## 1. Terminology



The language here is highly contentious. There are exceptions, but in
a long history mental disorders or illnesses have been referred to as
"evil", and "willful error" or, at the very
least, regarded as unwelcome
 misfortune.[1]
 And with some regularity, conditions like those listed in the current
diagnostic and classificatory manual of the American Psychiatric
Association (DSM-5 [APA 2013]) and or the International Statistical
Classification of Diseases and Related Health Problems (ICD-11 [WHO
2020]) have been provided new classificatory titles and terminology,
such revisions often solely aimed at reducing negative and
stigmatizing associations. Authors cited in what follows use
"mental disorder", "psychiatric disability",
"psychiatric disorder", "mental illness",
"madness", "psychopathology"and
"neuro-atypicality". Controversy attaches to these terms,
as it does to particular diagnostic labels (such as
"schizophrenia"). Because some would question whether
these mental differences are forms of illness or disorder at all, the
more neutral but rarely used, "mental difference" perhaps
better accommodates each side of this controversy, so the choice of
"disorder" here is for its greater familiarity, and not
intended to promote a disorder or illness view.



Three changes of language require special attention. With increasing
frequency, the term "*illness*" in "mental
illness" has been replaced by "*disorder*",
apparently without a consistent rationale beyond avoiding explicitly
medical associations. In a parallel recent trend "the
cognitive" and "cognition" are sometimes introduced
as equivalents or replacements for "the mental". This new
language around "cognition" collapses the earlier faculty
psychology divisions of affection and cognition: as much as doxastic
states, emotions are
 "cognitive".[2]
 Finally, increasing use of "mental *and
behavioral",* sometimes shortened to
"behavioral" (as in "behavioral health"),
reflects substantive changes, such as the inclusion of addictions in
the class of disorders, and a preference for precisely measurable
symptoms over subjective report.



Unless otherwise indicated, the expression "mental
disorder" replaces "mental illness" in what follows,
and refers not only to more "mental" conditions like
psychoses and affective disorders, but also to
"behavioral" conditions such as addictions and personality
disorders. Frequently, the shift from 'mental' to
"cognitive" also indicates allegiance to substantive
theoretical tenets. Here, however, "cognitive" and
"cognition" are used only as terms of art within
particular theoretical analyses.


## 2. Folk Psychology, Conceptual Analysis, and Science



Both common sense folk psychology and medical psychiatry employ
concepts of mental disorder or illness, engendering confusion.
("Depression" refers to roughly the same mood states and
attitudes, for example, used by a professionals or non-professionals.)
Inconsistencies arising at the boundaries, where mental disorders meet
other kinds of disorder, add ambiguity. Rather than traditionally
mental symptoms, for example, "hysterical"
("psychosomatic", "somatoform",
"functional" or "conversion") syndromes
exhibit bodily maladies and dysfunction ( Scull 2009). Yet they remain
mental disorders in common understanding, and have long found a place
in standard psychiatric
 classifications.[3]
 Also anomalous, some conditions with apparently mental symptoms are
the causal product of what are, indisputably, diseases of and damage
to the brain. (Delusions following cerebral hemorrhage are an
example.) They are judged to be neurological rather than psychiatric
complaints, and excluded from the class of mental disorders according
to both everyday conceptions, and diagnostic taxonomies. Similarly,
although perception is widely judged a mental capacity, some
conditions affecting sight, such as blindness, are absent from
diagnostic classifications.



There are different views about the conceptual relationship between
everyday and more clinical language about mental disorder, and
philosophers and others have approached this matter according to
varying foundational assumptions. Both commonsense psychology and
conceptual analysis reflecting it, are part of what Rachel Cooper
calls a broadly "descriptive" project, which engages
linguistic intuitions (Cooper 2020). Opinions vary as to the value and
importance of the resulting characterizations. Some insist that the
concept of mental disorder employed in psychiatry's conception
and classification of disorders is too closely allied to the parallel
concepts in folk psychology. According to Dominic Murphy, acceptance
of inconsistent folk psychological categorizing is ill-suited to the
properly scientific taxonomic task which, because it is tied to the
hope for a theory of the "hidden structure" of the
taxonomic domain, seeks causal explanation (Murphy 2012). Without a
principled and systematic way to identify the class of mental
disorders, these concerns suggest, any disorder taxonomy that is
presently employed will likely prove inaccurate, and indicate that the
out-moded, folk psychological category of mental disorder will
eventually be rendered otiose.



More conservatively, others have urged the practical importance of
maintaining the category of mental disorder (Brulde & Radovic
2006). Everyday language and the traditional classifications built
around it have provided a common framework for research and clinical
practice; and with any further blurring of the boundaries between
mental disorders and the brain damage and disease treated by
neurologists, demarcations of professional competence would be lost.
Fear of over-diagnosis, of granting too much power to medical
psychiatry and the psychopharmacology industry, and of relinquishing
to experts decisions about mental health and conceptions of eudaimonia
more appropriately resolved by non-scientists, have all challenged the
societal place occupied by medical psychiatry (see
 SS10).



It is not only for such considerations of practicality and custom that
common sense concepts have been supported. Some analyses adhere to an
account of mind and mental processing employing mentalist terms and
normative presuppositions inapplicable within an exclusively
neuro-physical framework (see
 SS4,
 SS5, and
 SS8).
 Others regard mental disorders as socially constructed entities, the
existence and classification of which are inextricably tied to
societal and interpersonal features of the world (see
 SS10).



A meta-taxonomy of these varying foundational assumptions includes
intersecting issues: what mental disorders are; how much we can
presently know about them; and different approaches to their analysis.
Thus, in one set of contrasts, objectivist (or naturalist) accounts
hold that as empirically discoverable items mental disorders can be
provided value-free description, while evaluativist (or normative)
analyses deny the possibility of such description (discussed in
 SS8.1).
 Revisionists, prepared to relinquish all current concepts, disagree
with conservatives favoring the retention of (at least some)
traditional categories. And, in a final sorting, the nature of mental
disorder will be sought either through *a posteriori*
scientific research based in neurocognitive science, or through
conceptual analysis derived in part or whole from social and cultural
norms.


## 3. The *Mental* in Mental Disorder



In a once-common practice, mental or "functional"
disorders were diagnosed just when no somatic traits were evident.
Such language is now explicitly disavowed, eclipsed by a growing
recognition that all disorders involve bodily states ( APA 2013: 309;
O'Leary 2021). Still, the "mental" in mental
disorder is variously construed.


### 3.1 Internal Causes and Downstream (Symptomatic) Manifestations



On traditional, two-part models from cell pathology, dysfunctional
organic processes internal to the individual are manifested in, and
causally responsible for, more readily observable signs and symptoms;
collectively, these two parts make up the disease. Applied to mental
disorder, certain of those underlying processes have been delimited as
mental by appeal to the traditional categories of faculty psychology
(perception, affection, cognition, memory, and so on). For example,
hallucinations represent dysfunctional perceptual capabilities, mania
and depression disturbed affect regulation, and delusions defective
cognitive processing. A disorder is thus determined to be mental as
distinct from physical if its internal causes involve psychological
faculties (Wakefield 1997). Other accounts ascribe disordered
mentality not to underlying features but to effects on the
subject's social and personal functioning (Rashed & Bingham
2014). For example, it is because her states of sadness and self-doubt
result in absenteeism, that the person with depression seeks medical
help (see
 SS4.2).
 More holistic and "biopsychosocial" accounts combine
these features (see Nordenfelt 1995; Davies & Roache 2017; Bolton
& Gillett 2019; O'Leary 2021).



On two-stage accounts both internal and outwardly-observed features
form integral parts. (At least this is true of mental disorders that
are prototypical, according to George Graham [2013].) Internal and
more readily observable features are each included in the DSM
definition of mental disorder:



> 
> 
> a syndrome characterized by clinically significant disturbance in an
> individual's cognition, emotion regulation, or behavior, that
> reflects a dysfunction in the psychological, biological *or*
> developmental processes underlying mental functioning. (APA 2013: 20,
> emphasis added)
> 
> 
> 



The different positions on mental disorder just
sketched--emphasizing internal conditions, observable
manifestations (or "symptoms"), and both--are
discussed in
 Section 4.
 Each position exhibits vulnerabilities. Accounts stressing inherent
features regularly rely on hypothetical entities or processes,
expecting that out of future discoveries will emerge knowledge of
causal mechanisms presently hidden from view. (This position has a
long history; for a thoroughgoing version, see Murphy 2012.) Often
accounted for by its status as a new science, this faith has been
sorely tested, thus far, by confused classifications, apparently
ill-grounded research, and other liabilities, as well as incomplete
models of mental dysfunction (see
 SS4
 and
 SS6).
 If these impediments can be overcome, emphasis on internal causes may
be expected to yield powerful explanatory models, laying the ground
for incalculably valuable, targeted interventions and effective
prevention and treatment. (See entry on Philosophy of Psychiatry).
Placing emphasis on disabling or dysfunctional observable symptoms has
comparable vulnerabilities. One setting's dysfunctional mental
symptom may be another's normal, admired, or useful trait; and
mental disorder must be distinguished conceptually from deviance, as
well as from normal responses to the losses and setbacks that are our
common human experience (these issues are discussed in
 SS4,
 SS8, and
 SS10).


### 3.2 The Mark of the Mental



In some philosophical accounts including those stemming from
phenomenological traditions, the mental is distinguished by particular
features: it bears a special relationship to conscious awareness, and
to persons, for example, or may be taken to exhibit the distinctive
"aboutness" or intentionality exclusive to mental
attitudes (see
 SS5).
 Similarly, some theorizing emphasizes the reasons-responsiveness of
all human thought and action, by which disorder can alone be explained
and understood (Campbell 2013; Thornton 2007; Summers &
Sinnott-Armstrong 2019).



Explanations in cognitive psychology have taken several different
forms over the years: information processing models, which themselves
were made up of computational processes and representations;
connectionist networks; and, more recently, directly neural accounts.
Moreover, philosophical reconstructions of cognitive psychology and
cognitive science must be distinguished from the cognitive psychology
practiced by psychologists--although little discussion of
"the mental" occurs in either. Instead, focus is on the
cognitive when, as was pointed out earlier, the
"cognitive" subsumes capacities, states, and processes
that used to be considered non-cognitive, such as sensations and
emotions. Widespread acceptance of these shifts in much theoretical
and research writing on mental disorder has gone some way toward
eclipsing more philosophical concepts of mind and the mental, even
though commonsense cognitive capacities, which are understood to
involve intentionality, remain the starting point of the research
program of cognitive science, and branches of cognitive psychology and
cognitive neuroscience address traditionally "mental"
processes such as reasoning and consciousness.



The focus of cognitive psychology usually lies with computation and
representation. Mental/cognitive states (representations) depict
features of the outside world (as well as other mental states and
abstract entities), and mental/cognitive processes operate on those
inner symbols, transforming and manipulating them (see Von Eckardt
1993; Friedenberg & Silverman 2011; Cratsley & Samuels 2013,
and the
 entry on Cognitive Science).
 Although demarcated by the faculties known as "mental",
the realm of the cognitive is typically construed as properties or
processes with a causal role in determining behavior, or behavioral
capacities, that offer no resistance to naturalistic characterization
(Chalmers 1996). Candidates for a distinctive "mark of the
cognitive" are debated--but so is the need for one ( see
Varga 2018; Allen 2017).


### 3.3 Metaphysical Implications



Mental disorders are conditions or states attributed to persons, but
this need entail neither that they are entirely non-physical in
nature, nor that they must (or even can), be explained in solely
neuro-scientific terms. Maintaining the separation between mental and
physical disorders is compatible with some forms of weak physicalism,
allowing that mental or psychological processing involved in functions
such as perception, reasoning and memory, are realized in the workings
of the brain (see Schaffner 2016; Jefferson 2021 and the
 entry on health).
 Problems of both supervenience and emergence theories have been seen
to argue towards the holistic "naturalistic dualism"
entailed in a biopsychosocial model (Bolton & Gillett 2019;
O'Leary 2021).


## 4. The *Disorder* in Mental Disorder



Depression and anxiety, the schizophrenias, obsessions, compulsions
and the like are core instances of mental disorder, but psychiatric
classification acknowledges many other conditions as well. From such a
large and apparently heterogeneous collection, the broad category may
best be judged a family resemblance one. Indeed, through a different
historical or cultural lens, the assembled variations known today as
mental disorders would likely appear incoherently arbitrary. Yet,
spurred by essentialist expectations (and out of concern about the
unwarranted "medicalization" of normal states and
behavior), the quest for a unifying conception of mental disorder
(illness, or disease) has persisted within philosophical research.
Characteristic features have been identified, including disunity,
irrationality, the presence of suffering and disability, several forms
of dysfunction, and even adaptive function. Proposed formal analytic
definitions are illustrated in
 Section 4.4.


### 4.1 Disunity and Irrationality



Works of ancient philosophy are focused more on the psyche's
health (or *eudaimonia*) than its illness. Nonetheless, there
are hints that just as a unified soul is one that is healthy (as well
as rational and virtuous), a soul lacking unity will be disturbed, or
mad. Offering an account of the harmonious soul, whose rational and
non-rational elements achieve unity, Aristotle leaves us a picture of
the warring and fractured state of an unhealthy soul, for
 example.[4]
 The emphasis on disunity is here tied to the vices and irrationality:
a fully unified soul is virtuous and rational, a dis-unified one
vicious and irrational in its unhealthy divisions. And, while adhering
to a different account of the passions and a more knowledge-based and
Platonic analysis of vice, this link with the vices and virtues is
also characteristic of the subsequent Stoic analyses (Irwin 2013). A
conception of mental illness as psychic disunity (as well as an
association between health, rationality and virtue) reoccurs in later
philosophy (in Spinoza, for example), and in psychoanalytic
traditions. Within present-day disorder descriptions, some symptom
clusters readily fit the classical emphasis on disunity (addictions,
and bipolarity, for example); others, including most personality
disorders, are less easily depicted in such terms (see Worrell &
Denham 2016).



As a characteristic attributed to mental disorder irrationality or
"unreason" has been linked to emphasis on order and logic
during the "Age of Reason". Together with the emergence of
empirical science, this emphasis is seen to have laid the foundation
for our contemporary psychiatric categories and
 theories.[5]
 In the present day, cultural norms and intuitive folk psychology
assign the boundaries of mental disorder, and these intuitions
conflict about some particular conditions (addictions, and disorders
of personality, for example). Yet disturbed or disabled doxastic
states and capabilities remain core examples of disorder, over which
intuitive agreement is strong. Characterized by incomprehensibly
disordered thought, failure to adjust beliefs in response to new
evidence, inconsistencies between thought and action, and delusional
convictions, psychosis and psychotic thought patterns are regularly
judged prototypical features of mental disorder. So the rationalistic
analysis of disorder corresponds--but only to a reduced version
of the presently sprawling overall category.



Forms of doxastic irrationality are still the mainstay of much policy
and legal analysis about mental disorder. Assessments of criminal
responsibility, of fitness to stand trial, and of the capacity to
undertake binding contracts, for example, are expressed in terms of
the defendant's ability to know and understand (Reznek 1987;
Robinson 1996, 2013; Adshead 2008). Ostensibly, construing mental
disorder as a want of rationality has been weakened by evidence from
behavioral economics showing that holding and acting on well-grounded
and reasons-responsive beliefs occurs rarely in the general
population, and common prejudices and superstitions seem barely
distinguishable from clinical delusions with respect not only to their
prevalence but to the way they are adopted and maintained (Bortolotti
2009, 2013, 2020).



Confidence that a want of rationality defines mental disorder is
similarly eroded if, understood as effective social function and
personal flourishing, mental health lies in traits such as unwarranted
optimism, and the distorting tendency to emphasize, and remember,
success over failure experiences in "positive
illusions"(Taylor & Brown 1988; McKay & Dennett 2009;
Jefferson et al. 2017). Along these lines, some illusions, delusions,
and hallucinations have recently been acknowledged to be
"perfectly acceptable, sometimes praiseworthy ways of being
hopeful, committed to imagining and enacting a better world for
oneself and others...making moral and meaningful
lives"(Flanagan & Graham 2017: 309)



But as this indicates, whether disorder is usefully characterized as a
want of reason also depends on guiding, normative conceptions of
mental health or *eudaimonia*, and on the role of reason in
those conceptions--not merely on facts of the matter, or on
consequentialist reasoning.


### 4.2 Suffering and Disability



Other depictions of disorder rely on one or both of the groups of
traits around *suffering, distress* and *psychic pain,*
on the one hand, and, on the other hand, *disability,
incapacity* and personal or behavioral *dysfunction*. These
are the features noted in a series of influential prefatory remarks in
the diagnostic and statistical manuals (the DSMs and ICDs). The
wording of the fifth edition of the DSM introduces a disjunction:



> 
> 
> Mental disorders are usually associated with significant distress
> *or* disability in social, occupational, or other important
> activities. (APA 2013 emphasis added)
> 
> 
> 



A very similar passage from the ICD-11 is comparably qualified:



> 
> 
> "Disorder"...is...a clinically recognizable set
> of symptoms or behavior associated *in most cases* with
> distress *and* with interference with personal functions. (WHO
> 2020, emphasis added)
> 
> 
> 



Psychodynamic or psychoanalytic presuppositions may posit underlying
distresses that are masked, or submerged within the psyche; and the
elusive phenomenology of some conditions suggests the presence of
nameless existential anxieties hidden from awareness (Ratcliffe 2008,
2017). But such explanations aside, distress has been widely regarded
as a ubiquitous feature of disorder. In symptom-focused accounts
laying stress on the *consequences* of the syndrome, distress
becomes prominent as a form of disabling dysfunction (Stein et. al.
2010). Instead of separate criteria (and either singly or jointly
sufficient for disorder, as in the respective DSM and ICD definitions
above), suffering and dysfunction are conjoined on a
"distress-impairment" analysis, where disorder status is
assigned with (and defined as) distress that is "unmanageable or
disabling" (Bolton 2013). The plausibility of this analysis
increases with what have been called "distress related
conditions", such as depression and anxiety, that are
"more constitutive of the illness" (Bolton 2012: 10; see
also
 SS4).



To accommodate exceptions that seem neither distressing nor disabling
(such as manic states), mental disorder is sometimes characterized not
by distress and dysfunction but by raised risk of such outcomes (Gert
& Culver 2004). But risk of disorder is not disorder, and risk
language invites troubling ethical issues around over-diagnosis and
false positives ((Schwartz 2008; Stein et al. 2010; Bolton 2013;
Broome, Fugar-Poli, & Wuyts 2013; Radden 2018).



Loosely understood, moreover, distresses such as these are an
inescapable part of the human condition and normal responses to
life's vicissitudes. When and whether normal (and even
appropriate) suffering reflects pathology has long been the source of
philosophical--and societal--disagreement (Wilkinson 2000;
Horwitz & Wakefield 2007). In the discussions of "normal
sadness" that accompanied the revision of a fifth edition of the
DSM, the grief exclusion that had (temporarily) exempted from
diagnosis the suffering around mourning and grief, was challenged, its
proposed elimination charged with "medicalizing" or
"pathologizing" normal and appropriate human feelings
(Zachar 2014; Wakefield 2012, 2020). The separation of normal from
pathological distress will be indicated by distress emanating from the
disorder itself, rather than from other contingencies. But presently,
distresses resulting from the stigma and discrimination that follow
diagnosis and treatment, as well as a host of other, frequently
negative, consequences in jarring and alarming disruptions to personal
lives, selves, and relationships, prove difficult to disentangle
(Tekin 2011).



Some predict that biological markers will eventually allow us to
distinguish distress that is a symptom of depression, for example,
from that which is a normal response to external contingencies
(Horwitz & Wakefield 2007). Such biomarkers may be welcomed by
those decrying over-diagnosis, although an evaluative interpretation
as to whether, and when, such biomarkers occur in healthy and
unhealthy form will be required.



Some argue that the subjective experience of distress and the extent
of impairment of the person's day-to-day functioning are
intrinsic properties of disorders like depression: conceptually,
disorder attributions are made on the basis of "consequences of
the syndrome as they manifest for the subject" (Rashed &
Bingham 2014: 245). Psychological symptoms may *constitute* a
mental disorder, even as it is caused by biological or social factors.
In the absence of known biomarkers, depression is attributed based on
psychological symptoms alone; and were known biomarkers present
without evidence of any psychological symptoms, our intuitions
suggest, disorder attribution would be withheld. These intuitions may
shift with time, it is recognized, depending on how most people and
most psychiatrists *now* understand, define, diagnose, and
treat, depression. But today at least, disorder would be attributed on
the basis of the symptoms of depression with or without biomarkers.
(See Cooper 2020).



Analyses characterizing felt distress as a property constitutive of
some given psychiatric condition (such as depression), are also
compatible with recent models focused on the causally interconnected
statistical networks making up symptom clusters. These clusters are
depicted as reinforced through feedback loops that serve to rope
together assorted symptoms independent of any underlying, antecedent,
common, cause. In the case of depression, a range of symptoms arise
from diverse sources and, through their looping interactions, form,
worsen, and maintain the disorder as a relatively stable entity and
conceptual whole (Kendler, Zachar, & Craver 2011; Borsboom &
Cramer 2013; Borsboom 2017).



Symptom-focused accounts may combine suffering with disability, as was
noted. But a conception in terms of what the affected person is
prevented from doing, or unable to do as well as others, captured in
the ideas of disability, impairment, incapacity and personal or
behavioral dysfunction, offers an alternative characterization that
can acknowledge disorders without apparent personal suffering (notably
mania, some personality disorders, and some addictions).



Dysfunction and disability have been allied, or treated as rough
equivalents; but sometimes disability is placed in opposition to
dysfunction. Instead of construed as internal to the person,
disabilities are often represented as *conditional*
impairments, dependent on context (including physical and social
arrangements). They impose limitations on the person's ability
to perform everyday activities and participate as more typically-abled
people do and, on this view, call for appropriate accommodation
analogous to ramps for those using wheelchairs (Oliver 2004; Polvora
2011). The analogies linking psychiatric with other disabilities may
not be complete, however, nor can accommodations be achieved as easily
as installing ramps (see Amundson & Tresky 2007; Rashed 2019).



Like disability, the deviance eliciting societal censure and
condemnation is also placed in contrast to dysfunction, although
efforts to further characterize that contrast have thus far been
incomplete (Aftab & Rashed 2021).


### 4.3 Dysfunction in Two Stage Analyses



Dysfunction forms a central element of the most widely discussed
analytic definition of mental disorder, introduced in
 Section 3.
 The notion of dysfunction applies in two distinct ways in
Wakefield's harmful dysfunction analysis, one way avowedly
objective, and the other not (see
 SS4.4).
 In the first, dysfunction occurs in some part or parts of a bodily or
neural system. That dysfunction in turn causes dysfunction in some
part or parts of the individual's social and personal system
(grounding the normative judgment of harmfulness). The first kind of
dysfunction permits non-evaluative description, it is supposed.



The characteristic dysfunction of mental disorder is here part of a
standard, *idiopathic* model, as we saw, with these disabling
traits understood as the symptomatic, causal manifestations of an
underlying, pathological process. The appropriateness of that model
for psychiatric conditions has received persistent critique (see
 SS10.1).
 Recent challenges rest on the persuasiveness of network models
(introduced in
 SS4.2),
 where symptomatic dysfunction does not emanate from some disabled
inner mechanism, but instead emerges piecemeal from interacting
experiences that cumulatively build clusters of disabling symptoms out
of feedback loops (Kendler, Zachar, & Craver 2011; Borsboom &
Cramer 2013). In support of this alternative model is accumulating
evidence from the social sciences that a range of factors combine to
bring about disorder: individualistic risk factors, but also aspects
of the broader context in which the individual finds herself (Bolton
2010; Kirmayer, Lemelson, & Cummings 2015). A more fundamental
critique rejects the dysfunction analysis of disorder, favoring
instead a madness-as-strategy account which draws strength from
adaptionism (Garson 2022; See Section 4.4).


### 4.4 Formal Definitions



Eschewing a more formal definitions, analyses such as the
"distress-impairment" one introduced earlier rely on
*prototypical* cases (see Graham 2013, for example), or point
to intrinsic vagueness that must thwart such efforts (Keil, Keuck
& Hauswald 2017). Others are more ambitious, proposing analytic
definitions in terms of necessary and sufficient conditions and even
encompassing other medical conditions as well as mental disorders.
(For those stressing the inseparability and interdependence of mental
and bodily disorder, no important distinction is acknowledged between
mental and physical disorders [Parvan 2015].) (i)-(vi)
below are a sample of these efforts. More recent definitions reflect
increasing recognition that the diversity of the category must
frustrate efforts at a covering definition.


1. *A disease is the absence of normal function of a mechanism or
process in a person that detracts from the person's survival or
reproduction* (Boorse 1977). More recent elaborations on this
early version of the definition emphasize biological function and
statistical normality, so that on a bio-statistical theory,
*diseases are internal states that depress a functional ability
below species-typical levels (relative to age and sex)* (Boorse
1997). Critiques of this definition have challenged its aspiration to
be value free; its introduction of an arbitrarily selected reference
class; and its failure to honor the accepted distinction between
"disease" with its implied defectiveness, and mere
difference (Bolton 2008).
2. *A condition is a mental disorder if and only if (a) the
condition causes some harm or deprivation of benefit to the person as
judged by the standards of the person's culture, and (b) the
condition results from the inability of some internal mechanism to
perform its natural function, wherein a natural function is an effect
that is part of the evolutionary explanation of the existence and
structure of the mechanism* (Wakefield 1992, 1997). Critiques of
this definition occur later in this section and in
 Section 5.
 In addition, definitions in evolutionary theoretic terms introduce a
category of innate risk factors that is belied by the way natural,
social, and individual factors are inextricably interwoven in disorder
(Bolton 2008). And the formulation relies on unsubstantiated,
empirical assumptions about the way natural selection underlies
natural function (Lilienfeld & Marino 1995; Murphy & Stich
2000). The relativism in (a) above has been challenged (Gert &
Culver 2004: 421; Bolton 2008). And rather than exhibiting
dysfunction, at least some mental disorders may be explained
relationally, by traits that are *mismatched* in the
person's context, due to their developmental or evolutionary
features (Garson 2015).
3. *A mental malady is a condition of a person, other than his
rational beliefs and desires, such that he is suffering, or at
increased risk of suffering, an evil (death, pain, disability, loss of
freedom or opportunity, or loss of pleasure), in the absence of a
distinct sustaining cause* (Gert & Culver 2004). The concept
of a sustaining cause is unacceptably vague and inclusive, permitting
conditions to count as disorders that are not, intuitively, disorders
at all (Murphy 2012). For example, some disorders leave permanent,
non-pathological alterations in the character that outlast any
immediate stressors.
4. *A condition is pathological if and only if it is an abnormal
bodily/mental condition that requires medical intervention and that
harms standard members of the species in standard conditions*
(Reznek 1987: 163-4). For criticisms of this definition's
appeal to baseline population norms, and to medical intervention, see
comments on (i), (ii) and (iv) above. Reference to required medical
intervention fails to acknowledge risks of over-medicalization and
over-diagnosis and invokes concerns over enhancement. (See Savulescu,
ter Meulen, & Kahane 2011.)
5. *Diseases involve deprivation, but a disease is a depriving
relation rather than a depriving entity, depending on the patient for
its existence...the person is not conceived as ontologically
diminished or defective because it suffers the deprivation*.
Drawing on Augustine's ontology of disease, bodily integrity,
and the human person, Alexandra Parvan argues that disease
stands in ontologically necessary connection with the patient as
person. (From this is derived a treatment approach based on how the
person relates to the disease, and a goal of reconfiguring the person
as deprived but not diminished [Parvan 2015, 2016].) This
account is limited inasmuch as it requires adherence to its
Augustinian ontology.
6. *Mental disorders are biological kinds whose effects lead to
harmful consequences ... more natural kinds of mental disorders
(e.g. schizophrenia, bipolar disorder) are biological kinds primarily
underwritten by biological mechanisms. More artificial kinds (e.g.,
hysteria, voyeuristic disorder) are social kinds primarily
underwritten by social mechanisms*. (Tsou 2022:10).
7. ... *at least some of the forms (of madness) ... are
strategies for solving problems, coping with aspects of the
environment, regulating one's mental economy ... the
creative problem-solving activity of the human mind, or God's
stern but benevolent hand, or the healing impetus of nature, or an
evolutionary adaptation, a purpose-driven process, a well-operated
machine* ... (Garson 2022:10). If neuropsychiatry ever
succeeds in identifying the defective mechanisms it seeks,
Garson's analysis must be weakened. Moreover, it seems
vulnerable to some of the accusations of complexity-defying
oversimplification that have dogged other adaptationist just-so
stories.


## 5. Phenomenological Approaches



The symptoms of mental disorder are primarily, if not exclusively,
states about which their subject can claim a sort of authority. (Since
in describing these states subjects can intentionally or
unintentionally mislead, such loosely phenomenological [or
"experience-near"] reports--however
necessary--may nonetheless present epistemic limitations as data
(Kontos 2016).) Psychology can provide reliable behavioral assessments
of disorder, and indicate its presence through laboratory performance
tests. But no mental disorder is thus far independently verifiable
(though blood tests or scans, for example). First person reports play
a special part in understanding such disorder for the clinician, or
for the researcher, and those establishing philosophical analyses are
similarly beholden (Flanagan 2011; Varga 2015). Carl Jaspers'
*General Psychopathology*, which combines close, clinical
description with the method and presuppositions of existential and
phenomenological thinkers such as Husserl and Heidegger, has been
widely discussed. This pairing of clinical and philosophical knowledge
makes him one of the undisputed originators of the research field
known as the philosophy of psychiatry and psychopathology (Jaspers1913
[1963]).) Confusingly, not every loosely
"phenomenological" clinical approach focused on the
patient's experience and report adheres to all of the tenets of
the philosophical discipline of Phenomenology derived from these
traditions, however (see Parnas & Sass 2008).



The phenomenological strand of philosophical analysis influenced by
thinkers like Husserl and Heidegger remains focused on immediate,
first person report (for example, self-experience in psychosis (Parnas
& Sass 2008; Madeira, Pienkos, et al. 2019)); disordered temporal
experience (Fuchs 2005, 2013); delusional states (Parnas & Sass
2008; Gallagher 2005, 2013); and affective disturbances (Ratcliffe
2008; Ratcliffe & Stephan 2014; Jacobs et. al. 2014)). In these
traditions neither psychology nor psychopathology are empirical
sciences in the usual sense because they involve distinctive forms of
explanation. Arising within nineteenth century social science, the
hermeneutical approach involving meanings calls for *Verstehen*
(understanding), a distinctive, interpretive way of apprehending human
action. (See Jaspers 1913 [1963]; Phillips 2013,Wiggins & Schwartz
2011; Spitzer & Uehlein 1992.) These differences of approach bring
differing orientations towards fundamentals, and writing following
German and French traditions has been placed in contrast to the
"Anglo-empiricist" approach judged more influenced by
empirical science, and showing greater emphasis on objectivity and
measurement (Mullen 2011; see also Gergel 2012).



These differences bring contrasting theories about psychology as
science. Whether, bypassing diagnostic categories and medical disease
models entirely, symptoms and the subjective life of the patient
should be the main or even sole locus of attention, is one
(Stanghellini 2004); another is whether the experiences associated
with psychosis, particularly, must be categorically divorced from more
typical psychological processes (Sass 2001; Parnas & Sass 2008).
Emphasizing the unique challenges imposed by interpretation in
psychiatry, Somogy Varga has argued for a hermeneutics distinctive to
psychiatry that is grounded in ideas about the self-interpreting
aspect of human beings, "mental disorder" thus standing in
an asymmetrical relation that is supervenes on our self identities
(Varga 2015).



There is disagreement over the correct application of phenomenological
method (Mishara 2007; Sass, Parnas, & Zahavi 2011). But
psychopathology likely offers a challenge so great as to call for a
range of approaches (Ratcliffe 2011; Wiggins and Schwartz 2011;
Gallagher 2013). Attempts have also been made to combine
phenomenological with empirical approaches: Matthew Ratcliffe's
work on affective states employs social research methods, for example
(Ratcliffe 2008; Ratcliffe & Stephan 2014). And efforts to tie in
phenomenological theorizing with findings in neuroscience have yielded
the hybrid methodology of phenomenological clinical neuroscience
advocating an initial study of subjective experience to *only
then* be probed for its underlying neurobiology (Mishara 2007:
34).



The merging of empirical and phenomenological methodologies is also
readily supported by the tenets of embodied and enactive cognition.
Conceptions of the embodied, embedded, and sense-making enactive mind
bring emphasis on the way, shaped by perceptual experience,
consciousness and the first person perspective form the basis of all
mental processing (Varela, Thompson, & Rosch 1991; Durt, Fuchs,
& Tewes 2017; Di Paolo & De Jaegher 2017). Applied to mental
disorder, this departure from classical cognitivist assumptions and
analogies suggests that at least some disorder grows out of
disturbances in embodied interaction with the environment, and not
from dysfunctions occurring in high-level cognitive mechanisms
(Drayson 2009; Stanghellini 2004, 2016; Maiese
 2016).[6]


## 6. Classification



While
 Section 3
 focused on what might separate mental from non-mental disorders, and
 Section 4
 was concerned with how to separate disordered from non-disordered
states, Section 6 addresses another aspect of classification:
controversies over how different types of putative mental disorders
should be distinguished from one another. These controversies, like so
many about psychiatry, span the disciplines of medicine, science
(including neuroscience and psychology) and philosophy.



The diagnostic and statistical classificatory manuals and
international disease classifications (DSMs and ICDs) share broad
features in providing a categorical scheme of separate mental
disorders: each disorder is idiopathic in arising at least in part
from morbid factors within the person, and each is identified
"descriptively", using polythetic (disjunctive) criteria
to be employed with clinical observation of individual patients
(including their self-report). Aside from serving the institutions
providing services, their uniformity is aimed to enhance
inter-diagnostician reliability; and research based on these reliable
classifications, it had been hoped, should eventually allow validation
of the categories, although failure to achieve this promised yield in
research findings has been conspicuous, and partly motivated the
revised research domain criteria (RDoC), described later in this
section.



Following early work by Carl Hempel (1961) that depicted
psychiatry's claim to scientific status as depending on the
value neutrality of its classifications, much philosophical discussion
of classification has been entirely critical, conceding little
usefulness to the approach, skeptical of the promise of validity,
doubtful of its methodology and claims to scientific authority,
un-persuaded by the categorical system employed, as well as its
individualistic and idiopathic emphasis, and dubious over its claim to
being, or being able to be, value-free. Philosophical analysis has
often been focused on particular symptom descriptions, disregarding or
disavowing the diagnostic categories of which they are presumed to be
clinical manifestations, in some cases introducing and employing
revised categories such as "distress related conditions"
(Bolton 2012), "body image disorders"(Morris 2013), and
"real hallucinations" (Ratcliffe 2017). Others have
accepted the entities so classified (Sass, Zahavi, Frith and
colleagues, for example).



Criticisms of DSM and ICD classifications have addressed their
research purposes and usefulness, categorical approaches and supposed
value-neutrality. (The claim to value neutrality is discussed in
 Section 8.
 These classifications recognize the presence of many overarching
values, including the methodological ones implicit in their goals of
achieving validity and reliability. But further, unsupportable values
(such as homophobia and misogyny) have been identified as well.)


### 6.1 Research Purposes and Usefulness



Even by those within psychiatry, it has been widely concluded that as
tools for research, the prevailing classifications are flawed,
producing findings that tend to be inconsistent, non-replicable,
non-specific, or ambiguous, with the categories involved exhibiting
problems of construct and predictive validity, as well as imprecise
phenotypic definitions, widespread heterogeneity, and extensive
comorbidity (Cuthbert & Insel 2013; Poland 2014; Poland & Von
Eckardt 2013; Tsou 2021). In partial defense of DSM-type
classifications, Elizabeth Lalumera points out that mental disorders
may correspond to theoretically informed and thus far incompletely
understood *concepts*, in contrast to descriptive
*conceptions* sufficient for identification practices in
diagnosis and care (Lalumera 2016)



Research-related concerns have led to the issuance of new, dimensional
criteria by which the research domain is to be approached (Revised
Domain Criteria, or RDoC). Separate units of analysis (genes, cells,
circuits, self reports, etc.) are each employed in specific research
domains (such as positive and negative valence systems, cognitive
systems, systems for social processes, and arousal/regulatory
systems), and the intersections of units of analysis with research
domains produce segments of a spectrum linking normal and atypical
features. Whether RDoC's goals are entirely compatible has been
questioned, but the aim here is to promote both more accurate research
and more effective treatments (Cuthbert & Insel 2013; Perring
2016; Morris, Sanislow et. al. 2022). And while answering some of the
concerns about the earlier classificatory model, RDoC has in its turn
been criticized: for its conception of validity; its assumptions about
the uniformity of normal distributions; its continuing acceptance of
clinical and medical presuppositions assigning disorder to the
individual rather than the broader social context; its finding little
place for personal agency, and assuming a traditional, individualistic
and autonomous model of self challenged by today's philosophical
analyses. (See essays in Poland & Tekin 2017; Tabb 2019.)


### 6.2 Categorical and Dimensional Approaches



Psychiatric classifications have often adhered, entirely or in part,
to a nineteenth century, Kraepelinian model, where each disease is a
discretely bounded entity, made up of a symptom cluster emanating from
underlying organic states or processes within the individual patient.
But the applicability of this model to mental disorder has been
challenged. Some would replace its idea of validity (involving a
relation between classificatory name and underlying disease) with the
statistical concept of predictive or prognostic validity, which
proceeds without reference to underlying causes. Rather than
discretely bounded, many disorders appear to be continuous with normal
states, and in an interpretive and definitional choice, over which the
data remains ambiguous, mental disorders arguably represent no more
than tails of normal distributions of particular traits in the general
population - although the uniformity of these normal
distributions has also been questioned (Zachar 2014;Poland & Tekin
2017; Machery 2017).



Some diagnostic conditions (post-traumatic stress disorder, most
unarguably) apparently arise from their subject's surrounding
social, economic, and cultural context. Even those with more claim to
idiopathic genetic, neurological, or biological causes as predisposing
factors are recognized to exhibit a course more strongly influenced by
environmental and epigenetic than any fixed inherent factors -
thus putting further pressure on the "common cause"
hypothesis, whereby a syndrome is explained by a single inherent
feature or set of features (Borsboom & Cramer 2013). Solely
internal, organic states and processes, and genes, cannot alone
explain all, and probably any, diagnostic disorders.



With their hypothesized common causes awaiting discovery, categorical
analyses present problems (such as the risk that allied symptoms may
not prove to emanate from a single common cause). But dimensional
approaches make more evident the so-called boundary problem (Rashed
2021) of where to assign the line between normal variation and
disorder. Theoretically, the "common cause" in categorical
analyses serves as an anchor uniting the often disparate and variable
observable symptoms making up a given disorder. (It is a feature that
justifies the nomological approach of diagnostic classifications.)
Aside from this theoretical solution, categorical models are similarly
beset by boundary (fuzzy edges) problems. The presence of disorder is
preceded and followed by a halo of prodromal and postdromal symptoms,
over which clinical (and everyday) judgements are often unresolved.
These boundary issues remain regardless of the model adopted. In an
explicitly normative attempt to resolve an aspect of the boundary
problem as it occurs in social and political contexts, Mohammed Rashed
employs criteria governing recognition of social identities as a guide
to pathological status (Rashed 2019, 2021).



Expanding with each new addition, the collection of disorders
enumerated and described in psychiatric classifications has prompted
alarm over the boundaries of mental disorder, the erosion of normal,
mentally healthy states and variations, and the inappropriate role
played by medical psychiatry and, finally, science, in dictating norms
of healthy psychic functioning. Philosophical criticisms of
"medicalization" emphasize the increasing influence of
neuroscience in transforming cultural expectations and diminishing
individual agency, and the power over psychological norms exhibited by
the psychopharmacological industry (Phillips 2009, 2013; Rose &
Abi-Rached 2013; Moncrieff 2008; Sadler 2005 , 2013, Whitaker &
Cosgrove 2015).



In contrast to these commonly-voiced apprehensions about
over-medicalization, there remains the persistent charge of
*under-*diagnosis and *under*-treatment of those with
diagnosable mental disorder, often attributed to stigma, and to the
socioeconomic status of under-served communities. Epidemiological
findings about the incidence of disorder, as distinct from its
diagnosis, are notoriously insufficient, however, quite apart from a
want of independent biomarkers, due to self-stigma and fear of
discrimination, for example, but also to distorting placebo effects,
and to research methods misleadingly susceptible to false positives
(Jopling 2009; Horwitz & Wakefield 2007; Poland & Von Eckardt
2013)). The actual epidemiological data remains opaque and equivocal,
leaving these contrary speculations unresolved and likely
unresolvable.



The DSM and ICD diagnostic classifications have been remarkably
influential worldwide: today, they appear almost immovably permanent.
But viewed within their broader moral, political, and social context,
which includes psychiatry's apparently uneven provision of
effective treatment, the appropriate stance to adopt towards them, as
Christian Perring has pointed out, remains critical and skeptical
(Perring 2016: 87).


## 7. Natural Kind Status



Philosophers of science have explored whether all or some mental
illnesses might be classified as natural kinds, the claim made about
particular diagnostic categories or symptom clusters (depression,
schizophrenic disorder, and autism, for example), as well as about
separate symptoms (Cooper 2007; Samuels 2009; Tsou 2021). With
recognition that even the category of biological species would not
meet an essentialist criterion for natural kind status, a
"homeostatic property cluster" account of natural kinds
has been proposed (Ellis 2001; Cooper 2007; Murphy 2012; Samuels
2009). (See entry on Species.) A natural kind must be able to ground
explanations and inductive inferences, and enable effective human
intervention. Linked by shared causal properties such as genes, on
this view, their homeostatic aspect ensures that property clusters
making up separate disorders (or symptoms) will remain stable enough
to behave the same way in response to the same conditions, due to a
similarity-generating mechanism explaining their co-occurrence. (See
essays in Kincaid and Sullivan 2014.)



Psychological categories may resemble biological species in some
respects. But differences here have often been seen as profound, as
three examples will demonstrate. (i) Some have taken psychological
categories to represent a different order of being, as we saw in
 Section 5,
 with its own distinctive forms of causal explanations (Jaspers 1913
[1963]; Bolton 2008; Wiggins & Schwartz 2011; Kusters 2016). (ii)
Others point out that psychological categories can alter, and
eventually even be altered by, the persons they classify, forming
"interactive" kinds through such looping effects. Indeed,
mental disorders have been denied the status of natural kinds because
instability in their properties results when they have been classified
and labeled (Hacking 1995). And (iii), some have tried to show that
the relation between mental illnesses and biological kinds differs
according to the role played by values in establishing the taxa of
mental illness (Wakefield 1992; this claim is discussed in
 SS8).
 None of these differences has gone un-criticized. A thoroughgoing
mind to brain reductionism would reject (i). About (ii), it has been
pointed out that the classification of biological species is also
subject to the instability wrought by looping effects (Khalidi 2010).
And similarly, it has been argued in response to (iii) both that
values also enter into the classification of biological species, and
that once we reach the categories of interest in this analysis,
non-evaluative traits form the observable taxa of such species (Cooper
2007).



Although the diverse ends to which disorder taxonomies can be put
argue against finding a single answer about the kind status of mental
disorders, focus on the purposes served by disorder language and
categories has proven fruitful, here. (i) Mental disorders have been
assigned to a category of "practical kinds", where
membership in this class depends on some external criterion that is
pragmatically relevant in the clinical context, such as a certain
degree of functional impairment, and remains unrelated to the
underlying structure of the kind (Zachar 2014). Moreover, they may be
further classified according to their status as dimensional, discrete,
and fuzzy kinds, and there is little reason to suppose that each and
all conform to any one of these (Haslam 2002, 2014). (ii) Whether or
not they exhibit the stability required of classifications into true
natural kinds, these disorders do possess the properties relevant, and
sufficiently stable, to guide clinical treatment, Serife Tekin
illustrates, using the lack of illness awareness
("insight") common in patients with some diagnoses (Tekin
2016).


## 8. Values and Mental Disorder



Values have unfailingly played a part in the way mental disorders are
classified, conceptualized, experienced as personal diagnosis, and
treated. Philosophical accounts differ over the possibility of a
value-free science of psychiatry (these are considered in
 SS8.1).
 Values also affect societal and personal attitudes towards disorder
and diagnosis, in ways that are more immediate, considerably more
urgent, and morally consequential (see
 SS8.2).
 Some of these issues are dealt with in bioethical research directed
specifically towards psychiatry
 (SS8.3).


### 8.1 Evaluativism (Normativism) and Objectivism (Naturalism)



Present day conceptions, classifications, and attributions of mental
disorder contain many values, some explicit, others implicit, some
moral, others non-moral. Unacceptable bias has been repeatedly
identified, exemplified in categories such as homosexuality (with its
homophobia), pre-menstrual syndrome (unwarrantedly assigning disorder
status to normal function), masochistic personality disorder
(pathologizing misogynist gender roles), and oppositional defiant
conduct disorders (exhibiting racial bias) (Sadler 2005, 2013; Potter
2014; Poland 2014, Gagne-Julien). As in all medicine, the
prefixes of "illness"and "disorder," like
"disease," already declare values such as the preference
for health over ill-health. A theory of values based medicine (VBM)
emphasizes that values over mental health are particularly
contentious, requiring distinctive forms of negotiation in clinical
practice (Fulford 2004, 2014).



The central philosophical question is whether moral values are
inescapably attached to the conceptualization and classification of
mental disorders at the level of theorizing, forming an inherent part
of their definition. Such "evaluativism"
("normativism", or "constructivism") is placed
in contrast to "objectivism" ("naturalism"),
which seeks a value-free account of mental disorder. Debates over
these questions have long dominated philosophical research on mental
disorder, many played out around attempts to define mental disorder in
ways that are value-free (see
 SS4).



As was shown
 (SS4.4),
 philosophical definitions aiming to avoid all values appeal to
allegedly value-neutral statistical norms, and adaptive function,
respectively. The vulnerability in Boorse's (1997) statistical
definition, where normal function is determined according to the
person's reference class identified by such criteria as age, and
sex, lies both with assigning the appropriate reference class, a
process that re-introduces values, and at the point on a continuous
distribution curve where deviance from the mean is granted the status
of dysfunctional (Bolton 2008). Recognizing that a trait may be
dysfunctional in evolutionary terms without being disvalued, and
disvalued without being evidence of dysfunction, Wakefield's
two-part definition explicitly accommodates the evaluative element
marking the category. This attempt to provide a naturalistic and value
free evolution-based account of "function" and
"dysfunction" has been subject to a range of damaging
objections, including the claim that with its preference for
evolutionary fitness, biological dysfunction is not, as promised,
value neutral, even in the first half of the definition. Discerning
what would be the maximal response in terms of perpetuating the
species represents another of these objections, since no agreed-upon
conclusion about this can be drawn in a value-neutral, or perhaps any,
way. (See Murphy & Stich 2000; Faucher & Forest 2021; Garson
2022.) Critiques of more general disease definitions are also
applicable mental disorder. (See Powell & Scarffe 2019.)



Evaluativism and objectivism are customarily depicted as incompatible
contraries, although the different domains where claims about disorder
occur (including ordinary usage; conceptually clean versions of
"health" and "disease"; the operationalization
of dysfunction, and the justification for that operationalization),
indicate need for a more nuanced analysis of the role of values in
health and disease (Kingma 2014). The broad contrast between
evaluativism and objectivism has also been resisted for other reasons.
Judgments about mental disorder need not be entirely arbitrary and
subjective as long as those values are taken to be real features of
the world along the lines of McDowell's secondary property value
realism, for example. In this relaxed naturalism, objectivism merely
means requiring no special subject for the disciplining, conception,
and framing of judgments, and providing a contrast between correct and
incorrect, or truth and falsity, for the relevant judgments (Thornton
2007).


### 8.2 Societal and Personal Attitudes Towards Disorder and Diagnosis



The present discussion concerns evaluations that are primarily
negative, although as we saw earlier, positive evaluations arise in
traditions valorizing madness, and many in the neuro-diversity
movement insist that autism spectrum and other mental disorders are
unexceptional human variations analogous to differences of gender,
which ought to be granted respectful accommodation, not clinical
treatment. (See Hoffman 2019; Chapman & Carel 2022.) Negative
social attitudes towards observable disorder have led to stigma,
self-stigma, and discrimination (Hinshaw 2009). The madman and
madwoman have been the subject of fear, misunderstanding,
disparagement and condemnation, their failings exaggerated and
humanity denied (Gilman 1985). With modernity, care and protection
apparently replaced earlier, moralistic and neglectful arrangements.
(The reforms' real effects and costs remain an unsettled matter
of historical
 debate.[7]
 ) At the same time formal exceptions and protections, such as the
insanity defense, recognized mental disorder as an exculpating excuse
for wrongdoing and negligence. Despite such attitudinal change,
however, these issues around responsibility remain contentious and
unresolved (Pouncey & Lukens 2010; Singh, Sinnott-Armstrong &
Savulescu 2013; Schramme 2014).



The effect of diagnoses on those so distinguished has been
demonstrated to be extensive, often personally transformative, and
usually not benign. The extent of these effects has drawn research
attention to first-person report, and to the eloquent madness memoirs
increasingly available for study. It has led to theorizing within
formal philosophical writing, and also within the rhetoric of social
movements and identity-focused political interest groups (see
 SS10).
 The Recovery movement, for example, stresses the way the self and
identity are diminished by diagnosis, which erodes and occludes
equally important and more positive, attributes making up the whole
person. (See Davidson 2013.) Critiques of diagnosis place emphasis on
its dehumanizing and "objectifying" effects that,
magnified by stigmatizing societal attitudes, engender self-stigma (
Hoffman & Hansen 2017; Hinshaw 2009; Thornicroft 2006). More
recently, however, social media and our hyperconnected contemporary
existence are seen as issuing in a less stigmatizing and
discriminatory world, where some particular disorder diagnoses form
social identities (Sulik 2011).


### 8.3 Psychiatric Bioethics and Neuroethics



Societal attitudes towards mental disorders, added to features
associated with such disorders themselves, have given rise to a
bioethics differing in emphasis from that addressing ethical issues in
most of general medicine. Widespread stigma about such disorder raises
extra privacy and confidentiality issues, for example. Because of the
powerful and disruptive effects of the experience of disorder,
conceptions of disorder, and its treatment are often linked to the
self and identity of the subject in distinctive ways (Tekin 2019). The
compromised perceptual, affective, and reasoning capabilities that at
least temporarily mark severe disorder are seen to jeopardize the
widely-valued traits of rational autonomy, responsibility, and
coherent and unified personhood, leading to challenges over agency and
decisional capacity (Radoilska 2012; Sadler, Fulford, & van Staden
2015). And most significantly, treatment regularly employs coercive
methods.



These coercive practices are judged of serious moral concern. For
example, coercive treatment seems to jeopardize rights proclaimed by
the United Nations Convention on the Rights of Persons with
Disabilities (2006). Important philosophical issues here include
whether there are person-centered and more paternalist principles that
would respectively obviate, and justify, coercive treatment; how to
define coercion; what constitutes valid consent; and links between
coercion and stigmatizing consequences (Kallert, Mezzich, &
Monahan 2011; Szmukler 2016; Cratsley 2019; Pouncey & Mertz 2019).
Recent theorizing addresses "mental disorder
exceptionalism" (different treatment for mental and physical
conditions), proposing tests for everyone with reduced capacity,
regardless of cause (Szmukler & Dawson 2011).



Aside from legal and moral liability, disorders affecting volition (in
addictive and compulsive behavior) have been considered in light of
the moral capacities associated with attributing full adult
responsibility. Efforts to ground the intuition that sufferers from
these conditions are less than fully responsible agents have appealed
to "deep self" and also "reasons
responsiveness" theories of responsibility. Neither theory alone
has been found to readily accommodate the collection of symptoms
associated with this group of disorders (Schramme 2014; Summers &
Sinnott-Armstrong 2019).



The related field of neuroethics explores developments and prospects
in neuroscience possessing increased urgency, or distinctive
relevance, for psychopathology. (See Bluhm, Jacobson, & Maibom
2012; Roskies 2007; Glannon 2015; Caruso & Flanagan 2018.) For
example, encroachment on "mental privacy" can be expected
to disproportionately affect those with stigmatized genders, disorders
and symptoms; and a future can be envisioned in which the semantic
authority of first person symptom descriptions is undermined by
diagnoses independently verified through imaging or other technologies
(Maibom 2012). More generally, this new knowledge seems likely to
foster a trend from the treatment of disorder to its prediction based
on observed risk factors, which in turn permits initiatives such as
the identification and treatment of early onset,
"prodromal" conditions in younger subjects (children and
youth), likely affecting identity development and self-management
(Broome, Fusar-Poli, & Wuyts 2013; Whitaker & Cosgrove 2015;
Radden 2018). (See entries on Philosophy of Neuroscience, and
Neuroethics.)



Responsibility concepts, together with those around personhood,
autonomy, diminished capacity and individual rights, make up an
inescapable aspect of the broad field of psychiatric ethics. Areas of
recent research concern responsibility and blame. Attitudes of blame
are customarily treated as an appropriate sequel to assigning
responsibility (Watson 2004), but Hanna Pickard uncouples
responsibility from blame. At least for the apparently willful
behavior of those diagnosed with disorders affecting agency, she
argues, the proper stance for the care-giver is grounded in an
empathic attitude that assigns responsibility without blaming, because
it is one most conducive to improvement and recovery (Pickard
2011).



Closely related responsibility issues involve the personality
disorders which, due to their long-recognized relationship to more
normal character weaknesses, and their evidently dimensional nature,
sit uneasily within psychiatric classifications (Sinnott-Armstrong
2008; Pickard 2011, 2016). One DSM grouping (cluster B personality
disorders, including borderline, narcissistic and antisocial), are
better approached using persuasion, and methods reminiscent of the
"moral treatment" of earlier times, Louis Charland argues
(Charland 2004).



Philosophical challenges to customary moral, ethical, and medical
presuppositions introduced in this section have been influenced by,
and are difficult to separate from, critiques of medical psychiatry
that have taken place not only within academe, but also beyond it.
These are discussed in
 Section 10.


## 9. Particular Psychopathologies



While often more ambitious and encompassing, philosophical attempts to
define or characterize mental disorder have also provided
finer-grained analyses.(See chapters in Fulford, Davies et al., 2013;
Moseley & Gala 2016; and Tekin & Bluhm 2019.) Beyond research
into the symptom clusters classified as the schizophrenias, that are
widely regarded as candidates for some kind of natural kinds status,
analyses have been offered for *anorexia and other eating
disorders* (Gadsby 2017a, 2017b, 2020;Bordo 1993; Giordano 2005,
2019; Svenaeus 2013; Morris 2013; Tan, Hope & Stewart 2003, Tan,
Stewart, Fitzpatrick & Hope 2010; Radden 2021); *addiction*
(West 2006; Poland & Graham 2011; Flanagan 2017; Vohs &
Heatherton 2000; Holton & Berridge 2013; Foddy & Savalescu
2010; Summers 2015; Lewis 2015; Levy, 2006, 2011, 2013; Kennett 2013;
Sripada 2018; Westin 2020; Glacken, Roberts & Krueger 2021;
Pickard 2016); *anti-social personality disorder*
(Sinnott-Armstrong 2008; Adshead 2013; Roskies 2003; Schramme 2014;
Levy 2007;Kennett & Fine 2008; Maibom 2014; Justman 2021);
*depressive and manic-depressive conditions* (Varga 2016; Bluhm
2011; Bluhm, Jacobson & Maibom 2012; Horwitz & Wakefield 2007;
Wakefield 2012; Bolton 2013; Hoffman & Hansen 2017; Ratcliffe
& Stephan 2014; Browne 2018; Radden 2013; Radoilska 2012; Biegler
2011; Fuchs 2001, 2005, 2013); *scrupulosity, Obsessive-Compulsive
and other volitional disorders* (Glas, 2013; Szalai 2016; Summer
& Sinnott-Armstrong 2019); *anxiety* (Horwitz &
Wakefield 2012); *autism spectrum conditions* (Adams 2013;
Baron-Cohen, Lombardo & Tager-Flusberg 2013); disorders of
dissociation (Worrell & Denham 2016; Maiese 2016); Defiant
Disorder (Potter 2014); Borderline Personality Disorder (Potter 2009)
and *Premenstrual Dysphoric Disorder* (Gagne-Julien
2021).



The category of psychosis, employed for extreme states of disorder
affecting perceptual capabilities (in hallucinations) and reasoning
(in delusions and other cognitive defects) have received considerable
philosophical attention. With almost unfailing consequences for their
subject in clinical, legal, social, and personal settings, the
severity of hallucinations and delusions serves to distinguish them
from many of the general controversies about disorder noted thus far.
The incidence of and pathology associated with hallucinations has been
questioned, as has their origins, and phenomenology (Leudar &
Thomas 2000; Ratcliffe 2017; Henriksen, Raballo, & Parnas 2015).
And delusions have attracted the particular attention of philosophers
for their incomprehensibility, and challenge to theories about
meaning, language, belief, and intention (Coltheart & Davies 2000;
Fletcher & Frith 2009; Bortolotti 2009, 2020; Miyazono 2019; Evans
2022). They have also been the impetus for important collaborative
work between several sciences: in addition to being psychiatric
disorders delusions occur as symptoms of neurological diseases of and
injury to the brain, and as such have been subject to considerable
empirical study. Philosophical research on delusions primarily
addresses issues their intelligibility; their status in relation to
more normal doxastic states; and their place in explanatory
models.



The intelligibility of delusions remains contested. Delusions are
expressed using unexceptional syntax, and some involve content that,
while inaccurate or implausible, is entirely comprehensible. These,
Jaspers insisted, are secondary delusions; primary delusions, in
contrast, are distinguished by their meaninglessness: attributing
meaning to them is a misapplication of the hermeneutic approach
(Jaspers 1913 [1963]; Gorski 2012). Others have adopted the position
that all delusions are meaningless utterances (Berrios 1991), and
findings in brain science have been employed to confirm that (Gerrans
2014). In contrast, it is argued that delusions are always
comprehensible, but only within a context that includes the
person's whole life, ideas and values, and recognizing
non-literal interpretation (Bentall 2004; Wickham & Bentall 2016,
Mullen & Gillett 2014; Glover 2014; Jeppsson 2021; Gipps
2022).



Delusions are belief-like, but disagreements arise over whether they
are beliefs, imaginings, an incomplete form of one of these two, or a
distinct hybrid form. The doxastic position (delusions are beliefs)
must somehow accommodate that compared to typical beliefs, delusions
are not responsive to countervailing evidence, and are only weakly
behavior guiding. (See Flores 2021 and entry for Delusions.)
Associated more with imagining than with believing, these same
features have led to the assertion that delusions are imaginings
mistakenly identified as beliefs (Currie & Ravenscroft 2002;
Broome & Bortolotti 2009), or the hybrid concept of
"bimagining" (Egan 2009).



Increasingly, explanations of delusions are multi-factorial.
Influential early models that grew out of research on single-themed
delusions resulting from brain damage, such as Capgras, hypothesized
two deficiencies: an initiating aberrant experience or perception due
to brain dysfunction, combined with some failure of the system of
"belief fixation" by which initial beliefs are critically
reviewed in light of other information (Davies et al. 2001; Davies
& Davies 2009; Young 2011). The second factor in such "two
factor" theories is faulty inference, and is on some accounts
distinguished by degree alone from common forms of reasoning error
such as attribution bias (Bentall 2004). On "prediction
error" models, perceptual aberrations conflict with prior
(Bayesian) expectations when accompanied by reasoning bias, giving
rise to delusions (Stone & Young 2007; Mishara & Corlett
2009). The "polythematic" and complex delusions more often
seen in the psychiatry clinic, that are partially driven by social and
environmental factors, present significant challenges for cognitive
science, since they involve the higher cognitive systems that
apparently resist modular analysis and decomposition.


## 10. Anti-psychiatry, Feminist Theory, Post- and Critical- Psychiatry, Neurodiversity and Identity Politics


### 10.1 Anti-psychiatry



"Anti-psychiatry" has come to stand for ideas from
mid-twentieth century thinkers such as Thomas Szasz, R.D. Laing, and
Michel Foucault. Many of these involved social and political critiques
and calls to action, with real-world consequences that have been
linked to deinstitutionalization, human rights movements, and a shift
towards more autonomy-focused mental health care. In English language
theorizing Szasz and Laing rejected the appropriateness of analogizing
particular "problems in living" (Szasz) with medical
disorders, insisting that misapplication of the medical model to
mental health was emblematic of the overreach of the medical
establishment. The practices and discourses within society and its
institutions making up the era's *episteme* are depicted
historically by Foucault, the focus on the exercise of psychiatric
power that, arising with modern science, is increasingly exerted
through mechanisms of protection, surveillance, and control. With
modernity, on this account, power is no longer brute force. Instead,
it takes a more diffused and subtle form that imperceptibly
disciplines and controls not only bodies, but selves (Foucault 1965,
Bracken & Thomas 2010, 2013; Rose 2010; Iliopoulos 2012).
Foucault's sweeping ideas remain central to the "post
psychiatry" and "critical psychiatry" that have
emerged during the beginning of the twenty-first century.


### 10.2 Feminist Theory



Interwoven with these ideas from the start have been critiques from
feminism and feminist theory. These include acknowledgment of the
women's actual, unwarranted, institutionalization, as well as
emphasis on harms of disempowerment and silencing (Kristeva 1987
[1989]), and of epistemic injustices (Dotson 2011; Kidd, Spencer &
Carel 2022; and see entry on Feminist Social Epistemology). In a
legacy affecting mental disorder even today, binary conceptualizations
have assigned women and the feminine to illogicality, emotionality,
subjectivity, the bodily, and madness, in contrast to men's more
valued traits (G. Lloyd 1984; Potter 2009). Feminist thinkers have
focused on the medicalization of women's normal traits, as well
as research neglect and distortion of gender-linked disorders;
separate and unequal treatments; the mental health vulnerabilities
associated with traditional women's roles and identities; and
diagnosis and treatment understood as tools of patriarchal social
control (Russell 1995; Ussher 2011; Gagne-Julien 2021).



Feminism has consistently rejected traditional causal explanations of
women's disorder derived from allegedly natural biological
predispositions, pointing instead to the effects of women's
oppressive socialization and to the consequences of devaluing
women's characteristics and abilities (Bluhm 2011). Similarly,
it has emphasized the embodiment, and relationality, of the self and
avoided the methodological individualism associated with psychiatric
medicine (Bluhm, Jacobson, & Maibom 2012). Influenced by social
theory and phenomenological approaches, more recent work focuses on
the intersection of gender with marginality, invisibility,
non-normativity and oppression in lived experience (Nissim-Sabat 2013;
Zeiler & Folkmarson Kall 2014).


### 10.3 Post and Critical Psychiatry



Objections to the modernist presuppositions of psychiatry also take
issue with the model by which disorder reflects flawed brain
mechanisms or processes, serving to enhance the status of psychiatry
and disempower those diagnosed with disorder (Bracken & Thomas
2005, Iliopoulos 2012). The new brain sciences will magnify this
disempowerment, it is argued, with the agency and authority previously
attributed to persons replaced by a bio-scientific "management
of the mind" (Phillips 2009, 2013; Rose and Abi-Rached 2013). A
more recent descendant of mid-twentieth century writing is the
collection of concerns known as critical psychiatry: critiques of the
influence of the pharmacological industry (Phillips 1996, 2013;
Moncrieff 2008; Whitaker & Cosgrove 2015; Karp 2017); a discourse
around mental disorder that, influenced by hermeneutics, aims to be
more sensitive to the meaning of symptoms (Bracken & Thomas 2010);
and the promotion of a more equal and collaborative relationship
between carers and those they treat (Double 2006; Cohen & Timimi
2008).



Associated with these ideas is growing recognition of the unique
expertise of "service users" or "survivors"
for understanding mental disorder, and the importance of its inclusion
for research (Faulkner & Leyzell 2000; Gergel 2012; Cooper 2017;
Bueter 2018). These innovations have been analyzed appealing to
critical theory, narrative research methods, the impediments to
representational authority, and the co-production of knowledge
(Voronka 2016; Russo & Sweeney 2016).


### 10.4 Neurodiversity



As the most recent among this range of broadly 'anti
psychiatry' positions, neurodiversity offers a coherent account
and has come of age within a cultural *episteme* that seems
hospitable to it. Mental differences, it asserts, are equally natural
and valuable, and no one type of functioning is more correct or valid
than another. Analogies are drawn with differences of gender,
ethnicity and culture, including analogies involving social power
inequalities. From its ready application to disorders on the autism
spectrum, efforts have been made to apply the neurodiversity position
more broadly, including to the symptoms of schizophrenia. (See Chapman
2019, Chapman & Carel 2022.)


### 10.5 Identity Politics



Claims arising from political movements made up of recipients of
psychiatric care call for a seat at the policy-makers' table;
representational authority in the co-production of knowledge based on
first person experience of psychiatric symptoms and treatment;
attention to complaints of unjust treatment by the
"survivors" of diagnosis and care; equality of mental with
other disabilities, and or mental with other medical conditions;
recognition of neuro-atypicality from proponents of a neurodiversity
model of disorder (Ortega 2009; Polvora 2011); and from "mad
pride", the claim that madness is an attribution from which to
draw strength and cultural identity. Largely neglected until now
within psychiatry or philosophical writing, the claims of mad pride
have recently been critically evaluated and related to the social
theory of philosophers like Honneth and Taylor (Rashed 2019,
2021).


## 11. Future Prospects



Where might we expect philosophical work on mental disorder to go from
here? One issue must be what role or roles remain for conceptual
approaches and commonsense psychology, and for the related tug of war
over who decides mental health - modern science, and the
merciless dictates of evolutionary biology, or some richer eudaemonic
vision? Even granted the authority to determine ideals of mental
health, philosophers would encounter hard questions. How to relinquish
evaluative thinking in view of liberal traditions around
responsibility and self identity? How generously to attribute normalcy
and diversity, rather than deficiency, and how to navigate at the
boundary of disorder and risk? New ways to understand, verify and
ameliorate mental disorders together with big data on their incidence
and circumstances, and the challenges introduced by the new
hyperconnectedness and biomedicalization of society can only augment
and extend such questions, perhaps in directions barely dreamed
of.