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
The 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.
These 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.
