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Context Does Not Determine “Disorderness” or Normality

Context Does Not Determine “Disorderness” or Normality

In part 1 of this essay, I argued that panic attacks are nearly always pathological and disordered states, even when they occur in an understandable context. I also distinguished the maladaptive aspects of panic attacks from the adaptive nature of the classic fight or flight response, sometimes known as the general adaptation syndrome. Indeed, because panic attacks per se appear predictive of subsequent psychopathology, one proposal for DSM-5 is to rate panic attacks as a separate dimension of pathology, across all mental disorders.

But the issue of context and its relationship to disorderness extends well beyond panic attacks: it arises in nearly all psychiatric diagnoses not explicitly defined contextually. Some DSM disorders, of course, are context-bound by definition (eg, PTSD requires a trauma, adjustment disorders require some precipitating psychosocial stressor). For most other DSM diagnoses, however, the basic question arises: if we can understand the patient’s presenting signs and symptoms, owing to an explanatory psychosocial or environmental context, are we entitled to regard the patient’s condition as normal, non-pathological, or non-disordered?

I would like to suggest that such an explanatory context does not remove a psychiatric condition’s pathology—or the need for treatment—once the condition crosses a certain threshold of suffering and incapacity. Context does not dissolve disorder, even if it seems to explain it. And often, we are quite wrong about such seeming explanations.2

Indeed, if someone who climbed mountains for a living repeatedly and frequently experienced panic attacks whenever standing on the edge of a cliff—resulting in prolonged or pronounced suffering and incapacity—this state of affairs would be the dysfunctional equivalent of disease. On this view, pathological states are constituted by pronounced or prolonged suffering and incapacity—or, if we prefer, by profound distress and disability. While the term “disease” resists an essential definition—ie, one specified by necessary and sufficient criteria—most “disease” conditions have pronounced or prolonged suffering and incapacity in common. These features constitute what the philosopher Wittgenstein3 termed “family resemblances” and may be compared to the overlapping fibers that make up a rope.

To be sure, not all pathological or disordered states constitute clinical disease. In our ordinary language, we usually don’t apply the term “disease” to states of suffering and incapacity that are related to a visible wound or injury, such as a knife wound. Nor do we usually apply the term “disease” to suffering and incapacity that is inflicted upon someone by external malefactors, such as terrorists or kidnappers. So, in this very limited sense, context does play some role in how we use the term “disease” in our ordinary language.

There is another sense in which context plays a limited role in how we assess the disorderness of a condition. When a person experiences intense or prolonged suffering and incapacity “out of the blue”—ie, in the absence of any known psychosocial precipitant or other explanatory context—our clinical suspicions are usually raised. We suspect some kind of internal disease process at work, such as a covert malignancy; or, in the case of major depressive symptoms, we suspect what used to be called an “endogenous” depression. In this limited sense, then, the contextualists are correct.

Where contextualists err is in supposing that the presence of an understandable, explanatory context—such as recent bereavement, job loss, or hanging off a cliff—somehow renders a condition normal, non-pathological, or non-disordered, all other things being equal. Curiously, this fallacious reasoning seems more common in psychiatry than in general medicine. Consider the patient who after abdominal surgery develops clinically significant pain at the incision site. The pain—while entirely understandable and perhaps even statistically common—is nevertheless considered pathological and is quickly treated by diligent clinicians. The patient in such pain is suffering and is probably incapacitated.

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