Psychiatry widely assumes an internalist biomedical model of mental illness. I argue that many of psychiatry’s diagnostic categories involve an implicit commitment to constitutive externalism about mental illness. Some of these categories are socially externalist in nature.

Substance addiction has been historically conceived and widely researched as a brain disease. There have been ample criticisms of brain-centred approaches to addiction, and this paper aims to align with one such criticism by applying insights from phenomenology of psychiatry. More precisely, this work will apply Merleau-Ponty’s insightful distinction between the biological and lived body. In this light, the disease model emerges as an incomplete account of substance addiction because it captures only its biological aspects. When considering addiction as a (...) brain disorder, it will be shown that research fails to account for the contextual, functional, and emotional aspects inherent to subjective health. It is concluded that, while the disease model is fundamental to our understanding of what happens in the brain, its brain-centred approach is cure-oriented. Instead, we suggest a care-orientated approach, which understands and treats the psychological feel as bodily experience situated in an environment, allowing for a more encompassing therapeutic perspective. (shrink)

Major Depressive Disorder (MDD) is a serious condition with a large disease burden. It is often claimed that MDD is a “brain disease.” What would it mean for MDD to be a brain disease? I argue that the best interpretation of this claim is as offering a substantive empirical hypothesis about the causes of the syndrome of depression. This syndrome-causal conception of disease, combined with the idea that MDD is a disease of the brain, commits the brain disease conception of (...) MDD to the claim that brain dysfunction causes the symptoms of MDD. I argue that this consequence of the brain disease conception of MDD is false. It incorrectly rules out genuine instances of content-sensitive causation between adverse conditions in the world and the characteristic symptoms of MDD. Empirical evidence shows that the major causes of depression are genuinely psychological causes of the symptoms of MDD. This rules out, in many cases, the “brute” causation required by the brain disease conception. The existence of cases of MDD with non-brute causes supports the reinstatement of the old nosological distinction between endogenous and exogenous depression. (shrink)

En este artículo se plantea una discusión con el enfoque doxástico de los delirios. A pesar de que esta línea de análisis ha hecho importantes aportes en cuanto a la comprensión del fenómeno, tiene dificultades importantes a la hora de aportar un marco explicativo completo de los delirios porque deja por fuera el aspecto total de la experiencia y sigue basándose implícitamente en la idea de que podemos estudiar de manera separada e independiente los aspectos físicos, cognitivos y experienciales de (...) un fenómeno tan complejo. Se propondrá que, más allá de la decisión acerca de si debemos considerar a los delirios como creencias irracionales o no, o de si puede concebírselos como creencias en absoluto, es necesario tener en cuenta la transformación drástica del mundo entero de experiencia que se da en el sujeto delirante, tal como lo plantea la fenomenología. (shrink)

In this paper, I present an argument that shows that the belief in libertarian freedom is inconsistent with two assumptions widely accepted by those who are physicalists with regard to the relation between the mental and the physical - that mental properties are distinct from physical properties, and that mental properties supervene on physical properties. After presenting the argument, I trace its implications for the question of the compatibility of libertarian free will and physicalism in general.

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. Addiction is currently classified as a medical disorder in DSM-5 and ICD-10. It is further labeled a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Lewis argues that the changes result instead from normal neuroplasticity (...) and learning in response to the intense rewards provided by addictive substances, thus that addiction is not a brain disease and by implication not a medical disorder at all. I argue that even if one accepts Lewis’s reinterpretation of the brain evidence, his conclusions do not follow. Relying on my harmful-dysfunction analysis of medical disorder, I defend the view that substance addiction is in fact a medical disorder and a brain disorder. In Part 1, I identify five arguments Lewis puts forward against the brain-disease view and evaluate them as arguments that addiction is not a disorder: Addiction is not a chronic, relapsing condition; There is no clear boundary between addiction and other strong desires; Negative consequences are not unique to disorders; The brain disease model does not account for behavioral addictions; and, Addiction is like love. I argue that Lewis’s arguments are invalid because they fail to take account of the context of addiction and its relation to biological design. (shrink)

I argue that denial plays a central but insufficiently recognized role in addiction. The puzzle inherent in addiction is why drug use persists despite negative consequences. The orthodox conception of addiction resolves this puzzle by appeal to compulsion; but there is increasing evidence that addicts are not compelled to use but retain choice and control over their consumption in many circumstances. Denial offers an alternative explanation: there is no puzzle as to why drug use persists despite negative consequences if these (...) consequences are not straightforwardly known. I describe the nature of the causal knowledge that one's drug use is causing negative consequences; map the conceptual landscape of denial and explain how it can block such knowledge; and explore some of the processes and mechanisms that have been studied by philosophy and the cognitive sciences and which may underpin denial in addiction, including well-established information-processing biases, motivational influences on belief formation and self-deception, and cognitive deficits with respect to insight and self-awareness. I conclude by suggesting that addiction is as much a disorder of cognition as a disorder of conation. (shrink)

This article explores and defends the claim that addictive desires—for alcohol in particular—are partly explained by the motive of self-escape. We consider how this claim sits with the neurophysiological explanation of the strength of addictive desires in terms of the effect addictive substances have on the dopamine system. We argue that nothing in the neuroscientific framework rules out pluralism about the causes of addictive desire.

It is often claimed in parts of the psychiatric literature that neuroscientific research into the biological basis of mental disorder undermines dualism in the philosophy of mind. This paper shows that such a claim does not apply to all forms of dualism. Focusing on Kenneth Kendler’s discussion of the mind–body problem in biological psychiatry, I argue that such criticism of dualism often conflates the psychological and phenomenal concepts of the mental. Moreover, it fails to acknowledge that there are different varieties (...) of dualism, and so overlooks the important metaphysical insights of contemporary dualist philosophers. I argue that while the neuroscientific research underpinning biological psychiatry challenges the traditional dualism of René Descartes, it does not pose any problem for the more modern dualism of David Chalmers. It is possible to take seriously the scientific claims of biological psychiatry while holding that this latter form of dualism is true. This has implications for the positioning of the mind–body problem in psychiatry. While the “easy” problem of explaining psychological processes is relevant to the aims of biological psychiatry, psychiatrists need not worry about the “hard” problem of consciousness. (shrink)

Marc Lewis argues that addiction is not a disease, it is instead a dysfunctional outcome of what plastic brains ordinarily do, given the adaptive processes of learning and development within environments where people are seeking happiness, or relief, or escape. They come to obsessively desire substances or activities that they believe will deliver happiness and so on, but this comes to corrupt the normal process of development when it escalates beyond a point of functionality. Such ‘deep learning’ emerges from consumptive (...) habits, or ‘motivated repetition’, and although addiction is bad, it ferments out of the ordinary stuff underpinning any neural habit. Lewis gives us a convincing story about the process that leads from ordinary controlled consumption through to quite heavy addictive consumption, but I claim that in some extreme cases the eventual state of deep learning tips over into clinically significant impairment and disorder. Addiction is an elastic concept, and although it develops through mild and moderate forms, the impairment we see in severe cases needs to be acknowledged. This impairment, I argue, consists in the chronic automatic consumption present in late stage addiction. In this condition, the desiring self largely drops out the picture, as the addicted individual begins to mindlessly consume. This impairment is clinically significant because the machinery of motivated rationality has become corrupted. To bolster this claim I compare what is going on in these extreme cases with what goes on in people who dissociate in cases of depersonalization disorder. (shrink)

Previous discussions of addiction have often focused on the question of whether addiction is a disease. This discussion distinguishes that question – the disease question – from the question of whether addiction is a disability. I argue that, however one answers the disease question, and indeed on almost any credible account of addiction, addiction is a disability. I then consider the implications of this view, or why it matters that addiction is a disability. The disease model of addiction has led (...) many to see addiction as primarily a medical problem, and to make medical treatment of the addicted person the first priority in addressing addiction. Once addiction is viewed as a disability, different concerns are foregrounded. The problem of addiction resides not only in the addicted person, but also in the social environment in which the addicted person finds herself. The fundamental ethical question about addiction is not how addicted persons can be treated or otherwise changed, but how a just society can make reasonable accommodations for addicted persons. (shrink)

I review the brain disease model of addiction promoted by medical, scientific, and clinical authorities in the US and elsewhere. I then show that the disease model is flawed because brain changes in addiction are similar to those generally observed when recurrent, highly motivated goal seeking results in the development of deep habits, Pavlovian learning, and prefrontal disengagement. This analysis relies on concepts of self-organization, neuroplasticity, personality development, and delay discounting. It also highlights neural and behavioral parallels between substance addictions, (...) behavioral addictions, normative compulsive behaviors, and falling in love. I note that the short duration of addictive rewards leads to negative emotions that accelerate the learning cycle, but cortical reconfiguration in recovery should also inform our understanding of addiction. I end by showing that the ethos of the disease model makes it difficult to reconcile with a developmental-learning orientation. (shrink)

In his target article and recent interesting book about addiction and the brain, Marc Lewis claims that the prevalent medical view of addiction as a brain disease or a disorder, is mistaken. In this commentary we critically examine his arguments for this claim. We find these arguments to rest on some problematical and largely undefended assumptions about notions of disease, disorder and the demarcation between them and good health. Even if addiction does seem to differ from some typical brain diseases, (...) we believe contrary to Lewis, that there are still good reasons to maintain its classification as a mental or behavioral disorder. (shrink)

This article uses Marc Lewis’ work as a springboard to discuss the socio-political context of the brain disease model of addiction. The claim that promotion of the BDMA is the only way the general public can be persuaded to withhold blame and punishment from addicts is critically examined. After a discussion of public understandings of the disease concept of addiction, it is pointed out that it is possible to develop a scientific account of addiction which is neither a disease nor (...) a moral model but which the public could understand. Evidence is reviewed to suggest that public acceptance of the disease concept is largely lip-service and that the claim the BDMA removes stigma among the public and professionals is unsupported by evidence. Further, there is good evidence that biogenetic explanations of mental/behavioural disorders in general have been counterproductive in the attempt to ally stigma. A model of addiction as a disorder of choice may attract special problems in public-facing communications and risks being misunderstood. However, ways of presenting this model to the public are suggested that may avoid such risks. Lastly, the claim that the BDMA is the only way of ensuring access to treatment and of maintaining research funding for addiction is disputed and a way in which these benefits can be retained under a disorder-of-choice model proposed. The article concludes by enthusiastically endorsing Lewis’ call for a third stage in the governing image of addiction. (shrink)

Some theorists have argued that we should understand the notion of free will from a functional perspective: free will just is our ability to choose effectively and adaptively in an ever-changing environment. Although far from what many philosophers normally mean by free will, those who adopt this biological-evolutionary perspective can clearly define and defend a notion of personal responsibility. One consequenceof this point of view is that addicts become responsible for their actions, for at each choice point, there is a (...) real sense in which the addict could have elected not to use or abuse. As a result, it has been argued that addiction is not a disease, that addictive behavior is voluntary, and that sometimes it is even rational. This paper defends a different way of thinking about addiction, one that aligns it with other complex chronic illnesses. The perspective put forth here suggests that these discussions about responsibility and free will represent an over-simplified and neuropsychologically inaccurate portrait of basic human capacities for behavioral choice. (shrink)

Lewis’ neurodevelopmental model provides a plausible alternative to the brain disease model of addiction that is a dominant perspective in the USA. We disagree with Lewis’ claim that the BDMA is unchallenged within the addiction field but we agree that it provides unduly pessimistic prospects of recovery. We question the strength of evidence for the BDMA provided by animal models and human neuroimaging studies. We endorse Lewis’ framing of addiction as a developmental process underpinned by reversible forms of neuroplasticity. His (...) view is consistent with epidemiological evidence of addicted individuals ‘maturing out’ and recovering from addiction. We do however hold some reservations about Lewis’ model. We do not think that his analysis of the neurobiological evidence is clearly different from that of the BDMA or that his neurodevelopmental model provides a more rigorous interpretation of the evidence than the BDMA. We believe that our understanding of the neurobiology of drug use is too immature to warrant the major role given to it in the BDMA. Our social research finds very mixed support for the BDMA among addicted people and health professionals in Australia. Lewis’ account of addiction requires similar empirical evaluation of its real-world implications. (shrink)

Libertarians concede that non-autonomous sentient beings pose a problem for their theory. But, while they acknowledge that libertarianism denies non-autonomous sentient beings basic moral rights, libertarians have overlooked how their theory also denies non-autonomous sentient beings basic moral powers. In this article, I show how the libertarian entitlement theory of justice, specifically, the theory for the original acquisition of holdings, denies non-autonomous sentient beings the moral power to originally acquire or make property. Attempts to avoid this problem by appealing to (...) interests or preference autonomy are likely to be unsuccessful. (shrink)

If mental illnesses are externally constituted, then so are somatic illnesses. Will Davies makes a persuasive case for externalism in psychiatry; as I show here, parallel examples exist in somatic medicine.

Addiction appears to be a deeply moralized concept. To understand the entwinement of addiction and morality, we briefly discuss the disease model and its alternatives in order to address the following questions: Is the disease model the only path towards a ‘de-moralized’ discourse of addiction? While it is tempting to think that medical language surrounding addiction provides liberation from the moralized language, evidence suggests that this is not necessarily the case. On the other hand non-disease models of addiction may seem (...) to resuscitate problematic forms of the moralization of addiction, including, invoking blame, shame, and the wholesale rejection of addicts as people who have deep character flaws, while ignoring the complex biological and social context of addiction. This is also not necessarily the case. We argue that a deficit in reasons responsiveness as basis for attribution of moral responsibility can be realized by multiple different causes, disease being one, but it also seems likely that alternative accounts of addiction as developed by Flanagan, Lewis, and Levy, may also involve mechanisms, psychological, social, and neurobiological that can diminish reasons responsiveness. It thus seems to us that nondisease models of addiction do not necessarily involve moralization. Hence, a non-stigmatizing approach to recovery can be realized in ways that are consistent with both the disease model and alternative models of addiction. (shrink)

There is a debate about the nature of addiction, whether it is a result of brain damage, brain dysfunction, or normal brain changes that result from habit acquisition, and about whether it is a disease. I argue that the debate about whether addiction is a disease is much ado about nothing, since all parties agree it is “unquestionably destructive.” Furthermore, the term ‘addiction’ has disappeared from recent DSM’s in favor of a spectrum of ‘abuse’ disorders. This may be a good (...) thing indicating more nuance in typing the heterogeneous phenomena we used to call ‘addiction’. (shrink)

Substance addiction affects millions of individuals worldwide and yet there is no consensus regarding its conceptualisation. Recent neuroscientific developments fuel the view that addiction can be classified as a brain disease, whereas a different body of scholars disagrees by claiming that addictive behaviour is a choice. These two models, the Brain Disease Model and the Choice Model, seem to oppose each other directly. This article contends the belief that the two models in the addiction debate are polar opposites. It shows (...) that it is not the large amount of addiction research in itself what sets the models apart, but rather their extrapolated conclusions. Moreover, some of the most fiercely debated aspects - for instance, whether or not addiction should be classified as a disease or disorder - are irrelevant for the conceptualisation of addiction. Instead, the real disagreement is shown to revolve around capacities. Discussing addiction-related capacities, especially regarding impaired control, rather than the assumed juxtaposition of the two models can be considered the true addiction debate. More insight into the extent to which the capacities of the addicted individual were affected would be highly useful in various other areas, especially legal responsibility. (shrink)

Substance addiction affects millions of individuals worldwide and yet there is no consensus regarding its conceptualisation. Recent neuroscientific developments fuel the view that addiction can be classified as a brain disease, whereas a different body of scholars disagrees by claiming that addictive behaviour is a choice. These two models, the Brain Disease Model and the Choice Model, seem to oppose each other directly. This article contends the belief that the two models in the addiction debate are polar opposites. It shows (...) that it is not the large amount of addiction research in itself what sets the models apart, but rather their extrapolated conclusions. Moreover, some of the most fiercely debated aspects - for instance, whether or not addiction should be classified as a disease or disorder - are irrelevant for the conceptualisation of addiction. Instead, the real disagreement is shown to revolve around capacities. Discussing addiction-related capacities, especially regarding impaired control, rather than the assumed juxtaposition of the two models can be considered the true addiction debate. More insight into the extent to which the capacities of the addicted individual were affected would be highly useful in various other areas, especially legal responsibility. (shrink)

Since the dawn of the internet, pornography has effectively become ubiquitous, pervasive, and increasingly normalised. Study findings show remarkable similarities in how the brain reacts to pornography, and other known addictive substances, and indicate that consuming pornography is comparable to consuming other known addictive substances. Moreover, two of the biggest risk factors for addiction are the substance’s availability and its easy accessibility, particularly in the case of younger persons. To date, pornography addiction has been conceptualised as a behavioural addiction. However, (...) the body of research data on pornography addiction does not provide conclusive support for behavioural addiction. The aim of this thesis is to put forward the idea that pornography can, and should, be conceptualised as an addictive substance, and, that when pornography is consumed, an addictive substance is consumed. In order to support this claim, there are many factors that must be addressed. I first clarify what pornography entails by exploring how it is conceptualised, what pornography ‘does’, and what it means to be a pornography consumer. Secondly, I examine the conceptualisations of substances, substance consumption and addiction, respectively, as well as the subsequent difference between substance and behavioural addiction. Thirdly, I give an inclusive overview of pornography addiction by not only examining the most recent perspectives of researchers, but also of pornography consumers. I conclude by suggesting how we should go about conceptualising pornography addiction, and then propose how the set of diagnostic criteria for pornography use disorder should be formulated for a future iteration of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. I argue that, given the abundance of academic research on substance addiction, compared to the scarcity of research on behavioural addiction, conceptualising pornography as an addictive substance is more likely to create a sense of urgency for the future research of pornography addiction than would be the case if it is considered a potential behavioural addiction. Furthermore, I argue that the classification of pornography as an addictive substance, and the inclusion of pornography use disorder in a future iteration of the DSM, will raise awareness of the potential adverse effects of pornography consumption and, therefore, the harmful consequences of pornography use disorder. (shrink)

The addiction literature is fraught with conceptual confusions, stalled debates, and an unfortunate lack of clear and careful attempts to delineate the phenomenon of addiction in a way that might lead to consensus. My dissertation has two overarching aims, one metaphysical and one practical. -/- The first aim is to defend an account of addiction as the systematic disposition to fail to control one’s desires to engage in certain types of behaviors. I defend the inclusion of desires and impaired control (...) in the definition, and I flesh out the notion of systematicity central to my dispositionalist framework. I engage the so-called ‘disease vs. choice’ debate, criticizing its presupposition that we are dealing here with a dichotomy and arguing that the movement towards a middle ground is the right track to take. I explain how the dispositionalist account can capture this middle ground and how it serves to expand upon existing views, in particular by filling in the metaphysical details. -/- The second aim is to show how the account I defend can help to unify the extant views and disciplinary perspectives in the literature. Both the dispositionalist aspect of my framework and the methodology adopted (applied ontology and systematic metaphysics) can move the literature towards both substantive and methodological unification. This will help to clear up conceptual confusions, resolve (or sometimes dissolve) apparently intractable disputes, situate different research perspectives with respect to each other, facilitate interdisciplinary dialogue, and help to frame important questions about addiction. Finally, I offer the beginnings of an ontology of addiction, which will provide a terminologically well-structured guide to the addiction literature in a way that will facilitate more effective and efficient communication and data management across disciplines. (shrink)

Technological artefacts have, in recent years, invited increasingly intimate ways of interaction. But surprisingly little attention has been devoted to how such interactions, like with wearable devices or household robots, shape our minds, cognitive capacities, and moral character. In this thesis, I develop an embodied, enactive account of mind--technology interaction that takes the reciprocal influence of artefacts on minds seriously. First, I examine how recent developments in philosophy of technology can inform the phenomenology of mind--technology interaction as seen through an (...) enactivist lens. Second, I show how an enactive account of remembering can improve operationalizations of the memory palace mnemonic through virtual reality devices. Third, I draw on virtue ethics to argue that an enactivist approach allows us to better grasp the morally shaping aspects of artefacts by looking at social robots. Fourth, I fend off an underlying metaphysical concern about enactivism by arguing that an embodied, enactive account is compatible with the multiple realization of cognitive processes. This principle is often seen as a crucial test favouring accounts such as extended functionalism over enactivism and I argue that some forms of enactivism pass this test as well. Finally, I conclude by considering what the future relationship between enactivism and functionalism may have in store for the study of mind--technology interaction. (shrink)