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On defining “mental disorder”: Purposes and conditions of adequacy

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Abstract

All definitions of mental disorder are backed up by arguments that rely on general criteria (e.g., that a definition should be consistent with ordinary language). These desiderata are rarely explicitly stated, and there has been no systematic discussion of how different definitions should be assessed. To arrive at a well-founded list of desiderata, we need to know the purpose of a definition. I argue that this purpose must be practical; it should, for example, help us determine who is entitled to publicly funded health care. I then propose eight conditions of adequacy that can be used to assess competing definitions (e.g., the ordinary language condition, the coherence condition, and the condition of normative adequacy). These conditions pull in different directions, however, and we must decide which are most important. I also suggest that there is no single definition that can help us deal with all the relevant practical issues.

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Notes

  1. The main reason why it is preferable to formulate the question in terms of disorder or malady rather than in terms of illness or disease is that the most practically relevant category is a broader category that also includes injury, retardation, and so on. The practically important thing is how we distinguish disorder from non-disorder, and not how we draw the line between, for example, disease and injury, or illness and disease.

  2. At this point, it is worth noting that conditions that are classified as mental disorders may well be associated with stigma for other reasons than that they are classified in this way. For example, the stigma associated with pedophilia would not disappear if we stopped classifying it as a disorder.

  3. To simply medicalize certain conditions (to regard them as medical problems) might have similar effects, regardless of whether this medicalization is accompanied by pathologization (to regard them also as pathological, i.e. as a disorder).

  4. A favorite example among medical sociologists is pregnancy and childbirth. When these phenomena came to be treated as medical problems in need of “medical regulation and supervision,” doctors (the new experts) became more powerful, whereas other groups became more powerless. The midwives became subordinate, and the pregnant women became more dependent on medical expertise, which (supposedly) made them more helpless, viz., by stripping them of the ability to cope with their own problems.

  5. On this radical view, it is never appropriate to categorize people’s “abnormal behaviour and mental afflictions” as disorders. This idea is often accompanied by the even stronger claim that we shouldn’t even medicalize these conditions. But what alternatives are there? The proponents of the radical view often want us to conceive of the relevant conditions as “social problems,” “problems in living,” or “deviations from social norms,” rather than in terms of, for example, madness, crime, sin, or obsession.

    The arguments offered for the radical view are sometimes theoretical. For example, Szasz has argued that “mental health” cannot, unlike “physical health,” be defined in a value-free way. There are also a number of practical arguments, however; for example, it is sometimes pointed out that the consequences would be better if the conditions that are now categorized as mental disorders were (instead) categorized as social problems or “problems in living.” It is true that mental illness is sometimes associated with stigma, and that it would be better for some people to be viewed as “deeply troubled” rather than as disordered, but most of the practical arguments in favor of this radical view are rather weak (as are the theoretical ones). However, this is not to say that all conditions currently classified as mental disorders ought to be classified in this way.

  6. It is worth noting that the term “disorder” is probably not very common in everyday speech. This suggests that what we should require instead is that a definition be consistent with how terms like “disease,” “illness,” and “injury” (terms which denote the different sub-categories of disorder) are used.

  7. The value condition is really a special case of the ordinary language condition, but because of its central importance, it is worth regarding it in a category of its own.

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Correspondence to Bengt Brülde.

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Brülde, B. On defining “mental disorder”: Purposes and conditions of adequacy. Theor Med Bioeth 31, 19–33 (2010). https://doi.org/10.1007/s11017-010-9133-1

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