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
Jerome Wakefield originally introduced the definition of mental disorder as a harmful dysfunction [1].
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].
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.
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.
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).
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.
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.
References
Wakefield, Jerome C. 1992. The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist 47: 373–388.
American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Publishing.
Cooper, Rachel. 2015. Must disorders cause harm? The changing stance of the DSM. In The DSM-5 in perspective: Philosophical reflections on the psychiatric babel, ed. Steeves Demazeux and Patrick Singy, 83–96. Dordrecht: Springer.
Amoretti, Maria Cristina, and Elisabetta Lalumera. 2019. A potential tension in DSM-5: The general definition of mental disorder versus some specific diagnostic criteria. Journal of Medicine and Philosophy 44: 85–108.
Boorse, Christopher. 1976. What a theory of mental health should be. Journal for the Theory of Social Behaviour 6: 61–84.
Boorse, Christopher. 1977. Heath as a theoretical concept. Philosophy of Science 44: 542–573.
Boorse, Christopher. 1997. A rebuttal on health. In What is disease?, ed. James M. Humber and Robert F. Almeder, 1–134. Totowa: Humana Press.
American Psychiatric Association. 1987. Diagnostic and statistical manual of mental disorders, 3rd ed, revised. Washington, DC: American Psychiatric Association.
American Psychiatric Association. 1994. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association.
American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association.
Amoretti, Maria Cristina, and Elisabetta Lalumera. 2018. Il criterio del “danno” nella definizione di disturbo mentale del DSM: Alcune riflessioni epistemologiche. Rivista Internazionale di Filosofia e Psicologia 9: 139–150.
Bayer, Ronald. 1981. Homosexuality and American psychiatry: The politics of diagnosis. Princeton: Princeton University Press.
Spitzer, Robert L. 1981. The diagnostic status of homosexuality in DSM-III: A reformulation of the issues. American Journal of Psychiatry 138: 210–215.
American Psychiatric Association. 1972. Diagnostic and statistical manual of mental disorders, 2nd ed. Washington, DC: American Psychiatric Association.
American Psychiatric Association. 1980. Diagnostic and statistical manual of mental disorders, 3rd ed. Washington, DC: American Psychiatric Association.
Wakefield, Jerome C. 2014. The biostatistical theory versus the harmful dysfunction analysis, part 1: Is part-dysfunction a sufficient condition for medical disorder? Journal of Medicine and Philosophy 39: 648–682.
Cabaj, Robert P., and Terry S. Stein (eds.). 1996. Textbook of homosexuality and mental health. Washington, DC: American Psychiatric Association.
Wakefield, Jerome C. 2017. Can the harmful dysfunction analysis explain why addiction is a medical disorder? Reply to Marc Lewis. Neuroethics 10: 313–317.
Phillips, Michael R. 2009. Is distress a symptom of mental disorders, a marker of impairment, both or neither? World Psychiatry 8: 91–92.
Mathers, Colin D., and Dejan Loncar. 2006. Projections of global mortality and burden of disease from 2002 to 2030. PLOS Medicine 3: e442. https://doi.org/10.1371/journal.pmed.0030442.
World Health Organization. 1980. International classification of impairment, disability and handicap. Geneva: World Health Organization.
World Health Organization. 2018. International statistical classification of diseases and related health problems, 11th revision. https://icd.who.int/en. Accessed April 25, 2019.
World Health Organization. 2017. International classification of functioning, disability and health. Geneva: World Health Organization.
Boorse, Cristopher. 2010. Disability and medical theory. In Philosophical reflections on disability, ed. D. Christopher Ralston and Justin Ho, 55–88. Dordrecht: Springer.
Gold, Liza H. 2014. DSM-5 and the assessment of functioning: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Journal of the American Academy of Psychiatry and the Law 42: 173–181.
Oliver, Michael. 1996. Understanding disability: From theory to practice. New York: St. Martin’s Press.
Wakefield, Jerome C. 2009. Disability and diagnosis: Should role impairment be eliminated from DSM/ICD diagnostic criteria? World Psychiatry 8: 87–88.
Murphy, Dominic. 2011. Conceptual foundations of biological psychiatry. In Philosophy of medicine, ed. Fred Gifford, 425–451. Amsterdam: Elsevier.
Simon, Jeremy R. 2011. Medical ontology. In Philosophy of medicine, ed. Fred Gifford, 65–114. Amsterdam: Elsevier.
Cooper, Rachel. 2002. Disease. Studies in History and Philosophy of Biomedical Sciences 33: 263–282.
Romme, Marius, Sandra Escher, Jacqui Dillon, Dirk Corstens, and Mervyn Morris. 2009. Living with voices: 50 stories of recovery. Monmouth: PCCS Books.
Wakefield, Jerome C. 1999. Evolutionary versus prototype analyses of the concept of disorder. Journal of Abnormal Psychology 108: 374–399.
Clouser, K. Danner, Charles M. Culver, and Bernard Gert. 1981. Malady: A new treatment of disease. Hastings Center Report 11(3): 29–37.
Kendler, Kenneth S., John Myers, and Sidney Zisook. 2008. Does bereavement-related major depression differ from major depression associated with other stressful life events? American Journal of Psychiatry 165: 1449–1455.
Wakefield, Jerome C. 2012. Should prolonged grief be reclassified as a mental disorder in DSM-5? Reconsidering the empirical and conceptual arguments for complicated grief disorder. Journal of Nervous and Mental Diseases 200: 499–511.
Spitzer, Robert L., and Jerome C. Wakefield. 1999. DSM-IV diagnostic criterion for clinical significance: Does it help solve the false positives problem? American Journal of Psychiatry 156: 1856–1864.
Miller, Joshua D., W. Keith Campbell, and Paul A. Pilkonis. 2007. Narcissistic personality disorder: Relations with distress and functional impairment. Comprehensive Psychiatry 48: 170–177.
Ong, Clarissa, Shirlene Pang, Vathsala Sagayadevan, Siow Ann Chong, and Mythily Subramaniam. 2015. Functioning and quality of life in hoarding: A systematic review. Journal of Anxiety Disorders 32: 17–30.
Narrow, William E., and Emily A. Kuhl. 2011. Clinical significance and disorder thresholds in DSM-5: The role of disability and distress. In The conceptual evolution of DSM-5, ed. Darrel A. Regier, William E. Narrow, Emily A. Kuhl, and David J. Kupfer, 147–162. Washington, DC: American Psychiatric Publishing.
Lehman, Anthony F. 2009. Disentangle diagnosis and disability. World Psychiatry 8: 89–90.
Curtis, Ted, Robert Dellar, Esther Leslie, and Ben Watson (eds.). 2000. Mad pride: A celebration of mad culture. Truro: Chipmunka.
Mann, Thomas. 1924. Der Zauberberg. Berlin: Fischer.
Ustün, Bedirhan, and Cille Kennedy. 2009. What is “functional impairment”? Disentangling disability from clinical significance. World Psychiatry 8: 82–85.
Sartorius, Norman. 2009. Disability and mental illness are different entities and should be assessed separately. World Psychiatry 8: 86.
Schalock, Robert L., Sharon A. Borthwick-Duffy, Valerie J. Bradley, Wil H.E. Buntinx, David L. Coulter, Ellis M. Craig, Sharon C. Gomez, et al. 2010. Intellectual disability: Definition, classification, and systems of supports, 11th ed. Washington, DC: American Association on Intellectual and Developmental Disabilities.
Kendler, Kenneth. 2017. Introduction to ‘Clinical significance, disability, and biomarkers: Shifts in thinking between DSM-4 and DSM-5’. In Philosophical issues in psychiatry IV: Psychiatric nosology, ed. Kenneth S. Kendler and Josef Parnas, 5–7. Oxford: Oxford University Press.
Boorse, Christopher. 2014. A second rebuttal on health. Journal of Medicine and Philosophy 39: 683–724.
Insel, Thomas R. 2014. The NIMH Research Domain Criteria (RDoC) Project: Precision medicine for psychiatry. American Journal of Psychiatry 171: 395–397.
Glasziou, Paul, Ray Moynihan, Tessa Richards, and Fiona Godlee. 2013. Too much medicine; too little care. British Medical Journal 347: f4247. https://doi.org/10.1136/bmj.f4247.
World Health Organization. 2000. World Health Organization Disability Assessment Schedule (WHODAS 2.0). Geneva: World Health Organization.
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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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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DOI: https://doi.org/10.1007/s11017-019-09499-4