A recent article published in Psychological Medicine explores the controversy around what constitutes a “mental disorder.” Based on empirical examples or “test-cases” that emerged during the writing of the DSM-5, psychiatrists Dan Stein and Kenneth Kendler and philosopher Andrea Palk discuss the “fuzzy” borders around mental disorders. In particular, they talk about clinical cases where there is “harm” but not “psychobiological dysfunction,” “psychobiological dysfunction” but not “harm,” and where both may potentially be present, but not without controversy.
“The question of ‘what is a mental disorder,’ is crucial, in part, because the real possibility exists of erroneously classifying various kinds of social deviance or behavioral variation as ‘disorder,’ when they are better conceptualized using other categories, such as ‘non-pathological individual differences,’ ‘lifestyle choice,’ or ‘crime,’ the authors write. “A paradigmatic example from DSM is that of homosexuality, which was conceptualized in DSM-I as a disorder, but by DSM-5 was no longer mentioned.”
Since the American Psychiatric Association published the DSM-5 in 2013, there has been a significant amount of controversy over defining a “mental disorder” accurately. Division 32 of the American Psychological Association—the Society for Humanistic Psychology—as well as the British Psychological Society both put out statements questioning some of the over-medicalizing categories put forth in the DSM-5.
Some of the controversies outlined in these letters include the lowering of diagnostic thresholds, which could lead to pathologizing many “normal” behaviors, sociocultural variation in psychopathology, including whether sociopolitical deviance should be categorized as mentally disordered, as well as new advances in pushing a biomedical model approach.
Many of these controversies are not new and did not emerge with the publishing of the DSM-5, of course, having a rich history within anti-psychiatric and peer-led movements.
The current article explores some of these controversies in-depth, paying particular attention to clinical “test-cases,” which illustrate some of the problems with conventional psychiatric models of mental disorder.
Among the test cases involving harm but not psychobiological dysfunction, the authors include such phenomena as aging, racism, and anxiety associated with life threats such as job loss and romantic rejection.
The authors explain that “a number of conditions are associated with harm to individuals and/or society, but are not considered disorders because they lack evidence of underlying psychobiological dysfunction.”
In short, there can be “unwanted” mental, physical, and behavioral changes which are not associated with dysfunction in the psychobiological sense. Aging qualifies here since although it is associated with certain kinds of dysfunction (like a spectrum of cognitive impairment, from mild to severe), many of the effects of aging are, in fact, quite “normal.”
Racism, likewise, may be associated with certain dysfunctional aspects of personhood, but the authors state that there is little evidence for underlying psychobiological functioning. This is in spite of the fact that racism obviously causes much harm both personally and socially. They state:
“Rather, there is relatively widespread consensus that racist beliefs and behavior are largely a product of socialization and culture. We would therefore argue that racism is not a disorder; it is a phenomenon that, while sanctioned in some cultures in the past, is now a form of social deviance that should be addressed by a range of different social and educational interventions. Thus, judgments about the inclusion of an entity in the nosology may require rigorous reflection on cultural and social values.”
Further, the authors also state that despite these phenomena not necessarily meeting the criteria for clinical mental disorders, individuals may still benefit from psychotherapy surrounding these issues. In addition, this can be complicated by the fact that “clear excessiveness” around these behaviors may begin to meet criteria for mental disorder categories.
For cases in which there is psychobiological dysfunction but no clear harm, the authors list conditions such as disability, autism spectrum disorders, and gender identity disorders. Although these kinds of conditions can cause “disadvantage and suffering,” the authors locate this in the realm of social acceptance and accommodation rather than any underlying dysfunction.
With the example of deafness, they state:
“Deafness itself is not intrinsically harmful; rather, it is societal responses, or lack of response in terms of ensuring adequate accommodation, that produces harm.”
Likewise, with autism spectrum (particularly milder cases) and gender identity conditions, as well as hearing voices, these issues are not necessarily inherently dysfunctional but may become dysfunctional in terms of personal experience and social access because of systemic barriers and prejudices.
Finally, the authors discuss conditions where there is both possible harm and possible psychobiological dysfunction. Despite some evidence for both of these criteria, these conditions are still controversial.
Examples here include compulsive sexual behavior disorder, internet gaming, gambling disorders, attenuated psychosis syndrome, and suicidal behavior. Controversies around these “disorders” exist because their harm is a risk rather than a necessarily actual problem. Because of this, including them as psychiatric disorders can lead to overdiagnosis and overmedicalization.
Additionally, the underlying etiologies for these disorders are often not fully developed in a psychobiological sense, relying instead on clinical judgment and severity of symptoms.
The authors caution:
“Judgments about whether or not an entity should be included in the nosology may require careful assessment of the degree of loss of control, and related impairment, particularly in the case of compulsive or addictive behaviors.”
In terms of suicidal behavior, the authors note that although it can be symptomatic of certain mental disorders, there are also compelling cases to be made for suicide as both a rational choice and as a form of political protest or “culturally sanctioned response to shame.”
The authors conclude:
“First, while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm, as well as of societal accommodation.
Second, while dysfunction is useful for conceptualizing mental disorders, the field would benefit from developing more sharply defined indicators of dysfunction.
Third, it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of a mental disorder and to further clarify the type and extent of data needed to support such judgments.”
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Stein, D. J., Palk, A. C., & Kendler, K. S. (2021). What is a mental disorder? An exemplar-focused approach. Psychological Medicine, 51(6), 894-901. (Link)
The article is interesting. I didn’t read the original paper.
In the context of a website like this, you’re going to have some who will simply assert, “this whole idea is a bunch of BS.” While others will be more willing to explore the nuances a bit, though not with an attitude much more favorable than sarcasm.
That clinicians still take this whole subject seriously speaks first to the intellectual limitations of their educations and second to their need to have a set of medical-sounding categories for billing purposes.
The fact remains (as far as I am aware) that the most common way this whole problem starts is when a person approaches a practitioner and says, “doctor I need your help,” or words to that effect.
A very common variation on this theme is when a friend, family member or government employee approaches the practitioner, rather than the actual patient, and says, “doctor, I need your help with (fill in the blank).”
The practitioner then starts the process by hearing a story, either from the patient or someone who knows the patient. This story may or may not be factual, but if the patient is telling the story, the practitioner can at least check certain points of the story against direct observation. At that point the practitioner can ask, “what should I do about this?” This is supposedly where the technical data really kicks in and a nosology (list of illnesses) should come in handy. But, the fact is, life often doesn’t work that way.
I could continue to draw out this whole process, but beyond my own very limited clinical experience, I am really not qualified to do that.
I do want to note what discussions like this tend to miss:
1) Intentions. Does the patient really need help, or are they just in need of some attention? Is the “friend” really interested in getting help for the patient, or really only wants to get rid of them?
2) Psychopathology. Is this person having trouble because of a crazy person in their environment? (This goes for physical injuries, not just emotional problems.) The patient may be unaware that they are connected to someone who is crazy, or may be afraid of “telling” on them. This is a very important missing step, the neglect of which often causes much harm.
3) Complexities. A practitioner who hopes to narrow every patient down to one “illness” and one treatment is on a losing path before they even start. Chances are very high that the situation is more complex than that. There could be a whole causal chain that could lead back to basics like lack of sleep, poor nutrition, illiteracy, an untreated physical problem, fighting parents, sexual abuse, or some combination of many different situations. The person, in coming into a clinical setting, may temporarily escape the turbulence in their life, but when released go back and “get sick” again.
In the light of the above points, particularly when addressing behavioral and emotional situations in a person’s life, the concept of a DSM becomes almost laughable. It gives someone like me the distinct impression that the whole group of professions who use the DSM either don’t know what they are doing, really don’t care, or aren’t very bright. I challenge the “mental health system” to prove me wrong!
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“Laughable” is right, or would be, if there weren’t so many casualties of the process!
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I must agree, after many decades of research into the DSM “bible” believers’ actions and beliefs, and their Pharmakia, “the whole group of professions who use the DSM either don’t know what they are doing, really don’t care, or aren’t very bright.” Or all of the above.
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“Defining Mental Disorders Can Be a ‘Fuzzy’ Affair”
“while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm ….”
Especially given the fact that, as in my case, an individual doctor – whose husband had committed easily recognized malpractice against one of that doctor’s patients (me) – might conclude that that patient now poses a possibility of “harm” (a potential malpractice suit) to that “individual” doctor and/or her husband. So that, paranoid of a non-existent malpractice suit, doctor inappropriately put that patient (me) on psychiatric drugs, while disingenuously calling them “safe … meds.”
“while dysfunction is useful for conceptualizing mental disorders, the field would benefit from developing more sharply defined indicators of dysfunction.” Indeed.
I have proof in some of my medical records that a psychiatrist (the psychiatric “snowing” partner in crime, of a now FBI convicted doctor) – who did not know me, nor even bothered to ask me what I did – incorrectly listed me as “unemployed” in my medical records.
When, in reality, I was a planning commissioner for my village; I co-chaired the art program for my local school, a job which required organizing and educating over 250 volunteer “art teacher” moms, for 24 different art projects every year; I headed up the re-design of another of my children’s schools; I was the Charter Rep of my son’s Boy Scout pack; I was a head room mom many times, as well as doing many other volunteer jobs for my children’s schools and our church, as well.
I was a very active and competent volunteer and mother of two children. My eldest child eventually graduated from university Phi Beta Kappa, he also got his masters, and is now working in hospital administration for the VA; my other child graduated cum laude, and is starting his doctorate this fall.
Not to mention, I was also an artist working on my portfolio, in the hopes of future financial gain. When a psychiatrist illegally noses into a person’s finances, instead of actually asking the person what they do, and incorrectly lists the person as “unemployed” – a likely considered “dysfunction.” I have to ask, when did being a stay at home mom, active volunteer, and artist – working for future profits – become dysfunctional?
Given the high number of artists, whose stories have been told on this website. It is clear to me that the “mental health” industry needs to garner insight into the fact that artists need to build up their portfolios, prior to trying to market and sell their work. And just because this, portfolio building, time in an artist’s life looks – to the psychiatrists – like a person is “unemployed.” The artist is actually “self-employed,” not “unemployed.”
And I will say, when a psychologist – who knew something about art – saw a show of my work. He handed over a guardianship contract, under the guise of an “art manager” contract, which stated his hope was to steal all profits from my work, my money, my story, and all my work. Because he thought my work was “prophetic,” and that “the world might be ready for a Chicago Chagall.” This attempted thievery was deplorable behavior on the part of that psychologist. But it does, perhaps, imply that psychologist thought that my work may be valuable some day.
So where’s the “dysfunction”? I’m quite certain the “dysfunction” is with the man, who thought it’d be clever to steal from widows in his church. Especially since the Holy Bible quite clearly states, “Do not take advantage of the widow or the fatherless.”
“it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of a mental disorder and to further clarify the type and extent of data needed to support such judgments.”
All of us here on MiA know that there is zero “diagnostic validity” to any of the DSM disorders, even according to the head of the NIMH, and now the WHO.
https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis
https://www.youtube.com/watch?v=Rl_Ad-Cfm_M
And we know that the psychiatric drugs can create the symptoms of the DSM disorders.
https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/
https://duckduckgo.com/?q=toxidrome&t=osx&ia=web
https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome
However, this valid medical information, is information that way too many of the psychiatric practitioners deny. But given these realities, there is no “validity” or “clinical utility” – other than that it’s very profitable, for the “mental health” clinicians and big Pharma, to make people sick for profit – in regards to the clinician’s judgements.
Indeed, “Defining Mental Disorders Can Be a ‘Fuzzy’ Affair.” And, personally, given the fact that the “mental health” workers are killing “8 million” innocent people EVERY year, with their “invalid” disorders and neurotoxic psychiatric drugs. I think it should be considered a criminal “affair” as well.
https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mortality-and-mental-disorders
Who are the people that are actually creating staggering “societal harm?” A hint:
http://www.webdc.com/pdfs/deathbymedicine.pdf
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Of course, “defining mental disorders” is a “fuzzy” business as they only exist in the minds of these psychiatrists, etc. and are not based in reality. Thank you.
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I think that we need a “physiology” association.
Then we can judge people to be defective physiologically.
This of course could be including tests, such as weight lifting, running, walking, and obviously they can be seen as “physiological “behaviours”.
And after you’ve been given some such label as “walking disorder”, or “looks disorder”, that can be kept in charts and made public and then the physiological association can print pamphlets that say the public should not “stigmatize” “defective walking disorders”.
We could then assume that since the person walks differently and can’t do the 10 mile marathon, that he is overall “defective”.
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There was a New York Times article a while back on the topic of privilege. For reasons I can’t remember now, I posted a comment under the article saying that I believed that being diagnosed with borderline personality disorder, and everything that followed from that, erased a lot of the privilege I had as a white, middle class, college educated woman.
Someone replied to my comment, saying that I did have white privilege and that I should recognize that if were a person of color, I would be “dead or in prison”.
I found it really interesting that this commenter assumed that because I had a diagnosis of borderline that I must be some type of criminal, and assumed that because I was white and middle class, instead of being convicted of that criminal behavior and sent to prison, I was “gifted” with psychiatric treatment instead.
It’s true that there are some crimes that are closely associated with borderline personality. The ones that come immediately to mind are stalking, illicit drug use, property damage, and, of course, home invasion and boiling other people’s pet rabbits.
Of course, these, and all, crimes are committed by a wide range of people with and without a borderline diagnosis. A fan of true crime, I’ve also seen several cases where a person is diagnosed with borderline personality or some other mental illness *after* they have committed a violent crime. Sometimes the diagnosis is put forth by the defense, other times by the prosecution. What does it all mean? It’s all pretty silly and irrational.
I think a better approach would be to leave psychiatric diagnoses out of it (since it’s true that they are fuzzy), to put people who commit crimes through the judicial system, and leave people who don’t commit crimes alone — let them keep their rights, even if you don’t like their personalities.
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