to preserve survival in the service of reproduction. Neuroplasticity refers to the capacity of neural systems to adapt and change. Our many evolved neuroplastic mechanisms including epigenetics, neurogenesis, synaptic plasticity, and white matter plasticity allow us to learn from, and adapt to, past experiences. This learning and adaption in turn allows us to better anticipate and physiologically prepare for future experiences that (nature assumes) are likely to occur, based on past experiences. However, neuroplastic mechanisms cannot discriminate between experiences; they function to embed experience regardless of the quality of that experience, generating vicious or virtuous cycles of psychobiological anticipation, to help us survive or thrive in futures that resemble our privileged or traumatic pasts. The etiology of suffering that arises from this process is not a pathology (a healthy brain is a brain that can adapt to experience) but is the evolutionary cost of surviving traumatizing environments. Misidentifying this suffering as a pathology and responding with diagnosis and medication is not trauma-informed and may cause iatrogenic harm, in part through perpetuating stigma and exacerbating the shame which attends complex trauma and ACEs. As an alternative, this study introduces the Neuroplastic Narrative, which is situated within an evolutionary framework. The Neuroplastic Narrative complements both Life History and Attachment Theory and provides a non-pathologizing, biological foundation for trauma-informed and Adverse Childhood Experience aware approaches.

What is a mental disorder? Evaluating the lay concept of Mental Ill Health in the United States

PURPOSE

How "mental disorder" should be defined has been the focus of extensive theoretical and philosophical debate, but how the concept is understood by laypeople has received much less attention. The study aimed to examine the content (distinctive features and inclusiveness) of these concepts, their degree of correspondence to the DSM-5 definition, and whether alternative concept labels ("mental disorder", "mental illness", "mental health problem", "psychological issue") have similar or different meanings.

METHODS

We investigated concepts of mental disorder in a nationally representative sample of 600 U.S. residents. Subsets of participants made judgments about vignettes describing people with 37 DSM-5 disorders and 24 non-DSM phenomena including neurological conditions, character flaws, bad habits, and culture-specific syndromes.

RESULTS

Findings indicated that concepts of mental disorder were primarily based on judgments that a condition is associated with emotional distress and impairment, and that it is rare and aberrant. Disorder judgments were only weakly associated with the DSM-5: many DSM-5 conditions were not judged to be disorders and many non-DSM conditions were so judged. "Mental disorder", "mental illness", and "mental health problem" were effectively identical in meaning, but "psychological issue" was somewhat more inclusive, capturing a broader range of conditions.

CONCLUSION

These findings clarify important issues surrounding how laypeople conceptualize mental disorder. Our findings point to some significant points of disagreement between professional and public understandings of disorder, while also establishing that laypeople's concepts of mental disorder are systematic and structured.

Causes or Cures: What makes us think of attention issues as disorders?

Are attention issues disorders or not? Philosophers of medicine have tried to address this question by looking for properties that distinguish disorders from non-disorders. Such properties include deviation of a statistical norm, a loss of function or experienced suffering. However, attempts at such conceptual analysis have not led to a consensus on the necessary and sufficient conditions for the application of the concept of disorder. Recently, philosophers have proposed an experimental approach to investigate in which circumstances people think a specific concept is applicable. Here we present a quantitative vignette study investigating whether disorder attribution depends on the perceived cause and the perceived type of treatment for an attention problem. The results of our study indicate that the attribution of a disorder decreased when the attention problem was understood as caused by bullying (social environmental cause) or by an accident (non-social environmental cause) rather than a genetic cause. When prescribed a pill, attention problems were considered a disorder to a larger extent than when the child was prescribed an environmental treatment. Our study also suggests that whereas successful environmental treatments will not necessarily decrease the disorder attribution, successful pharmacological treatments will decrease the likelihood that a person is thought to still suffer from a disorder after receiving the treatment.

Canalization and plasticity in psychopathology

This theoretical article revives a classical bridging construct, canalization, to describe a new model of a general factor of psychopathology. To achieve this, we have distinguished between two types of plasticity, an early one that we call 'TEMP' for 'Temperature or Entropy Mediated Plasticity', and another, we call 'canalization', which is close to Hebbian plasticity. These two forms of plasticity can be most easily distinguished by their relationship to 'precision' or inverse variance; TEMP relates to increased model variance or decreased precision, whereas the opposite is true for canalization. TEMP also subsumes increased learning rate, (Ising) temperature and entropy. Dictionary definitions of 'plasticity' describe it as the property of being easily shaped or molded; TEMP is the better match for this. Importantly, we propose that 'pathological' phenotypes develop via mechanisms of canalization or increased model precision, as a defensive response to adversity and associated distress or dysphoria. Our model states that canalization entrenches in psychopathology, narrowing the phenotypic state-space as the agent develops expertise in their pathology. We suggest that TEMP - combined with gently guiding psychological support - can counter canalization. We address questions of whether and when canalization is adaptive versus maladaptive, furnish our model with references to basic and human neuroscience, and offer concrete experiments and measures to test its main hypotheses and implications. This article is part of the Special Issue on "National Institutes of Health Psilocybin Research Speaker Series".

Addiction and autonomy: Why emotional dysregulation in addiction impairs autonomy and why it matters

An important philosophical issue in the study of addiction is what difference the fact that a person is addicted makes to attributions of autonomy (and responsibility) to their drug-oriented behavior. In spite of accumulating evidence suggesting the role of emotional dysregulation in understanding addiction, it has received surprisingly little attention in the debate about this issue. I claim that, as a result, an important aspect of the autonomy impairment of many addicted individuals has been largely overlooked. A widely shared assumption in the philosophical literature is that for addiction to impair a person's autonomy it has to make them (in some sense) take drugs against their will. So-called "willing addicts" are therefore usually seen as exempted from the autonomy impairment believed to characterize "unwilling addicts," the latter being those who "truly want" to stop using drugs but find their attempts repeatedly derailed by failures of self-control. In this article, I argue that the association between addiction and emotional dysregulation shows why this assumption is false. Emotional dysregulation is not only consistent with the possibility that many addicts take drugs "willingly," it supports the hypothesis that they use drugs because they truly want to. The article proposes an explanation for why emotional dysregulation should nevertheless be seen as an aspect of their loss of control and an important reason why they have impaired autonomy. I end by exploring some implications of this account for addict's decision-making capacity when they are prescribed the drugs to which they are addicted.

Towards a dispositionalist (and unifying) account of addiction

Addiction theorists have often utilized the metaphor of the blind men and the elephant to illustrate the complex nature of addiction and the varied methodological approaches to studying it. A common purported upshot is skeptical in nature: due to these complexities, it is not possible to offer a unifying account of addiction. I think that this is a mistake. The elephant is real-there is a there there. Here, I defend a dispositionalist account of addiction as the systematic disposition to fail to control one's desires to engage in certain types of behaviors. I explain this position, defend the inclusion of desires and impaired control, and flesh out the notion of systematicity central to my account. I then illustrate how my dispositionalist framework can unify the disparate and seemingly incompatible accounts of addiction (and their respective methodological approaches). I close with a brief plan to extend and implement my account.

Sluggish Cognitive Tempo (SCT), Comorbid Psychopathology, and Functional Impairment in College Students: The Clinical Utility of SCT Subfactors

BACKGROUND

Sluggish cognitive tempo (SCT) has been proposed to be either its own distinct disorder or a transdiagnostic process.

OBJECTIVE

To examine SCT within ADHD (and its specific presentations) and internalizing disorders and its relationship with functional impairment, particularly when considered from a multidimensional perspective.

METHOD

Undergraduate students (N = 2,806) completed self-report scales measuring SCT, ADHD, anxiety, depression, and functional impairment. The SCT scale consisted of three subfactors identified in prior research.

RESULTS

Students with internalizing disorders were equally as likely as those with ADHD to report clinically significant SCT, and having multiple other disorders predicted especially high levels of SCT symptoms. Only sleepy/sluggish symptoms incrementally predicted impairment.

CONCLUSIONS

These findings provide more support for SCT as a transdiagnostic process than as a distinct disorder. All areas of SCT symptoms are associated with ADHD, anxiety, and depression, but the sleepy/sluggish symptoms may be uniquely associated with problems in everyday living.

An integrative evolutionary framework for psychopathology

The field of psychopathology is in a transformative phase, and is witnessing a renewed surge of interest in theoretical models of mental disorders. While many interesting proposals are competing for attention in the literature, they tend to focus narrowly on the proximate level of analysis and lack a broader understanding of biological function. In this paper, we present an integrative framework for mental disorders built on concepts from life history theory, and describe a taxonomy of mental disorders based on its principles, the fast-slow-defense model (FSD). The FSD integrates psychopathology with normative individual differences in personality and behavior, and allows researchers to draw principled distinctions between broad clusters of disorders, as well as identify functional subtypes within current diagnostic categories. Simulation work demonstrates that the model can explain the large-scale structure of comorbidity, including the apparent emergence of a general "p factor" of psychopathology. A life history approach also provides novel integrative insights into the role of environmental risk/protective factors and the developmental trajectories of various disorders.

Concurrent and convergent validity of culture-specific psychopathology syndromes among Cambodian adolescents

Psychopathology is defined in part by its impacts on life functioning (e.g., fulfillment of daily responsibilities at work or school, in family relationships). Relations to life functioning are particularly important in the validation of culture-specific syndromes (patterns of mental health symptoms specific to a particular culture), to demonstrate that culture-specific symptom patterns do in fact represent pathology. The current study's goal was to assess the construct validity of the Cambodian Somatic Symptom and Syndrome Inventory (CSSI). The study focused on the statistically unique effects of the CSSI on life functioning (i.e., effects of the CSSI on life functioning, controlling for Western psychopathology syndromes), to determine whether the CSSI contributes information beyond standard Western measures, which would support CSSI culture-specific convergent validity. Because adolescence is a key period when psychopathology often develops, study participants were 391 high-school students in one urban and one rural area of Cambodia. Participants completed the CSSI, the Western psychopathology surveys Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder questionnaire (GAD-7), and life functioning measures assessing functional impairment, quality of life, and help-seeking. Results indicated strong CSSI concurrent validity (canonical correlation = 0.75) with the PHQ-9 and GAD-7, and CSSI total effects convergent validity on life functioning indicators. All CSSI statistically unique effects (controlling for the PHQ-9 and GAD-7) on life functioning measures were non-significant indicating that the CSSI, shown to be a valid assessment measure in the current study, does not add predictive information beyond standard Western measures. A key limitation that should be considered in interpretation of these results is that the life functioning measures, although reviewed by Khmer psychologists, were Western-based, thus potentially inflating relations with Western psychopathology measures.

Pathologizing Ugliness: A Conceptual Analysis of the Naturalist and Normativist Claims in "Aesthetic Pathology"

Pathologizing ugliness refers to the use of disease language and medical processes to foster and support the claim that undesirable features are pathological conditions requiring medical or surgical intervention. Primarily situated in cosmetic surgery, the practice appeals to the concept of "aesthetic pathology", which is a medical designation for features that deviate from some designated aesthetic norms. This article offers a two-pronged conceptual analysis of aesthetic pathology. First, I argue that three sets of claims, derived from normativist and naturalistic accounts of disease, inform the framing of ugliness as a disease. These claims concern: (1) aesthetic harms, (2) aesthetic dysfunction, and (3) aesthetic deviation. Second, I introduce the notion of a hybridization loop in medicine, which merges the naturalist and normative understanding of the disease that potentially enables pathologizing practices. In the context of cosmetic surgery, the loop simultaneously promotes the framing of beauty ideals as normal biological attributes and the framing of normal appearance as an aesthetic ideal to legitimize the need for cosmetic interventions. The article thus offers an original discussion of the conceptual problems arising from a specific practice in cosmetic surgery that depicts ugliness as the disease.

Is Aging a Disease? The Theoretical Definition of Aging in the Light of the Philosophy of Medicine

In the philosophical debate on aging, it is common to raise the question of the theoretical definition of aging in terms of its possible characterization as a disease. Understanding aging as a disease seems to imply its medicalization, which has important practical consequences. In this paper, we analyze the question of whether aging is a disease by appealing to the concept of disease in the philosophy of medicine. As a result of this analysis, we argue that a pragmatist approach to the conception of disease is the best alternative to highlight the relevance of the medicalization of aging. From this pragmatist perspective, it can be seen that the notion of aging is going through a conceptual change, and aging can today be understood as a not radically different process from any other condition that is usually considered a disease.

How to define today a medical disorder? Biological and psychosocial disadvantages as the paramount criteria

BACKGROUND

The 20th century has seen great developments in the concept of disease. Marked by the biopsychosocial paradigm, several strategies for disease definition were added to previous descriptive organic views, but a final concept is still out of reach.

METHOD

A critical review was carried out on thorough analysis of articles and textbooks to describe the main concepts and definitions of disease.

RESULTS

The concept 'disease' is a pragmatic construct, not a natural kind. Three main ways to define disease were identified, and characterized: Biological (disease as a lesion, disadvantage/deviation from normal and dysfunction), Psychosocial (distress and disability, existential potentials, descriptive prototype, and prototype typification), and values-based definition.

CONCLUSION

All the paradigms have advantages and flaws, but progressive use of all criteria in disease definition adds validity and reliability to diagnostic constructs. Such constructs must be, above all, useful for practice and research. Biological paradigm is relevant, but fails to cover all the complexity that involves human illness and the treatment process. An emphasis on distress, dysfunction, and carefully selected value-laden characteristics might be the right direction for useful diagnostic construct conceptions.

The concept of Narcissistic Personality Disorder-Three levels of analysis for interdisciplinary integration

In this paper, I distinguish three different levels for describing, and three corresponding ways for understanding, deficient empathy as the core of NPD (Narcissistic Personality Disorder). On the macro level, deficient empathy can be explained as disturbed interpersonal functioning, and is understood as lack of recognition. On the meso-level, deficient empathy can be described as psychic disintegration, and can be understood specifically in its dissocial aspects. Psychic disintegration in NPD correlates with somatic changes, i.e., dysfunctional affective empathy and mind-reading on the micro level of description, which is the third level. The "core-deficit-model of NPD" that I outline, while not rejecting reductionist approaches outright, argues in favor of integrating (top-down/bottom-up) functionalist descriptions of empathy into a wider conceptual framework of bio-psycho-social functioning. The "core-deficit-model of NPD" is interdisciplinary, can bypass monodisciplinary skepticism, and removes purported barriers between explaining and understanding the "lack" of empathy as the core of pathological narcissism.

Borderline personality disorder, therapeutic privilege, integrated care: is it ethical to withhold a psychiatric diagnosis?

Once common, therapeutic privilege-the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient-is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population.

Values in mental and medical disorder concepts: Their presence is not the point, being aware of them is

BACKGROUND

Both in medicine and in psychiatry, it's essential to find a general definition for medical and mental disorders. For this we have to analyze the concepts behind these definitions. In this article, we intend to review the proximity between the concepts of mental and medical disorders regarding the presence of values, and to propose a way to deal with the different kinds of values that might be present.

METHODS

The method used in this paper was a conceptual review/analysis.

RESULTS

Regarding the concept of medical disorder, it has resorted to different sub-concepts such as dysfunction and harm (distress disability). The concept of dysfunction, apparently being less value-laden, has been prioritized in relation to the harm component although several authors have already proved that implicitly and explicitly this concept is value laden. In medical-surgical disorder it is very unlikely to find any diagnostic information that includes moral values. In this type of disorder, the values in question are universally non-moral: pain, disability, distress (or risk for these) and risk of death. On the other hand, in several mental disorders, moral values have often been included in their diagnostic criteria.

CONCLUSION

It is concluded that values are present in the main concepts that have been used to define medical or mental disorder. What is essential is to understand what is descriptive and what is value and to try to avoid moral values in this context.

Is it good to be bad? An evolutionary analysis of the adaptive potential of psychopathic traits

Although psychopathy is widely conceptualised as a mental disorder, some researchers question the maladaptive nature of psychopathy, and argue that it might be advantageous from an evolutionary point of view. According to this view, psychopathy can be seen as an evolutionary adaptative strategy that relies on deception and manipulation to gain short-term reproductive benefits. Psychopathy is also identified as a fast life strategy in response to early life stress and an adaptation to harsh environments. This paper investigates the evidence that psychopathic traits are adaptive, while also addressing the limitations of current evolutionary models of psychopathy based on frequency-dependent selection and life history theory. We review recent studies on the fitness correlates of psychopathy and find that psychopathic traits present potential adaptive trade-offs between fertility and mortality, and offspring quantity and quality. On a proximate level, individual differences in stress reactivity and environmental risk factors in early development predispose to psychopathy through gene-environment interactions. We propose that environmental, developmental, social and cultural factors can mediate the relationship between psychopathic traits and fitness and therefore should be considered to make accurate predictions on the adaptive potential of psychopathy. We end by outlining gaps in the literature and making recommendations for future evolutionary research on psychopathy.

Folk psychiatry. La psichiatria fra immagine scientifica e psichiatria popolare

La ricerca scientifica in psichiatria sta creando un divario nei confronti delle nozioni di psichiatria che posseggono le persone comuni, in maniera analoga alla progressiva distanza fra psicologia scientifica e psicologia popolare e di senso comune. Vengono indagate le nozioni che la psichia-tria scientifica e quella popolare condividono, e quelle in cui si differenziano spesso con aspetti controintuitivi. Dopo aver delineato i tratti essenziali del concetto di senso comune e di psicologia popolare e delle loro teorie più rappresentative, viene sottolineato il ruolo centrale che i concetti popolari svolgono non solo nella teoria psichiatrica, in particolare nella diagnosi, ma anche nella pratica quotidiana. Questi concetti entrano poi nella immagine di sé stessi, del mondo e nelle rela-zioni interpersonali, mostrando la improponibilità di una psichiatria che miri a fare a meno del senso comune e la necessità di una attenta mediazione fra psichiatria scientifica e psichiatria popolare. Questo aspetto è ancora più importante nella psichiatria pratica che si rivela simile per molti aspetti alla psichiatria popolare.

'If it can't be coded, it doesn't exist'. A historical-philosophical analysis of the new ICD-11 classification of chronic pain

Chronic pain entails a large burden of disease and high social costs, but is seldom 'in the picture' and barely understood. Until recently, it was not systematically classified but instead viewed as a symptom or sign. In the new International Classification of Diseases, (ICD)-11, to be implemented in 2022, 'chronic' pain is now classified as a separate disease category and, to a certain extent, approached as a 'disease in its own right'. Reasons that have been given for this are not based so much on new scientific insights, but are rather of pragmatic nature. To explore the background of these recent changes in definition and classification of chronic pain, this paper provides a historical-philosophical analysis. By sketching a brief history of how pain experts have been working on the definition and taxonomy since the 1970s, we demonstrate the various social and practical functions that underlie the new ICD-11 classification of chronic pain. Building on this historical-empirical basis, we discuss philosophical issues regarding defining and classifying chronic pain, in particular performativity and pragmatism, and discuss their implications for the broader philosophical debate on health and disease.

Directing Technology Addiction Research in Information Systems

In this second part of a series of articles to direct technology addiction research in the information systems discipline, we discuss the history, conceptualization, and measurement of technology addiction. We admit that it is possible to label the phenomenon as overuse or excessive use as long as it is defined and measured by the presence and the magnitude of the six core symptoms of behavioral addictions: salience, mood modification, tolerance, withdrawal, conflict, and relapse. The advantage of this terminology is that it does not attribute one's problems to helplessness and does not pathologize the behavior, implying that it may possibly be corrected. Nevertheless, we posit that the term technology addiction is currently the most reasonable choice that may need to be adjusted as we learn more about this phenomenon and its potential similarities to and differences from established behavioral addictions. Dependence, obsessive/compulsive use, and pathological/problem use terms should not be used as synonyms for technology addiction as a form of mental disorder. Researchers should not include the name of the IT artifact as the subject of addiction (e.g., "Facebook addiction"). Instead, they should focus on the activity that is mediated through the IT artifact (e.g., "addiction to Facebook use").

Reconsidering harm in psychiatric manuals within an explicationist framework

The notion of harm has been a recurring and a significant notion in the characterization of mental disorder. It is present in eminent diagnostic manuals such as DSM and ICD, as well as in the discussion on mental disorders in philosophy of psychiatry. Recent demotion of harm in the definition of mental disorders in DSM-5 shows a general trend towards reducing the significance of harm when thinking about the nature of mental disorders. In this paper, we defend the relevance of the notion of harm in the characterization of mental disorder against some of these attacks. We approach this issue by using the method of conceptual explication pioneered by Rudolf Carnap. Within this framework, we argue that keeping the notion of harm not only helps to discriminate what is pathological from the nonpathological but also prevents potential misuses of psychiatric authority.

Integrating Evolutionary, Cultural, and Computational Psychiatry: A Multilevel Systemic Approach

This paper proposes an integrative perspective on evolutionary, cultural and computational approaches to psychiatry. These three approaches attempt to frame mental disorders as multiscale entities and offer modes of explanations and modeling strategies that can inform clinical practice. Although each of these perspectives involves systemic thinking, each is limited in its ability to address the complex developmental trajectories and larger social systemic interactions that lead to mental disorders. Inspired by computational modeling in theoretical biology, this paper aims to integrate the modes of explanation offered by evolutionary, cultural and computational psychiatry in a multilevel systemic perspective. We apply the resulting Evolutionary, Cultural and Computational (ECC) model to Major Depressive Disorder (MDD) to illustrate how this integrative approach can guide research and practice in psychiatry.

Is addiction a brain disease? A plea for agnosticism and heterogeneity

RATIONALE

Although increasingly subject to criticism, the brain disease model of addiction (BDMA) remains dominant within addiction science. Yet few advocates or critics of the BDMA have provided an account of what a brain disease is. The aim of this review is to conceptually clarify what it would mean for the BDMA to be true, rather than to argue decisively for or against it.

OBJECTIVES

Conceptual clarification of the BDMA requires consideration of possible models of disease and their relationship to the BDMA. A barrier to such consideration is belief that the BDMA is necessary to combatting addiction stigma. To address this barrier, I begin with discussion of what we know about the effects of the brain disease label on addiction stigma, and why labelling effects should have no bearing on the validity of the BDMA. I then distinguish strong, minimal, network, and mismatch models of disease, and I argue that the BDMA aligns with a strong disease model. This means that underlying brain pathology is hypothesized to be the cause of the personal-level observable signs and experienced symptoms characteristic of addiction. Evaluation of the BDMA therefore requires analysis of the concepts of brain dysfunction and causation, and their application to addiction science.

RESULTS

Brain dysfunction cannot be analyzed merely as brain changes or brain differences; nor can it be inferred merely from the presence of personal-level signs and symptoms. It is necessary to have an account of normal brain function by which to measure it. The theoretical and empirical challenges to developing such an account are not insurmountable, but they are substantial. Although there exist competing analyses of causation, there is a relatively standard method used to establish it within experimental science: intervention. Using this method, the causal significance of brain states, such as, e.g., extensive gray matter loss and/or neuroadapations in the mesocorticolimbic dopamine system, is not yet fully demonstrated. Further studies are necessary to determine their effect compared with other possible variables, such as, e.g., alternative reinforcers.

CONCLUSIONS

Conceptual clarification and preliminary empirical assessment of the BDMA recommends agnosticism about its validity and an openness to heterogeneity; in some cases addiction may be a brain disease, in others not. Either way, addiction stigma can be combatted by fighting moralism about drugs and moralistic drug policies directly, as opposed to resting hopes on the brain disease label.

Wherein is the concept of disease normative? From weak normativity to value-conscious naturalism

In this paper we focus on some new normativist positions and compare them with traditional ones. In so doing, we claim that if normative judgments are involved in determining whether a condition is a disease only in the sense identified by new normativisms, then disease is normative only in a weak sense, which must be distinguished from the strong sense advocated by traditional normativisms. Specifically, we argue that weak and strong normativity are different to the point that one 'normativist' label ceases to be appropriate for the whole range of positions. If values and norms are not explicit components of the concept of disease, but only intervene in other explanatory roles, then the concept of disease is no more value-laden than many other scientific concepts, or even any other scientific concept. We call the newly identified position "value-conscious naturalism" about disease, and point to some of its theoretical and practical advantages.

Health and disease as practical concepts: exploring function in context-specific definitions

Despite the longstanding debate on definitions of health and disease concepts, and the multitude of accounts that have been developed, no consensus has been reached. This is problematic, as the way we define health and disease has far-reaching practical consequences. In recent contributions it is proposed to view health and disease as practical- and plural concepts. Instead of searching for a general definition, it is proposed to stipulate context-specific definitions. However, it is not clear how this should be realized. In this paper, we review recent contributions to the debate, and examine the importance of context-specific definitions. In particular, we explore the usefulness of analyzing the relation between the practical function of a definition and the context it is deployed in. We demonstrate that the variety of functions that health and disease concepts need to serve makes the formulation of monistic definitions not only problematic but also undesirable. We conclude that the analysis of the practical function in relation to the context is key when formulating context-specific definitions for health and disease. At last, we discuss challenges for the pluralist stance and make recommendations for future research.

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.

How Does Comparison With Artificial Intelligence Shed Light on the Way Clinicians Reason? A Cross-Talk Perspective

In order to create a dynamic for the psychiatry of the future, bringing together digital technology and clinical practice, we propose in this paper a cross-teaching translational roadmap comparing clinical reasoning with computational reasoning. Based on the relevant literature on clinical ways of thinking, we differentiate the process of clinical judgment into four main stages: collection of variables, theoretical background, construction of the model, and use of the model. We detail, for each step, parallels between: i) clinical reasoning; ii) the ML engineer methodology to build a ML model; iii) and the ML model itself. Such analysis supports the understanding of the empirical practice of each of the disciplines (psychiatry and ML engineering). Thus, ML does not only bring methods to the clinician, but also supports educational issues for clinical practice. Psychiatry can rely on developments in ML reasoning to shed light on its own practice in a clever way. In return, this analysis highlights the importance of subjectivity of the ML engineers and their methodologies.