ADHD, Schiz, OCD, and the like, are NOT REAL

[biogirl215]

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But wouldn't it be easy to classify deafness as a "harmful dysfunction"?:
-Significantly interferes with life function and possibly safety (communication, perception of dangers)
-Impacts social function
-Often, though not always, has a biological cause (genetics, neurological damage, damage to the ear) and always has a biological indication

Most people think of deafness as a definite disability, and many think Deaf people should not be able to choose to be deaf or not. They believe that cochlear implants should be required for children, that ASL should not be taught, that people that chose to remain deaf or not to keep their children deaf are stupid, misguided, ill-informed, neglectful, abusive, and/or illogical nearly to the point of "craziness" (using the colliqual here).*

I don't believe in these paralells myself at all, but one could easily draw parallels to all sorts of mental illness with this if they wanted.

The reason that it really frustrates me is because I can't really believe that anybody who has experience with schizophrenia can ever believe that it's status as an "illness" is purely a social construct... Who can believe that?

I don't think anyone on this thread truly believes that sz is a simple social construct... I think most of us simply think this is an interesting topic. I do think, however, that there is a social/behavorial/environmental/cognitive component to most disorders (and to human life in general 🙂 ) and that is why "talk therapy" can work--independently or with medication--very well in treating a lot of disorders and sub-clinical issues. Obviously, in some cases like schizophrenia and bipolar, meds are pretty much a necessity , and I don't think any clinician would argue with that. Still, CBT and other therapies have been shown empirically to have some success in improving functionality (social skills, stress management) even in these medication-imparative causes. I don't think anyone believes that you can cure schizophrenia by talking, but with a stably medicated schizophrenic, therapy can potentially help improve their functioning (I have a friend who did a ton of graduate work in this area [that is, schizophrenia and other psychotic disorders], so I've heard her talk about her research from time to time). Also, I think you would probably have to look long and hard for someone who didn't give some credance to the use of exposure/CBT for things like simple phobias.

*I am not one of those people--in fact, I lean far more to the other side.

 

[solumanculver]

But wouldn't it be easy to classify deafness as a "harmful dysfunction"?:
-Significantly interferes with life function and possibly safety (communication, perception of dangers)
-Impacts social function
-Often, though not always, has a biological cause (genetics, neurological damage, damage to the ear) and always has a biological indication

Hey, all of this stuff implies that deafness is a dysfunction, but the criteria for "harmful" is a normative judgment. The problem is, should we accept the judgment of the deaf person, or of society?

I think that we should accept the judgment of the patient provided they are competent to make the judgment, otherwise we need to use some kind of consensus judgment for them.

Most people think of deafness as a definite disability, and many think Deaf people should not be able to choose to be deaf or not. They believe that cochlear implants should be required for children, that ASL should not be taught, that people that chose to remain deaf or not to keep their children deaf are stupid, misguided, ill-informed, neglectful, abusive, and/or illogical nearly to the point of "craziness".

Deafness is a definite disability and a great impoverishment of life... but if deaf people want to remain deaf, then who's going to stop them?

Of course, in the case of minors, or maybe some of the mentally ill, who can't really make a judgment about what they want, somebody else has to decide what whether to treat them.

My impression is that forcing a child to remain deaf is tantamount to child abuse, and deaf parents shouldn't be allowed to do it. But that's really a discussion that's out of my league...

I don't think anyone on this thread truly believes that sz is a simple social construct... I think most of us simply think this is an interesting topic.

Well, I've argued this topic enough times that it's not really fun for me anymore... if everybody is in agreement that the big psychiatric disorders are, in fact, diseases of the brain, then I can happily retire from this discussion...

I do think, however, that there is a social/behavorial/environmental/cognitive component to most disorders (and to human life in general 🙂 ) and that is why "talk therapy" can work--independently or with medication--very well in treating a lot of disorders and sub-clinical issues.

I think that all disorders are biological disorders, but some can be caused by environmental stimuli... maybe like comparing PTSD to a broken bone, with only external causes... I don't think that PTSD has only external causes, but just as an example...

As far as I can tell, therapy works in the same way that medication does, by causing some change in the brain... some changes induced by therapy are really complex and hard to replicate pharmacologically, and the disorders that are best treated by those means may never succumb to medical treatment. On the other hand, there are some changes that can never be achieved by psychotherapy, and in those cases we have to effect our neural modulation pharmacologically. I'd say personality disorders are in the first camp and schizophrenia is in the second...

In general, my impression is that, if a disease has equal success being treated pharmacologically and with some kind of psychotherapy, the medical method is more desirable. It's cheaper and takes less time...

I don't think anyone believes that you can cure schizophrenia by talking, but with a stably medicated schizophrenic, therapy can potentially help improve their functioning

I'd take it a step further and say that any person, regardless of mental illness, can improve their functioning with some kind of therapy... particularly people with medical disorders that are very sensitive to their lifestyle, like diabetes. It seems like psychologists should spend more time promoting therapy for diabetics and other medically ill people rather than lobbying for drug privileges for the mentally ill... But then again, I also support excising psychotherapy from psychiatry and letting psychologists have it all to themselves... But doesn't that make for a more orderly world?

 

[toby jones]

I'm sorry that I missed participating in this thread as it unfolded. I apologize that I haven't read all of the replies, and apologize (in advance) if my points have already been covered.

Ian Hacking is a good source on this. He has a book on social constructionism "The Social Construction of What?" He tries to unpack all the different things that people have held to be social constructions (race, gender, mental illness, institutions, physical entities etc) and the different things that might be meant when one says that something is a social construction.

Note that it doesn't follow from 'x is a social construction' to 'x does not exist'. Money is a paradigmatic example of something that is socially constructed (only counts as money in virtue of our social practices around buying and selling) and yet I don't think anybody would conclude from money being a social construction to money not existing! Indeed, I wonder how something can not exist and yet exist as a social construction at the same time (sounds contradictory to me).

Hacking has another book "Multiple Personality and the Sciences of Memory" where he argues that Multiple Personality Disorder is a 'looping kind'. Consider this:

Chairs, tables etc were brought into existence in virtue of our social practices (we made them for a particular purpose). If there hadn't been any people to make them there wouldn't be any chairs and tables. If all the people disappeared tomorrow (along with their social practices) then the chairs and tables wouldn't suddenly cease to exist, however.

(Chairs and tables depend on social practices for their initial existence as chairs and tables. Once they exist as chairs and tables they don't need social practices to go on existing as chairs and tables).

Lisenced dog ownership, Member of Parliament etc were brought into existence in virtue of our social practices. If we change our social practices... Then while there are still people there wouldn't be lisenced dog owners or members of parliament anymore, however.

(Lisenced dog owners depend on social practices for their initial existence as lisenced dog owners. If the social practices disappeared tomorrow then their wouldn't be any lisenced dog owners, however. The social practices need to be sustained in order for lisenced dog owners to go on existing AS lisenced dog owners).

Now...

In some society or other there is this state of being possessed by a wild pig. If a person is possessed by a wild pig then they typically go around mildly assaulting others and stealing items of small value. Being possessed by a wild pig is thought to be something that is outside the persons control (not their fault) and they are also thought to be entitled to receive food and financial support while they are possessed.

(Possession by a wild pig depends on social practices (receiving food and financial support) for the practice to be sustained. If people stopped believing that possession was involountary then people would no longer behave as though possessed).

One of Hacking's ideas is that some social constructions (money, members of parliament, lisenced dog ownership) can survive our realization that they are social constructs (that our social practices - in some instances - are responsible for the maintenence of the phenomena). Other social constructions (being possessed by a wild pig, - very controversially multiple personality disorder) cannot survive our realization that our social practices are what is responsible for the production and maintenence of the phenomena. If the Gururumba people became aware that pig possession was socially constructed then they would cease to believe in it, cease to reinforce those who acted possessed, and thereby extinguish the phenomena.

That is his take on Multiple Personality Disorder, too. And... Hysterical Paralysis... Etc.

Very controversial... But a very interesting topic, methinks.

I'm interested in this idea that our BELIEFS ABOUT a phenomenon has the power to CHANGE THE PHEONOMENON. Hacking writes about looping kinds where the behavioural symptoms are shaped by our evolving beliefs about the behavioural symptoms. He traces the evolution of splitting (into two) then fragmentation (into more than two) and how clinician's evolving beliefs eventually dragged memory (or forgetting) into multiple personality disorder (which is where things were at when Hacking was writing).

Ron Mallon has done some stuff on niche construction - too. About how environments can stabilise sets of behavioural symptoms.

I'm particularly interested in whether a system of classification (e.g., the DSM) creates something of an 'observer paradox'.

- DSM tries to describe some behavioural symptoms.
- That causes more individuals to meet the behavioural symptoms as listed (as they or their therapists try and legitimate their distress)
- That causes the DSM description to evolve in response to the different behavioural symptoms that are exhibited (in this particular example rising prevalence)
- Which feeds into how the behavioural symptoms evolve.

And so on...

🙂


> if everybody is in agreement that the big psychiatric disorders are, in fact, diseases of the brain, then I can happily retire from this discussion...

Depends what you mean by disease ;-)

> In general, my impression is that, if a disease has equal success being treated pharmacologically and with some kind of psychotherapy, the medical method is more desirable. It's cheaper and takes less time...

I don't think that is true. Most medication trials are run in too short an amount of time to really compare the costs. I don't think they factor in 'drug x for the rest of your life' vs 'two years of therapy'. I think they tend to do 'seven weeks of benzo's' vs 'seven weeks of therapy'. That way you avoid building in the costs of addiction / withdrawal, too. We simply don't know much about the long term side-effects of psychiatric medications. I really don't believe that medication intervention is cheaper than psychotherapy in the real world.

 

[toby jones]

Jerome Wakefield is the main defender of the HD (harmful dysfunction) analysis of mental disorder.

He actually argues that:

Disorders are failures of an INNER MECHANISM to perform its EVOLUTIONARY FUNCTION where that results in HARM (either to the individual and / or to society).

There are thought to be objective facts about evolutionary functions (and whether internal mechanisms are failing in them) that are to be discovered by science.

Whether someone is harmed or not is thought to vary depending on which society a person is in and so that makes facts about harm normative.

Problems:

1) Biologists make use of at least three DIFFERENT notions of function.
a) evolutionary
b) systemic
c) statistical
To that we might add
d) teleological / rational
Wakefield has more work to do to establish that science has discovered that the EVOLUTIONARY notion is the relevant notion of psychiatry / psychology.

2) Why does there need to be a failure of an INTERNAL MECHANISM? Why can't mental disorder simply be malfuntioning mental symptoms. Imagine a person who produces dopamine at the high end of the normal range and has dopamine receptors that are at the high end of the normal range and has enzymes for getting rid of dopamine at the low end of the normal range. In this case it seems that all the internal mechanisms are within normal range. We could imagine this to be the case, but because of the precise values here the output of the whole dopamine system could produce behaviours that seem disordered in the psychiatric sense. Seems to me that the only grounds that we would have for saying that this person had a dysfunctnioning dopamine system would be the behavioural output and we don't have any independent reason to posit an internal malfunction.

3) If it is an analytic (logical) truth that 'a person is better off if they aren't malfunctioning' then function and malfunction are normative and not SOLELY objective after all. Wakefield simply denies this, but other people don't want to deny this.

________________

I don't think harm is solely normative.

If I eat poison then I'm harmed. Doesn't matter whether I think I am or whether I think I'm not - fact is I'm harmed. Doesn't matter what anybody else thinks either, the whole world might think I'm not harmed, but the fact is I'm harmed.

There are facts about harm the same as there are facts about whether the earth is flat or whether the earth is round.

It is a fact that pedophiles are disvalued in Western Society. That is a fact that can be studied scientifically. Sociologists could do surveys and ask people whether they value pedophilia or not.

Is it a fact that pedophilia (or addiction) is a MENTAL DISORDER as opposed to CRIMINAL MISCONDUCT, however?

If we find that pedophiles have brain state x and non pedophiles don't have that brain state how do we know that brain state x counts as DYSFUNCTIONAL?

If we find that everyone who committs fraud has brain state y and everyone who doesn't doesn't have brain state y then is fraud a mental disorder?

What makes a neural state a DYSFUNCTION as opposed to merely a DIFFERENCE?

Hard questions...

 

[solumanculver]

Hi Toby, I've been wondering where you were

If it is an analytic (logical) truth that 'a person is better off if they aren't malfunctioning' then function and malfunction are normative and not SOLELY objective after all. Wakefield simply denies this, but other people don't want to deny this.

I don't think that there is any such thing as an analytic truth of the form "X is better than Y". The term "better" is by definition a normative term, and the fact that almost everyone agrees that it's better to be functioning rather than malfunctioning doesn't change the fact that each person had to make a normative judgment on that matter in order to come to their conclusion.

I don't think harm is solely normative.

I want us to take the word "harm" to be a technical term for the normative component of a disease... In the same way we should drain the term dysfunction of any normative component. That way we can discuss separately whether or not a condition is "harmful" and whether or not it is "dysfunctional", or both, or neither...

If I eat poison then I'm harmed. Doesn't matter whether I think I am or whether I think I'm not - fact is I'm harmed. Doesn't matter what anybody else thinks either, the whole world might think I'm not harmed, but the fact is I'm harmed.

I think that here we should say that the poison causes a dysfunction as an objective fact, and that the presence of harm will be normatively decided...

Why does there need to be a failure of an INTERNAL MECHANISM? Why can't mental disorder simply be malfuntioning mental symptoms. Imagine a person who produces dopamine at the high end of the normal range and has dopamine receptors that are at the high end of the normal range and has enzymes for getting rid of dopamine at the low end of the normal range. In this case it seems that all the internal mechanisms are within normal range. We could imagine this to be the case, but because of the precise values here the output of the whole dopamine system could produce behaviours that seem disordered in the psychiatric sense.

Hey Toby, we haven't really discussed the problem of classifying dysfunction in this thread, only harm. I think that your argument is about whether or not the property "dysfunction" is transitive through explanatory levels... is that right?

Behavior supervenes on brain, but behavior can be disordered without brain being disordered... it's because the parameters of order and disorder are determined independently for brain and behavior.

All I can really say about this is that a normatively "bad" condition without an actual dysfunction is not really a disease... but there is still precedent for its treatment.

It's like having small breasts... no dysfunction there... but if having larger breasts is judged to be "better", then there is a surgery that can be done... In general, these examples of physicians treating the healthy kind of bother me, and I consider them to be in a different class altogether than ordinary medicine used to treat the sick... I just believe that psychiatry has much more in common with internal medicine than it does with plastic surgery, for that reason... Schizophrenics are more similar to diabetics than they are with healthy, but small-breasted actresses.

Seems to me that the only grounds that we would have for saying that this person had a dysfunctnioning dopamine system would be the behavioural output and we don't have any independent reason to posit an internal malfunction.

Well, I think that's not really true... sure, with personality disorders we don't really have a very compelling reason to posit an internal dysfunction, but I think we have plenty with Schizophrenia, OCD, Depression, etc.

 

[solumanculver]

I don't think that is true. Most medication trials are run in too short an amount of time to really compare the costs. I don't think they factor in 'drug x for the rest of your life' vs 'two years of therapy'. I think they tend to do 'seven weeks of benzo's' vs 'seven weeks of therapy'. That way you avoid building in the costs of addiction / withdrawal, too. We simply don't know much about the long term side-effects of psychiatric medications. I really don't believe that medication intervention is cheaper than psychotherapy in the real world.

Hi, Toby. It's kind of a unbalanced view to take that the drug treatment would last the rest of the patients life, while the therapy would last only a couple of years. It seems like most anti-depressant treatments are finite, I suppose I have a bit of personal experience with this one from high school... Also seeing a therapist, for me, was like torture. I'll take the pill any day over having to spend hours a week talking to someone about my problems...

 

[Ollie123]

Hi, Toby. It's kind of a unbalanced view to take that the drug treatment would last the rest of the patients life, while the therapy would last only a couple of years. It seems like most anti-depressant treatments are finite, I suppose I have a bit of personal experience with this one from high school... Also seeing a therapist, for me, was like torture. I'll take the pill any day over having to spend hours a week talking to someone about my problems...

I think this largely depends on the individual.

There are MANY people who spend years upon years on antidepressants or benzos (the latter in particular) when a relatively brief course of therapy could at least decrease the duration of meds, if not make them unnecessary altogether. Many times depression is short-lived, and in some of these cases it will not recur. Where I think therapy might be a better, cheaper, option is when the depression is consistently recurring, or when they have a single episode that has persisted for years.

I can think of two people I know personally with some social anxiety, who pop a Xanax practically everytime they're going to have to speak to another human being, and have been doing this for quite a few years now. If they'd listen to me and just go see a damn therapist they could probably be off the meds within the year, but both will continue going on like this, and I have no doubt the cost of repeated medication management visits combined with the insane cost of drugs these days will far exceed the cost of therapy.

 

[solumanculver]

There are MANY people who spend years upon years on antidepressants or benzos (the latter in particular) when a relatively brief course of therapy could at least decrease the duration of meds, if not make them unnecessary altogether.

Hi, is this true? Does therapy make medication unnecessary? I know that therapy works well in conjunction with medication...

Does therapy "cure" depression so that it doesn't recur? It seems like a lot of psychologists argue that therapy solves the problems behind mental illness, while medication "masks" the problems... I would like to see the evidence for this, and the reasoning as to why it would be this way...

But benzos aren't exactly a precision medication, I don't think that they should be used as the example... everyone knows that they just mask a problem without treating the underlying cause... Better examples are anti-depressants, anti-psychotics, lithium... that kind of stuff

 

[solumanculver]

Where I think therapy might be a better, cheaper, option is when the depression is consistently recurring, or when they have a single episode that has persisted for years.

But going to therapy definitely sucks more... that's for sure, maybe that's worth a little extra money.

 

[toby jones]

Hey, been busy, yeah.

> I don't think that there is any such thing as an analytic truth of the form "X is better than Y". The term "better" is by definition a normative term...

Ah. How about this: 'It is worse to commit two moral wrongs than to commit one moral wrong'.

The idea is that: There can be objective facts about:

1) What norms a particular person and / or society endorses
2) What norms a particular person and / or society SHOULD endorse (given their aims)
Perhaps... 3) There are even facts about certain norms like 'It is morally wrong to torture an innocent child solely for fun' that obtain despite what you or me or any particular culture believes. Though.. This is controversial and I can't make much sense of it truth be told. I think that 'it is worse to commit two moral wrongs than it is to commit one' is analytically true. And that is an objective fact just like it is an objective fact that 'two is greater than one'.

Science can study norms. Sociology can find out about what they are. We can see whether those norms really do assist a person and / or society meet their aims / goals. Wakefield runs together normative = subjective = non scientific = a feature of behaviour. But that doesn't follow, that doesn't follow at all.

> I want us to take the word "harm" to be a technical term for the normative component of a disease... In the same way we should drain the term dysfunction of any normative component.

Yes, that is what Wakefield attempts to do. I think that his distinction doesn't work, however.

> That way we can discuss separately whether or not a condition is "harmful" and whether or not it is "dysfunctional", or both, or neither...

One needs to get clearer on dysfunction before one can assess whether it is necessary for mental disorder. Wakefield maintains that the relevant notion of function is the evolutionary notion of function. There are problems with this.

- If schizophrenia etc were failures of evolutionary function then why is prevalence as high as it is? Prevalence rates suggest there might be something adaptive lurking in the vicinity. (Much work has been done on how phobias are adaptive responses to evolutionary historical environments. If we buy these explanations then it turns out there is no failure of evolutionary function after all).

- Assignment of evolutionary functions to mental mechanisms assumes that the mind is massively modular. Now all the familiar arguments against massive modularity come into play. Mental disorders seem to be disorders of central system processes rather than breakdowns in localised modules. Language and perception are hardly likely to be representative of the structure of the rest of mentality. Colour blindness isn't even a mental disorder anyway. The relevant notion of 'function' might have something to do with the Aristotelian notion of rationality more than evo bio.

- Mental disorders could be failures of spandrels. In which case they wouldn't be evolutionary malfunctions.

- Mental disorders could be failures of ex-aptations. In which case they wouldn't be evolutionary malfunctions.

So... Evolutionary malfunction might well be unnecessary for mental disorder.

> I think that here we should say that the poison causes a dysfunction as an objective fact, and that the presence of harm will be normatively decided...

Ah. No... I want to say that it is an objective fact that my writhing around on the floor in pain is a jolly bad thing. Doesn't matter whether I think it is a bad / harmful thing, or whether you think it is a bad / harmful thing. I want to say that there are objective facts about whether someone is harmed.

(Remember malfunction only applies to INTERNAL mechanisms - Wakefield is explicit about it NOT applying to BEHAVIOURS).

> I think that your argument is about whether or not the property "dysfunction" is transitive through explanatory levels... is that right?

No. I know Wakefield talks about the appendix (as an example of a system that doesn't have an evolutionary function). - Now the appendix is something that does have an evolutionary function, what it lacks is a current function, but we shall go with him for the sake of argument. He maintains that even if we grant that the appendix doesn't have an evolutionary function and therefore can't malfunction as an appendix, we can talk about the cells that make up the appendix having an evolutionary function and those can malfunction (e.g., by becomming inflamed).

My problem with Wakefield is that evolutionary malfunctions seem to be coming too easy / cheap. There is no independent way to establish whehter someone has an internal evolutionary malfunction or not (because we don't know what the evolutionary functions are). And even if we did know what the evolurionary functions are it is far from clear that this is the relevant notion of function.

I think what happens is that:

- We judge that some behaviour just seems to be weird... Disordered...
- We then face a little criticism for considering the behaviour disordered (like from lobby groups who think that homosexuality isn't a disorder after all)
- We then attempt to define what a disorder is (explain how conditions got to be included in the DSM).

That is what happened... Know what they said? 'Homosexuality isn't a disorder because whether or not they have an inner malfunction they aren't harmed'.

But of course... Living in a bigoted society... Living in a society where one is discriminated against... Has gotta be harmful. Hell... Political dissentors in Russia were harmed in virtue of their political dissent. They were locked up against their will by psychiatrists! (Which - I believe - is an OBJECTIVE harm).

> behavior can be disordered without brain being disordered... it's because the parameters of order and disorder are determined independently for brain and behavior.

Yes. But Wakefield maintains:
1) Functions and malfunctions only apply to the INNER CAUSES of behaviour. He rails against the DSM talking about behavioural malfunction (provides the example of someone meeting criteria for reading disorder because was never taught to read vs someone who meets criteria because they have never been able to learn despite sufficient instruction).
2) Harm is something that happens to PERSONS and it is OUTER BEHAVIOUR that is assessed for harm to persons.

But... Birdsong is something with an evolutionary function.

But... Birdsong is an OUTER BEHAVIOUR.

If paradigmatic cases of mental disorder (depression, mania, schizophrenia, psychosis) turn out NOT to involve evolutionary malfunction then it seems to me that the right thing to conclude is that mental disorders aren't failures of evo functions after all and Wakefield was wrong.

 

[solumanculver]

Ah. How about this: 'It is worse to commit two moral wrongs than to commit one moral wrong'.

Hey, this is a tricky one... It may only be analytic because it's part of the way we define normativity.

Our concept of "badness" is a primitive notion, so we define it kind of axiomatically. There is no amount of non-normative facts that we can we combine to discover a normative fact... But if our axiomatic definition of badness contains a statement like 'It is worse to commit two moral wrongs than to commit one moral wrong', then it will be trivially analytically true.

1) What norms a particular person and / or society endorses
2) What norms a particular person and / or society SHOULD endorse (given their aims)
Perhaps...
3) There are even facts about certain norms like 'It is morally wrong to torture an innocent child solely for fun' that obtain despite what you or me or any particular culture believes. Though.. This is controversial and I can't make much sense of it truth be told.

1) is objective,
2) is objective inasmuch as it is an epistemic claim about rationality, the "should" in that sentence takes the normative content of the sentence for granted, like "you should wash your hands (if you don't want to get sick)". Here we take for granted that getting sick is "bad", it's different than "you should worship God", which is itself expressing a primitive normative notion about what is "good"...
3) is not objective... torturing children has consequences, but we have to make a normative judgment to know if they're "bad"... I'm not even sure that being tortured myself is "bad" unless I make a judgment about it... it's not logical clear that it's "better" to be alive or dead... or in excruciating pain, we just judge things to be that way.

> I want us to take the word "harm" to be a technical term for the normative component of a disease... In the same way we should drain the term dysfunction of any normative component.

Yes, that is what Wakefield attempts to do. I think that his distinction doesn't work, however.

It works, it just means that we turn "harmful" and "dysfunction" into technical terms... we could just replace the term with, "normatively bad and objectively maladaptive", it just doesn't have the ring to it...

If schizophrenia etc were failures of evolutionary function then why is prevalence as high as it is?

How is that different from any disease?

This stuff about types of dysfunction is not very practically useful. I think that we're trying to find an intension for the word "disease" that maps to an extension we already have in mind, namely the set of things we call "diseases"...

We already have an a priori notion of disease, it's the set that contains things like ebola, a cold, and schizophrenia... whatever type of dysfunction is required to map to this set of things is the type we're looking for... I don't know about evolutionary dysfunction or whatever, but I think we generally have a pretty good idea that something is not working in a relevant way in a psychotic individual...

> I think that here we should say that the poison causes a dysfunction as an objective fact, and that the presence of harm will be normatively decided...

Ah. No... I want to say that it is an objective fact that my writhing around on the floor in pain is a jolly bad thing. Doesn't matter whether I think it is a bad / harmful thing, or whether you think it is a bad / harmful thing. I want to say that there are objective facts about whether someone is harmed.

No, because normative facts can only be derived from other normative facts, and there is nothing logically necessary to the proposition that "it's better to be healthy and productive than it is to be writhing in agony and near to death"... that's a judgment that we make, but it's not derived from any objective laws, it's derived from our normative belief that pain is worse than pleasure... Well it's only worse from our perspective because we decided it's worse...

 

[toby jones]

> It may only be analytic because it's part of the way we define normativity.

Yes, thats it. Analyticity has a lot to do with how we define our terms. Once we have a fixed meaning for '1' and '+' and '=' it is analytically true that '1+1=2'. In fact... It is a necessary truth (couldn't have been otherwise GIVEN that the terms mean what we take them to mean).

Hume famously argued that you can't derive an 'ought' from an 'is'. Or (in other words) that even if we had a complete description of the way things are in the world, we would not be able to deduce from that description the way things should be in the world.

While this view reigned for a time these days people are a lot less hostile to the role of science for ethics. In particular, if you don't believe that there are categorical imperitives (of the form you simply should do x) and you only believe in hypothetical imperitives (of the form that if you desire y then you should do x because x is the best way to achieve your desire) then... Ethics seems to be objective after all. There are facts about whether x or z or y is the best way to obtain y. That fact obtains despite what you or I believe about it.

I'm sympathetic to the attempt to naturalize ethics. The attempt to try and explain why we have the ethical intuitions that we have by appealing to facts about our psychology and our social environments. This means... That I don't believe that science and ethics are as sharply distinguishable as the 'is-ought gap' would encourage us to believe.

And this naturalistic world-view (that you would think Wakefield would be sympathetic to) encourages us to rethink the malfunction and harm distinction as articulated by Wakefield.

> It works, it just means that we turn "harmful" and "dysfunction" into technical terms...

Of course we could do that. We could define disorder in the following way:
S has a disorder is true iff: 1) S has a xxx AND 2) S has a yyy
Whether the definition is theoretically (or scientifically) useful hinges on what xxx and yyy are.

The distinction (as enumerated by Wakefield) runs as follows:
Dysfunction - Internal - Evolutionary - Objective (uncovered by science)
Harm - Feature of behaviour - Subjective (varies according to culture) - Not discoverable by science

I have problems with the Harm condition and I have problems with the Dysfunction condition, too. I don't think that this is a useful way of trying to say what disorders are. I think the normative and the evaluative aspects are more closely intertwined than he appreciated. I don't think that the scientific aspect can profitably be carved off from the normative aspect. But: All is not lost, because there can be objective facts about the relevant norms anyhoo.

> This stuff about types of dysfunction is not very practically useful.

It goes some way towards undermining Wakefield's claim that disorders are failures of evolutionary functions. The idea is... That failure of evolutionary function is not a necessary condition for disorder.

> I think that we're trying to find an intension for the word "disease" that maps to an extension we already have in mind, namely the set of things we call "diseases"...

Interesting...
I think we seem to have a number of intuitions:

1) Certain conditions are paradigmatic of disorders (broken legs, HIV, cancer)

2) There is something wrong with people who have these conditions

3) Science will tell us what is wrong with them

And the trouble is that our intuitions in 1 seem to be doing most of the work. That is what a satisfactory analysis of 'disorder' needs to be answerable to (if a definition of disorder tells us that people with broken legs aren't disordered then we seem to have falsified our definition).

Wakefield maintains that we should look to the natural sciences to tell us what is wrong with these people. He maintains that natural science has found that they have evolutionary malfunctions. I think this is empirically false.

Even if all current instances of disorder are failures of evolutionary function that wouldn't show us that evolutionary dysfunction was necessary for disorder.

Similarly, even if all current instances of consciousness are instantiated on neurones this doesn't show us that neurones are necessary for consciousness.

Computers might be programmed such that they are conscious, for instance.
And... They might count as having disorders?

(Just try giving psychotropic medication to Parry the Paranoid)

;-)

 

[solumanculver]

Yes, thats it. Analyticity has a lot to do with how we define our terms. Once we have a fixed meaning for '1' and '+' and '=' it is analytically true that '1+1=2'. In fact... It is a necessary truth (couldn't have been otherwise GIVEN that the terms mean what we take them to mean).

But that's not the case with 'It is worse to commit two moral wrongs than to commit one moral wrong'. It's not derived from anything, it's simply the way we define "moral wrongs", it doesn't show that normative concepts themselves can be analytically right or wrong, it just shows that statements about normative concepts can be trivially true by definition... that's a big difference.

that if you desire y then you should do x because x is the best way to achieve your desire) then... Ethics seems to be objective after all. There are facts about whether x or z or y is the best way to obtain y. That fact obtains despite what you or I believe about it.

When you make a statement like "X is good", then that's a normative statement. If you say, "If you think X is good, then you should do Y", that's not a normative statement, it's a statement about rationality that takes the normative judgment for granted... It's more of an epistemic proposition that an ethical one... so there's "should" of ethics, and "should" of epistemology... Not the same.

This means... That I don't believe that science and ethics are as sharply distinguishable as the 'is-ought gap' would encourage us to believe.

Well, there are other normative judgments than ethical ones... If I just say something like "reggae is good", that's a normative judgment that's not really ethical... there's no fact to the matter whether reggae is good, or "diabetes is bad", but there are plenty of facts about reggae and diabetes on which we can base our normative judgments, but without making some primitive normative statements we can't derive our higher-level judgments only on the facts.

I don't think that the scientific aspect can profitably be carved off from the normative aspect.

Well, I think you're right to an extent. A thing can only be a dysfunction is it's "bad"... which is a normative judgment. If we coalesce all normative judgments into the "harm" term, I think that all we need is a "difference in biological function" which is subjectively "bad" for a thing to be a disease.

And the trouble is that our intuitions in 1 seem to be doing most of the work. That is what a satisfactory analysis of 'disorder' needs to be answerable to (if a definition of disorder tells us that people with broken legs aren't disordered then we seem to have falsified our definition).

Well, I think it's obvious that there is some property that is exclusive to the main set of things that we call "disorders" that can function as an intention to map to them.

Are you arguing that there is no logical property that maps neatly to the set of things like broken legs and schizophrenia? Surely there has to be something...

We can make two different categories, a broader one that includes schizophrenia and a smaller one that is all non-psychiatric diseases... this might be useful in some way... But I think that if we make an intension that intuitively picks out cancer and broken legs as diseases, it will also naturally capture schizophrenia and OCD. My belief is that it will be more difficult to come up with a criteria that includes all the things that we must include in our group of diseases, but that specifically excludes the psychiatric kind, than it will be to come up with one that includes them.

 

[toby jones]

> 'It is worse to commit two moral wrongs than to commit one moral wrong'... it's simply the way we define "moral wrongs", it doesn't show that normative concepts themselves can be analytically right or wrong, it just shows that statements about normative concepts can be trivially true by definition...

I guess there are two questions. 1) What concepts should we adopt. 2) What analytically follows from our present concepts.

Analyticity is a fact about meaning / definition of either concepts or words. Thats just what analyticity is. With respect to which concepts we should adopt, that might sound normative. I think it depends on what it is that we are going to be doing with that concept.

> When you make a statement like "X is good", then that's a normative statement. If you say, "If you think X is good, then you should do Y", that's not a normative statement

Well, that is controversial. I think that the truth conditions for categorical statements (insofar as there are truth conditions for them) are going to be in the form of hypothetical statements. You could say 'but on that view you are simply denying that there is ethics!' or you could say 'but that means the nature of morality is different from what we supposed!' I prefer the second way of phrasing things, but what you will (so long as you don't call me an anti-ethicist)

;-)

> there's "should" of ethics, and "should" of epistemology... Not the same.

Though a substantive view would be the view that there is a substantial overlap, or that the normativity of ethics can be grounded in the normativity of epistemology or something like that. Indeed, there are other kinds of normativity too. Aesthetic, prudential etc. What kind of normativity is relevent for psychiatry / psychology / medicine, do you think? One of the above mentioned kinds or something else?

> Well, I think it's obvious that there is some property that is exclusive to the main set of things that we call "disorders" that can function as an intention to map to them.

But what kind of property will there be?
Here is a property: the property 'blah'
Something is blah iff: it is either a duck or a brick or a cloud or a beer bottle.
Scientists don't study blah's. They have no room for it in their investigations. How come? Because blah isn't a very useful property. If we know that something is blah, then there isn't very much that we know about it really. I mean, we could try studying blahs... We could try and try... But generalizations and predictions about blahs will be few and far between. Perhaps this is best understood by way of contrast... If we know that something is made of H2O there are a variety of true generalizations that we can make about its other properties. There are also a variety of true predictions that we can make about how it is likely to behave under different circumstances and under different manipulations both inside and outside of the lab. Not so with blah.

Is mental disorder more like blah or like H2O?
Methinks it is more like blah.
Is somatic disorder more like blah or like H2O?
Methinks it is more like blah.
Is schizophrenia or depression, or mania etc more like blah or like H2O?
Better than before... But still... More like blah, methinks.
We haven't hit upon the natural kinds yet...

The above assumed that yes, an intension could be found. It is just that that intension doesn't seem helpful for the purposes that we want (e.g., to enable researchers to form true generalisations and predictions, for clinicians to apply successful treatments). If our folk beliefs or intuitions about disorder (or mental disorder) turned out to be contradictory... Then there couldn't be something that instantiated the intension. This is arguably the case with free will. With our thinking that 'could have done otherwise' is necessary (uncaused act) and with our also thinking that 'caused by me' is necessary (determined act). Accounts of free will are often REVISIONARY in that they argue that if we adopt this new non-contradictory concept and give up on either the first or the second intuition then we have a concept that explains most of our other intuitions.

One is of course free to define concepts and words any way one likes... But the point is to either capture the folk concept or to construct a concept that is very useful for a particular purpose. It is unclear whether the folk have consistent beliefs / intuitions about mental disorder. Something might have to give.

Consider a manual of computer breakdowns. Consider the kind of disorder 'blank screen'. Is 'blank screen' a natural kind of disorder? What causes 'blank screen'? Why, lots of different things do. There isn't a common cause for blank screen. If there is a blank screen then we know that 'either the power is turned off at the wall, or the display settings are set to darkest or...'

Should we classify on the basis of superficial properties (e.g., blank screens)
Or should we classify on the basis of the cause of those (e.g., not turned on at the wall)

> But I think that if we make an intension that intuitively picks out cancer and broken legs as diseases, it will also naturally capture schizophrenia and OCD.

Argument adapted from Szasz:

P1) 'disorder' applies to bodily states (by definition)
P2) the mind is not the body (szasz is a dualist)
p3) there aren't any mental disorders

I deny premiss one and premiss two.
But still... If at least some of the folk have the intution that disorders must be disorders of bodily states... Then either paradigmatic mental disorders are really neurological disorders (bodily after all) or they aren't really disorders. Maybe... Szasz has one concept of disorder... And the rest of us have another.

Why should we adopt his over ours or vice versa?

What hangs on whether someone is dx'd with a mental disorder or not?

- third party funded treatment
- they get to play the sick role
- they get out of responsibility for some actions that are thought to be part of the sickness

and so on.

Szasz thinks we should change our social practices around how we treat people who are mentally ill. He questions the efficacy of current treatments and he thinks that we do mentally ill people a disservice by absolving them of responsibility. That our paternalism is not in the interests of the persons autonomy. That we consider them 'broken' instead of looking at how their behaviour is the product of a (metaphorically) disordered society. Szasz is alright. He is a little extremist, sure. But no more so than the extremism exhibited by some of the biological reductionists. There has got to be a middle ground...

 

[JockNerd]

Grad school just started up again and so I've been missing out on this thread, which now seems to have spun out completely beyond by ability to catch up. 😛 One quick comment:

Argument adapted from Szasz:

P1) 'disorder' applies to bodily states (by definition)
P2) the mind is not the body (szasz is a dualist)
p3) there aren't any mental disorders

I think this is something of a mischaracterization. Szasz' argument, as I understand is, is that beliefs and thoughts aren't diseases in the same way that the flu is a disease, because one is diagnosed based on ethical and moral grounds about behaviours, and the other is diagnosed based on a comparison with a structurally functioning body. Doesn't have to do with dualism so much as the difference between social and non-social definition of a disease.

There was also a comment by SC somewhere up there about anti-psychiatry or social explanations for disorders being detrimental to patients. I don't think this is the case at all. I don't think either biological or social explanations are intrinsically empowering or disempowering; race and sex are biological, but that doesn't stop minorities and women from being discriminated against.

 

[toby jones]

Okay...
Lets just integrate those thoughts into a revised version...

Disease is essentially non-social / somatic
Since mental disorders are not non-social or somatic (because the are social and mental)
Mental disorders are not disorders

Better?

> There was also a comment by SC somewhere up there about anti-psychiatry or social explanations for disorders being detrimental to patients. I don't think this is the case at all. I don't think either biological or social explanations are intrinsically empowering or disempowering...

I agree.

Those who advocate that mental disorders are just like physical disorders seem to have this in mind. If mental disorders are bona fide disorders just like physical disorders then it turns out that my symptoms aren't my fault (and that can be experienced as either empowering via absence of guilt, or as disempowering via reduced ability to take control over them). Neither of those necessarily follow.

There are similar worries with characterizing mental disorders as psychological or social or genetic or whatever.

I think it is sad that there is still so much dichotomizing going on. Surely the nature / nurture controversy has shown us that the correct answer isn't going to be one of them. The correct answer is going to be in figuring out the precise contribution of each in each particular case. Same goes for mental disorders, methinks.

 

[solumanculver]

I think it is sad that there is still so much dichotomizing going on. Surely the nature / nurture controversy has shown us that the correct answer isn't going to be one of them. The correct answer is going to be in figuring out the precise contribution of each in each particular case. Same goes for mental disorders, methinks.

Hi. I agree that the causes of a mental disorder will be a combination of genetic, social, environmental... whatever.

But what this means to say is that all of these things have an impact on the brain, which then determines behavior. There is no change in behavior without a change in the brain... This means that whatever the non-biological causes do, they achieve their effect precisely by having some effect on the brain.

So the proximate cause of every mental disorder is biological, even though there are a host of environmental causes.

It's just like any other disease, though... What causes cancer? Smoking, or uncontrollable cell growth? Well, both... but it's the cellular features that are the proximate cause of it... What is the best way to treat cancer? By stopping the person from smoking, or by stopping the cells from dividing? Well, both... Maybe a psychologist can do one and a physician can do the other.

But there's no dichotomy here. There's just biology, and the things that affect biology... There is a fundamental level... it's the biology, not the environmental stimuli.

And Toby, particle physics is more fundamental than biology, I know... When we change a biological feature of the organism we are changing the arrangement of quarks... All that shows is that in effecting a high-level change you are also causing a low-level change... So if therapy, which changes behavior, has any effect, it accomplishes it by causing biological change, because behavior supervenes on biology, but this doesn't matter.

Therapy is good, but it's a blunt tool... If a disease is caused by a malfunctioning gene, we can turn that gene off directly rather than do some elaborate scripted therapy which causes a million chemical cascades which culminate in the body naturally modulating that gene-expression...

The natural way to look at a disease is the way that is most effective for treatment... but in the end, they're all "biological" processes... I believe that, for some conditions, we will never have pharmacological treatments, and we will have to rely entirely on psychotherapy... but that's a concession to the limits of human understanding, nothing more. We will never be able to effectively treat something we don't physically understand, and in those cases we can try to help the body heal itself through its own devices through therapy... but if we understood better what was happening we could find a way to just fix it outright.