This is the final 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. In part two, we examined how the American Psychiatric Association, publishers of the “bible” of mental health – the DSM, have defined these terms both in the past and in the future. Below, I address why we use categories that may not be highly scientific and how we can move forward as an evidence-based field.
What to Do?
Given the problems with all of the preceding definitions of a mental disorder, one might begin to question the need for such a term or concept. After all, if it cannot be easily and accurately defined, what use is it? If the DSM categories are problematic, then why diagnose using them? The simple answer is “We use them because we need them.”
Humans are natural categorizers, with a need to group and order things that we encounter. Our diagnostic typologies reflect this underlying need. It is much easier to understand and communicate to someone that a client is diagnosed with obsessive-compulsive disorder and generalized anxiety than to say something like “Their general anxiety level is at the 87th percentile, while they also have more obsessive, intrusive thoughts than 94% of the population and a subsequent rate of compulsive, anxiety reducing behaviors greater than all but 16% of their peers.” In many cases, dimensional models of psychopathology, although perhaps more accurate, may simply be too confusing and/or complex to be useful in the real world.
Doing diagnostic work, and giving a patient a diagnosis based on presenting symptoms and lab findings, is an enormous part of all health professions. This is true even though dimensional models actually make more sense for almost all of what are called diseases (e.g., “Your blood pressure is higher than 95% of males your age, weight, and fitness level” rather than “You have high blood pressure.”) Given clinical psychology’s development and outgrowth from medicine, it makes sense that diagnosis would be part of our heritage. In many ways, it also establishes the credibility of psychiatry and clinical psychology by allowing these professions to stake out their “territory.” Having something like the DSM essentially says “These problems and dysfunctions are the domain of psychiatry, so you other types of health providers back off.” Losing diagnoses as part of the profession would mean that, in essence, we were losing our domain of health care. These reasons are, of course, in addition to the facts discussed previously about how real-life requires caseness or non-caseness in many occasions.
So, we as a profession and a society need definitions of mental disorders, and yet there does not appear to be a scientific consensus or definition on what a mental disorder actually is. So if there can be no truly scientific definition, what are we left with?
Mental Disorders as Social Constructions
Mental disorders, mental illness, and psychopathology are best understood as products of our history and culture, and should try to be defined as some sort of universal, scientific construct. Mental disorders are, in a very real sense, invented. This does not, however, mean that they are not real. Instead, our conception of what is and is not normal behavior is influenced by everything from social and cultural forces, to politics and economics, to which professional groups have the most influence and clout at the time new definitions are being written. Mental disorders, then, are social constructs, a concept that is constructed by a particular group (in this case, the committee members of the DSM Work Groups, who are in turn influenced by researchers, clinicians, politicians, lay people, industry, religious beliefs, and more).
Accepting that mental disorders are a social construct, for some, implies that they are somehow fake or unimportant. Nothing, in fact, could be further from the truth. To put this in perspective, consider a number of other social constructs: love, beauty, race, poverty, wealth, physical disease. Each of those is constructed, and you will see different definitions of each when moving across time and between cultures.1 This does not rob any of them of their importance, or make any of them less real. The same is true of mental disorders.
Mental disorders are hard to define, even by those who make it their life’s work to study and treat them. Although there are certainly faults and flaws with the most widely used and social constructed definition, that of the DSM, the drawn boundary between normal and abnormal are essential to clinical psychology as a profession, persons with mental illness, and society as a whole.
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.