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Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder

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Abstract

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the presence of distress or disability, which may be bracketed as the presence of harm, is taken to be merely usual, and thus not a necessary requirement: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for defining the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others pertaining to the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be (provisionally) maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified.

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Notes

  1. Jerome Wakefield originally introduced the definition of mental disorder as a harmful dysfunction [1].

  2. For the purposes of this paper, it is not important to specify the exact meaning of ‘usual’, but it is sufficient to assume that this implies that harm is not necessary for mental disorders [3].

  3. As the problems related to the dysfunction requirement are not the focus of this paper, we simply follow the DSM-5 definition in assuming its necessity.

  4. The conceptual history of the upgrading and downgrading of the harm requirement is well illustrated by Rachel Cooper [3]; we briefly address this issue in [11].

  5. Of course, it is important to address what is wrong with each of these objections in greater details, but such an endeavour falls outside the scope of the present paper.

  6. Even if it is true that there is no distress where a condition causes no negative feelings, it can still be possible for that condition to be a mental disorder; cases of severe lack of insight in psychopathy or schizophrenia are examples of this (see the following section).

  7. Whose distress is relevant, and who should evaluate it? In the next section, we argue that some of the criteria for specific disorders involving harm are ambiguous in their answers to such questions.

  8. The distress experienced can have different sources, as people can be distressed either by their personalities as such or by the reactions that others have to their personalities. Both kinds of distress, however, seem not to be necessary to diagnose mental disorders such as narcissistic personality disorder or histrionic personality disorder.

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Author Contributions

Although this paper was mutually conceived and discussed, Maria Cristina Amoretti should be considered responsible for the sections entitled ‘The harm requirement’ and ‘The harm requirement as a diagnostic criterion’, while Elisabetta Lalumera should be considered responsible for the sections entitled ‘Introduction’ and ‘Against the harm requirement’.

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We wish to thank Luca Malatesti and two anonymous reviewers for Theoretical Medicine and Bioethics for their insightful comments and constructive criticisms.

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Correspondence to Maria Cristina Amoretti.

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Amoretti, M.C., Lalumera, E. Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder. Theor Med Bioeth 40, 321–337 (2019). https://doi.org/10.1007/s11017-019-09499-4

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