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This chapter shows that the book’s account of malady generates the objective account of mental disorders that has been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) from DSM III R to DSM IV TR. It defends this definition from the criticisms of Jerome Wakefield and others, and explains why the DSM account of the paraphilias continues to change from DSM III R to DSM IV TR. An account of volitional disabilities and a classification of actions that distinguishes between intentional, voluntary, and free actions are also provided.

This chapter examines the current era of “diagnostic psychiatry” by comparing two revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM) – the widely heralded “paradigm shift” of DSM-III in 1980 and the failed paradigm shift of DSM-5 in 2013. The first part of the chapter discusses how self-styled “Neo-Kraepelinian” reformers used the DSM-III revision as a vehicle to reinvent psychiatry, masking psychiatric ignorance behind tidy categories of mental disorders. The second part of the chapter describes the ambitious yet doomed revision to DSM-5, which pursued a paradigm shift to address DSM-III's failure to resolve psychiatric ignorance. The DSM-5 revision process ended in controversy, and, in the process, raised questions about the viability of reinvention as a professional strategy. This chapter highlights the importance of mundane-seeming activities like classification in the management of ignorance.

The last chapter summarizes the previous findings and suggests that focusing on learning mechanisms can help to appreciate the malleability and diversity of human behavior. It is suggested that dimensional and computational approaches can foster a new understanding of mental disorders and create classifications based on basic dimensions of human learning and decision making. This chapter emphasizes that a focus on learning mechanisms should help to reduce the stigma of mental disorders, as it emphasized human creativity and resilience when dealing with stressful situations.

In the introduction, a philosophically informed concept of mental disorders is presented. In order to define a clinically relevant mental malady, it suggests to focus on functional impairments relevant for human survival and the individually harmful consequences resulting from these dysfunctions. While this approach generally defines what can count as a mental disorder, it does not help to understand the neurobiological underpinnings of specific disorders. Traditional disease categories, on the other hand, do not reflect current neurobiological research. With respect to neurobiological lay based disease classifications, it is suggested to assess alterations of basic mechanisms of decision making and reward related learning, which cut across established nosological boundaries. For example, dopamine-dependent reinforcement learning is altered in psychotic, affective and addictive disorders.

There has been renewed interest in psychiatric classification, with the recent development of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the 11th edition of the International Classification of Disease (ICD-11), and the Research Domain Criteria (RDoC) framework. This chapter will consider issues relevant to cognitive enhancement, particularly interventions for individuals with subthreshold symptoms, from the perspective of debates in psychiatric classification. DSM-5, ICD-11, and RDoC each take a somewhat different approach to delineation of the normal from the pathological, and so to the conceptualization of individuals with subthreshold symptoms. For the foreseeable future, an integrative approach to the assessment and treatment of patients with subthreshold symptoms will emphasize the fuzziness of the boundary between enhancement and treatment, will incorporate DSM, ICD, RDoC and a range of other constructs, and will weigh up a broad range of relevant facts and values in clinical decision-making.

Scrupulosity is a mental illness. This is not determined simply by inclusion in or exclusion from the current DSM. The features that characterize Scrupulosity needn’t be disordered, and this chapter addresses skepticism—eliminativism and social constructionism—about mental illness more generally. Illnesses, according to skeptics about mental illness, require physical markers and a value-free diagnosis. These are not present for Scrupulosity, nor are they present for many mental illnesses. The chapter considers dysfunction and harm as definitive of mental illness. It then examines the DSM-5 definition of mental illness and finds that Scrupulosity fits that definition.

While dopaminergic neurotransmission has largely been implicated in reinforcement learning and model-based versus model-free decision making, serotonergic neurotransmission has been implicated in encoding aversive outcomes. Accordingly, serotonin dysfunction has been observed in disorders characterized by negative affect including depression, anxiety and addiction. Serotonin dysfunction in these mental disorders is described and its association with negative affect is discussed.

This chapter analyzes the legislative process that culminated in the passage of South Africa’s first statutory law on abortion, The Abortion and Sterilization Act (1975). It shows that by the early 1970s, the National Party could no longer withstand calls to amend the abortion law: members of the judiciary and the medical and legal professions, ARAG, and the Commission of Inquiry into the Mental Disorders Act were demanding law reform. The regime considered calls for a new abortion law a symptom of “permissiveness,” the moral disease infecting white South Africa, and initially ignored them. But the outcome of prosecutions of medical abortionists, especially the acquittal in 1971 of Dr. Laurence van Druten who helped a teenager pregnant from rape, brought the law’s authority into doubt. The government had to act and finally tabled draft legislation that was subsequently sent to a Select Committee and a Commission of Inquiry for review and amendment.