Having a sad

I believe I have previously confessed to being a New England Patriots fan. Yes, I know, to you football is probably stupider than Celebrity Apprentice, but there it is. If you haven't been living under a rock you know that Patriots tight end Aaron Hernandez is in jail, charged with murder. This is bad news for the team because his if-anything-even-more-unstoppable counterpart Rob Gronkowski has had multiple surgeries and who knows if he'll play again or how good he'll be. When they were on the field together, they could not be defended. But now genius coach Bellicheck and golden boy quarterback Tom Brady will need a plan B.

You don't need me to tell you that making heroes and role models of athletes is fool's gold. There are some good and wise among them but the ranks of professional athletes are not the place to go looking for such. In fact, that's where you go to look for arrogant pricks because they've been entitled, worshiped and enjoyed impunity since high school or even earlier.

This, however, is an outlier. Hernandez had just signed a contract for $40 million and trousered a $16 million signing bonus. He has an 8 month old baby and fiancee. If you haven't followed the details, according to the prosecutor's statement in court, Hernandez summoned a couple of low-life acquaintances from his old home town of Bristol, Connecticut, and they all went and picked up this guy Odin Lloyd, who was dating the sister of said fiancee and so was a potential brother in law. They drove him to a gravel pit and shot him five times. The only motive offered by the prosecutor was that Lloyd had spoken with the wrong people in a bar. Who knows what that means.

For those of you wishing to commit similar murders, here are a few tips. If you leave your cell phone on while driving around, the police can retrace everywhere you have been. They can also read all your text messages. Also, too, there are surveillance cameras all over creation. It's not just the NSA that can see all this, the only difference being that the police need a warrant. But if you kill people, they can get one.

Another tip: if you bring in small timers on a big ticket (e.g., life without parole), they'll flip like pancakes. One of the accomplices walked into a police station in Miramar, Florida, and said "Hi, you're looking for me?" He's obviously planning to be sweetly cooperative given the right incentive, and I'm sure the DA will be happy to offer, say, 10 to 20, maybe out in 8, in return for a well performed recital.

So, a trial presumably awaits but assuming the worse for Mr. Hernandez, unfortunately, the $16 million won't be taking care of the baby. In addition to the wrongful death suit from Lloyd's family, rumors are flying about that Hernandez was responsible for a drive-by shooting in Boston last summer that killed two completely innocent, law-abiding clubgoers. It seems they had been involved in some sort of altercation earlier in a bar at which Hernandez was present. Oh yeah. A guy in Florida is already suing Hernandez for shooting him in the head after -- wait for it -- an argument in a bar.

I would advise Hernandez to stay out of bars from now on but that probably won't be necessary. The point of all this, if there is one? This guy is starting to look like a psycho Steven King could not have imagined. Also astonishingly stupid. Most folks who shoot people over nothing have nothing to lose. Maybe he's been bumped in the head too many times, I wouldn't know. But whatever the reason, as I've said before, when the cerebral cortex goes haywire it can act in totally unpredictably. Anything can happen. It's a wondrous gift, this network of neurons that distinguishes us from the beasts, and a terrible curse.

Radio Daze

On my drive back from Baltimore, I-95 was a 300 mile long demolition derby. One of my unscheduled stops found me at the exact mid-point of the Millard Tydings bridge over the Susquehanna river at the top of Chesapeake Bay, dead stop, for an hour. It was rather festive, actually. The people got out of their vehicles to take photographs of the magnificent view, smoke cigarettes (the rate of smoking among people driving on the interstate seems to be considerably higher than that of the general population), empty bottles of urine, and otherwise enjoy themselves.

The bad news, other than whatever horrific injuries and/or deaths had occurred ahead of us, was the available radio frequency electromagnetic radiation. We were beyond the signal of the NPR station in Baltimore and had yet to pick up WHYY in Philadelphia. The FM featured 5 different Christian stations with various blowhards explaining the meaning of the Bible and how we were doomed to the fate of Sodom, one Christian music station, and one station playing really crappy country music.

So I checked out the AM. Get this: Rush Limbaugh was on six different stations. Really. Simultaneously. How do they compete with each other for listeners? And is the vulgar pigboy on 24 hours a day, or what? Another station featured a different right wing extremist, there was a sports talk station, and another station playing really crappy country music. And that was it.

So if the good people of Havre de Grace want to listen to the radio, these appear to be their options. Is it like this in much of the country?  

Sharing the convention center

I don't really have much value added to go with this observation, but there are two conferences going on right now in the Baltimore Convention Center: Academy Health, and the Armed Forces Communications and Electronics Association. I didn't even know what the other conference was for a couple of days, even though their registration booth is right on the path from the hotels to our half of the building, because the name of the organization does not appear anywhere, only the initials. 

Anyhow, I looked up the calendar of events on-line and figured out what it is. 

Event Name:	AFCEA International Cyber Symposium Website
Event Date:	06/25/2013 - 06/27/2013
Event Organizer:	AFCEA
Description:	National security is continuously being redefined as awareness of the cyberspace domain evolves. Cyber threats and challenges grow every day. Successfully defending our networks requires a team approach. With this in mind, the Cyber symposium will engage the key players, including the U.S. government, the international community, industry and academia, to discuss the development of robust cyberspace capabilities and partnerships.
Event Category:	Symposium
Event Theme:	Defining Full Spectrum Global Cyberspace Operations
Location:	Baltimore Convention Center Baltimore, MD

A few tips:

OPSEC Note

Events like the AFCEA International Cyber Symposium present opportunities for America's adversaries to target U.S. Government employees, academia, defense industry, and other personnel in order to collect our Critical Information. Be a hard target!  Use good OPSEC practices to protect yourself and your organization's mission.

Here are some things to think about:

• Be aware of your surroundings when discussing sensitive unclassified Critical Information during the conference and after hours, in common/public areas (e.g. social gatherings, networking mixers, etc.).
• Don't make it easy for eavesdroppers to be part of your conversations.
• Be suspicious of strangers - even though they sound like they belong at the conference, don't assume they are there for the same purpose as you.
• Use caution when sharing information with someone you don't know. Ask others to confirm a person's identity before sharing Critical Information about your organization's past, ongoing or future operations/activities/events.
• Protect your personal information, such as your room number and daily schedule.  Don't give out your business cards freely, particularly when outside the United States. Remember, phishing is still the #1 adversary threat vector into your personal and government computers/devices/networks, etc.
• If you use a laptop or other portable electronic device (personal or government-owned) use it cautiously. Disable the Bluetooth and WLAN/Wi-Fi connections when not in use, and if you use this type of connectivity understand that you may expose personal and work-related Critical Information to an adversary. Be especially cautious when using unencrypted/unsecure WLAN/Wi-Fi hotspots.

                                   

BE SMART!    BE SAFE!   PRACTICE GOOD OPSEC!

Look, I suppose this is necessary. Maybe. If we lack imagination. But I don't particularly like living in a world where I have no secrets from the government, but they have lots of secrets from me. The armed forces work for the taxpayers. We're supposed to know what they're doing, and decide if we like it or not, and our elected representatives are supposed to be responsive to our wishes in their fully informed control over what the military does. Obviously, that's not how it is.This is very wrong.

 

Why do we even bother?

I often ask myself. I'm at the Academy Health Annual Research Meeting, which as I believe I mentioned is the bit health services research shindig. What most of these people do is crunch huge so-called administrative data sets -- that's like Medicare and Medicaid billing data, for example, combined with other available data that give some idea of outcomes, be it deaths or diagnoses  -- so they can look at things like hospital admissions and readmissions, screening rates, and other outcomes associated with various policies and practices. The idea is to inform policy makers. If you ask almost anybody here, they'll tell you that what we really need is single payer national health care, but it ain't gonna happen.

Anyway, this morning we heard from my colleague Chima Ndumele, who finds that when Massachusetts and other states expanded Medicaid eligibility to include people with incomes above poverty, it did not, repeat did not, lead to reduced access for people who already were covered. This is a big objection that many people have to the Affordable Care Act, i.e. there aren't enough primary care providers so you're just going to make it harder for people who are already covered. Don't know what will happen in the Republican states, but so far the states that did it on their own haven't had major problems.

Susan Haber of RTI finds that states that offer higher Medicaid reimbursement for primary care visits also have higher rates of cervical, colorectal and breast cancer screening -- regardless of the reimbursement for those services. Makes sense. You have to get in to see the doctor in order to get referred for screening. Less colorectal cancer will also save money in the long run, given that nobody cares whether poor people get cancer.

Suk-Fong Tang finds that pediatricians are more likely to accept new Medicaid patients when, yes, they are paid more, but also when it's easier for them to get their patients referred for specialty care, including dentistry. Also makes sense, it's a big pain if they have to spend all their time tracking down somebody who will meet their patients' needs.

Yeah yeah. If we pay primary care doctors half decently (Medicaid pays a fraction of private insurance and less than Medicare), if we make more people eligible for health insurance, if we have a better integrated system, more people will get the care they need and get and stay healthier. We'll have a more productive society and it will be well worth it. But that doesn't matter. Public policy isn't built on facts and reason, it's built on ideology and the will of the powerful. You can tell all this to your congressional representatives and state legislators, but they won't care.

A scholar's life

As if I haven't baltied enough already, tomorrow I'm going to Balti more. Specifically, the Academy Health Annual Research Meeting, Academy Health being the health services research association. I'll be presenting my super duper innovative methods for breaking down and reproducibly characterizing clinical communication.

I won't bore y'all with the details, but the major idea is that you can identify specific kinds of tasks -- such as collecting information to make a diagnosis or otherwise put a name on a problem, educating a patient, making a treatment decision, or providing emotional support and building rapport -- specific subject matter of importance, such as symptoms, pharmaceutical treatment, diagnosis, health-related behaviors, psycho-social problems -- and specific speech transactions (illocutions or speech acts) such as various forms of questioning, giving concrete information, expressing feelings or desires, giving instructions, and so on. If you break down a transcript on all three dimensions, you can say a whole lot about what happened in a visit and what the relationship between the people was like.

There's no Nobel Prize for this, and it won't make the New York Times either, but if you think about it, talking with patients is 90% of medicine. It doesn't matter what the pills do if you don't take them. Whether I can really do any good with all this remains to be seen, but I'm hopeful.

Emptying the inbox

A couple of worthwhile gleanings from amongst the continual torrent of spam. . . .

The consulting firm Avalere Health, apparently in the now required hope that I'll give them some free  publicity, keeps sending me freebie information from their studies. Today they let us know that:

As plans begin to unveil their initial health plan rate filings [in accordance with the Affordable Care Act], a new Avalere Health analysis shows that in nine states the second-lowest cost “Silver” premiums appear to be lower than the Congressional Budget Office (CBO) estimate for 2016. Premiums for the second-lowest cost Silver plans for a 40-year-old nonsmoker will range from a low of $205 in one region in Oregon to a high of $413 in another region in Vermont. CBO previously projected nationwide the average monthly premium for the second-lowest cost Silver plan would be $433.

 

These second-lowest cost Silver premiums will be used to set federal premium subsidies. If premiums are lower than was projected by CBO, federal costs for per-person subsidies may be lower than expected, thus saving the federal government money.

 

“The initial data suggest that competition in exchanges is working to lower premiums, which will benefit nonsubsidized enrollees and the federal government,” says Caroline Pearson, vice president at Avalere Health.

On the whole, as implementation of the Kenyan Muslim Socialist Communist Atheistic Obamacare approaches, prospects for a reasonably smooth roll out seem to be looking better.

Yes, yes, young healthy people who are not eligible for subsidies will still pay more than they would if they were buying insurance in today's less regulated market, even given the above good news. But calm down. which most of them are not doing anyway. So their experience will not be, in most cases, a rate increase, but rather the requirement to buy insurance at all. (If you're a young person insured through employment, nothing will change.) But that's a feature, not a bug. Yes, the young and healthy will subsidize the older and sicker, which is what happens in a single payer system or really any reasonably equitable system of universal coverage. But that is precisely what creates justice and equity -- over the life course, rather than cross sectionally. Which is what you want, because, sorry to break it to you, you will get older.

On another front, the Campaign for Tobacco Free Kids is celebrating (if that's the word) the 100th birthday of Camel cigarettes. R.J. Reynolds has killed 1 million times as many people as John Marturano, the gangster who is currently testifying against Whitey Bulger. Yeah, it's appalling that Marturano only did 12 years for 20 murders, but Daan Delen, Chief Executive Officer of R.J. Reynolds, hasn't done a day.

A thought experiment

You're more likely to be seriously injured or killed by falling in your bathroom than by terrorists. (Fact!) So, do you support the federal government setting up a system of surveillance cameras in all the bathrooms in the United States? Don't worry, the Booz Allen employees promise not to look unless a sensor goes off suggesting that somebody might have fallen. Really. They promise.

And do you support spending something like $100 billion dollars a year (you don't know the exact amount, it's a secret) to save you from this fate? Yeah, the word has gotten out about the video surveillance in your bathroom but you have no idea what else they are doing. But why should you worry? It's for your own protection.

Now, in fact, I don't know about the $100 billion or the secrets or the surveillance -- I'm thinking you're probably against that, even if you're for the anti-terrorism thing. (Or whatever the real reason is they're doing it -- that's actually a secret as well.) But it would actually make sense to spend more modestly on a voluntary program where the local Visiting Nurse Association could inspect your home for fall risks, then install grab bars and hand rails, put traction material on the bottom of the tub, remove tripping hazards, and so on. That would keep people out of nursing homes and save Medicare and Medicaid a lot of dough.

Priorities, however.

The Cervantes Bullshit Translator

So Deputy National Security Adviser Ben Rhodes announces that the Syrian military has used chemical weapons, thereby crossing the "red line" established by president Obama and, accordingly, the U.S. will begin providing weapons to "moderate" opposition group, the Supreme Military Council.

Translation: President McCain has been calling us wusses and the corporate media is channeling him and this is not a good time for us to look "soft" on something that might be confused with national security. So we need to do something to look like badasses.

Here are your basic facts.

Whatever evidence the U.S. has had about this, they've had for months. They could have made this announcement at any time, but up until now they've said it was inconclusive.

Anyway, it doesn't actually matter. This whole chemical weapons thing is bogus. Yes, it's against international norms, but not for any particular reason. Blowing people up or shooting them actually works better. Nerve gas doesn't work if you're holed up indoors, and it's not much use in a high wind or rain. Soldiers can wear protective gear and go about their business. Bombs, however, work just great no matter the weather, they can blow up buildings with people inside them, and believe me, you won't care whether you were blown to pieces or poisoned.

The specific claim is that maybe 100 people have been killed by chemical weapons. That is out of about 100,000 who have been killed altogether in the conflict. So, 1/1,000 of the total. But that's just intolerable, whereas the 99,000 dead from bullets and bombs is not.

So this is nothing but a pretext. The corporate media will never deconstruct it or even appear the slightest bit skeptical, however. This proves that Bashar Assad is an evildoer and the U.S., being responsible for the punishment of evildoers everywhere, at least the ones we choose not to ignore or give billions of dollars a year in aid, has no choice but to act.

Also true fact: The Supreme Military Council is not the supreme military council. It represents almost none of the actual insurgent fighters, and it will never run Syria or any part of Syria. It's a phony construction of the west to give them somebody to relate to who does not include, in its official ideology, the expulsion of U.S. power and influence from the Islamic world. Once we give them weapons, they will have to find people to use them, and those will be the same people we won't give weapons to directly.

The outcome of all this is completely unpredictable but it is of little direct interest to the well being of the good people of Peoria, one way or the other. And no, they don't even have oil in Syria. Remember, Assad controlled all of Syria before this whole thing started, and nothing obviously bad was happening to us. The danger that he might regain control of more of it than he has now does not seem like an existential threat, or in fact a threat of any kind.

Indeed Senator Tester

The solon says that Snowden's leaks do not endanger national security. In fact, he thinks they're all to the good because now we'll have a debate about this stuff.

Exactly. So again, here's the real point: Why was all this a secret in the first place?

Sigh. I guess I need to say something . . .

about the current frou frah. There are many who urge us all to calm down, the government isn't snooping into your e-mails or phone calls. They're just saving their own database of information about every single phone call made in, to or from the United States -- who called what number and how long they talked, and maybe where they were physically if that's available -- in case they want to check any of it out later. And they can get all sorts of Internet activity by foreigners, which of course could include interactions with Americans but they try not to get the latter on purpose without a court order. So no biggie.

Okay, a few dots to connect here . . .

1) This is costing us bazillions of dollars. (We don't know exactly how many because it's a secret. The NSA has 20,000 employees, but that's just the beginning. There are something like 1 million people working for U.S. intelligence. They're creating billions of dollars of additional computer infrastructure. They're new data center in Utah draws 60 megawatts of electricity to run its computers. . . .

2) Meanwhile we supposedly can't afford food stamps . . .

3) Why was this a secret? Presumably any evildoer who has one neuron to rub against another assumes his phone calls and Facebook posts are available to the NSA already . . .

4) The whole Global War on the Existential Threat of Terrorism thing is complete bullshit. The only "terrorist plots" they've managed to thwart since 9/11, as far as we know, consist of dipshit losers who were recruited by provacateurs and given fake weapons. Mueller and Stewart, in the linked article which you aren't allowed to read, inventory all 50 of them. They're all like that. Sample:

49. Tampa, 2012. Under suspicion after he walked into a store seeking to purchase an al-Qaida flag, an Albanian-American loner in Tampa, Florida, plots with a police officer to detonate a car bomb, fire an assault rifle, wear an explosive vest, and take hostages, in addition to bombing nightclubs, a police center, a bridge, and a Starbuck's coffee shop. . .

44. Seattle. 2011. Two financially destitute men, angry over U.S. foreign policy, are arrested in Seattle after they purchase an FBI-supplied machine gun that they plan to use to attack a military recruiting center after they save up enough money to purchase bullets . . . .

And it goes on and on like that. We have a lot of problems we ought to be spending money on, but this isn't one of them. The original al Qaeda, that perpetrated the Sept. 11 attack, has never put together another action of consequence anywhere in the world and no longer exists. The brand name has been taken over by various organizations avenging local grievances in the Middle East. Even in 2001, more than ten times as many Americans died in car crashes as died from terrorism.This is essentially a minor, if not non-existent problem to begin with.

But the national security state is a gravy train for Booze Allen corporation and many other government contractors, and it's created all sorts of sinecures within government. Like the War on Drugs and the prison industry, it's now a very powerful vested interest.

And that's why it's a secret. Because if we know all about it, and we have an honest political debate about it, we'll stop doing it.

Onward to the murky swamps of the DSM

Since it turns out that Eric Holder and James Clapper already know all about my pathetic social life (and BTW, Glenn Greenwald says there is more to come), I might as well fess up here. I was bummed out a while back by a relationship that didn't work out, and I'm still kinda bummed out. I don't happen to want to talk to a professional counselor about it, but somebody else might. Do I have a disease? What if I stay sad for a really long time? Do I have a disease after six weeks, or six months? Do I have to be more than a certain amount sad? What difference does it make what you call it?

As you may recall, drug companies used to run ads claiming that depression was caused by a deficit of a specific neurotransmitter, serotonin; and that their pills fixed it by increasing the amount of serotonin in your brain. One of them even had a little cartoon showing serotonin ostensibly flowing between brain cells and their pill keeping it from being reabsorbed, whereupon the person got happy.

This was total, unmitigated bullshit. People diagnosed with depression have the same amount of serotonin in their cerebrospinal fluid as everybody else; and most people with depression don't respond to anti-depressants at all. (Absolutely true. At best 15% of people show a clinically meaningful response. The rest just get the side effects.)

The brain is not a bag of chemicals, and our moods, thoughts and feelings do not correspond to some overall level of one or any combination of chemicals. The brain generates the mind in all its states through highly complex processes -- networks of excitation flowing among millions of neurons to produce each and every phenomenon of consciousness. Once we have ruled out the gross abnormalities of structure or biology I discussed earlier, we are left with states that are only arbitrarily classifiable and which nobody understands very much about.

It would be nice to have a pill that could stop us from being sad. Actually, they used to prescribe amphetamines, which do work. You could ask Lenny Bruce but, uh, he's dead. It would also be nice if we could take pills so we wouldn't be shy, wouldn't be anxious, wouldn't get angry. Well, there are pills that have these effects to some extent, but it's usually a very bad idea to take them for very long. The reason is that our shyness and anxiety and anger are not caused by a deficiency of a chemical, and if you do pump in a lot of some chemical that changes how your brain works, the effects are going to be a whole lot more than the specific one you're looking for.

In fact, there are occasions on which it is very wise to be anxious, or shy, or angry. Evolution has equipped us with these states because they sometimes can save our lives, or benefit our kin. And people's personalities and capacities vary enormously, which is also a good thing for society and makes life more interesting.

Alas, we sometimes make unwise choices, or get locked into emotional states that are unpleasant or counterproductive. Some people behave in a self-defeating way consistently, or are frequently obnoxious to others. It can get so bad sometimes that we want to get help. Here's where psychiatrists come in. They want to be thought of as real doctors, so they need to be treating diseases, and they need to have pills to do it with. And so we get official names for mood disorders and personality disorders. But these are not real entities. They are pareidoilia, an "illusion or misperception involving a vague or obscure stimulus being perceived as something clear and distinct," like Jesus appearing on toast.

Oh yeah, about dementia

I'm going to interrupt the walk through the DSM to pick up on the extensive comment from KwC, on the previous post. It so happens that my father also suffered from fronto-temporal dementia, although fortunately, the personality changes he manifested were much easier for others to deal with. He did go through a stage where he was a bit stubborn about his obsessions, but quickly became sort of sweetly apathetic. His helplessness was certainly very frustrating to my mother and other caregivers, but at least he wasn't proactively obnoxious.

Unfortunately, KwC's experiences are not uncommon. Dementia can cause people to become argumentative, resentful of loved ones, paranoid, amoral, irresponsible, accusatory, even violent. Nursing home staff will often drug such people into a stupor, for their benefit rather than the patient's. It's presumably unethical, but physical restraint doesn't seem a much better option. There is no cognitive behavioral therapy or other counseling approach to such people, they are completely impervious to reason. That's the very nature of the disease.

I wish I had an answer for folks but what I do want us to consider here is the fundamental undermining of our notions of accountability and free will. However terrible it feels to see a loved one's personality so horribly transformed, few of us will say that we blame the person or believe they should be punished for their behavior. It's an organic disease of the brain, not their intention to be hurtful.

Uh oh. Dementia or not, the brain is always a physical organ which produces behavior. I can't find any defensible reason why we excuse people if we can find a brain tumor, or a traumatic brain injury, or some neurodegenerative process that shows up on a CT scan or an MRI; but otherwise put all the blame for evil on the evildoer. None of us created our self, our brains got to the state which generates our current behavior through the unfolding of genetic potential in whatever environment we happened to find ourselves, and so we became what we are at this moment.

The illusion of free will may be necessary, but that's all it is. At the extreme, that people can be spared the death penalty if they can convince a judge that they lacked the capacity to conform their conduct to the requirements of the law is nonsensical. If a person does not conform his or her conduct to the requirements of the law, a fortiori, he or she lacked the capacity to do so. We are what we are.

More on psychiatric diagnosis

Now that we've laid out some foundational issues, this seems a good time to go back to the DSM and finish constructing our deconstruction. Various categories of psychiatric diagnosis present quite different sets of issues. My friend Gary, in The Book of Woe, raises most of them in one way or another but he doesn't march us through them systematically -- it's not that kind of book. I'm a more boring sort of writer, however, so I'll just put the ducks in a row and knock them down.

There are indeed various things that can go wrong with our brains which have all the right stuff to be called a specific disease, and treated like one (to the extent treatment is possible). These would include Alzheimer's, Parkinson's, stroke, brain tumors, traumatic brain injuries, encephalitis of whatever cause. Here, we can find some gross abnormality in the perceptible physical appearance of the brain, and we can link these consistently and explicably to symptoms which are clearly undesirable and out of the ordinary. The bad news for the APA is that none of these are really psychiatric disorders. Neurologists, oncologists, surgeons, infectious disease specialists get the fees.

Then there's addiction, which seems to have a lot of the right stuff. A fairly well accepted theory of addiction to many commonly indicted chemicals is that they essentially hijack a specific circuitry in the brain that controls motivation, mediated by the neurotransmitter dopamine. There isn't exactly a lab test for this but the receptors involved are known. Effective chemical treatments are coming along for alcoholism and we also have designer opioids that can be titrated to satisfy craving without producing sedation or euphoria. (Other drugs which are sometimes abused or can produce dependency work in other ways, but again there is basic understanding of their mechanisms.)

The real debate here is whether the "disease" concept is the most practically useful, or perhaps morally appropriate, way to think about addiction. People who invite harm or risk by their ingestion of psychoactive chemicals have very different patterns of consumption, from a little bit all the time to occasional major binges; and as many people argue, it isn't the bad chemicals that produce addiction, it's usually other problems people have such as not having something else they want to do badly enough to motivate being sober. In this view, addiction isn't really an essential disease but rather a symptom of not having a life, as it were. More controversial, from the point of view of the neuroscience, the etiology, and the ontology, are proposed non-chemical addictions such as gambling, food, shopping and sex. If you accept that these can also be addictions, then the disease label seems even more problematic. The diagnosis is even fuzzier, especially since total abstinence from some of these activities is itself either abnormal or fatal; and the question of morality and personal responsibility becomes more vexed for many.

I don't have a right answer here. If the disease concept works for you in these instances, use it. If  you'd rather think of it another way, that's also defensible.

Then we have your so-called "major" mental "disorders," which are more or less schizophrenia and what is now becoming a penumbra of variously named psychotic conditions; bipolar disorder; and major depression. That these seem to have mutual inter-heritability suggests some (completely unknown) common etiological core, which helps make the case for disease. Schizophrenia has a classic presentation with onset in late adolescence or early adulthood; and a complex of symptoms including hallucinations, disordered speech and thinking, delusions, and deficits in social interaction.  There are drugs that can calm down the hallucinations and delusions, although they do leave people with flat affect and apathy, and can have terrible physical side effects.  (The drugs don't tell us anything about the cause of schizophrenia however. By analogy, the pain of a broken leg is not caused by morphine deficiency.)

All this argues for the ontological status of schizophrenia as a disease. It seems to be a reasonably identifiable specific thing, and you definitely don't want it. It turns out, however -- and this came as news to me -- that the diagnostic reliability of schizophrenia is not nearly what you might think. Many people don't exactly have all the symptoms. Ted Kakzcynski, for example (the Unabomber) was given a diagnosis of schizophrenia, but he does not have disordered speech -- on the contrary, he's pretty good with words -- and he doesn't hallucinate. Arguing that he is delusional gets you onto very thin ice -- he has opinions which are unconventional and subversive, but so do I. He doesn't think they're being beamed into his brain from Aldebaran. That he has the same "disease" as Jared Loughner is highly questionable.

In fact people's diagnoses can cycle among the major mental disorders and their sub-types, and diagnosticians will come up with different answers for the same person. One strongly suspects that there is some sort of common etiological core here, and in any case that some day we may have a specific physical  marker that corresponds to these presentations, or perhaps markers that can differentiate among them. The drugs we have for these entities, be they legitimate diseases or not, you would rather not take unless the alternative is even worse, which it often is. So the disease frame seems pretty defensible, but the attempt at sub-classification and naming, at the current state of knowledge, not so much. The basic problem here, then, is ignorance.

Next I'll go on to depression and other affective disorders; behavioral diagnoses; and personality disorders.