What is a mental disorder? An exemplar-focused approach

Abstract

The question of ‘what is a mental disorder?’ is central to the philosophy of psychiatry, and has crucial practical implications for psychiatric nosology. Rather than approaching the problem in terms of abstractions, we review a series of exemplars – real-world examples of problematic cases that emerged during work on and immediately after DSM-5, with the aim of developing practical guidelines for addressing future proposals. We consider cases where (1) there is harm but no clear dysfunction, (2) there is dysfunction but no clear harm, and (3) there is possible dysfunction and/or harm, but this is controversial for various reasons. We found no specific criteria to determine whether future proposals for new entities should be accepted or rejected; any such proposal will need to be assessed on its particular merits, using practical judgment. Nevertheless, several suggestions for the field emerged. 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 defining mental disorder, the field would benefit from more sharply defined indicators of dysfunction. Third, it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of mental disorder, and to further clarify the type and extent of data needed to support such judgments.

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“…Deliberations examined the quality and quantity of studies being reviewed and the strength of the evidence in each study for various measures such as prior psychiatric history, clinical outcomes, course of illness, diagnostic stability, familial aggregation and/or co-aggregation, biological markers, comorbidity patterns, treatment response, environmental risk factors, and sociodemographic factors such as age, sex, and social class, among others. In addition to diagnostic validity, these formulations include evidence of clinical utility [ 39 ].…”

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“…Nevertheless, that we cannot simply carve nature at her joints ( Campbell et al., 2011 ), does not mean that “anything goes” ( Feyerabend, 1975 ). Instead, drawing a line between disorder and normality requires employing “essentially contested” constructs ( Gallie, 1955 ), working with graded or fuzzy categories ( Geert, Lara, & Rico, 2017 ; Lakoff & Johnson, 1999 ; Stein, 2013 ), and appreciating that our goals are not so much immediate resolution as ongoing rigorous debate and practical judgment ( Stein, Palk, & Kendler, 2021 ).…”

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“…In the field of psychiatric diagnostic nosology, there are “fuzzy” borders around many mental disorders. For example, in considering the issue of “what is a mental disorder?” Stein et al (2021) recently noted that the real possibility exists of erroneously classifying behavioral variations as “disorders,” when they might be better conceptualized using other categories such as “non‐pathological individual differences.” One promising development of the DSM‐5 (APA, 2013), compared to earlier editions, is that a greater cultural sensitivity and humility is incorporated throughout the manual. For example, DSM‐5 has updated its diagnostic criteria to reflect cross‐cultural variations in presentations and provides more detailed and structured information about cultural concepts of distress.…”

“…For example, in considering the issue of "what is a mental disorder?" Stein et al (2021) recently noted that the real possibility exists of erroneously classifying behavioral variations as "disorders," when they might be better conceptualized using other categories such as "nonpathological individual differences." One promising development of the DSM-5 (APA, 2013), compared to earlier editions, is that a greater cultural sensitivity and humility is incorporated throughout the manual.…”