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We maintained the ordering and numbering of the listings from our prior rules to ease the transition to these final rules, when possible. Comment: One commenter suggested that the listings should consider combined disability for schizophrenia The listings should expect this, and allow for this. Response: We did not adopt the comment. Although we appreciate the issues raised by the commenters, it is not necessary or practical to provide listings that combine mental disorder categories for four reasons. Second, when we determine whether a person's mental disorder is disabling under the law, it does not matter whether the person has a diagnosis or a combination of diagnoses.

The controlling issue is whether the medically determinable mental impairment s result s in limitations in functioning that prevent the person from working. Third, given the numerous examples of co-morbid mental disorders, we do not think it is feasible to provide listings for all possible co-morbidities. Fourth, the listing criteria allow us to evaluate the range of effects of any combination of mental disorders on functioning Start Printed Page independently, appropriately, effectively, and on a sustained basis. Several sections of the introductory text have lists that are not exhaustive.

Comment: One commenter noted that in proposed Response: We adopted this suggestion and ended final We evaluate cognitive impairments that result from neurological disorders under Comment: One commenter was concerned that the description of listing For example, adults with mental disorders who are homeless or incarcerated may have histories of physical abuse including blows to the head, fights or falls involving episodes of unconsciousness, or as pedestrian victims of vehicular accidents. These brain injuries, which can result from recurring, less traumatic assaults rather than from one or more traumatic injuries, can nevertheless add up to impaired cognitive functioning.

The commenter urged us to include some direction to adjudicators in the listing about how to evaluate such histories. Response: We did not adopt the comments. We agree that it is important for adjudicators to understand the differing impacts of TBI and a history of concussive injuries, as well as the lasting effects of substance use on the brain.

However, the list of symptoms and signs and the examples of disorders in this listing category are not limited to those presented in Furthermore, they would readily include a history of concussive injuries resulting in brain damage. We believe that the list of symptoms and signs is sufficiently descriptive of the brain damage a person may incur after several such injuries that it is not necessary to expand it at this time. Comment: A few commenters stated that it is difficult to determine whether listing Response: We adopted this comment.

We included substance-induced cognitive disorder associated with drugs of abuse, medications, or toxins among the examples of disorders in this category in Comment: Some commenters stated that the descriptions in Unfortunately, which category encompasses these conditions is unclear from the descriptions of these two categories. Response: We partially adopted these recommendations. We included mental impairments resulting from vascular malformation or progressive brain tumor in final We did not include all of the examples that the commenters recommended because the lists of example disorders in The examples include the impairments that we see most often in child claimants seeking benefits under our program.

We may find that other disorders not included in the examples may meet or medically equal the respective listings, depending on the facts of each case. We also added an explanation to final We evaluate catastrophic genetic disorders under the listings in We evaluate genetic disorders that are not catastrophic under the affected body system s. In addition, to respond to this comment, we updated the title of listing Another intended distinction between these two listings is that of knowing, compared with not knowing, the cause of a child's mental impairment.

If we know that the mental impairment has an organic cause, we will evaluate the impairment under listing Comment: The spokesperson for a professional organization recommended that we add language to proposed Response: We adopted the comment because the DSM-5 also indicates that personality disorders have an onset in adolescence or early adulthood. Final The commenter recommended that we state clearly that the diagnosis can apply to both children and adults. Response: We adopted the comment.

We are aware that the DSM-5 includes this diagnosis under the category of disruptive, impulse-control, and conduct disorders. We also revised the titles and the criteria for listings The new paragraph B4 criterion for adults and for children age 3 to age 18, adapt or manage oneself, also provides for consideration of problems of self-regulation and impulse control.

Comment: One commenter had several suggestions about proposed First, the commenter recommended that we wait until the expert panel that was revising the DSM-IV completed its work before we proposed a definition for autism spectrum disorder ASD. The commenter raised concern that failing to consider a new DSM-5 definition of these disorders could foster confusion among professionals, parents, and consumers, and could breed inconsistent definitions of ASD that might hinder the rights of children and adults to secure important benefits.

Second, the commenters recommended that we should conduct in-depth research, expert consultation, and study to ensure that any proposed revision in the definition of ASD is warranted and correct. Third, the commenter stated that our proposed definition and criteria did not recognize that the core nature of ASD is not an intellectual impairment but a social and behavioral disability.

Therefore, the commenter thought that the use of the paragraph B1 criteria understand, remember, or apply information and B3 criteria concentrate, persist, or maintain pace pointed to our lack of understanding of ASD. Response: We did not adopt the comments, although we appreciated them, particularly given the intense concern and dialogue currently focused on ASD among medical professionals, educators, and parents.

The discussion of ASD in final We understand that ASD is a highly complex disorder that interferes with a person's functioning in many ways, especially communication and social interaction. Therefore, the description of ASD in Although some people with ASD do not have cognitive limitations, some do. Any method of evaluation intended to apply to everyone with ASD must provide criteria for assessing the range of possible limitations that individuals with the disorder may experience.

For this reason, we apply all four of the paragraph B criteria, including paragraphs B1, understand, remember, or apply information, and B3, concentrate, persist, or maintain pace, to ASD. Response: We adopted the comment, and we removed the references to Asperger's disorder in final Comment: Some commenters suggested including specific mention of conduct disorder and oppositional defiant disorder in proposed One of the commenters explained that these disorders are included in a similar chapter of the DSM-IV and are common diagnoses in childhood and adolescence.

Additionally, the paragraph A criteria for final listing We did not include conduct disorder or oppositional defiant disorder in the list of examples of disorders that we evaluate under listing However, the list of examples in final Either or both of these impairments may meet or medically equal the criteria in listing Comment: Several commenters requested that we include language in Response: We partially adopted this comment.

We typically do not repeat guidance that we provide elsewhere in our regulations. However, in response to this comment, we added a reference to our regulations on evaluating opinion evidence in Comment: We received various comments regarding our reference to health care providers, such as physician assistants, nurses, licensed clinical social workers, and therapists, as medical sources whose evidence we will consider when evaluating a person's mental disorder and the resulting limitations in the person's functioning.

Some organizations and individual commenters strongly supported our inclusion of these professionals, because they may be most familiar with a person's limitations in functioning. Response: We did not adopt the recommendations. The list of these other medical sources in our regulations is not all-inclusive, and our mention of licensed clinical social workers and clinical mental health counselors in final We believe that these other medical professionals—because they typically see patients regularly—are important sources of the evidence we need to assess the severity of a person's mental disorder and the resulting limitations in the person's functioning.

This person noted that because the scope of social work is so broad, some people may be confused about the specific expertise of LCSWs, which is the largest group of therapists in the country. Comment: The spokesperson for an organization requested that we add case managers and similar staff as examples of non-medical sources of evidence. We added the examples of community support and outreach workers and case managers in final Comment: While commenting on proposed Many direct service providers stressed the importance of obtaining information from people who, because they know and spend time with the person with a mental disorder, are in the best position to tell us how the person functions.

Response: We adopted the comments. We removed the provision in proposed We discuss that change and our reasons for making it below, where we explain our responses to public comments about sections Regarding the commenters' suggestions about sources of evidence and our evaluation of mental disorders, we appreciate the views and recommendations, and the NPRM and the final rules reflect them.

For example, in final We state that we consider all relevant medical evidence, including the results of physical or mental status examinations, structured clinical interviews, psychiatric or psychological rating scales, measures of adaptive functioning, and observations and descriptions of how a claimant functions during examinations or therapy. As another example, in final We added to the list examples of people who can provide us with this evidence. The list of examples includes family, caregivers, friends, neighbors, clergy, social workers, shelter staff, or other community support and outreach workers.

Regarding the suggestion for a case-by-case assessment of each claimant, our longstanding principle has been to evaluate each person who files a disability claim on an individualized basis. We understand that no mental disorder affects all individuals in the same way; rather, mental disorders affect each person uniquely in every aspect of his or her life.

Our process of evaluating four criteria that reflect a person's functional abilities and rating the person's limitations for each criterion is just one example of our commitment to individualized, case-by-case assessments. Comment: One commenter recommended that we recognize the unique circumstances of people who are experiencing homelessness, and permit longitudinal evidence of their mental disorders from social workers.

In final This section also lists social workers as a source of longitudinal evidence of a person's mental disorder. Comment: Some commenters recommended that we emphasize the value and importance of using standardized assessment instruments specifically developed for use with children. The commenter suggested that, for example, additional language could be included in proposed Response: Although we appreciate the concern raised by the commenter, we did not adopt the comment.

We cannot control what standardized instruments medical and educational providers use when evaluating children. We consider all relevant evidence that we receive. If we receive the results from standardized assessment instruments not specifically developed for use with children, or that were not appropriate to the age and condition of the child, those are important facts that we will consider when we evaluate the evidence. To the extent that the comments pertained to our policies for ordering standardized assessment instruments when we purchase psychological consultative examinations for children, the comment would be outside of the scope of the proposed rulemaking.

Comment: Spokespersons for two professional organizations expressed concern about the absence of specific reference to neuropsychological testing and its application in the evaluation of claims of both adults and children with mental disorders. One spokesperson said that neuropsychological examinations are particularly relevant when neurodevelopmental or acquired brain dysfunction forms the basis of a person's category of disability.

Response: We did not adopt these comments. We do not believe that it is necessary to refer to both psychological and neuropsychological testing because neuropsychological testing is a subset of psychological testing, and the same broad principles apply to our evaluation of these tests. In addition, neuropsychological test batteries, while useful in clinical and research settings, Start Printed Page have limited applicability in the disability program. This is because such batteries generally contain a number of subtests that focus on small units of behavior.

These types of clinical measures often have little direct relevance to functional behavior as we assess it under the disability program. We will consider the results from neuropsychological assessments when they are a part of the evidence in the case record. We will not purchase formal neuropsychological test batteries, such as the Halstead-Reitan Neuropsychological Test Battery.

We may purchase a neuropsychological test to assess specific neurocognitive deficits if the case evidence is insufficient to evaluate the claim, or to obtain evidence needed to resolve a conflict, inconsistency, or ambiguity in the evidence. Comment: Spokespersons for some professional organizations recommended that we use symptom validity testing SVT to enhance validity of psychological consultative examinations PCE and to identify malingering.

The commenters said that using SVT in disability evaluations is one method of enhancing validity, and they made two related recommendations. First, the commenter suggested that we consult with the American Academy of Clinical Neuropsychology and related organizations to take advantage of their expertise in revising and expanding provisions addressing symptom validity in the regulations. Second, the commenter suggested that we promote training in SVT methods or encourage change in PCE practice to include routine use of SVT to evaluate response bias, effort, and malingering during psychological examinations.

Inaccurate self-report of symptoms and behavior occurs when individuals, because of psychiatric disorders or personality traits, over- or under-report the nature, range, and severity of symptoms. Inaccuracy in self-report does not necessarily mean there is no medically determinable impairment that imposes real limitations. Since we do not adjudicate a claim based on symptoms alone, objective observation and description of the person's behavior must support any conclusions based on a test s of malingering.

Additionally, the conclusions must be consistent with other evidence. Comment: Several commenters asked that we make clear that the list of psychosocial supports and structured settings and living arrangements does not include all possible supports a person with mental disorder may receive, or in which he or she may be involved. We did not intend the list of supports in proposed We intended that the list only include examples of such supports and settings. In response to the comments, we added a phrase to final Comment: Several commenters requested that we add supported housing with wrap-around services as an example of psychosocial supports and highly structured settings in proposed Comment: One commenter recommended that we expand the list of psychosocial supports and highly structured settings to include examples relevant to people whose impairments have contributed to homelessness and infrequent access to supports.

The commenter said that the list of psychosocial supports, structured settings, and treatment presumes that a person has a regular and stable place to live, has social connections with family and friends, and has connections with treatment and services. However, clients of health care services for homeless people are often socially isolated, disconnected from services, and do not have a place to live, or live in residential facilities for homeless people. We added an example in final Comment: We received comments presenting several different reasons for retaining the prior paragraph B1 criterion, activities of daily living ADL.

The spokesperson for an organization was concerned that the proposed change to paragraph B1 will hinder accurate disability determinations for people with severe disabilities who do not regularly engage in work or treatment. This commenter said that the category of ADL is easily understandable to providers and that important information and significant details will be lost if this category is eliminated.

Two commenters remarked that it is easier to document limitations in ADL than the proposed paragraph B1 criterion, particularly with respect to adults with mental disorders who are homeless and unable to access or attend consistent treatment. Another commenter said that if a person cannot adequately manage his or her ADL, it is reasonable to assume that working at substantial gainful activity levels would be extremely unlikely.

One commenter said that removing ADL as a criterion partly ignores the basic self-reported information we have about what a person actually is doing while not in a work setting. However, we will continue to consider how a person performs ADL when we evaluate the effects of a mental disorder on the person's functioning and ability to work. ADL information will continue to be central to our documentation of a person's mental disorder, because knowing how the mental disorder affects the person's day-to-day functioning can help us evaluate how it would affect the person's functioning in a work setting.

The final rules will use information about a person's ADL as a principal source of information, rather than as a criterion of disability. This change is congruent with the focus of the paragraph B criteria on the mental abilities a person uses to perform work activities. The principle is that any given activity, including ADL, may involve the simultaneous use of the paragraph B areas of mental functioning. For example, with respect to the same activity, one person may have trouble understanding and remembering what Start Printed Page to do, while another person may understand the activity but have trouble concentrating and staying on task to do it.

Still another person may understand the activity but be unable to engage in it with other people, or may feel such frustration in doing it that he loses self-control in the situation. Rather than ADL being one separate area in which we evaluate a person's functioning, ADL are now a source of information about all four of the paragraph B areas of mental functioning. We will focus on this aspect of the final rules in our formal training of adjudicators. Comment: A commenter stated that the ADL information solicited from a person experiencing homelessness, along with third party evidence, is crucial to providing adjudicators with an accurate portrayal of limitations in daily functioning.

A spokesperson for a professional organization raised concern that increased documentation requirements would disproportionately affect homeless people with mental illness, because they do not have access to transportation to appointments, and face significant challenges in seeking treatment, attending appointments, and obtaining documentation. The spokesperson indicated that although homelessness is not an indication of functional limitation under the paragraph B criteria, a prolonged period of homelessness reflects significant barriers, such as a disabling condition, in obtaining and maintaining housing and health stability.

The commenter suggested that it would be an oversight to ignore the most significant factor of a person's ADL homelessness. A related comment was that it would be helpful to claimants and adjudicators if we provided examples of evidence we need from the person filing for disability benefits and from people who know him or her. As we explained in response to a previous comment, ADL information continues to be central to how we document a person's mental disorder and its effects on a person's daily functioning. Under these rules, we will use ADL as a source of information about all four of the paragraph B areas of mental functioning.

We appreciate the unique difficulties that homeless people have with respect to access to transportation to appointments, and their significant challenges in seeking treatment, attending appointments, and obtaining documentation. We have special case processing and development guidance for homeless claimants in our field offices and our State agency partners in our sub-regulatory policies.

Furthermore, we do not agree that these final rules increase documentation requirements.

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However, in final Comment: The spokesperson for one organization said that it might be difficult to identify and distinguish sufficient information to satisfy the criteria in paragraphs B1 and B3, because the categories appear to be redundant. While proposed paragraph B1 understand, remember, and apply information involves a person's cognitive abilities, proposed paragraph B3 concentrate, persist, and maintain pace involves attention. Response: We did not make any changes to the final rules in response to these comments. It is also true that approaches to categorizing human abilities and functioning—in other contexts and for other reasons—use different categories to describe mental abilities.

In our prior rules on evaluating mental disorders, there is precedent for using the two separate paragraph B criteria to evaluate a person's functioning. Since , in the rules for evaluating mental disorders in children, we have used separate criteria for assessing a child's cognitive functioning and the child's concentration, persistence, and pace see Our programmatic experience has been that when a person's difficulties with the abilities described in paragraphs B1 and B3 rise to the level of marked limitation, the medical and non-medical evidence in the record is typically sufficient to distinguish the person's limitations in those abilities.

The misinterpretation would be that a claimant would have to demonstrate limitation in each of the three parts of B1 and B3 rather than in only one part. They also recommended that we make clear in the Response: We agree with the commenters and the reasons they provided. Therefore, we adopted these recommendations.

To ensure that adjudicators apply these criteria properly, we explain in new sections, final Comment: Several commenters expressed concern about the new paragraph B4 criterion, manage oneself. Response: We partially adopted the comments. Another change we made was adding that a person's ability to maintain personal hygiene and attire should be appropriate to a work setting. Additionally, we note that the content of the B4 criterion is not new or different from what adjudicators are already accustomed to evaluating and documenting.

With respect to the comment that self-management and skills for independence encompass more than the workplace, we agree that the ability and skills we address in paragraph B4 are important in daily life as well as the workplace. The statutory definition of disability for adults limits our determination to whether a person is able to work and, therefore, function in the workplace. However, we use all the information available to us about how a person functions, including how the person manages him- or herself from day-to-day at home and in the community, to make this determination.

The commenter noted that evaluating a person's decompensation patterns over time is crucial for determining the full impact of a mental disorder. The commenter also said that current medical records, particularly those for people with transient treatment, provide only a momentary snapshot of the illness. To address the chronic nature of a mental disorder, we provide guidelines in several sections of the final rules: Final Comment: One commenter found the proposed definitions of the B criteria lacking in detail and examples to guide adjudicators and advocates, particularly when compared to our prior rules.

Another commenter said that the proposed B2 criterion for interacting with others was too broad, and difficult to assess and use in determining a person's mental status. The commenter said it would be more helpful if we were to provide examples of more specific interpersonal behaviors that reflect how one handles conflicts in adaptive, compared with maladaptive and impaired, ways.

Response: We adopted these comments. We included more examples of each of the criteria in final Comment: Many commenters representing various organizations, health care professionals, families of people with mental disorders, and others opposed the language in proposed Response: In response to these comments, we removed this provision in the final rule. We had included the language in proposed In the ANPRM, we invited the public to send us comments and suggestions for updating and revising the mental disorders listings.

In response to that recommendation, and as explained in the NPRM, we included these provisions from the childhood rules in proposed In these final rules, we removed the provisions and explanations that were in proposed We provide guidance that is different from what we proposed in For example, we provide a five-point rating scale, with definitions of each point on the scale that are unrelated to standardized test results. We explain how we use the paragraph B criteria and the rating scale to evaluate a person's ability to function independently, appropriately, and effectively, on a sustained basis.

The commenter said that we should base our determination of the level of a child's limitation on the overall clinical assessment of the child, with equal emphasis placed on both testing and clinical assessment. Response: We do not rely on test scores alone when we decide whether a child is disabled.

We do not consider any single piece of evidence, including test scores, in isolation. The medical evidence we consider includes clinical observations from, for example, a child's physician, Start Printed Page psychiatrist, psychologist, or speech-language pathologist, and from other medical sources such as physical, occupational, and rehabilitation therapists. These sources of evidence may provide us their clinical assessments of a child's impairment s and its effects on the child's functioning.

Professional sources such as teachers and school counselors, as well as the child's caregivers and others who know the child, also provide information important to any disability determination.

Comment: Many commenters recommended that we use a 5-point or 6-point scale to evaluate impairment severity. They recommended that, to provide more clarification to adjudicators and medical sources, we should use a 6-point scale consisting of: No limitation; slight limitation; moderate limitation; marked limitation; extreme limitation; and total limitation. Response: We adopted the recommendation to retain the 5-point rating scale from our prior rules to assess impairment severity for adults.

By using the same words to describe the same policies, we hope to prevent any confusion that would result from using a new and different word. We do not believe the additional clarification that the commenter requested is necessary in these final rules. The introductory text states in multiple places that we will consider all relevant evidence when we evaluate a person's ability to function in the workplace. Final section In final section We do not believe the additional statement requested by the commenter is necessary in light of the other guidance throughout final Comment: Several commenters suggested that we consider homelessness along with a diagnosis of mental illness as an indicator of functional impairment.

The commenters also proposed that we could establish a period of homelessness that we would consider an indicator of functional difficulty. When we evaluate a person's mental disorder s , we consider all the information available to us that could indicate limitations in the person's functioning. If the person is homeless, we consider that fact, including how long he or she has been homeless.

As stated in final However, it would not be appropriate to establish a specific period of homelessness as an indicator of limited functioning, because we do not believe there is a measurable correlation between the severity of a person's mental disorder and the length of time the person has been homeless. Comment: A commenter requested that we place a greater emphasis on a claimant's ability to sustain work activity for 8 hours per day, five days per week, on a regular and continuing basis.

At this step, we consider whether the person's impairment meets or equals a listed impairment. Thus, people who have Start Printed Page moderate limitation in three or more functional areas do not always meet our definition of disability. We assess these types of claims most accurately at the fourth step of the sequential evaluation process, where we consider a claimant's residual functional capacity and work experience, and the fifth step of the sequential evaluation process, where we also consider a claimant's age and education.

They suggested that we include language in Response: We adopted the first comment for the reason the commenters provided.

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We added the recommended language to final We did not adopt the second comment for three reasons. The different definitions of these terms in the DSM-5 serve the needs of trained medical and psychological specialists. However, they would be confusing and burdensome for our adjudicators to use. As a result, if we were to rely on the DSM-5 definitions of these terms, we would not have definitions for all types of impairments. The DSM-5 definitions are not comprehensive enough for our program purposes.

Although we did not provide definitions for most of these terms until now, the definitions in final As a result, the definitions we provide in these rules do not represent a departure from prior policy. However, the DSM-5 definitions for these terms are not consistent with how we have used these words in our program in the past. We believe that using familiar definitions and concepts to define familiar terms will be easier for the public and adjudicators, rather than describing familiar terms in changed and unfamiliar ways.

For these three reasons, we did not adopt the second recommendation.

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Comment: A commenter recommended that we add language to proposed We added final sections We explain that the more extensive the support the person needs from others, or the more structured the setting the person needs in order to function, the more limited we will find him or her to be. They further noted that a person with a serious and persistent mental illness does not need to be in a state of full-blown decompensation to have serious deficits in daily activities and in social or occupational functioning.

Another commenter recommended that we keep some of the examples in prior Comment: One commenter was concerned that the emphasis in proposed The commenter suggested that proposed We added language to final Both proposed Comment: One commenter was concerned that the paragraph C criteria, and the description of the criteria in proposed The commenter stated that many people with mental disorders lack awareness about their mental disorders and therefore refuse treatment. The commenter recommended that the policies should not place at a disadvantage those claimants whose mental disorders cause them to refuse to attend or follow up with treatment.

Response: We agree with the commenter's reasoning, and we adopted the recommendation. We added language in final The section explains that if the evidence indicates that the claimant's inconsistent treatment or lack of compliance is a feature of his or her mental disorder, and it has led to an exacerbation of his or her symptoms and signs, we will not use it as evidence to support a finding that the claimant has not received ongoing medical treatment. Comment: Several commenters were concerned that proposed The commenters also stated that the language in this section would give an inappropriate amount of discretion to the adjudicators, who do not have the expertise of the test administrators.

Response: We adopted most of these comments by making several changes in the final rules. First, we removed the discussion of evaluating test scores from final Like proposed However, final Second, we added a new section, final We moved the discussion about standardized test scores into final Third, we revised the guidance to indicate that only qualified specialists, Federal and State agency medical and psychological consultants, and other contracted medical and psychological experts, may conclude that an obtained IQ score s is not an accurate reflection of a claimant's general intellectual functioning.

This change serves several purposes. It responds to the commenters' concern that proposed However, it also allows our agency's medical and psychological experts to reach different conclusions than those reached by the individual test administrator, when appropriate. This option is important because during our case development, we often receive a more complete picture of a claimant's functioning from a variety of sources of information other than the test administrator s. The proposed rules removed the detailed information on psychological testing in prior However, in these final rules, we added section In this section, we included the information from prior In addition, we expect to provide formal and accessible guidance to adjudicators about intelligence testing and final listings We discuss why we do not require standardized assessments of adaptive behavior in our response to another comment below.

As discussed above, we added final That section includes a sub-section about how we consider a claimant's work activity when we evaluate his or her functional abilities. We state that we will consider all factors involved in a claimant's work history, including whether the work was in a supported setting, whether the claimant required additional supervision, how much time it took the claimant to learn the job duties, and the reason the work ended, if applicable. Comment: The spokespersons for several organizations recommended that we further clarify how adjudicators will evaluate deficits in adaptive functioning.

One commenter suggested that we mention standardized tests as a valuable source of evidence. Another commenter recommended that we evaluate and rate deficits in adaptive functioning in terms of scores that are two or more standard deviations below the mean. Response: We adopted the suggestion to provide more clarification about how adjudicators will evaluate deficits in adaptive functioning. As we discussed Start Printed Page earlier in this preamble, the reorganized criteria in final listings Alternatively, final The revised organization of final listings We then added final section We did not adopt the suggestion to evaluate and rate deficits in adaptive functioning in terms of scores that are two or more standard deviations below the mean.

However, the use of standard deviations as a required measure of deficits in adaptive functioning under listing The suggestion is not feasible because inclusion of such criteria in the listing would mean that we would have to require the results of a standardized test of adaptive functioning in every case evaluated under that listing.

Although we can agree with the recommendation in principle, the medical evidence of record for claims that we would evaluate under listing Financial constraints within the disability program preclude our purchasing such testing in every case lacking such results. Additionally, the suggestion is unnecessary because the areas of mental functioning described in the For that reason, as for all other mental disorders, we use the paragraph B areas of mental functioning to evaluate the limitations in a person's adaptive functioning under listing We explain in final However, to evaluate and determine the severity of those deficits, we will use the guidelines in final Comment: Several commenters requested that we more clearly define the criteria and guidelines for determining the nature and effects of substance use on a person's functional capacity.

Response: This request is outside the scope of the notice of proposed rulemaking, and we did not adopt this comment in these final rules. However, we appreciate the importance of clear guidance for implementing the statutory drug addiction and alcoholism DAA policy. Department of Health and Human Services, and our adjudicative experience. The SSR provides detailed guidance for adjudicators at all administrative levels. It consolidates information from our regulations, training materials, and question-and-answer responses to explain our DAA policy.

In cases of alleged mental impairment in which a substance use disorder is involved, we will evaluate the person's mental impairment, as appropriate, under the mental disorder listing for the involved condition for example, depressive, bipolar and related disorders; schizophrenia spectrum and other psychotic disorders , and according to the guidelines in SSR p.

Comment: We received many comments on the proposed change in the name of listing One commenter, acknowledging a minority opinion, argued that we ought not to eliminate use of the prior title at any time. Several other commenters, while favoring the idea of changing the name of the listing, did not endorse the term proposed in the NPRM. Response: We adopted the last suggestion. Public comments in response to the NPRM generally supported the change in terminology, and the proposed change became a final rule on August 1, 78 FR We agree with their perspective and their recommendation, and we have adopted their proposed name change.

Comment: Some commenters, including the spokesperson for a national organization, recommended that we make changes to listing We reorganized the requirements of listing Listing Paragraphs A claimant's impairment must satisfy the three criteria in either paragraph We provide additional explanation about the revisions to listing Comment: Several commenters thought that proposed Other commenters thought that proposed Response: We made several changes in these final rules in response to these comments. First, as we mention in our response to an earlier comment, we revised the criteria in listings The changes clarify that there are three criteria that must be satisfied in order for an impairment to meet one of these listings.

The three criteria, restated here, are: 1. For claimants who are able to take a standardized intelligence test, the listing criteria about daily functioning requires that the claimant's impairment result in significant deficits in adaptive functioning, evidenced by extreme limitation in one, or marked limitation in two, of the four paragraph B areas of mental functioning see final We discuss the revisions we made to listing Second, we removed proposed We indicate that only qualified specialists, Federal and State agency medical and psychological consultants, and other contracted medical and psychological experts may conclude that an obtained IQ score s is not an accurate reflection of a person's general intellectual functioning.

The conclusion of the qualified specialist, or medical or psychological consultant or expert, about the accuracy of the obtained IQ score s determines whether the person's cognitive impairment satisfies the IQ score criterion. Third, in response to concerns that an adjudicator might misinterpret information about a person's daily functioning, we included guidance in three sections of the final rules to ensure proper evaluation of that information.

We state that a person may demonstrate both strengths and deficits in adaptive functioning, and we cite examples of the kinds of commonplace activities that a person might engage in. We describe special circumstances that may have made it possible for the person to work. In these two sections, we explain that we will not assume that doing some commonplace activities or work activity demonstrates that the person's impairment does not satisfy the criteria in It has been our experience that there can be considerable variability in the quality of reports of psychological examinations and intelligence testing.

Moreover, our mental disorders listings are function-driven, not diagnosis-driven. To address this situation, and for the reasons explained in other sections of the preamble, we believe that the revision to listing Response: We adopted the comment, in part. However, as part of the overall reorganization of listing Comment: We received differing public comments regarding the appropriate IQ score we should use for determining whether a person has significantly subaverage general intellectual functioning.

Some commenters supported the continued use of the lowest IQ score such as a part score, or component score on a test that provides more than one score. Others questioned why we would use a part score rather than the full scale IQ score. These definitions call for the use of the full scale IQ score, except in limited circumstances. Response: We partially adopted these comments.

We agreed with the reasons provided by the commenters who suggested that we use a full scale IQ score to determine whether a person's cognitive impairment satisfies the criteria in final listings In our experience, full scale IQ scores are the most reliable evidence that a person has intellectual disability and not another impairment that affects cognition. Additionally, in , we commissioned a report from the National Research Council NRC about intellectual disability and determining eligibility for social security benefits, published in In its report, the NRC concluded that for purposes of assessing impairment in people with intellectual disability, full scale IQ scores are generally better representations of general intelligence than are part scores because they combine a person's various skills and abilities to better reflect overall cognitive functioning.

Despite this recommendation, the NRC noted that in some instances when a person obtains a full scale IQ score from 71 through 75, it can be appropriate to use certain part scores verbal or performance IQ scores that are 70 or below to establish that the person has significant limitations in general intellectual functioning.

We largely adopted this recommendation for final listings We may find that a person's impairment satisfies the criteria in final Response: We partially adopted the recommendations. The medical community recognizes measurement error for IQ scores for example, the standard error of measurement. Test publishers often provide a range of scores around a person's obtained score that may also accurately represent a person's intellectual functioning. Similarly, as discussed above, one of the NRC's recommendations was to consider a range of full scale IQ scores from in some instances.

In these final rules, we addressed these aspects of IQ testing by largely adopting the NRC recommendation. We added an alternative option for establishing that a person has significantly subaverage general intellectual functioning in final This alternative enables some people with significantly subaverage general intellectual functioning and full scale IQ scores that fall within a range of to satisfy the IQ score requirement in final listings Additionally, we expect to provide formal and accessible guidance to adjudicators about intelligence testing and final listings The commenter asserted that the full scale IQ score can be artificially inflated in the newer Wechsler scale test editions, relative to older Wechsler tests.

The commenter explained that because of the highly concrete nature of their tasks, the WMI and PSI scores can be relatively higher among intellectually disabled claimants and thus do not reflect deeper learning potential or problem-solving ability. The commenter believes that the GAI is a better summary measure of working memory and processing speed in the calculation of overall intelligence because it does not include WMI and PSI subtests.

We appreciate the commenter's observations about differences between the two scores. However, the full scale IQ score contains more subtests 10 than the GAI 6 , and therefore the full scale IQ score has higher and more stable reliability and validity coefficients. For these reasons, we do not agree with the recommendation to encourage adjudicators to use the GAI rather than the full scale IQ score as a summary measure of intelligence for listing Comment: Some commenters recommended that we add a provision to listings As explained earlier in this preamble, the final rules reorganize listings Final listings Comment: Several commenters objected to the proposal to remove prior listing They provided various reasons in support of their position.

Department of Health and Human Services, have documented the impact that these disorders have on the health and functioning of disabled people. As a third example, a commenter stated that substance abuse is one of the behavior disorders that can seriously affect functional capacity. That commenter also noted that a large percentage of cases requiring medical expert testimony related to mental disorders involve substance abuse issues.

Response: Although we appreciate the issues raised by the commenters, we did not adopt the recommendation to keep prior listing Furthermore, if a claimant's substance use is a medically determinable impairment and is material to a finding that the claimant is disabled, then we must find that the claimant is not disabled. See our response to the prior comment that requested that we more clearly define the criteria and guidelines for determining the nature and effects of substance use on a person's functional capacity for more information about our guidance on how we assess of the impact of substance use disorders.

These final rules remove prior listing In addition, listing As we revise the listings, we are also trying to eliminate reference listings. Finally, listing For these reasons, we are removing the listing. Comment: A commenter requested that we keep the name of prior listing Comment: The spokesperson for an organization suggested that we replace the proposed name of listing To avoid confusion, we are keeping the titles of listings Each listing does not include separate listings within it.

However, we make clear that the list of examples is not all-inclusive. Fetal alcohol spectrum disorders FASD are known to produce the kinds of delay or deficit in the development of age-appropriate skills involving motor planning and control, learning, relating and communicating, and self-regulating that we address in listing As with any disorder, the effects and severity of FASD can be highly variable across individuals.

If an infant or toddler manifests a medically determinable developmental disorder of the severity described in listing Comment: Some commenters recommended that we use age-related percentiles rather than fractions to assess developmental disorders in younger children. The commenters remarked that proposed listing The commenters illustrated the concern with the observations that performance of half of expected age in a 4-month-old infant represents a delay of only 2 months, while half of expected age for a 4-year-old child is a much more severe delay.

Response: We did not adopt the comment for two reasons. First, proposed section However, proposed Rather than repeat guidance that we provide elsewhere in our regulations, in these final rules, we removed those provisions from As a result, the final rules no longer include the language the commenter mentions. We use the fractions as an approximation when we do not have standardized test results in the case record. Our adjudicators are now very familiar with using these fractions in our program, and they find that the fractions are an accurate alternative and helpful when the case record does not have standardized test results.

Therefore, we do not use fractions to assess the functioning of 4-year-old children. Comment: A commenter recommended that we not defer disability determination for pre-term infants until attainment of corrected chronological age of 6 months. The commenter observed that adjustment of chronological age to account for a period of gestational prematurity is an accepted practice until a chronological age of 2 years, after which such adjustments are often not made.

It would thus be critical not to defer disability determination in these cases, as this could result in delay in services to children with severe neurodevelopmental disorders. We do not believe the final rule in In Similarly, adjudicators have the option to defer determination beyond a child's attainment of 6 months, if the available evidence warrants deferral.

The first claims that the irreducible special sciences, which are the sources of irreducible predicates, are not wholly objective in the way that physics is, but depend for their subject matter upon interest-relative perspectives on the world. This means that they, and the predicates special to them, depend on the existence of minds and mental states, for only minds have interest-relative perspectives.

The second claim is that psychology—the science of the mental—is itself an irreducible special science, and so it, too, presupposes the existence of the mental. Mental predicates therefore presuppose the mentality that creates them: mentality cannot consist simply in the applicability of the predicates themselves. First, let us consider the claim that the special sciences are not fully objective, but are interest-relative.

A mass of matter could be characterized as a hurricane, or as a collection of chemical elements, or as mass of sub-atomic particles, and there be only the one mass of matter. But such different explanatory frameworks seem to presuppose different perspectives on that subject matter. This is where basic physics, and perhaps those sciences reducible to basic physics, differ from irreducible special sciences. On a realist construal, the completed physics cuts physical reality up at its ultimate joints: any special science which is nomically strictly reducible to physics also, in virtue of this reduction, it could be argued, cuts reality at its joints, but not at its minutest ones.

If scientific realism is true, a completed physics will tell one how the world is, independently of any special interest or concern: it is just how the world is. It would seem that, by contrast, a science which is not nomically reducible to physics does not take its legitimation from the underlying reality in this direct way. Rather, such a science is formed from the collaboration between, on the one hand, objective similarities in the world and, on the other, perspectives and interests of those who devise the science.

The concept of hurricane is brought to bear from the perspective of creatures concerned about the weather. Creatures totally indifferent to the weather would have no reason to take the real patterns of phenomena that hurricanes share as constituting a single kind of thing. With the irreducible special sciences, there is an issue of salience , which involves a subjective component: a selection of phenomena with a certain teleology in mind is required before their structures or patterns are reified.

The entities of metereology or biology are, in this respect, rather like Gestalt phenomena. Even accepting this, why might it be thought that the perspectivality of the special sciences leads to a genuine property dualism in the philosophy of mind? It might seem to do so for the following reason. Having a perspective on the world, perceptual or intellectual, is a psychological state.

So the irreducible special sciences presuppose the existence of mind. If one is to avoid an ontological dualism, the mind that has this perspective must be part of the physical reality on which it has its perspective. But psychology, it seems to be almost universally agreed, is one of those special sciences that is not reducible to physics, so if its subject matter is to be physical, it itself presupposes a perspective and, hence, the existence of a mind to see matter as psychological. If this mind is physical and irreducible, it presupposes mind to see it as such. We seem to be in a vicious circle or regress.

We can now understand the motivation for full-blown reduction. A true basic physics represents the world as it is in itself, and if the special sciences were reducible, then the existence of their ontologies would make sense as expressions of the physical, not just as ways of seeing or interpreting it. The irreducibility of the special sciences creates no problem for the dualist, who sees the explanatory endeavor of the physical sciences as something carried on from a perspective conceptually outside of the physical world.

But psychology is one of the least likely of sciences to be reduced. If psychology cannot be reduced, this line of reasoning leads to real emergence for mental acts and hence to a real dualism for the properties those acts instantiate Robinson There is an argument, which has roots in Descartes Meditation VI , which is a modal argument for dualism. One might put it as follows:. The rationale of the argument is a move from imaginability to real possibility. I include 2 because the notion of conceivability has one foot in the psychological camp, like imaginability, and one in the camp of pure logical possibility and therefore helps in the transition from one to the other.

See, for example, Chalmers , 94—9. This latter argument, if sound, would show that conscious states were something over and above physical states. It is a different argument because the hypothesis that the unaltered body could exist without the mind is not the same as the suggestion that the mind might continue to exist without the body, nor are they trivially equivalent. The zombie argument establishes only property dualism and a property dualist might think disembodied existence inconceivable—for example, if he thought the identity of a mind through time depended on its relation to a body e.

When philosophers generally believed in contingent identity, that move seemed to them invalid. But nowadays that inference is generally accepted and the issue concerns the relation between imaginability and possibility.

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  • No-one would nowadays identify the two except, perhaps, for certain quasi-realists and anti-realists , but the view that imaginability is a solid test for possibility has been strongly defended. There seem to be good arguments that time-travel is incoherent, but every episode of Star-Trek or Doctor Who shows how one can imagine what it might be like were it possible. It is worth relating the appeal to possibility in this argument to that involved in the more modest, anti-physicalist, zombie argument.

    The possibility of this hypothesis is also challenged, but all that is necessary for a zombie to be possible is that all and only the things that the physical sciences say about the body be true of such a creature. As the concepts involved in such sciences—e. There is no parallel clear, uncontroversial and regimented account of mental concepts as a whole that fails to invoke, explicitly or implicitly, physical e.

    For an analytical behaviourist the appeal to imaginability made in the argument fails, not because imagination is not a reliable guide to possibility, but because we cannot imagine such a thing, as it is a priori impossible. The impossibility of disembodiment is rather like that of time travel, because it is demonstrable a priori, though only by arguments that are controversial. The argument can only get under way for those philosophers who accept that the issue cannot be settled a priori, so the possibility of the disembodiment that we can imagine is still prima facie open.

    A major rationale of those who think that imagination is not a safe indication of possibility, even when such possibility is not eliminable a priori, is that we can imagine that a posteriori necessities might be false—for example, that Hesperus might not be identical to Phosphorus. But if Kripke is correct, that is not a real possibility. Another way of putting this point is that there are many epistemic possibilities which are imaginable because they are epistemic possibilities, but which are not real possibilities.

    Richard Swinburne , New Appendix C , whilst accepting this argument in general, has interesting reasons for thinking that it cannot apply in the mind-body case. In the case of our experience of ourselves this is not true. Now it is true that the essence of Hesperus cannot be discovered by a mere thought experiment. That is because what makes Hesperus Hesperus is not the stereotype, but what underlies it. But it does not follow that no one can ever have access to the essence of a substance, but must always rely for identification on a fallible stereotype.

    One might think that for the person him or herself, while what makes that person that person underlies what is observable to others, it does not underlie what is experienceable by that person, but is given directly in their own self-awareness. This is a very appealing Cartesian intuition: my identity as the thinking thing that I am is revealed to me in consciousness, it is not something beyond the veil of consciousness.

    Now it could be replied to this that though I do access myself as a conscious subject, so classifying myself is rather like considering myself qua cyclist. Just as I might never have been a cyclist, I might never have been conscious, if things had gone wrong in my very early life. I am the organism, the animal, which might not have developed to the point of consciousness, and that essence as animal is not revealed to me just by introspection. But there are vital differences between these cases. A cyclist is explicitly presented as a human being or creature of some other animal species cycling: there is no temptation to think of a cyclist as a basic kind of thing in its own right.

    Consciousness is not presented as a property of something, but as the subject itself. Yet, even if we are not referring primarily to a substrate, but to what is revealed in consciousness, could it not still be the case that there is a necessity stronger than causal connecting this consciousness to something physical? To consider this further we must investigate what the limits are of the possible analogy between cases of the water-H 2 O kind, and the mind-body relation. We start from the analogy between the water stereotype—how water presents itself—and how consciousness is given first-personally to the subject.

    It is plausible to claim that something like water could exist without being H 2 O, but hardly that it could exist without some underlying nature. There is, however, no reason to deny that this underlying nature could be homogenous with its manifest nature: that is, it would seem to be possible that there is a world in which the water-like stuff is an element, as the ancients thought, and is water-like all the way down. The claim of the proponents of the dualist argument is that this latter kind of situation can be known to be true a priori in the case of the mind: that is, one can tell by introspection that it is not more-than-causally dependent on something of a radically different nature, such as a brain or body.

    What grounds might one have for thinking that one could tell that a priori? The only general argument that seem to be available for this would be the principle that, for any two levels of discourse, A and B , they are more-than-causally connected only if one entails the other a priori. And the argument for accepting this principle would be that the relatively uncontroversial cases of a posteriori necessary connections are in fact cases in which one can argue a priori from facts about the microstructure to the manifest facts.

    In the case of water, for example, it would be claimed that it follows a priori that if there were something with the properties attributed to H 2 O by chemistry on a micro level, then that thing would possess waterish properties on a macro level. What is established a posteriori is that it is in fact H 2 O that underlies and explains the waterish properties round here, not something else: the sufficiency of the base—were it to obtain—to explain the phenomena, can be deduced a priori from the supposed nature of the base.

    This is, in effect, the argument that Chalmers uses to defend the zombie hypothesis. The suggestion is that the whole category of a posteriori more-than-causally necessary connections often identified as a separate category of metaphysical necessity comes to no more than this. If we accept that this is the correct account of a posteriori necessities, and also deny the analytically reductionist theories that would be necessary for a priori connections between mind and body, as conceived, for example, by the behaviourist or the functionalist, does it follow that we can tell a priori that consciousness is not more-than-causally dependent on the body?

    It is helpful in considering this question to employ a distinction like Berkeley's between ideas and notions. The self and its faculties are not the objects of our mental acts, but are captured only obliquely in the performance of its acts, and of these Berkeley says we have notions , meaning by this that what we capture of the nature of the dynamic agent does not seem to have the same transparency as what we capture as the normal objects of the agent's mental acts.

    It is not necessary to become involved in Berkeley's metaphysics in general to feel the force of the claim that the contents and internal objects of our mental acts are grasped with a lucidity that exceeds that of our grasp of the agent and the acts per se. Though we shall see later, in 5. The conceivability argument creates a prima facie case for thinking that mind has no more than causal ontological dependence on the body.

    Let us assume that one rejects analytical behaviourist or functionalist accounts of mental predicates. Then the above arguments show that any necessary dependence of mind on body does not follow the model that applies in other scientific cases. This does not show that there may not be other reasons for believing in such dependence, for so many of the concepts in the area are still contested.

    For example, it might be argued that identity through time requires the kind of spatial existence that only body can give: or that the causal continuity required by a stream of consciousness cannot be a property of mere phenomena. All these might be put forward as ways of filling out those aspects of our understanding of the self that are only obliquely, not transparently, presented in self-awareness. The dualist must respond to any claim as it arises: the conceivability argument does not pre-empt them. All the arguments so far in this section have been either arguments for property dualism only, or neutral between property and substance dualism.

    In this subsection, and in section 4. The ones in this section can be regarded as preliminaries to that in 4. Hume is generally credited with devising what is known as the 'bundle' theory of the self Treatise Book I, Part IV, section VI , according to which there are mental states, but no further subject or substance which possesses them.

    He famously expresses his theory as follows. Nevertheless, in the Appendix of the same work he expressed dissatisfaction with this account. Somewhat surprizingly, it is not very clear just what his worry was, but it is expressed as follows:. Berkeley had entertained a similar theory to the one found in Hume's main text in his Philosophical Commentaries , Notebook A, paras , but later rejected it for the claim that we could have a notion , though not an idea of the self.

    This Berkeleian view is expressed in more modern terms by John Foster. There is a clash of intuitions here between which it is difficult to arbitrate. There is an argument that is meant to favour the need for a subject, as claimed by Berkeley and Foster. To say that, according to the bundle theory, the identity conditions of individual mental states must be independent of the identity of the person who possesses them, is to say that their identity is independent of the bundle to which they belong.

    Hume certainly thought something like this, for he thought that an impression might 'float free' from the mind to which it belonged, but it is not obvious that a bundle theorist is forced to adopt this position. Perhaps the identity of a mental event is bound up with the complex to which it belongs. That this is impossible certainly needs further argument. Hume seems, however, in the main text to unconsciously make a concession to the opposing view, namely the view that there must be something more than the items in the bundle to make up a mind.

    He says:. Talk of the mind as a theatre is, of course, normally associated with the Cartesian picture, and the invocation of any necessary medium, arena or even a field hypostasize some kind of entity which binds the different contents together and without which they would not be a single mind. Modern Humeans - such as Parfit ; or Dainton - replace the theatre with a co-consciousness relation.

    So the bundle theorist is perhaps not as restricted as Hume thought. The bundle consists of the objects of awareness and the co-consciousness relation or relations that hold between them , and I think that the modern bundle theorist would want to say that it is the nexus of co-consciousness relations that constitutes our sense of the subject and of the act of awareness of the object.

    This involves abandoning the second of Hume's principles. The Humean point then becomes that we mistake the nexus of relations for a kind of entity, in a way similar to that in which, Hume claims,we mistake the regular succession of similar impressions for an entity called an enduring physical object.

    Whether this really makes sense in the end is another matter. I think that it is dubious whether it can accommodate the subject as agent , but it does mean that simple introspection probably cannot refute a sophisticated bundle theory in the way that Lowe and Foster want. Hume's original position seems to make him deny that we have any 'sense of self' at all, whilst the version that allows for our awareness of the relatedness accommodates it, but explains how it can be an illusion. The rejection of bundle dualism, therefore, requires more than an appeal to our intuitive awareness of ourselves as subjects.

    We will see in the next section how arguments that defend the simplicity of the self attempt to undercut the bundle theory. There is a long tradition, dating at least from Reid , for arguing that the identity of persons over time is not a matter of convention or degree in the way that the identity of other complex substances is and that this shows that the self is a different kind of entity from any physical body. Criticism of these arguments and of the intuitions on which they rest, running from Hume to Parfit , have left us with an inconclusive clash of intuitions.

    The argument under consideration and which, possibly, has its first statement in Madell , does not concern identity through time, but the consequences for identity of certain counterfactuals concerning origin. It can, perhaps, therefore, break the stalemate which faces the debate over diachronic identity. The claim is that the broadly conventionalist ways which are used to deal with problem cases through time for both persons and material objects, and which can also be employed in cases of counterfactuals concerning origin for bodies, cannot be used for similar counterfactuals concerning persons or minds.

    Concerning ordinary physical objects, it is easy to imagine counterfactual cases where questions of identity become problematic. Take the example of a particular table. We can scale counterfactual suggestions as follows:. The first suggestion would normally be rejected as clearly false, but there will come a point along the spectrum illustrated by i and iii and towards iii where the question of whether the hypothesised table would be the same as the one that actually exists have no obvious answer.

    There will thus be a penumbra of counterfactual cases where the question of whether two things would be the same is not a matter of fact. Let us now apply this thought to conscious subjects. Suppose that a given human individual had had origins different from those which he in fact had such that whether that difference affected who he was was not obvious to intuition. What would count as such a case might be a matter of controversy, but there must be one. Perhaps it is unclear whether, if there had been a counterpart to Jones' body from the same egg but a different though genetically identical sperm from the same father, the person there embodied would have been Jones.

    Some philosophers might regard it as obvious that sameness of sperm is essential to the identity of a human body and to personal identity. In that case imagine a counterpart sperm in which some of the molecules in the sperm are different; would that be the same sperm? If one pursues the matter far enough there will be indeterminacy which will infect that of the resulting body. There must therefore be some difference such that neither natural language nor intuition tells us whether the difference alters the identity of the human body; a point, that is, where the question of whether we have the same body is not a matter of fact.

    How one is to describe these cases is, in some respects, a matter of controversy. Some philosophers think one can talk of vague identity or partial identity. Others think that such expressions are nonsensical. There is no space to discuss this issue here. It is enough to assume, however, that questions of how one is allowed to use the concept of identity effect only the care with which one should characterize these cases, not any substantive matter of fact.

    If there were, then there would have to be a haecceitas or thisness belonging to and individuating each complex physical object, and this I am assuming to be implausible if not unintelligible. More about the conditions under which haecceitas can make sense will be found below. One might plausibly claim that no similar overlap of constitution can be applied to the counterfactual identity of minds.

    In Geoffrey Madell's words:. Why is this so? Imagine the case where we are not sure whether it would have been Jones' body—and, hence, Jones—that would have been created by the slightly modified sperm and the same egg. Can we say, as we would for an object with no consciousness, that the story something the same, something different is the whole story: that overlap of constitution is all there is to it? For the Jones body as such, this approach would do as well as for any other physical object.

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    The creature who would have existed would have had a kind of overlap of psychic constitution with me. The third answer parallels the response we would give in the case of bodies. But as an account of the subjective situation, it is arguable that this makes no sense.

    Clearly, the notion of overlap of numerically identical psychic parts cannot be applied in the way that overlap of actual bodily part constitution quite unproblematically can. This might make one try the second answer. It is difficult to see why it does not. Suppose Jones found out that he had originally been one of twins, in the sense that the zygote from which he developed had divided, but that the other half had died soon afterwards. He can entertain the thought that if it had been his half that had died, he would never have existed as a conscious being, though someone would whose life, both inner and outer, might have been very similar to his.

    He might feel rather guiltily grateful that it was the other half that died. It would be strange to think that Jones is wrong to think that there is a matter of fact about this. If the reasoning above is correct, one is left with only the first option. If so, there has to be an absolute matter of fact from the subjective point of view. But the physical examples we have considered show that when something is essentially complex, this cannot be the case. When there is constitution, degree and overlap of constitution are inevitably possible. So the mind must be simple, and this is possible only if it is something like a Cartesian substance.

    Putting his anti-materialist argument outlined above, in section 1, in very general terms, Aristotle's worry was that a material organ could not have the range and flexibility that are required for human thought. His worries concerned the cramping effect that matter would have on the range of objects that intellect could accommodate. Parallel modern concerns centre on the restriction that matter would impose on the range of rational processes that we could exhibit.

    Godel, for example, believed that his famous theorem showed that there are demonstrably rational forms of mathematical thought of which humans are capable which could not be exhibited by a mechanical or formal system of a sort that a physical mind would have to be. Penrose has argued that Turing's halting problem has similar consequences. In general, the fear is that the materialist monist has to treat the organ of thought as, what Dennett calls, a syntactic engine : that is, as something that operates without any fundamental reference to the propositional content of what it thinks.

    It works as a machine that only shadows the pattern of meaning. But it is hard to convince oneself that, as one, for example, reflectively discusses philosophy and struggles to follow what is being said, that it is not the semantic content that is driving one's responses. But if we are truly semantic engines, it is difficult to see how we can avoid at least a property dualism. These issues are, of course, connected with problems raised by Brentano, concerning the irreducibility of intentionality.

    Despite the interest of the arguments for dualism based on the irreducible flexibility of intellect, most of the modern debate turns on arguments that have a Cartesian origin. We have already discussed the problem of interaction. In this section we shall consider two other facets of dualism that worry critics. First, there is what one might term the queerness of the mental if conceived of as non-physical. Second there is the difficulty of giving an account of the unity of the mind. We shall consider this latter as it faces both the bundle theorist and the substance dualist.

    Mental states are characterised by two main properties, subjectivity, otherwise known as privileged access, and intentionality. Physical objects and their properties are sometimes observable and sometimes not, but any physical object is equally accessible, in principle, to anyone. From the right location, we could all see the tree in the quad, and, though none of us can observe an electron directly, everyone is equally capable of detecting it in the same ways using instruments. But the possessor of mental states has a privileged access to them that no-one else can share.

    This suggests to some philosophers that minds are not ordinary occupants of physical space. Physical objects are spatio-temporal, and bear spatio-temporal and causal relations to each other. Mental states seem to have causal powers, but they also possess the mysterious property of intentionality—being about other things—including things like Zeus and the square root of minus one, which do not exist. The nature of the mental is both queer and elusive. Ghosts are mysterious and unintelligible: machines are composed of identifiable parts and work on intelligible principles.

    But this contrast holds only if we stick to a Newtonian and common-sense view of the material. Think instead of energy and force-fields in a space-time that possesses none of the properties that our senses seem to reveal: on this conception, we seem to be able to attribute to matter nothing beyond an abstruse mathematical structure. Whilst the material world, because of its mathematicalisation, forms a tighter abstract system than mind, the sensible properties that figure as the objects of mental states constitute the only intelligible content for any concrete picture of the world that we can devise.

    Perhaps the world within the experiencing mind is, once one considers it properly, no more—or even less—queer than the world outside it. Whether one believes that the mind is a substance or just a bundle of properties, the same challenge arises, which is to explain the nature of the unity of the immaterial mind. For the Cartesian, that means explaining how he understands the notion of immaterial substance. For the Humean, the issue is to explain the nature of the relationship between the different elements in the bundle that binds them into one thing.

    Neither tradition has been notably successful in this latter task: indeed, Hume, in the appendix to the Treatise , declared himself wholly mystified by the problem, rejecting his own initial solution though quite why is not clear from the text.


    If the mind is only a bundle of properties, without a mental substance to unite them, then an account is needed of what constitutes its unity. The only route appears to be to postulate a primitive relation of co-consciousness in which the various elements stand to each other. There are two strategies which can be used to attack the bundle theory. One is to claim that our intuitions favour belief in a subject and that the arguments presented in favour of the bundle alternative are unsuccessful, so the intuition stands. The other is to try to refute the theory itself. Foster , —9 takes the former path.

    This is not effective against someone who thinks that metaphysical economy gives a prima facie priority to bundle theories, on account of their avoiding mysterious substances. The core objection to bundle theories see, for example, Armstrong , 21—3 is that, because it takes individual mental contents as its elements, such contents should be able to exist alone, as could the individual bricks from a house. Hume accepted this consequence, but most philosophers regard it as absurd.

    There could not be a mind that consisted of a lone pain or red after-image, especially not of one that had detached itself from the mind to which it had previously belonged. Therefore it makes more sense to think of mental contents as modes of a subject.

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    Bundle theorists tend to take phenomenal contents as the primary elements in their bundle. Seeing the problem in this way has obvious Humean roots. This atomistic conception of the problem becomes less natural if one tries to accommodate other kinds of mental activity and contents. How are acts of conceptualising, attending to or willing with respect to, such perceptual contents to be conceived? These kinds of mental acts seem to be less naturally treated as atomic elements in a bundle, bound by a passive unity of apperception.

    William James , vol. James attributes to these Thoughts acts of judging, attending, willing etc, and this may seem incoherent in the absence of a genuine subject. But there is also a tendency to treat many if not all aspects of agency as mere awareness of bodily actions or tendencies, which moves one back towards a more normal Humean position.

    Whether James' position really improves on Hume's, or merely mystifies it, is still a moot point. But see Sprigge , 84—97, for an excellent, sympathetic discussion. The problem is to explain what kind of a thing an immaterial substance is, such that its presence explains the unity of the mind. The answers given can be divided into three kinds. There are two problems with this approach.

    Second, and connectedly, it is not clear in what sense such stuff is immaterial, except in the sense that it cannot be integrated into the normal scientific account of the physical world. Why is it not just an aberrant kind of physical stuff? Account a allowed the immaterial substance to have a nature over and above the kinds of state we would regard as mental. The consciousness account does not. This is Descartes' view. The most obvious objection to this theory is that it does not allow the subject to exist when unconscious. This forces one to take one of four possible theories.

    One could claim i that we are conscious when we do not seem to be which was Descartes' view : or ii that we exist intermittently, though are still the same thing which is Swinburne's theory, , : or iii that each of us consists of a series of substances, changed at any break in consciousness, which pushes one towards a constructivist account of identity through time and so towards the spirit of the bundle theory: or iv even more speculatively, that the self stands in such a relation to the normal time series that its own continued existence is not brought into question by its failure to be present in time at those moments when it is not conscious within that series Robinson, forthcoming.

    This is Foster's view, though I think Vendler and Madell have similar positions. He has half escaped because he does not attribute non-mental properties to the self, but he is still captured by trying to explain what it is made of. Let's have it specified! In this respect, however, there is no difference between this attribute, which constitutes the subject's essential nature, and the specific psychological attributes of his conscious life….

    Admittedly, the feeling that there must be more to be said from a God's eye view dies hard. The reason is that, even when we have acknowledged that basic subjects are wholly non-physical, we still tend to approach the issue of their essential natures in the shadow of the physical paradigm.

    Berkeley's concept of notion again helps here. One can interpret Berkeley as implying that there is more to the self than introspection can capture, or we can interpret him as saying that notions, though presenting stranger entities than ideas, capture them just as totally. Varieties of Dualism: Ontology 2. Varieties of Dualism: Interaction 3. Arguments for Dualism 4.

    Problems for Dualism 5. The ontological question: what are mental states and what are physical states? Is one class a subclass of the other, so that all mental states are physical, or vice versa? Or are mental states and physical states entirely distinct? The causal question: do physical states influence mental states? Do mental states influence physical states?

    If so, how? The problem of consciousness: what is consciousness? How is it related to the brain and the body? The problem of intentionality: what is intentionality? The problem of the self: what is the self? Other aspects of the mind-body problem arise for aspects of the physical. For example: The problem of embodiment: what is it for the mind to be housed in a body?

    What is it for a body to belong to a particular subject? Varieties of Dualism: Ontology There are various ways of dividing up kinds of dualism. Varieties of Dualism: Interaction If mind and body are different realms, in the way required by either property or substance dualism, then there arises the question of how they are related. For more detailed treatment and further reading on this topic, see the entry epiphenomenalism. One might put it as follows: It is imaginable that one's mind might exist without one's body.

    I can never catch myself at any time without a perception, and can never observe any thing but the perception. Somewhat surprizingly, it is not very clear just what his worry was, but it is expressed as follows: In short there are two principles, which I cannot render consistent; nor is it in my power to renounce either of them, viz. A natural response to Hume would be to say that, even if we cannot detect ourselves apart from our perceptions our conscious experiences we can at least detect ourselves in them Surely I am aware of [my experience], so to speak, from the inside - not as something presented, but as something which I have or as the experiential state which I am in If the bundle theory were true, then it should be possible to identify mental events independently of, or prior to, identifying the person or mind to which they belong.

    It is not possible to identify mental events in this way. Therefore, The bundle theory is false. Lowe defends this argument and argues for 2 as follows. What is wrong with the [bundle] theory is that But it emerges that the identity of any psychological mode turns on the identity of the person that possesses it. What this implies is that psychological modes are essentially modes of persons, and correspondingly that persons can be conceived of as substances.

    He says: The mind is a kind of theatre where several perceptions successively make their appearance; pass, re-pass, glide away and mingle in an infinite variety of postures and situations. We can scale counterfactual suggestions as follows: This table might have been made of ice.

    This table might have been made of a different sort of wood. In Geoffrey Madell's words: But while my present body can thus have its partial counterpart in some possible world, my present consciousness cannot. Any present state of consciousness that I can imagine either is or is not mine. There is no question of degree here. Problems for Dualism We have already discussed the problem of interaction. In this respect, however, there is no difference between this attribute, which constitutes the subject's essential nature, and the specific psychological attributes of his conscious life… Admittedly, the feeling that there must be more to be said from a God's eye view dies hard.

    Bibliography Almog, J. Hamlyn trans. Armstrong, D. Averill, E. Ayer, A. Baker, M. Goetz eds. Berkeley, G. Luce and T. Jessop eds. Bricke, J. Broad, C. Chalmers, D. Collins, C. Collins, R. Crane, T. O'Hear ed. Dainton, B. Davidson, D. Foster and J. Swanson eds Experience and Theory , London: Duckworth. Dennett, D. Descartes, R. Cottingham trans. Ducasse, C. Hook ed. Dimensions of Mind , New York: Collier, 85—9. Eccles, J. Efron, A. Feigl, H. Feigl, M. Scriven and G. Maxwell, eds. Fodor, J. Foster, J. Smythies and J. Fumerton, R.. Green, C. Hamlyn, D.

    Mental Revision of a Spirit Lost - AUTHORSdb: Author Database, Books and Top Charts

    Hart, W. Guttenplan ed. Hawthorne, J. Heil, J. Herbert, R. Himma, K. Hodgson, D. Honderich, T. Hume, D. VI, and Appendix, D. Norton and M. Norton eds.