• What exactly is a mental disorder, anyway? – Part 2

    This is the second in a three part series on the difficulties with defining “mental disorders.” In part one, we looked at a number of common ways to divide normal from abnormal behavior and found each definition significantly wanting. Below, we will examine how the American Psychiatric Association, publishers of the “bible” of mental health – the DSM, have define these terms both in the past and in the future.

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    DSM Definitions of Mental Disorder

    DSM-IV-TRThe Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association, and is the most widely used classification system of mental disorders in the United States (outside of the U.S., both the DSM and the International Classifications of Disease, or ICD, are used). It provides diagnostic criteria for almost 300 mental disorders. But how exactly does it define mental disorder? In the most recent edition, published in 1994, the following features are considered descriptive of a mental disorder:

    a) A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual

    b) Is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

    c) Must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one

    d) A manifestation of a behavioral, psychological, or biological dysfunction in the individual

    e) Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual

    The DSM-IV goes on to state, though, that “no definition adequately specifies precise boundaries for the concept of “mental disorder” and that “the concept of mental disorder (like many other concepts in medicine and science) lacks a consistent operational definition that covers all situations.” Even with those caveats, this definition has considerable concerns: What exactly does “clinically significant” mean? How much distress is enough distress and who determines that? Who says what is or is not “culturally sanctioned”? And last, but perhaps most important, what defines a “behavioral or psychological syndrome or pattern”?

    The categorical nature of the DSM-IV is also of concern, and the authors even state that they recognize the actual, dimensional nature of mental disorders, but due to the need for caseness (as described above) must operate in a categorical nature. This, in turn, contributes to the high amount of diagnostic overlap, or comorbidity, present in clinical populations. In one of the most well-conducted studies to examine this issue, Ronald Kessler and his research team (2005) found that 26.2% of Americans met criteria for a mental disorder; of these, 45% met criteria for two or more disorders.

    DSM-5These concerns and questions are certainly on the minds of many researchers and clinicians, and in fact a special group was assembled to rework the definition of a mental disorder for the upcoming revision of the DSM, the DSM-5, which is scheduled to be published in May 2013. The proposed revision, which was made available both online at DSM5.org and in an article by D.J. Stein and colleagues (2010), is as follows.

    a) A behavioral or psychological syndrome or pattern that occurs in an individual

    b) That reflects an underlying psychobiological dysfunction

    c) The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)

    d) Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)

    e) That is not primarily a result of social deviance or conflicts with society

    As in the DSM-IV definition, there are other proposed caveats or considerations. A mental disorder should, by this definition, have diagnostic validity, clinical utility, and be differentiated from other, similar disorders. In addition, it is again acknowledged that there is no precise boundary between normality and mental disorders, and that the addition or deletion of a condition from the DSM should have substantial potential benefits which outweigh potential harms. While this proposed definition, and the revisions to many disorders that actually specify measures to determine severity and symptom level, are certainly an improvement over the DSM-IV (which was, in turn an improvement over earlier versions), there are still concerns over this definition. Specifically, will such severity indicators be used in real-world practice, and how will the introduction of such dimensionality impact treatment, reimbursement, and diagnostic practices? Will the improved diagnostic categories decrease the amount of overlap and comorbidity seen in mental health settings?

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    In the final part of this series, I will conclude with an examination of what it means if we cannot scientifically define “mental disorders,” and how we move forward as a science.

     

    Key References

    American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC: Author.

    American Psychiatric Association (2011). Definition of a mental disorder. Retrieved from http://www.dsm5.org/proposedrevision/Pages/proposedrevision.aspx?rid=465 on June 28, 2011.

    Bergner, R. M. (1997). What is psychopathology? And so what? Clinical Psychology: Science and Practice, 4, 235-248.

    Brown, P. (1995). Naming and framing: The social construction of diagnosis and illness. Journal of Health and Social Behavior, 35 (Extra Issue), 34-52.

    Eisenberg, L. (1988). The social construction of mental illness. Psychological Medicine, 18, 1-9.

    Maddux, J.E., Gosselin, J.T., & Winstead, B.A. (2005). Conceptions of psychopathology: A social constructionist perspective. In J.E. Maddox & B.A. Winstead (Eds.), Psychopathology: foundations for a contemporary understanding. Mahwah, NJ: Lawrence Erlbaum Associates.

    Stein, D.J., Phillips, K.A., Bolton, D., Fulford, K.W.M., Sadler, J.Z., & Kendler, K.S. (2010). What is a mental/psychiatric disorder? From DSM‐IV to DSM‐V. Psychological Medicine, 40, 1759‐1765.

    Widiger, T. A. (1997). The construct of mental disorder. Clinical Psychology: Science and Practice, 4, 262-266.

    Category: Mental HealthPsychologyScience

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    Article by: Caleb Lack

    Caleb Lack is the author of "Great Plains Skeptic" on SIN, as well as a clinical psychologist, professor, and researcher. His website contains many more exciting details, visit it at www.caleblack.com

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    • jacksmi

      The issue here is not what mental ILLNESS is — for mental illness can easily be
      defined as the DSM-5 group advocates simply by tautology (that is, illness is biological, by
      definition). The question, though, is what a mental DISORDER is. If the above
      reasoning is transferred to mental disorders, then it represents a species of reductionism (see Ernst Mayr). Its correctness depends on which kind of reductionism one intends to invoke here. If one invokes constitutive reductionism, then the above argument is true, but trivially so (i.e., everything has SOME basis in brain activity); on the other hand, if one invokes explanatory reductionism, then the above argument is false and can easily be shown to be false by counter-example, e.g. a classically conditioned phobia, as in the classic case of Little Albert. The constructs of classical conditioning are both sufficient and necessary to adequately conceptualize and treat this type of phobia, whereas it is, at best, dubious that neurobiological constructs add anything to this kind of treatment. The failure to make these kinds of distinctions can lead to problematic assumptions about the nature and treatment of psychological disorders.

    • aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

      If you believe mental illness is socially constructed, doesn’t that make you a mental illness denialist? What about all the neuroscience we have supporting brain differences in those with schizophrenia, depression, ADHD, etc?

      • Denier of mental illness? Not so much.

        I’d never deny that there is enormous amounts of research supporting behavioral, cognitive, and biological differences in “normal” vs “disordered” groups. Social construction of mental (and physical) illness is not a bad thing, I’m not saying “mental illness isn’t real!” That’s obviously ridiculous, and I work every day to help those with problems like OCD, Tourette’s, and trichotillomania directly and train the next generation of therapists in evidence-based practice.

        As an analogy, consider rich vs poor. What is poor in one society is not necessarily poor in all others. I may be middle class in the US, but one of the top 5% in Honduras. Does that make me rich here in the US? No. Similarly, what is considered “disordered” in one society may (or may not) be considered that way in other societies or across time (homosexuality’s removal from the DSM in the 1970s is an excellent example of this).

        But, that does not mean that I would agree with Novella’s latest article completely, in that a completely biological reductionist model really ignores way too much of what we know about WHY people have these types of problems in terms of environmental causes (social interaction, learning history, stressors, etc.).

        So, I don’t in any way deny that mental illness is real or important or harmful. But, it is a social construction, in that these are not really scientific constructs in the same way that something like the speed of light in a vacuum or the atomic weight of helium is, but instead are mutually agreed-upon problems and concepts.

        • aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

          So, you’re a relativist. Of course that would mean you’d disagree with Novella.

          Well, calling it a social construction is basically another way of saying it’s not real, that what people are experiencing is an illusion of sorts.

          Anyway, do you believe the mind is separate from the brain?

          • Apparently you don’t understand what a social construct is, or you may be thinking I am using the term in a post-modernist sense (aka “strong social constructionist,” which I’m not). Either way, see below.

            When did I say mental illness is an illusion? Do you even have any idea who I am and what I do for a living? I’m a clinical psychologist, meaning I’ve spent the last 12 years learning about mental illness and how to help those who have them. I have personally trained dozens and dozens of therapists, given seminars on best ways to treat disorders to thousands more, and do research constantly to better understand how to help those with anxiety and repetitive behavior disorders. Why would I commit my life to fighting “illusions”?

            Mental illness is no more “not real” than poverty, or beauty, or health. Each of those concepts, though, is a social construction. Who determines what is beautiful? Or healthy? Your society does, just as a society determines what “depression” or “anxiety” is, to the extent of demarcating normal from abnormal in terms of mental health. That they are social constructions does not rob them of meaning or in any way belittle the suffering they cause.

            To gain a more full view of this, I’d recommend a couple of good articles:

            http://www.ncbi.nlm.nih.gov/pubmed/20943584
            http://www.ncbi.nlm.nih.gov/pubmed/7560848

            For your second question: of course not. The mind is what the brain does. This does not, though, invalidate understanding mental illness (or physical illness) from a constructionist perspective.

            To truly understand any psychological phenomenon (learning, memory, perception, behavior, etc) you need to look at multiple levels of explanation (social, behavioral, cognitive, neurological/physiological, neurochemical, molecular). If you only focus on one or two levels you can miss many important aspects of our experience. Integration of all the levels, though, can help us gain a broad picture of what psychology (in this case, mental illness) is and why we experience it. This includes social levels of understanding, such as why we call certain behaviors abnormal and label them as needing to be fixed.

            • aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

              Yes, I thought you were using it in a post-modernist sense. I’m going to read the rest of your post now. Thank you for being polite and patient despite my being rude & assumptive.

            • I’m about as far from a post-modernist as a person can get 🙂

            • aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

              Honestly, I’m still not understanding how your use of the term is different from how post-modernists use it. Could you explain how your usage is different from a postmodernist’s? I don’t have access to the links you posted.

              It sounds like you’re saying mental illness only exists in a person’s subjective experience and that it can’t be objectively measured. I mean, we have ways of quantifying beauty (rather people’s preferences of it), health, and poverty – but it seems like you’re framing it by relativistic terms, which is antithetical to an objective reality. I understand that doctors have to rely on the subjective experience of the patient’s symptoms. But, with some mental illnesses those symptoms are consistent with the patient’s neurochemistry. Novella talks about ADHD being one, for example.

              And I know you’re a psychologist, but that doesn’t always prevent someone from becoming a mental illness denialist. I understand that social/environmental factors are just as important as biological factors in finding the causal link behind symptoms and that it’s damn near impossible to separate the two kinds of factors (sorry, I grouped everything you said into two categories even though you made it clear you believe it’s an oversimplification). It’s easy to assume all factors play a role, but it would be useful to separate the factors when it comes to health & illness, especially when some mental illnesses have strong evidence of biological/genetic causes. It seems to be an unfair generalization to say they’re all “socially constructed.”

            • I think the confusion is between what I’m talking about (weak social construction) and the post-modernist version (strong social construction).

              From Wikipedia: ‘Strong’ social constructivism as a philosophical approach tends towards the suggestion that “the natural world has a small or non-existent role in the construction of scientific knowledge.”

              In other words, very post-modernist, “reality is what I make of it, there is nothing objective out there” kind of stuff.

              What I’m saying is that the symptoms of ADHD/OCD/depression are quite real, but that how we group them together or divide them, and even if we consider them an illness, is a product of society (weak social construction). You gave beauty and poverty as things that can be objectively measured, but the measures have to be constructed (e.g., there’s not scientific construct telling us what is “poor” and what is “rich). Same thing in mental health.

              Think about schizophrenia as an example. 2000 years ago you could walk around, proclaim yourself as hearing voices and commands from god(s), say you were seeing angels/demons, and (many) people would take that at face value and believe you. Who knows, maybe you’d even start a religious movement. In other words, it wouldn’t necessarily have the same negative connotation that they have now. Today, with the same symptoms/behaviors, you get diagnosed as having schizophrenia, put on meds, and considered ill and disabled.

              Regarding measures, sure we can measure the symptoms of schizophrenia (using things like the PANAS or PAI), but our dividing it into different types (catatonic, paranoid, etc like we did in DSM-IV) is pure construction – witness the changes in DSM-5 where it’s all back in one category. Even separating it out from other similar illness (delusional disorder, psychotic disorder NOS) is just construction and drawing lines in the sand. Are there brain processes involved? Of course. Are there some genetic links? Absolutely. Does this mean that our society, right now, considering a person who displays the symptoms of what we collectively call schizophrenia is mental ill is a scientific construct? Not so much. Certainly, we can measure quality of life, or negative impact on financial earning, or decrease in lifespan, and show that all are negatively impacted by schizophrenia symptoms. But, we are still, as a society, determining what a “good” quality of life, or earnings, or lifespan is. There’s not an objective, scientific constant for “acceptable quality of life.”

              Again, it doesn’t mean or imply that mental illness isn’t real, or harmful, or important. It’s just that what we consider illness changes over time (homosexuality is a mental disorder! wait, now it’s not! paraphillias are a sexual disorder! wait, now we are not considering them a disorder!), both as our society changes and our scientific knowledge grows.

              Another good example is a new to the DSM-5 disorder: Hoarding Disorder. Research on hoarding was basically non-existent 25 years ago, now it’s estimated that 3-5% of people have this disorder (and by have this disorder, I mean display the behavioral and cognitive characteristics that we as a profession are now calling Hoarding Disorder).

              Again, we construct the disorder, but we don’t “make up” the symptoms (behavioral, cognitive, personality traits, etc.). We simply decide what to call them, how to divide them up, and when something is normal versus abnormal. That’s the social construction I’m talking about.

            • aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

              “Regarding measures, sure we can measure the symptoms of schizophrenia (using things like the PANAS or PAI), but our dividing it into different types (catatonic, paranoid, etc like we did in DSM-IV) is pure construction – witness the changes in DSM-5 where it’s all back in one category. Even separating it out from other similar illness (delusional disorder, psychotic disorder NOS) is just construction and drawing lines in the sand. Are there brain processes involved? Of course. Are there some genetic links? Absolutely. Does this mean that our society, right now, considering a person who displays the symptoms of what we collectively call schizophrenia is mental ill is a scientific construct? Not so much.”

              I’m still not understanding why. There’s proof that schizophrenia is biological, why *wouldn’t* it be a scientific/biological construct? Because quality of life is a subjective measure? Can’t you say that about any disease’s impact on a person’s quality of life? Seems like a double standard.

              I understand now what you mean about health, beauty, and poverty – that they’re defined by how society defines them. But when a schizophrenic brain displays abnormalities that are consistent with their symptoms, why isn’t schizophrenia a scientific construct?

              Can you explain the diff. between what constitutes a scientific construct versus a social construct?

            • aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

              I wonder if you’d call all disease social constructs, but it makes me wonder what you’d consider a scientific construct.

            • i would consider scientific constructs would be those things that don’t actually change from society to society, or within a society across time: atomic weights of various elements, speed of light in a vacuum, those kinds of things. The atomic weight of helium is the same everywhere, so it’s a scientific construct.

              I do consider disease (all kinds) to be social constructs, but this again does not take away from the suffering they cause. Take high blood pressure as an example: our definition of what was “too high” 15 years ago is different than what we consider “too high” today. That doesn’t mean that people in 1990 with today’s levels of “too high” weren’t have problems as a result of it.

              A diagnosis of major depressive disorder (MDD) in the 1950s basically required symptoms so intense that you had to be hospitalized; today almost 1/5 of the US population qualifies for MDD at some point in their lives.Does this mean that people with the same level of MDD symptoms that we today consider diagnosable were not suffering in the 1950s? Certainly not. It does demonstrate, though, that our definition of MDD has changed over time…because it is a socially constructed definition. Sixty years ago, those people with today’s MDD would not have likely been given treatment. Today they are, because we as a society consider them ill. This, again, doesn’t diminish the decrease in QoL or suffering those people had 60 years ago, but illustrates that we as a society determine what is healthy vs unhealthy.

              This is the example I gave in a book I had come out recently:

              “As an example, consider a typical human and virulent, invasive colony of E. coli: When certain strains are ingested by humans, and begin proliferating, it can cause an enormous amount of disruption to the host, so we (humans) label it as a bad bacterium. However, this organism is doing only what it has adapted to do, and is thus fulfilling
              the evolutionary directive to multiply and spread its genetic material. We have decided as a society that this species is bad, and our health is paramount over its health, and thus call it a disease and infection. This is social constructionism.”

              As I said in another response, biology obviously plays a huge role in mental illness. But, one of the major problems with saying that any mental illness is purely biological or identifying it as such is that these are very heterogeneous populations. Just taking schizophrenia, there are dozens of possible symptom presentations that can get you the same diagnosis. Are there some brain dysfunction commonalities shared in the group? Sure, but there will also be people who can get that diagnosis who do not show those same abnormalities. This is why (at least right now), brain imaging research is fairly useless when it comes to diagnosis. Now, if we change our diagnostic criteria to rely on imaging rather than behavioral or cognitive markers, it will become highly useful…but we are then changing our (social agreed upon) definition of the disease.

              Genetic research into our currently defined mental disorders is pretty terrible, in that the largest, most well-conducted studies can only account for miniscule percentages of variation in schizophrenia symptoms (or OCD, or Tourette’s) by looking at genetics. Identical twins, for example, only have about a 50% concordance rate for schizophrenia, meaning it’s not just genetic in any way. There’s some big promise in epigenetic research to help explain this, but we aren’t there yet in any way.

            • aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

              ” It does demonstrate, though, that our definition of MDD has changed over time…because it is a socially constructed definition.”

              I don’t think that’s a good criterion. Science changes all the time too with new knowledge.

              “i would consider scientific constructs would be those things that don’t actually change from society to society, or within a society across time”

              Ok, I understand what you’re saying now, but I think you’re confused about your definitions. You’re talking about things or objects in nature, not constructs (see difference here: http://en.wikipedia.org/wiki/Construct_(philosophy_of_science)). The nature of something is *not* a construct, it’s how we understand the thing (the scientific method) that’s a construct. If you’ve ever read/studied Kant the nature of something or the thing in itself is what he called the noumena. We gain knowledge of it through scientific constructs (evidence, facts, theories, etc). How you’re using construct doesn’t even make sense because our knowledge of objective reality, or physics and chemistry, change (like light was thought to be a wave, then a particle, now it’s both), and nature of something is what it is and we use constructs to understand it. To say the thing in itself is a construct of the mind would make you an idealist, the most extreme kind of skeptic worse than a postmodernist.

              It also makes your definition of social construction so extremely broad that it would be practically meaningless.

              “As I said in another response, biology obviously plays a huge role in mental illness. But, one of the major problems with saying that any mental illness is purely biological or identifying it as such is that these are very heterogeneous populations. Just taking schizophrenia, there are dozens of possible symptom presentations that can get you the same diagnosis. Are there some brain dysfunction commonalities shared in the group? Sure, but there will also be people who can get that diagnosis who do not show those same abnormalities.”

              Thank you for that explanation. If that is the case (I admittedly didn’t know that about schizophrenia), you’re right in that there is too much variation to say it is purely biological.

    • Falco

      “That is not primarily a result of social deviance or conflicts with society.”

      This version fails to explicitly state that deviant behavior and primary conflicts between the individual and society are not mental disorders. Instead, the new proposal focuses on whether mental disorder is a “result” of deviance/social conflicts.

      Taken literally, DSM-5’s version suggests that mental disorder may be the result of these factors so long as they are not “primarily” the cause. In other words, this change will require the clinician to draw on subjective etiological theory to make a judgment about the cause of presenting problems.

      It will further require the clinician to make a hierarchical decision about the primacy of these causal factors, which will then (partially) determine whether mental disorder is said to be present. Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder.

      http://www.ipetitions.com/petition/dsm5/

      • I have a number of large concerns with the DSM-5 in particular and how we diagnose and conceptualize mental illness more broadly. What you stated, for example, is only one of many. I would argue, as I do in part 3 of this series, that “mental disorders” are social constructions (although not in a post-modernist sense), but that this does not rob them of their importance.

        A website that has basically collated these concerns is http://dsm5-reform.com