Dr Aftab is a geriatric psychiatry fellow at University of California San Diego (UCSD) in La Jolla, CA, and a former psychiatry resident at Case Western Reserve University/University Hospitals Cleveland Medical Center in Cleveland. He is also a member of the Psychiatric Times Advisory Board. He can be reached at [email protected].
This is the third and final part of a three-part series on a pertinent philosophical question in the era of diagnostic inflation: What conceptual means are available to prevent deviant and undesirable behavioral conditions from being diagnosed as mental disorders as a result of social bias and stigma? The series is based on an essay (“Social Misuse of Disorder Designation: Exploring Dysfunction and Harm-Based Conceptual Defenses”) that was awarded the 2018 Karl Jaspers Award by the Association for the Advancement of Philosophy and Psychiatry. Dr Aftab has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry, and this series constitutes one effort to bring this discussion to a wider audience. Part 1 and Part 2 can be viewed online.
In Part 2, I argued that a dysfunction-based defense strategy does not adequately protect against arbitrary disorder designations. In Part 3 of this series, I will explore the notion of a harm-based defense.
At a minimum, a mental disorder is considered an undesirable and unwanted condition either for the individual or the society. However, that is clearly very relativistic and does little to protect against social misuse of disorder designation. Wakefield defines the concept of harm in a broad fashion, barely distinguishable from negative social evaluation. For instance, Wakefield writes: "As traditional value accounts suggest, a condition is a mental disorder only if it is harmful according to social values and thus at least potentially warrants medical attention. . . . ‘Harm’ is construed broadly here to include all negative conditions."1
We can, however, restrict undesirability to certain kinds of harm to come up with a criterion that offers more protection. Consider the following degrees of undesirability:
1. Unwanted/undesired/negatively evaluated by the individual only;
2. Unwanted/undesired/negatively evaluated by the society;
3. Associated with harm (distress/disability/harm to others) (DSM);
4. Associated with intrinsic harm (distress or disability which is a direct result of a specific biological or psychological process).
The only way to reliably exclude ego-dystonic homosexuality from the realm of mental disorders is to require intrinsic harm to be a necessary criterion for a mental disorder definition. Homosexuality can be (and was) negatively evaluated by individuals as well as society, and it can be (and was) perceived to be harmful according to social values; ego-dystonic homosexuality is also associated with distress.
There is no conceptually a priori reason for limiting harm in the definition of mental disorder to intrinsic harm. It is an artificial maneuver that is difficult to justify on conceptual analysis aside from saying that it offers protection against social prejudice. This point has been well-articulated by Bingham and Banner2:
In any case, it would be an artificial polarisation to attempt to understand distress or harm as separable from cultural values, and it is not obviously desirable for healthcare to be informed by a narrow view of harm. This would run counter to ideals of holistic healthcare and attempts understand people in context. If correct, Wakefield rightly extends ‘harm’ to cultural standards. But if so, then socially undesirable conditions are not excluded from the definition of disorder by distress or harm criteria.
I agree with Bingham and Banner that such a move would conceptually be an artificial polarization. There is, however, a strong ethical argument to be made requiring intrinsic harm as a necessary criterion for mental disorder designation in the practice of psychiatry. We have an ethical obligation to prevent social misuse of disorder designation, and we need a conceptualization of mental disorder that would exclude “states that are wrongly pathologised due to prejudice and social exclusion, including those we might not have identified as such yet.”
Let us dig further into the notions of distress and impairment.
Distress refers to some sort of psychological suffering. Although the DSM makes no further classifications, the following distinctions can be made regarding types of distress:
Intrinsic distress is distress that is the direct result of a specific biological or psychological process.
Extrinsic distress is not the direct result of a specific biological or psychological process. It can originate from conflict with society (ie, individual would not experience distress if society were to accept the condition as normal—exogenous distress) or it can originate from within the individual due to internalized moral and social values (ie, internalized distress) but not as a direct result of biological or psychological processes.
The distinction between intrinsic distress and extrinsic distress in the case of a particular condition can be facilitated by means of a thought experiment. If social norms were to change such that the condition in question is no longer considered disordered, does the distress disappear? Even if society were to accept generalized anxiety as a normal variant, the persistent anxiety remains distressing for the individual experiencing it. In the past, homosexual individuals were distressed by the sexual orientation due to the antagonism with social norms and sought conversion therapy for that reason. However, with change of social norms, homosexual individuals are (by and large) no longer distressed.
1. Wakefield JC. The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis. World Psychiatry. 2007;6:149-156.
2. Bingham R, Banner N. The definition of mental disorder: evolving but dysfunctional? J Med Ethics. 2014;40:537-542.
3. Rashed AM, Bingham R. Can psychiatry distinguish social deviance from mental disorder? Philosophy, Psychiatry, & Psychology. 2014;21:243-255.
4. Aftab A, Chen C, McBride J. Flibanserin and its discontents. Arch Womens Ment Health. 2017;20:243-247.