Clinical definition Distress, disability, and the need to treat

Derek Bolton

in What is Mental Disorder?

Published on behalf of Oxford University Press

Published in print February 2008 | ISBN: 9780198565925
Published online February 2013 | e-ISBN: 9780191754401 | DOI:

Series: International Perspectives in Philosophy & Psychiatry

Clinical definition Distress, disability, and the need to treat

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The main problem area of this chapter is how to conceptualize mental disorder without reliance on naturalistic definitions, the general conclusion being that the essential features are harm and the professional healthcare response.

The first section reconsiders the definitions of mental disorder given in the psychiatric manuals. Referring to the literature from around the time that the DSM definition was constructed, it is suggested that the aim was not so much to achieve an intellectually rigorous analysis of the concept of mental disorder – a task most suited perhaps for philosophy – but was rather to characterize as accurately as possible the conditions newly compiled in the manuals – this being a task appropriately for psychiatry. The definitions in the manuals emphasize first and foremost the distress, disability, or risk of adverse outcomes. The surrounding literature makes it clear that the manuals were compilations of the kinds of problem people bring to the clinic. This leaves outstanding, however, whether among the problems brought are normal problems of living, or socially defined problems. These issues are left unresolved in the manuals, to be taken up by naturalist theories of mental disorder of the kind discussed and rejected in the previous chapter.

In the second section some key features of mental disorder are considered which are prominent once naturalist theories are removed. The problem – the disorder – is within the phenomena, in the person's life, up front, not relative, for example, to evolutionary history. The norms of functioning that are broken are characteristically personal and social, not natural in a sense that can be distinguished from these. The presenting problem typically though not invariably includes a failure of comprehensibility, a rupture of meaningful connections in psychic life – using Jaspers’ terminology.

The third section, 4.3, considers the possibility that mental disorder can be defined in terms of breakdown of meaningful connections. This possibility – which is suggested by folk as well as psychiatric uses of terms relating to mental disorder – is found to be wanting in many ways, especially in the context of psychological models of psychopathology. The main point is that restricting the term mental disorder to cases in which meaning has run out is far too strong, and it would exclude many or most of the conditions and presentations characterized in the psychiatric manuals.

The fourth section explores the implications of diagnosis of disorder being tied to the need to treat, this being understood in the broad sense of warranting mental healthcare professional attention. Judgement that treatment is necessary because of distress, disability or perceived risk is fundamentally one involving personal and social values and priorities. At an individual level this is negotiated between patient and clinician (though other stakeholders are involved); at the social, public health level it involves decisions about healthcare provision and costs. Epidemiological studies used in planning provision of health services try to use a cut-off for ‘caseness’ that coincides with need to treat, and it was mainly for this reason that the criterion of ‘significant distress or impairment’ was introduced into the DSM-IV diagnostic criteria for many disorders.

In the fifth section, 4.5, on the domain of healthcare, the conclusion is drawn that insofar as naturalistic definitions of disease and disorder are unviable, the domain of medicine and of healthcare generally cannot be marked out primarily in terms of a special kind of condition to which they apply. There is no hard and fast demarcation between normal and abnormal suffering, or between normal and abnormal causes. Rather, the domain of healthcare is distinguished by one kind of response to suffering, however caused, namely the healthcare response, with characteristic professional ethics, training, use of science, and expertize in management and treatment.

Finally in this chapter, in section 4.6, there in an overview of some large-scale, cultural ontological and epistemological assumptions that have operated in western modernity and which have become involved in the development of western psychiatry. These include naturalism, empiricism, and rationalism. It is noted that assumptions have changed in post- or late modernity, and that these dynamics show up in psychiatry as elsewhere. Absolute ideas of order and disorder characteristic of modernity are contrasted with more relativistic ideas which have order as created through time, in activity, and in intersubjectivity. In this episteme, the notion of disorder as a boundary condition is evasive and complex. Another shift, at the social level, is globalization, which requires western mental services to adapt to different cultural conceptions of health and illness.

Chapter.  25762 words. 

Subjects: Psychiatry

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