his article develops a set of recommendations for the psychiatric and medical community in the treatment of mental disorders in response to the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, that is, DSM-5. We focus primarily on the limitations of the DSM-5 in its individuation of Complicated Grief, which can be diagnosed as Major Depression under its new criteria, and Post-Traumatic Stress Disorder (PTSD). We argue that the hyponarrativity of the descriptions of these disorders (...) in the DSM-5, defined as the abstraction of the illness categories from the particular life contingencies and personal identity of the patient (e.g., age, race, gender, socio-economic status), constrains the DSM-5's usefulness in the development of psychotherapeutic approaches in the treatment of mental disorders. While the DSM-5 is useful in some scientific and administrative contexts, the DSM's hyponarrativity is problematic, we argue, given that the DSMs are designed to be useful guides for not only scientific research, but also for the education of medical practitioners and for treatment development. our goal therefore is to offer suggestions for mental health practitioners in using the DSM-5, so that they can avoid or eliminate the problems that may stem from the limitations of hyponarrativity. When such problems are eliminated, we believe that effective psychotherapeutic strategies can be developed, which would be successful in repairing the very relationships that are strained in mental disorder: the patient's relationship to herself, her physical environment, and her social environment. (shrink)

How should we define ‘health’ and ‘disease’? There are three main positions in the literature. Naturalists desire value-free definitions based on scientific theories. Normativists believe that our uses of ‘health’ and ‘disease’ reflect value judgments. Hybrid theorists offer definitions containing both normativist and naturalist elements. This paper discusses the problems with these views and offers an alternative approach to the debate over ‘health’ and ‘disease’. Instead of trying to find the correct definitions of ‘health’ and ‘disease’ we should explicitly talk (...) about the considerations that are central in medical discussions, namely state descriptions and normative claims . This distinction avoids the problems facing the major approaches to defining ‘health’ and ‘disease’, and it more clearly captures what matters in medical discussions. (shrink)

This paper argues for the importance of approaching medicine, as a theoretical science, through values. The normative concepts of benefit and harm are held to provide a framework for the analysis of medicine which reflects the obligations of the doctor-patient relationship, suffices to define the key concept of medical relevance, yields a general necessary condition for the basic concepts of medicine, explains the role of such nonnormative conceptions as discomfort, dysfunction, and incapacity, and avoids the mistakes of other normative approaches (...) which hold that unhealthy conditions are disvaluable or should be treated. Neutralist analyses are criticized, especially those approaching health through proper functioning. (shrink)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

In this paper I defend an etiological theory of biological functions (according to which the proper function of a trait is the effect for which it was selected by natural selection) against three objections which have been influential. I argue, contrary to Millikan, that it is wrong to base our defense of the theory on a rejection of conceptual analysis, for conceptual analysis does have an important role in philosophy of science. I also argue that biology requires a normative notion (...) of a "proper function", and that a normative notion is not ahistorical. (shrink)

In the months preceding the writing of this review, bioethics has been in the news a great deal. In congressional and public policy debates surrounding stem cell research, human cloning, and the Human Genome Project, bioethics and bioethicists have gained national attention and been subject to public scrutiny. Commentators have asked who these self-appointed moral experts are to tell us what is right and wrong.

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. (shrink)

Extensive and diverse conceptual work towards developing a definition of ‘mental disorder’ was motivated by the declassification of homosexuality from the Diagnostic and Statistical Manual in 1973. This highly politicised event was understood as a call for psychiatry to provide assurances against further misclassification on the basis of discrimination or socio-political deviance. Today, if a definition of mental disorder fails to exclude homosexuality, then it fails to provide this safeguard against potential abuses and therefore fails to do an important part (...) of the work it was intended to do. We argue that fact-based definitions of mental disorder, relying on scientific theory, fail to offer a robust definition of mental disorder that excludes homosexuality. Definitions of mental disorder based on values do not fare better: these definitions are silent on questions about the diagnostic status of individuals in oppressive societies and over-inclusive of mental or behavioural states that happen to be negatively valued in the individual's social context. We consider the latest definition proposed for the Diagnostic and Statistical Manual-5 in light of these observations. We argue that definition fails to improve on these earlier deficiencies. Its inclusion in the manual may offer false reassurance against repetition of past misclassifications. We conclude with a provocation that if candidate definitions of mental disorder are unable to exclude homosexuality, it might perhaps be preferable not to attempt a definition at all. (shrink)

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. (shrink)

1 Overview of the problem2 Situationally Specific Normal Functioning and Capacities3 Kingma’s Criticism4 How Normal Responses can be Pathological5 Too Many Pathologies?6 Conclusions.

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. (shrink)

There is an apparent epidemic of mental illness. At the end of 2011, untreated mental disorders accounted for 13% of the total global burden of disease, and for 25.3% and 33.5% of all years lived with a disability in low-and middle-income countries, respectively. Depression affects 350 million people globally and is the leading cause of disability. One in five U.S. adults takes psychiatric medication. One study found that by age 32, 50% of people surveyed qualified for an anxiety disorder, more (...) than 40% for a mood disorder, and more than 30% for substance dependence. Another study reported that... (shrink)