A (Very Brief) Introduction to the Concept "Disorder"
One of the most difficult parts of the scientific study of psychopathology is identifying etiologically discrete and conceptually valid diagnoses. Currently, the diagnostic and statistical manual of mental disorders (DSM) provides clinicians with symptom criteria that provide a theory-neutral basis for diagnosis. However, some DSM disorders have so many symptoms that two different people can have the same disorder without having more than two overlapping symptoms. Famously, there are 227 different mathematical combinations of symptoms that can lead to a diagnosis of a major depressive episode according to the criteria in DSM-5.
The problem with this is that it suggests that what we are calling depression is actually many different conditions with different presentations and likely different etiologies. Researchers have criticized the diagnosis of major depressive disorder (MDD), for example, on the basis that it interferes with research and clinical treatments for depression, and other authors have proposed more fine grained alternatives, including non-melancholic depression.
The importance of these distinctions are important, but there is a deeper conceptual issue at the heart of medicine. Every condition present in DSM regardless of its specific symptom criteria must represent a genuine disorder, and what the concept disorder means is a matter of significant controversy. In this post, I examine the current state of academic discussion on the concept of disorder. (Note: to indicate that I am referring to the concept, I put the word in italics. For example, the word ‘disorder’ refers to the concept disorder.)
This is, obviously, going to be a somewhat different kind of post - more similar to our posts about psychotherapy and artificial intelligence (see part 1, part 2, and part 3), autism and neurodiversity, and therapy for chronic illnesses, where we discuss issues in the field, one of our clinician's areas of research, things other than what to look for in a depression therapist in Manhattan. We will not be discussing therapy for depression, anxiety therapy, or trauma therapy in NYC, but we will be back to our usual posts next week.
Why Does Disorder Matter?
In order to appreciate the discussion to follow, it will be helpful to have a sense of why this matters and, at the risk of sounding over-dramatic, a great deal is at stake. (In fact, it was central to the Lindsay Clancy case that has captivated the attention of millions.)
First, in the United States, the courts have decided that because it is a disorder, imprisonment of heroin addicts is cruel and unusual (Robinson v. California 370 U.S. 660 [1962]), and in Australia, Canada, England and Wales, Hong Kong, India, the Republic of Ireland, New Zealand, Norway and the majority of U.S. states, so called M’Naghten rules stipulate that an individual is not to be held legally culpable for their actions if a psychiatric disorder prevented their ability to exercise the relevant faculties (e.g., of reason). In other words, if a person commits a crime, they may avoid certain penalties if it can be shown that they could not have acted otherwise due to the presence of a disorder. Obviously, quite a bit hangs on whether or not a person’s behavior is informed by a genuine disorder, rather than some other mental state or process.
Second, the provision of certain goods, including educational resources, financial assistance, and even therapy is often distributed on the basis of an individual’s diagnosis. As a society, we accept that if a child has a disability, they may be entitled to accommodations, some of which may be limited in number and at the tax-payers expense (e.g., laptops or iPads). If programs such as these are to continue then, particularly in school districts that are less affluent and which cannot provide every child these devices, some way to determine whether a child does genuinely need the device is needed. For this, a clear account of the concept disorder is required.
Finally, psychotherapeutic research, including on medications, relies on forming homogenous groups and dividing these into control and experimental group in order to determine the efficacy of whatever treatment is being tested. If you are testing an anti-depressant medication, for example, or the efficacy of a particular therapy for depression on a group of people, some of which have depression, but some of which only appear to have depression but actually have, say, anxiety, and some are sad but not clinically depressed, then even if the treatment worked on the people who are depressed, if it didn’t work on the anxious or sad people, then it will appear that the drug didn’t work at all. The inclusion of non-disordered people into a research on disorders potentially undermines the entire research program.
The BioStatistical Theory (BST)
In the 1960s and early 1970s there was a movement known as antipsychiatry that posed a powerful challenge to the mental health establishment. Rather than a legitimate field of inquiry, these scholars argued that mental health professionals were really in the business of social control, masquerading as a medical discipline and operating with medical authority. These arguments ranged from Thomas Szasz’s (1961) claim that mental illness is a “myth” and R.D. Laing’s (1967) argument that schizophrenia is a normal reaction to abnormal family environments—both from within psychiatry itself—to sociologist Thomas Scheff’s (1966) “labeling” theory of diagnosis and historian-of-ideas Michel Foucault’s (1965) “history of madness” portraying mental disorder as a socially constructed category.
In an influential series of papers, the philosopher Christopher Boorse offered a response, arguing that disease occurs when a part or process of an organism performs one of its normal biological functions at a level of efficiency below that typical for members of the same species, sex, and age. Boorse’s biostatistical theory (BST) provided a well-reasoned way to distinguish between normal and disordered conditions based on purely factual basis of whether a dysfunction is present, thereby posing a powerful counterargument to the anti-psychiatrists. Combined with several social factors – including the rapid deinstitutionalization movement combined with the slow development of community mental health care centers as well as legislation preventing involuntary psychiatric committal causing many more laypersons to be exposed to people with psychiatric disorders than they had previously, revealing to many the romanticization of the anti-psychiatric critique – the BST effectively responded to the challenge of the period.
However, the BST faces serious challenges that render it controversial as an account of the concept disorder as it is used in medicine. Some of these challenges have to do with the way that the BST conceives of “dysfunction”. For instance, in virtue of the BST’s emphasis on statistical normality, certain obviously adaptive traits that are nevertheless species-, sex-, or age-sub-typical would nevertheless be classified as disorders (e.g., sickle-cell trait, the presence of blood alterations that allow Tibetan Sherpas that allow them to climb high altitudes without oxygen tanks). Or, because age is used as a reference class, the BST is committed to claiming that depending on what the age cut-offs are, a child may have a disorder one year and not the next though their symptoms remained the same, simply because they got older. Perhaps the most odd feature of the BST’s commitment to statistical normality occurs from so called “universal” disorders: if everyone on earth right now broke their arm, according to the BST, it would not be a disorder to have a broken arm. Although that may sound like nothing more than a philosopher’s thought experiment, the reality is that prior to the advent of vaccinations, it may have been statistically normal for a child to have measles.
There are several other problems with the BST which are technical in nature and for which there is not the space here (some of these will be addressed below). However, it is worth identifying one in particular. The BST does identify something important – a trait that performs its evolved function in a less survival- or reproduction-realizing way than those of the same age and sex is, appears to be at a disadvantage relative to those normally and supra-normally functioning others. The problem is that it is entirely possible that this dysfunctioning actually makes no difference to the organism at all . Consider, for example, a benign angioma which occurs when capillaries proliferate abnormally in a localized area of the skin, producing a small red dot on the skin. Benign angiomas (sometimes called cherry angiomas) don’t hurt or itch or smell or have any propensity to form into a more malignant disorder and, although they are dysfunctions, are not considered a disorder.
The point is that the BST seems to identify when something has gone wrong biologically, and not necessarily when something has gone wrong medically. Medicine is a field that refers, in some way, to what matters to people. If a condition emerges that doesn’t effect you in any way, but it is statistically subnormal, the BST will capture it, but most physicians will tell you not to worry about it. That doesn’t sound like “disorder.”
Dimensionalism
Dimensionalism about disorder may be the most widespread approach to the concept. According to dimensional approaches, there is no natural boundary between normal conditions and disorders – the latter are really just extreme positions on dimensions that extend through the normal population.
For example:
low anxiety ←———— typical anxiety ————→ very high anxiety
According to dimensionalists, there is no natural boundary at which ordinary anxiety becomes an entirely different kind of thing called anxiety disorder.
The problem with the dimensionalist view is that it doesn’t reflect medical views or most
people’s intuitions in most cases. Although it seems correct to say that a depressive disorder or an anxiety disorder must be extreme positions on a dimension of those traits (though, more on this later), consider other non-disordered states such as attractiveness, athleticism, singing ability, and so on. Are those that fall on the extremes of the dimension of attractiveness disordered? Or talentlessness? Or not having a green thumb? The reality is that some people are very good at some things, and others are very bad at some things, but not all of these things are relevant to medicine.
And, is it true there are no good, principled, places to draw a line between normality and disorder? Consider, for example, illiteracy and dyslexia. Both conditions have a similar phenotype – that the person is unable to read. However, one is a disorder and the other is not? Why is that? The answer seems to have something to do with why the person cannot read. Someone who has never been taught to read lacks an acquired ability; someone with dyslexia has difficulty acquiring that ability despite adequate instruction because of an underlying neurodevelopmental impairment. The mere fact that reading ability varies continuously therefore cannot explain why one condition is pathological and the other is not. Dimensionalism may tell us how much difficulty someone has, but it does not, by itself, tell us why that difficulty constitutes a disorder.
Abilities-based Approaches
A very prominent view right now, particularly in Europe, holds that disorder involves the loss of some ability. Abilities based views start from the view that disorders occur to people, not to sub-personal mechanisms within organisms. The fundamental problem with accounts of the concept disorder that take as their starting point the presence of a dysfunction is that they miss that dysfunctions are to parts and processes, but disorders occur to the organism as a whole, and when an organism has a disorder, they are unable to perform in some way that, without the disorder, they would be able to perform.
The way these inabilities get spelled out is different among different theorists. Very crudely: Sanja Dembić, for example, explains that when one is unable to respond to reasons, one has a disorder; Garson Leder and Tadeusz Zawidzki argue that when one is unable to skillfully self-regulate, on has a disorder; Sander Werkhoven contends that when one’s ability to engage certain dispositions fails, one has a disorder, and so on.
Each of these different theories has merits, but they each fail to represent the concept disorder as it is currently used in medicine. (In fact many, though by no means all, abilities-based theorists argue that they are explicating or engineering a new concept that should be adopted by medicine, rather than an analysis of the concept that is currently used by medicine.) It is beyond the scope of this post to examine each theory individually, but as a whole there is something unsatisfying about abilities-based approaches. The reality is that our abilities supervene upon various sub-personal mechanisms and processes. Our ability to see, for example, relies upon our eyes, visual cortices, and so on; these sub-personal mechanisms and processes are not always sheerly physiological: our experience of happiness may (and likely does) rely on mental states – such as beliefs about oneself, values one holds about the world, etc. – that are themselves the product of mental, rather than physical, mechanisms, that ultimately redound to the brain. The point is that, if one fails to be able to do something – say, to see why they shouldn’t be depressed, or to stop taking an addictive substance – then there is something going on beneath the level of experience that is causing that experience, and it seems intuitive that the cause of that experience is the disorder.
The Harmful Dysfunction Analysis (HDA)
The harmful dysfunction analysis (HDA) began in 1992 with a couplet of papers by Jerome Wakefield, and starts from the view that Boorse was correct in ascribing a naturalistic criterion to the concept disorder – from the time of Hippocrates and Galen, to have a disease or a disorder meant that something had “gone wrong” with the organism and this is plausibly explained by a dysfunction criterion.
However, rather than understand dysfunctions as a result of a statistical deviance from the reference-class-average, the HDA claims that a condition is dysfunctional if it fails to perform the function for which it evolved by natural selection. (The “for which” element is crucial here – one’s heart performs many functions: to increase one’s overall weight, to affect one’s gravitational pull on the moon, etc. - but the function for which it evolved is to pump blood.)
Equally important is that, unlike the BST, the HDA argues that dysfunctions must be harmful in order to count as a disorder. Just as we saw above with benign angiomas, harmless dysfunctions tend not to be considered disorders. For instance, homosexuality had for many years been considered a mental disorder until Robert Spitzer, the creator of the modern DSM system, met with many gay psychiatrists and physicians and learned that being gay caused no harm outside of the prejudicial views of others. Once Spitzer realized that the only thing that caused harm to gay people was other people, he pushed for it to be depathologized. (This was interestingly discussed on This American Life.)
However, the HDA faces its own challenges. Although many now agree that it seems as though some harm criterion is contained within the concept disorder, it is unclear in what such harm consists. Several disorders, particularly some sexual paraphilias, cause harm to others and not the person with the condition. Moreover, the way Wakefield specifies the harm criterion is that a dysfunction must be harmful according to social values. Wakefield argues that that medicine is a socially sanctioned profession and so it must reflect the values of society so that fringe doctors are unable to create idiosyncratic diagnoses. However, this means that the concept disorder is relative to the medical-linguistic community using it and so, a person may be diagnosed with a disorder in the United States, take a flight to the far East, and lose their disorder somewhere over the Atlantic as the social values change. Additionally, animals and plants also seem to suffer from disorders but do not have social values, and so it seems that the concept disorder does always mean harmful dysfunction (at least not as it is spelled out by the HDA).
Where to go from here…
Currently, the HDA is the most widely used account of disorder in the clinical literature, being used to explain everything from paraphillias to psychopathy, and is endorsed or at least accepted by several leading mental health professionals. And, in full transparency, a member of Lexington Park Psychotherapy's team, Dr. Jordan Conrad, has argued that the HDA provides a perspicacious view into the way disorders may be depathologized and explains in what the controversy consists when there is controversy about the disorder status of a condition (here); have defended the HDA’s harm criterion (here), even against a version of the BST (here); and have applied it to issues related to the philosophy of business and management. I also believe that the challenges posed above to the HDA will be resolved.
However, there is quite a lot of work still to do, and a healthy debate remains.
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