Addiction, the Concept of Disorder, and Pathways to Harm: Comment on Levy

Levy (2013) argues that “addiction is not a brain disease,” an important claim because, contrary to common wisdom, believing that mental disorders are brain diseases apparently increases stigma (Angermeyer and Matschinger, 2005; Schomerus et al., 2012). Levy presupposes the harmful dysfunction (HD) analysis of disorder (Wakefield, 1992a,b, 1999a,b, 2006): “[A] n individual suffers from a disorder only if they experience a biological dysfunction and that dysfunction is harmful, where the judgment of harm is made by reference to social norms of flourishing” (Levy, p. 11). He accepts that addicted individuals have substance-induced brain dysfunctions, and that when their dysfunctions cause harm (e.g., suffering, impairment of agency), such individuals are addictively disordered. (Note that throughout this commentary, consistent with HD and standard psychiatric usage, I use “disorder” as a generic term for medical pathology, inclusive of Levy’s term “disease.”) Given these preliminary points, why does Levy then claim that addictive disorders are not brain diseases? Levy interprets the HD analysis as requiring that, to be a disorder, a dysfunction must not only cause harm but cause harm “in almost any accessible environment” (AAE) (p. 8); “[D] ysfunction plus impairment is not sufficient for disorder, when the impairment is due to social conditions that can relatively easily be altered” (p. 8). Levy observes that addicts sometimes abstain successfully or obtain safe, reliable drug access, suffering no harm. Thus, addictive disorder is not identifiable with brain dysfunction. Why the AAE? Levy says it “is necessary to rule out conditions in which the appropriate response to suffering is to alter the environment and not to ‘treat’ the person” (p. 8). However, whether a condition is a disorder or not and whether treatment of the condition should be aimed at the person or the environment are two different questions. Many disorders are appropriately treated environmentally (e.g., dietary restriction in phenylketonuria, lowering episode-triggering expressed emotion in mentally ill individuals’ families). Levy struggles with the many common disorder attributions that are apparent AAE counterexamples. A New Yorker’s pollen allergy and Arizona resident’s snake phobia are considered disorders, even if switching residences would alleviate both harms. Levy claims accessibility costs make such counterexamples “only apparent”; peanut allergies are disorders because “avoiding peanuts is, right now, far from costless” (p. 8). This defense of the AAE raises difficult questions about how costs are to be evaluated in deciding whether an environment is “easily altered” and an alternative environment “accessible.” It also potentially renders the AAE operationally meaningless because virtually any social change entails peanutallergy-level costs. To defend the AAE, Levy cites dyslexia, a presumed brain dysfunction impairing reading ability: “[I]f it is true that dyslexia was not a disease in the pre-literate past, because it did not cause an impairment..., then it seems that if it were possible costlessly to alter the environment so that it did not cause an impairment in sufferers today, it would not count as a disease today” (p. 9). Levy is not arguing that dyslexia is not a disorder today; rather, he is arguing that, as the AAE predicts, if there existed a costless way to alter the environment and eliminate dyslexia’s harm today, then, as in pre-literate times, dyslexia would not be a disorder today, either. This argument’s appeal as a defense of the AAE turns on an equivocation between actual versus counterfactual harmlessness. Pre-literate dyslexia was actually harmless, thus non-disordered; and if costless environmental changes were implemented that rendered dyslexia actually harmless today, then dyslexia would again be non-disordered. However, the AAE asserts the stronger claim that, if costless alterations to render dyslexia harmless did exist today, then even if they were not implemented and dyslexia remained quite harmful in our reading-demanding society, dyslexia would still not be a disorder simply because the possibility of such costless alterations means that an “easily accessible (possible) environment” would exist in which dyslexia would not be harmful. Nothing about pre-literate dyslexia’s status implies this counterintuitive conclusion that just the possibility of costlessly eliminating a dysfunction’s harm means that the dysfunction while it continues to cause harm is not a disorder. Our intuitive “disorder” concept that tracks actual harmful biological dysfunctions requiring our attention seems essentially abandoned by the AAE. Nonetheless, the AAE suggests an important truth about the “harm” component of “disorder”: the social judgment that a condition is harmful may be based on misguided social values, and deeper judgments about what serves justice in the long run can override superficial harm judgments and thus negate disorder attributions. To this extent, my (1992) claim that harm is judged by social values was overly simplistic. For example, imagine that runaway slaves and Soviet dissidents (both claimed by respective social authorities to be disordered) had minor brain dysfunctions that made them less tolerant of oppression and more freedom-aspiring than others. These groups’ actions were socially judged as harmful by their societies, potentially justifying a disorder diagnosis if dysfunctions did exist. Addiction, the concept of disorder, and pathways to harm: comment on Levy