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 Part 2 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? This 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 3 are available online.
At the end of Part 1, we noted that DSM recognizes the need to prevent arbitrary disorder designation of negatively valued conditions and does so by adopting a dysfunction-based defense. However, I argue that a dysfunction-based defense against misuse of disorder designation has serious conceptual deficiencies, is vulnerable to social biases, and offers very little protection in practice. Let us take a closer look at some of these problems with dysfunction.
Lack of official definition
Given the important role dysfunction plays here, one would imagine that the DSM (and psychiatry, more broadly) would have a valid, unambiguous definition of dysfunction that would clearly determine which deviancies and conflicts are disorders and which are not, even in situations of controversy. Sadly, that is not the case. DSM never formally defines this crucial term. It is not surprising, then, that the authors of the DSM 5 white paper on nomenclature felt that the mental disorder definition “is not cast in a way that allows it to be used as a criterion for deciding what is and is not a mental disorder, and it has never been used for that purpose.”1
This lack of official definition is compounded by the fact that the presence of dysfunction can only be inferred or hypothesized in vast majority of the cases due to the current state of neuroscientific knowledge. Again, the authors of the DSM 5 white paper on nomenclature noted: “The problem is that too little is known about the cerebral mechanisms underlying basic psychological functions, such as perception, abstract reasoning, and memory, for it to be possible in most cases to do more than infer the probable presence of a biological dysfunction” [emphasis added].1
Biological causation is not equivalent to dysfunction
A distinction needs to be made between dysfunction and etiology/biological causation. Often in practice, etiology becomes dysfunction when the condition has already been designed as a disorder on the behavioral level. However, mere determination of causal pathway is not enough, as even normal phenomena have causal pathways. For instance, in our example red hair being labeled as a disorder, we know red hair is produced by recessive genes and from a specific ratio of pheomelanin and eumelanin, but etiology by itself does not tell us that red hair results from a dysfunction. What is needed is a discriminative account of what sort of causal mechanisms or what sorts of etiologies constitute dysfunction.
Robert Spitzer, MD, made a similar argument in the discussion on homosexuality2:
Often in discussions of this kind a hope is expressed that some biological ‘abnormality,’ such as an endocrine or genetic disturbance, will be discovered and will resolve the issue once and for all. It is hard to see how this would answer the question any more than would knowledge of the biological cause or antecedents of left-handedness (surely there must be one) indicate whether that condition should be regarded as a normal variant or pathology.
Derek Bolton, PhD, explains this reasoning in the context of functional neuroimaging3:
By all means it is the case that if we are assuming that a specific psychological condition is a disorder then we may say in a derivative sense that the brain activity involved in producing it is disordered, but the inferential logic runs this way round, not the other: we do not see from the functional neuroimages that the brain activity (or the areas involved in the brain activity) are disordered, and then infer that the associated psychological functioning is a disorder.
1. Rounsaville BJ, Alarcón RD, Andrews G, et al. Basic nomenclature issues for DSM-V. In: A Research Agenda for DSM-V. Arlington, VA, US: American Psychiatric Association; 2002:1-29.
2. Spitzer R. The diagnostic status of homosexuality in DSM-III: a reformulation of the issues. Am J Psychiatry. 1981;138:210-215.
3. Bolton D. What is Mental Disorder?: An Essay in Philosophy, Science, and Values. Oxford, United Kingdom: Oxford University Press; 2008.
4. Boorse C. Health as a theoretical concept. Philosophy of Science. 1977;44:542-573.
5. Kingma E. What is it to be healthy? Analysis. 2007;67:128-133.
6. Wakefield JC. The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis. World Psychiatry. 2007;6:149-156.
7. First MB, Wakefield JC. Diagnostic criteria as dysfunction indicators: bridging the chasm between the definition of mental disorder and diagnostic criteria for specific disorders. Can J Psychiatry. 2013;58:663-669.
8. Matthewson J, Griffiths PE. Biological criteria of disease: four ways of going wrong. J Med Philos. 2017;42:447-466.
9. Schwartz PH. Progress in defining disease: improved approaches and increased impact. J Med Philos. 2017;42:485-502.