Evolutionary versus prototype analyses of the concept of disorder

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.

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.

Changes of intuition in paranoid personality disorder

Wherever psychopathology operates with the concept of (disorders of) the self and personality, it can address the role of the intuitive access we have toward ourselves, others, and the world. This study discusses the concept of oikeiôsis. It examines its role in explaining paranoia as a change in intuitive self-and-world relatedness. In the first step, symptomatic features of paranoid personality disorder are sketched, with a focus on the explanatory role of attentional and interpretative biases, which correlate with significant changes in intuitive processing. In the second step, the prototypical phenomenality of feelings of unfamiliarity and mistrust are discussed against the backdrop of changes of oikeiôsis in paranoid personality disorder. In the third step, the main therapeutic challenge in treating paranoid personality disorder-building a trustful relationship-is explored. It is concluded that the notion of oikeiôsis resonates particularly with introspection-based therapeutic approaches.

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.

What is the expected human childhood? Insights from evolutionary anthropology

In psychological research, there are often assumptions about the conditions that children expect to encounter during their development. These assumptions shape prevailing ideas about the experiences that children are capable of adjusting to, and whether their responses are viewed as impairments or adaptations. Specifically, the expected childhood is often depicted as nurturing and safe, and characterized by high levels of caregiver investment. Here, we synthesize evidence from history, anthropology, and primatology to challenge this view. We integrate the findings of systematic reviews, meta-analyses, and cross-cultural investigations on three forms of threat (infanticide, violent conflict, and predation) and three forms of deprivation (social, cognitive, and nutritional) that children have faced throughout human evolution. Our results show that mean levels of threat and deprivation were higher than is typical in industrialized societies, and that our species has experienced much variation in the levels of these adversities across space and time. These conditions likely favored a high degree of phenotypic plasticity, or the ability to tailor development to different conditions. This body of evidence has implications for recognizing developmental adaptations to adversity, for cultural variation in responses to adverse experiences, and for definitions of adversity and deprivation as deviation from the expected human childhood.

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.

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.

Wakefield's harmful dysfunction analysis of disorder and the problem of defining harm to nonsentient organisms

This paper criticizes Jerome Wakefield's harmful dysfunction analysis (HDA) of disorder by arguing that the conceptual linkage it establishes between the medical concepts of health and disorder and the prudential notions of well-being and harm makes the account inapplicable to nonsentient organisms, such as plants, fungi, and many invertebrate animals. Drawing on a previous formulation of this criticism by Christopher Boorse, and noting that Wakefield could avoid it if he adopted a partly biofunction-based account of interests like that often advocated in the field of environmental ethics, I argue that integrating such an account of interests into the HDA would generate serious concerns. Specifically, it would make dysfunction sufficient for disorder and so reestablish between dysfunction and disorder precisely the kind of sufficiency relation that harm-requiring accounts of disorder strive to avoid; blur the line between the HDA's dysfunction and harm components and, in so doing, deprive the HDA of its alleged main advantage over monistic dysfunction-based accounts of disorders like Boorse's; and tie the HDA to an understanding of harm that is in itself problematic. I argue that these three concerns, and the dilemmas they generate, rob the HDA of much of its prima facie appeal, ultimately indicating that a satisfactory account of disorder should most likely eschew all references to prudential notions of well-being and harm.

Why do sleep disorders belong to mental disorder classifications? A network analysis of the "Sleep-Wake Disorders" section of the DSM-5

This article proposes to investigate how Sleep disorders have been conceptualized within the DSM-5 through symptom network analysis of the diagnostic criteria of the "Sleep-Wake Disorders" section in the DSM-5. We hypothesize that the analysis of the most central symptoms will allow us to better analyze the position of Sleep disorders in Mental disorders. We thus i) extracted the symptoms of the DSM-5 diagnostic criteria of Sleep-Wake disorders, ii) built the Sleep-Wake disorder DSM-5 network representation, and iii) quantified its structure at local and global levels using classical symptom network analysis. Thirty-four different symptoms were identified among the 53 DSM-5 diagnostic criteria of the 9 main disorders of the "Sleep-Wake Disorders" section. The symptom network structure of this section showed that the most central sleep symptoms are "Daytime Sleepiness", the Insomnia symptoms group ("Insomnia initiating", "Insomnia maintaining" and "Non-restorative sleep"), and Behavioral sleep symptoms (such as "Altered oniric activity", "Ambulation", "Abnormal responsiveness"). This network analysis shown that the belonging of Sleep-Wake disorders in the DSM-5 have been associated with central sleep symptoms considered as "Mental", given their phenomenality (qualitative nature of the experience) and subjectivity (in personal mental lives). Such a symptom network analysis can serve as an organizing framework to better understand the complexity of Sleep-Wake disorders by promoting research to connect the architecture of the symptom network to relevant biological, psychological and sociocultural factors.

Sex Differences in Voyeuristic and Exhibitionistic Interests: Exploring the Mediating Roles of Sociosexuality and Sexual Compulsivity from an Evolutionary Perspective

Sociosexuality and sexual compulsivity predict sex differences in voyeuristic interest in the population. In this study, we used a sample of 1113 participants from the UK (46% men) to consider whether sociosexuality and sexual compulsivity interacted to explain these sex differences and whether this relationship extended to the related domain of exhibitionism. In doing so, we tested novel predictions derived from an evolutionary perspective which views voyeuristic and exhibitionistic interest as manifestations of a short-term mating strategy. Participants reported their levels of repulsion toward voyeurism and exhibitionism and their interest in performing such acts under different levels of risk. There were clear sex differences in voyeuristic and exhibitionistic repulsion that were partially mediated by the serial combination of sociosexuality and sexual compulsivity. Examining the sexes separately revealed qualitatively different relationships between sociosexuality and sexual compulsivity when predicting exhibitionistic, but not voyeuristic, repulsion. Combined, sociosexuality and sexual compulsivity also mediated the sex difference in willingness to commit acts of voyeurism, but not exhibitionism, which was equally low for both sexes. The results highlight the role sociosexuality plays in voyeuristic and exhibitionistic interest, which coupled with an evolutionary perspective, may have implications for how we view courtship disorders.

Harm as a Necessary Component of the Concept of Medical Disorder: Reply to Muckler and Taylor

Wakefield's harmful dysfunction analysis asserts that the concept of medical disorder includes a naturalistic component of dysfunction (failure of biologically designed functioning) and a value (harm) 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.

How to Draw the Line Between Health and Disease? Start with Suffering

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization.

Different cultures, similar daydream addiction? An examination of the cross-cultural measurement equivalence of the Maladaptive Daydreaming Scale

BACKGROUND AND AIMS

Maladaptive Daydreaming (MD) is a proposed mental disorder, in which absorption in rich, narrative fantasy becomes addictive and compulsive, resulting in emotional, social, vocational, or academic dysfunction. Most studies on MD were carried out on aggregated international samples, using translated versions of the Maladaptive Daydreaming Scale (MDS-16). However, it is unknown whether the properties of MD are affected by culture. Thus, we investigated the cross-cultural measurement invariance of the MDS-16.

METHODS

We recruited both individuals self-identified as suffering from MD and non-clinical community participants from four countries: the USA, Italy, Turkey, and the UK (N = 1,081).

RESULTS

Configural invariance was shown, suggesting that the hypothesized four-factor structure of the MDS-16 (including Yearning, Impairment, Kinesthesia, and Music) holds across cultures. Metric invariance was shown for Impairment, Kinesthesia, and Music, but not for Yearning, suggesting that the psychological meaning of the latter factor may be understood differently across cultures. Scalar invariance was not found, as MD levels were higher in the USA and UK, probably due to the over-representation of English-speaking members of MD communities, who volunteered for the study.

DISCUSSION AND CONCLUSIONS

We conclude that the urge to be absorbed in daydreaming and the fantasies' comforting and addictive properties may have different meanings across countries, but the interference of MD to one's daily life and its obstruction of long-term goals may be the central defining factor of MD.

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.

What Makes Some Diseases More Typical than Others? A Survey on the Impact of Disease Characteristics and Professional Background on Disease Typicality

Health professionals tend to perceive some diseases as more typical than others. If disease typicalities have implications for health professionals or health policy makers' handling of different diseases, then it is of great social, epistemic, and ethical interest. Accordingly, it is important to find out what makes health professionals rank diseases as more or less typical. This study investigates the impact of various factors on how typical various diseases are perceived to be by health professionals. In particular, we study the influence of broad disease categories, such as somatic versus psychological/behavioral conditions, and a wide range of more specific disease characteristics, as well as the health professional's own background. We find that professional background strongly impacted disease typicality. All professionals (MD, RN, physiotherapists and psychologists) considered somatic conditions to be more typical than psychological/behavioral. As expected, psychologists also found psychological/behavioral conditions to be more typical than did other groups. Professions of respondents could be well predicted from their individual typicality judgments, with the exception of physiotherapists and nurses who had very similar judgment profiles. We also demonstrate how various disease characteristics impact typicality for the different professionals. Typicality showed moderate to strong positive correlations with condition severity and mortality, and only non-severe conditions were rated as atypical. Hence, studying how different disease characteristics and occupational background influences health professionals' perception of disease typicality is the first and important step toward a more general study of how typicality influences disease handling.

Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the presence of distress or disability, which may be bracketed as the presence of harm, is taken to be merely usual, and thus not a necessary requirement: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for defining the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others pertaining to the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be (provisionally) maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified.

An evolutionary perspective on paranoia

Paranoia is the most common symptom of psychosis but paranoid concerns occur throughout the general population. Here, we argue for an evolutionary approach to paranoia across the spectrum of severity that accounts for its complex social phenomenology - including the perception of conspiracy and selective identification of perceived persecutors - and considers how it can be understood in light of our evolved social cognition. We argue that the presence of coalitions and coordination between groups in competitive situations could favour psychological mechanisms that detect, anticipate and avoid social threats. Our hypothesis makes testable predictions about the environments in which paranoia should be most common as well as the developmental trajectory of paranoia across the lifespan. We suggest that paranoia should not solely be viewed as a pathological symptom of a mental disorder but also as a part of a normally-functioning human psychology.

Current evolutionary adaptiveness of anxiety: Extreme phenotypes of anxiety predict increased fertility across multiple generations

OBJECTIVE

Although recent research has begun to examine the impact of elevated anxiety on evolutionary fitness, no prior research has examined anxiety across a continuum. Such research is important as the effect of traits across a continuum on fertility hold important implications for the levels and distribution of the traits in later generations.

METHOD

In a three-generational sample (N = 2657) the linear and quadratic relationship between anxiety and the number of children, grandchildren, and great-grandchildren 15 years later was examined.

RESULTS

The findings suggested that anxiety had a positive quadratic relationship with the number of children, grandchildren, and great-grandchildren 15 years later. These relationships were not significantly moderated by sex. Moreover, most of the variance between anxiety and the number of great-grandchildren was explained by anxiety's influence on the number of children and grandchildren, as opposed to anxiety having an independent direct impact on the number of great-grandchildren.

CONCLUSION

These findings suggest that extreme values from the mean anxiety are associated with increased evolutionary fitness within the modern environment.

Echoes of Early Life: Recent Insights From Mathematical Modeling

In the last decades, developmental origins of health and disease (DOHaD) has emerged as a central framework for studying early‐life effects, that is, the impact of fetal and early postnatal experience on adult functioning. Apace with empirical progress, theoreticians have built mathematical models that provide novel insights for DOHaD. This article focuses on three of these insights, which show the power of environmental noise (i.e., imperfect indicators of current and future conditions) in shaping development. Such noise can produce: (a) detrimental outcomes even in ontogenetically stable environments, (b) individual differences in sensitive periods, and (c) early‐life effects tailored to predicted future somatic states. We argue that these insights extend DOHaD and offer new research directions.

The Philosophy of Nosology

Many scholars believe that psychiatric nosology is undergoing a crisis of confidence. Some of the issues up for debate hark back to the introduction of the natural history approach to classification in the seventeenth century. Natural histories map sameness and difference rather than speculate about causes. In contrast, the natural classification approach aspires to carve nature at the joints by demarcating classifications by causes. Natural classifications are more ideal scientifically, but speculation about causality has had a poor track record in psychiatric nosology. A natural classification of psychiatric disorders may have the added burden of requiring normative assumptions in addition to the discovery of fact. In the natural classification tradition, the epistemic iteration perspective, the Research Domain Criteria (RDoC) initiative, and dimensional models offer different views about the criteria of naturalness (or validity). Also in this tradition, some thinkers believe that causes can be empirically indexed by latent variable models, especially if the latent variables are moderately heritable, but these assumptions may be neither statistically nor genetically warranted.

Re-evaluating concepts of biological function in clinical medicine: towards a new naturalistic theory of disease

Naturalistic theories of disease appeal to concepts of biological function, and use the notion of dysfunction as the basis of their definitions. Debates in the philosophy of biology demonstrate how attributing functions in organisms and establishing the function-dysfunction distinction is by no means straightforward. This problematization of functional ascription has undermined naturalistic theories and led some authors to abandon the concept of dysfunction, favoring instead definitions based in normative criteria or phenomenological approaches. Although this work has enhanced our understanding of disease and illness, we need not necessarily abandon naturalistic concepts of function and dysfunction in the disease debate. This article attempts to move towards a new naturalistic theory of disease that overcomes the limitations of previous definitions and offers advantages in the clinical setting. Our approach involves a re-evaluation of concepts of biological function employed by naturalistic theories. Drawing on recent insights from the philosophy of biology, we develop a contextual and evaluative account of function that is better suited to clinical medicine and remains consistent with contemporary naturalism. We also show how an updated naturalistic view shares important affinities with normativist and phenomenological positions, suggesting a possibility for consilience in the disease debate.

Where's the problem? Considering Laing and Esterson's account of schizophrenia, social models of disability, and extended mental disorder

In this article, I compare and evaluate R. D. Laing and A. Esterson's account of schizophrenia as developed in Sanity, Madness and the Family (1964), social models of disability, and accounts of extended mental disorder. These accounts claim that some putative disorders (schizophrenia, disability, certain mental disorders) should not be thought of as reflecting biological or psychological dysfunction within the afflicted individual, but instead as external problems (to be located in the family, or in the material and social environment). In this article, I consider the grounds on which such claims might be supported. I argue that problems should not be located within an individual putative patient in cases where there is some acceptable test environment in which there is no problem. A number of cases where such an argument can show that there is no internal disorder are discussed. I argue, however, that Laing and Esterson's argument-that schizophrenia is not within diagnosed patients-does not work. The problem with their argument is that they fail to show that the diagnosed women in their study function adequately in any environment.

[Where is going philosophy of psychiatry ?]

This contribution provides a critical outline of the current trends in the field of "philosophy of psychiatry" by following their developments in the last decade. The first part of the paper focuses on the evolution of this field from a strictly conceptual approach to a perspective more attentive to the social, practical, and clinical dimension of psychiatry. The second part of the paper points out that the need of a mutual commitment of philosophy and psychiatry is perceived according to different ways by the countries involved in this research area. The paper deals especially with the case of France, where the enthusiasm for the "new philosophy of psychiatry" has not had the same impact on the philosophical scene as in the English speaking countries. In conclusion, the paper shows that the field of philosophy of psychiatry stands as a fertile ground for new forms of interaction between the analytic, and the continental philosophical traditions. This interaction takes place, more particularly, as regards such topics as normativity, language, and interpretation.

Implications of an Emerging Integration of Universal and Culturally Specific Psychologies

Psychological researchers increasingly recognize that human behavior reflects a complex interplay of universal human capacities, cultural responses to unique histories and circumstances, and individual differences. Many psychological processes appear to reflect culturally specific instantiations of universal capacities. Current integrative research focuses on further clarifying definitions of universality and on refining methods for identifying universal and cultural components of psychological processes. In this article, we consider implications of this emerging integration. To illustrate possible implications for psychology, we apply it to the study of psychopathology. We report on formal models that explain why some cultures embrace dysfunction among members. We then use the integrative framework to describe methods for determining whether putative disorders bring universal or contextual life dysfunction and to clarify etiological models of three disorders. Models of psychopathology can be more informed and precise if they include careful consideration of both universal and cultural influences on behavior.

Drugs as instruments: a new framework for non-addictive psychoactive drug use

Most people who are regular consumers of psychoactive drugs are not drug addicts, nor will they ever become addicts. In neurobiological theories, non-addictive drug consumption is acknowledged only as a "necessary" prerequisite for addiction, but not as a stable and widespread behavior in its own right. This target article proposes a new neurobiological framework theory for non-addictive psychoactive drug consumption, introducing the concept of "drug instrumentalization." Psychoactive drugs are consumed for their effects on mental states. Humans are able to learn that mental states can be changed on purpose by drugs, in order to facilitate other, non-drug-related behaviors. We discuss specific "instrumentalization goals" and outline neurobiological mechanisms of how major classes of psychoactive drugs change mental states and serve non-drug-related behaviors. We argue that drug instrumentalization behavior may provide a functional adaptation to modern environments based on a historical selection for learning mechanisms that allow the dynamic modification of consummatory behavior. It is assumed that in order to effectively instrumentalize psychoactive drugs, the establishment of and retrieval from a drug memory is required. Here, we propose a new classification of different drug memory subtypes and discuss how they interact during drug instrumentalization learning and retrieval. Understanding the everyday utility and the learning mechanisms of non-addictive psychotropic drug use may help to prevent abuse and the transition to drug addiction in the future.

Using Evolutionary Theory to Guide Mental Health Research

Evolutionary approaches to medicine can shed light on the origins and etiology of disease. Such an approach may be especially useful in psychiatry, which frequently addresses conditions with heterogeneous presentation and unknown causes. We review several previous applications of evolutionary theory that highlight the ways in which psychiatric conditions may persist despite and because of natural selection. One lesson from the evolutionary approach is that some conditions currently classified as disorders (because they cause distress and impairment) may actually be caused by functioning adaptations operating "normally" (as designed by natural selection). Such conditions suggest an alternative illness model that may generate alternative intervention strategies. Thus, the evolutionary approach suggests that psychiatry should sometimes think differently about distress and impairment. The complexity of the human brain, including normal functioning and potential for dysfunctions, has developed over evolutionary time and has been shaped by natural selection. Understanding the evolutionary origins of psychiatric conditions is therefore a crucial component to a complete understanding of etiology.

Conducting Psychopathology Prevention Research in the RDoC Era

The Research Domain Criteria (RDoC) initiative promoted by the National Institute of Mental Health emphasizes a dimensional approach to psychopathology that is agnostic to DSM diagnosis. The RDoC project offers exciting possibilities for advancing research aimed at preventing psychopathology. However, prevention has historically been defined using diagnostic status, requiring the field to redefine what constitutes prevention using an RDoC approach. This article outlines new criteria for prevention in the RDoC context and provides guidance for implementing these criteria. We also describe the role of prevention-mechanism trials that examine whether preventive interventions change proximal etiological mechanisms known to be associated with psychopathology. We hope that these modified criteria and recommendations will stimulate new possibilities for prevention research that will advance the field.

Diagnostic Issues and Controversies in DSM-5: Return of the False Positives Problem

The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was the most controversial in the manual's history. This review selectively surveys some of the most important changes in DSM-5, including structural/organizational changes, modifications of diagnostic criteria, and newly introduced categories. It analyzes why these changes led to such heated controversies, which included objections to the revision's process, its goals, and the content of altered criteria and new categories. The central focus is on disputes concerning the false positives problem of setting a valid boundary between disorder and normal variation. Finally, this review highlights key problems and issues that currently remain unresolved and need to be addressed in the future, including systematically identifying false positive weaknesses in criteria, distinguishing risk from disorder, including context in diagnostic criteria, clarifying how to handle fuzzy boundaries, and improving the guidelines for "other specified" diagnosis.

A second rebuttal on health

This essay replies to critics since 1995 of my "biostatistical theory" (BST) of health. According to the BST, a pathological condition is a state of statistically species-subnormal biological part-functional ability, relative to sex and age. Theoretical health, the total absence of pathological conditions, is then a value-free scientific notion. Recent critics offer a mixture of old and new objections to this analysis. Some new ones relate to choice of reference class, situation-specificity of function, common diseases and healthy populations, improvements in population health, the practice of pathologists, "Cambridge changes" in health status, and comparative vs. absolute health concepts. I make no changes in doctrine, except to consider treating "normal aging" as pathological by taking young adults as the standard for all adults.

The harmful dysfunction model of alcohol use disorder: revised criteria to improve the validity of diagnosis and prevalence estimates

AIMS

To formulate harmful dysfunction (HD) diagnostic criteria for alcohol use disorder (AUD) and test whether they increase validity relative to standard DSM criteria, as evidenced by lowered prevalence, increased validator levels including service use, severity and family history and enhanced specificity.

DESIGN

DSM-IV AUD, DSM-IV dependence, DSM-5 AUD and HD AUD definitions were compared on eight validity related tests using nationally representative community data.

SETTING

United States.

PARTICIPANTS

National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) respondents, aged 18-54 years (wave 1, n = 29 673; wave 2, n = 24 244).

MEASURES

NESARC DSM-IV and DSM-5 criteria were taken from published studies. Whereas DSM-5 diagnosis requires any two AUD symptoms, HD criteria were constructed from NESARC items to require symptoms of both impaired-control dysfunction [withdrawal, drink to prevent/stop withdrawal, cannot stop/reduce drinking, or craving (wave 2 only)] and harm (sacrificed important activities, problems caring for home/family, job/school problems, health problems, psychological problems or problems with family/friends). Validators included service use, severity and family history, among others. Specificity was tested using a teen transient drinker criterion group.

FINDINGS

Compared with DSM-5 AUD (DSM-IV results were similar), HD criteria yielded lower prevalence (95% confidence intervals): HD life-time 6.7% (6.2, 7.2%), 1-year 2.3% (2.0, 2.5%); and DSM-5 life-time 38.2% (36.5, 39.9%), 1-year 12.4% (11.7, 13.1%). HD AUD was higher than DSM-5 on pathology validators, including: life-time alcohol-related service use: HD 41.0% (38.1, 43.9%), DSM-5 11.5% (10.7, 12.3%); severity (number of life-time alcohol symptoms): HD 20.8 (20.4, 21.2), DSM-5 10.6 (10.4, 10.8); and family history of alcohol problems: HD 50.1% (47.3, 52.9), DSM-5 32.8% (31.6, 34.0). HD criteria eliminated 83% of a DSM-5 teen transient drinker false-positives criterion group.

CONCLUSIONS

Prevalence estimates of alcohol use disorder are lowered and diagnostic validity improved when using 'harmful dysfunction' diagnostic criteria compared with standard DSM criteria, partly by reducing misdiagnosis of teenage transient drinkers.

DSM-5, psychiatric epidemiology and the false positives problem

The revision effort leading to the publication of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was flawed in process, goals and outcome. The revision process suffered from lack of an adequate public record of the rationale for changes, thus shortchanging future scholarship. The goals, such as dimensionalising diagnosis, incorporating biomarkers and separating impairment from diagnosis, were ill-considered and mostly abandoned. However, DSM-5's greatest problem, and the target of the most vigorous and sustained criticism, was its failure to take seriously the false positives problem. By expanding diagnosis beyond plausible boundaries in ways inconsistent with DSM-5's own definition of disorder, DSM-5 threatened the validity of psychiatric research, including especially psychiatric epidemiology. I present four examples: increasing the symptom options while decreasing the diagnostic threshold for substance use disorder, elimination of the bereavement exclusion from major depression, allowing verbal arguments as evidence of intermittent explosive disorder and expanding attention-deficit/hyperactivity disorder to adults before addressing its manifest false positives problems.

An Evolutionary Approach to Emotion in Mental Health With a Focus on Affiliative Emotions

Emotions evolved to guide animals in pursuing specific motives and goals (e.g., to find food, avoid harm, seek out sexual partners, rear offspring). They function as short-term alertors and regulators of behaviour and can be grouped into their evolved functions (evolutionary function analysis). Emotions can coregulate/influence each other, where one emotion can activate or suppress another. Importantly, affiliative emotions, that arise from experiencing validation, care and support from others, have major impacts on how people process and respond to threats and emotions associated with threats. Hence, exploring how affiliative emotional experiences change and transform the capacity to cope with threat and pursue life goals, are salient research issues.

Sign-tracking to an appetitive cue predicts incubation of conditioned fear in rats

Although post-traumatic stress disorder (PTSD) and addiction are very different disorders, both are characterized by hyperreactivity to trauma- or drug-related cues, respectively. We investigated whether an appetitive conditioning task, Pavlovian conditioned approach, which predicts vulnerability to reinstatement of cocaine-seeking, also predicts fear incubation, which may be a marker for vulnerability to PTSD. We classified rats based on whether they learned to approach and interact with a food predictive cue (sign-trackers), or, whether upon cue presentation they went to the location of impending food delivery (goal-trackers). Rats were then exposed to extensive Pavlovian tone-shock pairings, which causes the fear response to increase or "incubate" over time. We found that the fear incubation effect was only present in sign-trackers. The behavior of goal-trackers was more consistent with a normal fear response-it was most robust immediately after training and decayed slowly over time. Sign-trackers also had lower levels of brain-derived neurotrophic factor (BDNF) protein in the prefrontal cortex than goal-trackers. These results indicate that, while many factors likely contribute to the disproportionate co-occurrence of PTSD and substance abuse, one such factor may be a core psychological trait that biases some individuals to attribute excessive motivational significance to predictive cues, regardless of the emotional valence of those cues. High levels of BDNF in the prefrontal cortex may be protective against developing excessive emotional and motivational responses to salient cues.

The cycle of classification: DSM-I through DSM-5

The Diagnostic and Statistical Manual of Mental Disorders (DSM) was created in 1952 by the American Psychiatric Association so that mental health professionals in the United States would have a common language to use when diagnosing individuals with mental disorders. Since the initial publication of the DSM, there have been five subsequent editions of this manual published (including the DSM-III-R). This review discusses the structural changes in the six editions and the research that influenced those changes. Research is classified into three domains: (a) issues related to the DSMs as measurement systems, (b) studies of clinicians and how clinicians form diagnoses, and (c) taxonomic issues involving the philosophy of science and metatheoretical ideas about how classification systems function. The review ends with recommendations about future efforts to revise the DSMs.

Naturalism about health and disease: adding nuance for progress

The literature on health and diseases is usually presented as an opposition between naturalism and normativism. This article argues that such a picture is too simplistic: there is not one opposition between naturalism and normativism, but many. I distinguish four different domains where naturalist and normativist claims can be contrasted: (1) ordinary usage, (2) conceptually clean versions of "health" and "disease," (3) the operationalization of dysfunction, and (4) the justification for that operationalization. In the process I present new arguments in response to Schwartz (2007) and Hausman (2012) and expose a link between the arguments made by Schwartz (2007) and Kingma (2010). Distinguishing naturalist claims at these four domains will allow us to make progress by (1) providing more nuanced, intermediate positions about a possible role for values in health and disease; and (2) assisting in the addressing of relativistic worries about the value-ladenness of health and disease.

Truth or consequences in the diagnosis of substance use disorders

AIMS

This commentary critically evaluates the use of substance-related negative psychosocial and health consequences to define and diagnose alcohol and other substance use disorders.

METHODS

Narrative review.

RESULTS

The consequences of substance use cause much suffering and are major public health and economic problems. However, there are a number of conceptual and measurement problems with using consequences as diagnostic criteria for substance disorders. Data indicate that substance-related consequences introduce systematic bias and degrade the validity of diagnostic systems.

CONCLUSIONS

Negative psychosocial and health consequences of substance use should play a fundamentally reduced role in modern diagnostic systems for, and definitions of, addictive disorders.

Health and functional efficiency

This essay argues that what is central to Christopher Boorse's biostatistical theory of disease as statistically subnormal part function (BST) are comparisons of the "functional efficiency" of parts and processes and that statistical considerations serve only to pick out a healthy level of functional efficiency. On this interpretation, the distinction between health and pathology is less important than comparisons of functional efficiency, which are entirely independent of statistical considerations. The clarifications or revisions of the BST that this essay offers are friendly amendments that render moot some of the most prominent criticisms of Boorse's account.

The biostatistical theory versus the harmful dysfunction analysis, part 1: is part-dysfunction a sufficient condition for medical disorder?

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.