Wakefield doesn't mind my focus on parallels between addiction and love. But love can fall outside the bounds of what evolution intended. So, he claims, comparing addiction with love does not preclude a naturally defined "disorder." I counter with the argument that evolution handed us such highly general response systems, the bounds of normality cannot be defined.

Although I reject neuronormativity -- an idea central to the Brain Disease Model of Addiction -- Henden and Gjelsvik argue that the disease definition might refer to normativity in nonneural domains. They profess that a cognitive dysfunction, or a mismatch of evolutionary intentions, could also qualify as norm violations, thus legitimizing the disease label. The need for dividing lines is questioned as well. I rebut these criticisms in turn, but I must admit they are thought provoking.

Although these authors sometimes resort to medical terminology, we strongly agree that addiction is not a disease and that the Brain Disease Model of Addiction captures only one part of the story and distorts the big picture. Yet Satel and Lilienfeld continue to conflate a neurobiological model with a disease model. They also complain that my modeling of addiction reveals a hidden “neurocentric” bias, despite my integration of multiple levels of analysis, exactly as they recommend.

Both Matthews and I see addiction as the outcome of developmental processes that arrive at diverse levels of dysfunction for different individuals at different stages. Matthews characterizes "late-stage" addiction in terms of lost control and extreme automaticity, a degree of dysfunction he calls a "disorder" and compares to another disorder -- depersonalization. I don't mind the label "disorder." Yet addiction is no more like depersonalization than it is like other conditions, most notably obsessive-compulsive disorder. Automaticity is never pure or total. (...) My dual focus on the phenomenology and neuroscience of addiction has helped me capture these critical details and differences. In fact, I think we've had enough of comparing, classifying, and defining addiction. It's time to recognize addiction as a thing in itself, unlike anything else. (shrink)

Frank and Nagel are very interested in the causes and consequences of moralizing about addiction. If addiction is a disease, moralistic concerns are sidelined. If it's a choice, we'd better identify clear reasons to absolve addicts from blame. While these are interesting considerations, they don't have much to do with the model of addiction I put forward in the target article.

I applaud Fenton and Wiers' attempt to find a demarcation point between cases of addiction that fall within the range of normal function and those that may count as disease. However, I argue that continua don't offer demarcation points, the mechanisms involved are not demonstrably different, and trying to pin down subjectivity doesn't help.