The practice of psychiatry makes little use of dysfunction
Perhaps one of the most telling practices is the use of other specified or unspecified disorders. Even when symptom presentations do not satisfy DSM thresholds of dysfunction indicators, the accepted practice is to label them as disorders and prescribe treatment for them as such. For instance, if a person presents to a psychiatrist with depressive symptoms that do not meet criteria for major depression, the presentation is usually labelled as “other specified depressive disorder” if the patient finds them distressing. DSM clearly sanctions the disorder designation when there is insufficient evidence of dysfunction, even by its own indirect inferential standards.
Consider someone who presents with overwhelming anxiety after being given the diagnosis of a terminal cancer. Does the anxiety represent a failure of an internal mechanism to perform a natural function? If we were to ask the practicing psychiatrist, we would find that they are hardly concerned with this abstract question of failure of natural design. What the psychiatrists will assess is the degree of distress and impairment. If the degree of distress and impairment is judged to warrant treatment, the psychiatrist will call it a disorder ( “other specified anxiety disorder” or something else).
All these conceptual difficulties surrounding dysfunction make it clear that dysfunction does not protect against social misuse of disorder designation. In current practice of psychiatry, disorder designation is driven by distress and impairment with little essential role played by dysfunction. The existence of dysfunction is inferred on the basis of normative judgments, which are not only unable to differentiate dysfunction from other ways of going wrong but are also heavily influenced by social views of normality. The weakness of dysfunction to protect against social misuse of disorder designation is also clear from the history of nosology. The declassifications of homosexuality, ego-syntonic cases of some paraphilias, and ego-syntonic cases of transgender identity in recent times were all justified on the basis of lack of harm and not on the basis of dysfunction.
Since a dysfunction-based defense does not adequately protect against arbitrary disorder designations, we will explore what a harm-based defense might look like in Part 3.
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