Beyond Dysfunction: Distress & the Distinction Between Social Deviance & Mental Disorder

Over the course of last year I have been working on a small project with Rachel Bingham examining the possibility of distinguishing ‘social deviance’ from ‘mental disorder’ in light of recent work on concepts of health. The result was an essay published recently in the journal Philosophy, Psychiatry & Psychology (21:3-September 2014).

Johanna Moncrieff and Dan Stein wrote commentaries on our essay to which we responded in a short piece published in the same issue with the original essay.

In our response to Moncrieff and Stein we found it necessary to point out that in the writings of some critical psychiatrists and psychologists there is a problematic conflation of empirical with conceptual issues in relation to ‘mental disorder’. That section is reproduced below. Note that Criterion E is the final clause in the DSM definition of mental disorder. It states that a mental disorder must not solely be a result of social deviance or conflicts with society.

Mental Disorder: Separating Empirical From Conceptual Considerations

Let us begin by revisiting the conceptual basis of attributions of mental disorder. Criterion E is not, as we argued with Stein et al. (2010, 1765), conceptually necessary, but is of ethical and political importance given the historical context. Thus, notwithstanding the other criteria, a condition can only be considered for candidacy for mental disorder if “dysfunction” is present. What is a dysfunction? As Moncrieff puts it, there is a tautology in the definition of mental disorder where it is stated that a mental disorder reflects an “underlying psychobiological dysfunction” (Moncreiff 2014). Moncrieff argues that this is flawed because underlying processes have not been established, which renders the definition tantamount to saying that a dysfunction is a reflection of a dysfunction: a definition that adds nothing to our knowledge.

Here Moncrieff follows Thomas Szasz in finding a lack of resemblance to physical disorder to be the primary problem with the concept of mental disorder (see Fulford et al. 2013).1 In pursuing this, the critical psychiatrist not only fails to see the complexity of the concept of physical disorder, but also commits the same error as the biological psychiatrist. The latter implies that an ever longer awaited complete neurochemistry of mental health conditions would solve the conceptual problems. The former—the critical psychiatrist—implies the converse; that the absence of proof for the “existence of separate and distinct foundational processes,” as Moncrieff (2014) puts it, proves that mental health conditions are not disorders. As we have argued elsewhere, identifying the biological basis for a set of behaviors or symptoms does not in itself pick out what is pathological or disordered: for example, a complete description of the neurochemical states governing sexuality would not permit the inference that homosexuality is a disorder, any more than discovery of the neural correlates of falling in love or criminality would make these mental illnesses (Bingham and Banner 2012). Neurobiological changes—their presence or their absence—tells us about conditions when we find them by other means, but it does not tell us what is or is not a disorder. The same arguments could be run for underlying psychological processes. Consequently, emphasis on scientific progress or failure to progress in understanding the neurobiological correlates of mental health conditions does little to advance the conceptual debates, a point that may help to explain the impasse in the ongoing exchange between critical and biological psychiatrists.

Thus, although Moncrieff is right in pointing out that the term ‘dysfunction’ is redundant in the definition of mental disorder, she is wrong about the reason why this is so. It is not, as she claims, due to the point that no “separate and distinct foundational processes” (2014) that can ground dysfunction have been discovered empirically. After all, this leaves her open to the simple response that they actually have been, a response many biological psychiatrists do offer. The redundancy of the term ‘dysfunction’ in the definition of mental disorder is a result of conceptual analysis (and not empirical evidence), whereby it has not proven possible to define dysfunction in a way that excludes values. Here, we follow Derek Bolton in the view that once we “give up trying to conceptually locate a natural fact of the matter [dysfunction] that underlies illness attribution… then we are left trying to make the whole story run on the basis of something like ‘distress and impairment of functioning’” (2010, 332). We are left then with those things that matter in real life, the reasons that lead to healthcare being sought: usually the presence of significant distress and disability.

This is what the terms ‘dysfunction’ and ‘mental disorder’ pick out once we achieve some clarity on their referents. Stein is clearly aware of the problems inherent in defining dysfunction. However, somewhat surprisingly, the assumption that we can talk of ‘dysfunction’ over and above experienced factors (distress and disability in particular) arises through Stein’s commentary. In other words, although Stein has acknowledged the conceptual problem, in places he still writes as if there were a clear definition of dysfunction, without telling us what this would be. For example, he describes “situations when there is evidence of dysfunction, but an absence of distress and/or impairment” and gives the example of tic disorders which have no “clinical criterion (emphasizing distress and/or impairment)” (Stein 2014). We would argue that, despite the lack of explicit acknowledgement in DSM, tic disorders enter the manual because of their association with clinically significant distress and disability. It is important to avoid confusing the empirical questions (e.g., Why do people have tics? Can people have tics and not be distressed?) with the conceptual questions (e.g., When is a tic a disorder? Can tics be disorders if they do not cause distress or impairment?).

A further potential pitfall is to conflate the technical use of ‘dysfunction’ with the ordinary use of that term. This might occur where, on the one hand, we perceive a ‘dysfunction’ but on the other hand we are unable to say what the dysfunction consists of. When Moncrieff writes that dysfunction and distress are not co-extant, because, “people may neglect themselves and act in other ways that compromise their safety and survival without necessarily being distressed,” she is offering a description of behavior many would consider ‘dysfunctional’ in the lay sense (2014). Considered as a basis for conceptual analysis, however, this does not illuminate any “underlying psychobiological dysfunction”, which previous definitions aspired to do. Indeed, it is somewhat surprising that Moncrieff provides this counterexample rather than sticking to her argument that dysfunction in fact does not exist. In citing safety and survival, Moncrieff’s phrase does resemble the evolutionary theoretic approach (notably described in Wakefield’s Harmful Dysfunction Analysis), which as has been discussed widely elsewhere and noted in our paper, has fallen out of favor owing to problems with evolutionary theory specifically and naturalistic definitions in general. What of importance is left in Moncrieff’s putative definition if not underlying psychobiological and evolutionary dysfunction? We would argue: only the harm or threat of harm experienced by the individual, whether that harm is cashed out as distress and disability or as some other similar negatively evaluated experienced factor.

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Culture, salience, and psychiatric diagnosis: exploring the concept of cultural congruence & its practical application

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Culture, salience, and psychiatric diagnosis: exploring the concept of cultural congruence & its practical application. Philosophy, Ethics and Humanities in Medicine (Journal)

This article is part of the series: Towards a new psychiatry: Philosophical and ethical issues in classification, diagnosis and care

Abstract

Cultural congruence is the idea that to the extent a belief or experience is culturally shared it is not to feature in a diagnostic judgement, irrespective of its resemblance to psychiatric pathology. This rests on the argument that since deviation from norms is central to diagnosis, and since what counts as deviation is relative to context, assessing the degree of fit between mental states and cultural norms is crucial. Various problems beset the cultural congruence construct including impoverished definitions of culture as religious, national or ethnic group and of congruence as validation by that group. This article attempts to address these shortcomings to arrive at a cogent construct.

The article distinguishes symbolic from phenomenological conceptions of culture, the latter expanded upon through two sources: Husserl’s phenomenological analysis of background intentionality and neuropsychological literature on salience. It is argued that culture is not limited to symbolic presuppositions and shapes subjects’ experiential dispositions. This conception is deployed to re-examine the meaning of (in)congruence. The main argument is that a significant, since foundational, deviation from culture is not from a value or belief but from culturally-instilled experiential dispositions, in what is salient to an individual in a particular context.

Applying the concept of cultural congruence must not be limited to assessing violations of the symbolic order and must consider alignment with or deviations from culturally-instilled experiential dispositions. By virtue of being foundational to a shared experience of the world, such dispositions are more accurate indicators of potential vulnerability. Notwithstanding problems of access and expertise, clinical practice should aim to accommodate this richer meaning of cultural congruence.

Abstract for the 15th International Philosophy & Psychiatry Conference: July 2012: Safety in Numbers and Crazy Cultures: the Limits of Diagnosis

With Natalie Banner, Rachel Bingham, Norman Poole, Roman Pawar, and Abdi Sanati

Overview
This workshop considers the role of community in understandings of normality. In 1994, the DSM added a caveat to the definition of mental disorder, that cultural congruence protects individual’s beliefs and values from being labelled as pathological. This reflected a blossoming political and ideological notion of ‘tolerance’, which now underpins widespread efforts to respect – and not alienate – communities with non-mainstream value systems and beliefs. The INPP 2012 conference reflects continued efforts to understand and embrace difference and promote tolerance. Yet, mental disorder is fundamentally about ‘difference’, and is by definition not tolerated but treated. We therefore propose the following presentations in an exploration of ‘difference’ as it arises within, and between, communities. The first presentation questions why it is that a single individual with an unshakable and dangerous value system may sometimes be diagnosed with a mental disorder, while an unshakable and dangerous value system held by a group may be criminal, but is not ‘pathological’. The second presentation considers the features of communities which protect against diagnosis. We consider the dependence of this immunity on being sufficiently  organised and having a discourse and dialogue of acceptability or tolerance. The final presentation discusses the successes of the homosexual civil rights movement in establishing a respected orientation as opposed to a repressed medical condition. We consider the conceptual problems illuminated by this shift, which reveal important features of diagnosis itself.

Relevant links:

INPP Conference 2012 Website

Breivik Trial

Hearing Voices Movement

Pro-Ana Blog