Boundaries and terminology in flux

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

Boundaries and terminology in flux

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At the opening of the chapter it was noted that a definition of mental disorder is required to draw boundaries around the concept, to distinguish between what is and what is not mental disorder. So far as concerns the psychiatric diagnostic manuals, the purpose would be assess whether conditions included as mental disorders really were so, to remove non-disordered conditions included by mistake, and to assess whether there other disorders that should be included in the next edition. The definitions of mental disorder given in the manuals are harm led; that is to say, they emphasize first and foremost that the conditions in the manuals are characterized by harm, by distress and disability, or risk of adverse outcomes. It is evident that there are many conditions involving distress and impairment of day-to-day functioning that are not disorders, although it is hard to say in a clear and helpful way what the real difference is. Gestures are made using terms such as personal dysfunction, and unexpectable responses. The naturalist definitions of mental disorder are the most elaborate attempts to demarcate mental disorder from social deviance on the one hand and ordinary problems of living on the other. Problems involved in getting these naturalist definitions to work have been considered in previous chapters, the point for here is that they do not effectively draw boundaries around mental disorder, demarcating what is from what is not. Nor do the harm-led definitions in the manuals.

The second section of the chapter considers a major problem current at the time the definitions of mental disorder were being constructed, the political abuse of psychiatry in diagnosing and detaining political dissidents. The naturalist definitions of mental disorder were the most elaborate responses to the intellectual task of distinguishing medical disorder from social deviance, including political dissidence, and the conclusion that they are not viable has to be brought face to face with the original problem: how then are we to distinguish mental illness from social deviance and from political dissidence in particular? The reply made is that prevention of the social abuse of psychiatry cannot be located in the difference between mental illness and social deviance, but has to be located in law, specifically in human rights legislation.

The third section makes the point that the list of harms associated with mental disorder given in the psychiatric manuals, most fully in the DSM, are those that accrue to the individual with the problems. This is consistent with the general medical practice. However, in psychiatry the harms involved are sometimes more to others than to the self, most obviously so in the antisocial behaviour conditions. Each of these two kinds of case – harm to self and harm to others – raises different boundary issues.

The fourth section considers issues that arise in the management of risk to others. The point is made that control of individuals for the purpose of protecting others from harm is fundamentally an activity of the state. This is obscured to the extent that management of risk to the public is seen as a matter for and assigned to the medical profession – or to any other health profession.

The fifth section on stakeholders in diagnosis and treatment notes that in practice conditions have found their way into the psychiatric manuals not so much because of a prior definition of mental disorder, but because they are the kinds of problem people have brought and continue to bring to the clinic. In practice diagnosis is given when thresholds of severity, distress or impairment are such as to indicate need for treatment or some other form of management. In this process of help-seeking and help provision, there are various stakeholders, not just patients and clinicians, some pressuring to facilitate diagnosis and access to treatment, others to inhibit them. They include families and carers, advocacy groups, manufacturers of treatment technologies, and the funding agencies.

The following section, 5.6, considers various issues under the general heading of mental disorder in the community. It starts with the often-made assumption that prevalence rates of some common mental disorders are rising. It should be said that this assumption is not straightforward, because the epidemiological methodologies to assess it are varied and complicated – see the bibliographical section below for selected references. If prevalence estimates are rising, there are various possible explanations, only one of which is relevant to the themes of this essay, namely, that the concept of mental disorder is being stretched to include more kinds of case, including some that are not really disorders at all. This kind of concern and this boundary problem can be seen as a consequence of the closure of the asylums and the discharge of mental illness/disorder into the community. How much of it there is amongst us and our children, what exactly it is and how it differs from normal problems of temperament, personality, and day-to-day living – all concern us. At the same time the social representation of the problems shifts from the old madness to something more familiar and accessible – something more like mental health problems.

Terminological issues are taken up in more detail in the seventh section. The main point is that there is current a great terminological variety, some would say anarchy, with different words for the conditions of interest being used for different purposes in different contexts; with related variety in what is considered an appropriate name to apply to the people who have the conditions and seek help for them.

Medicalization is the topic of section 5.8, that is to say, the construal of problems as being distress and disability and those in turn as medical problems, as opposed to various other kinds of construction. Alternative constructions include social, political, religious, and moral, each of varying kinds. There are also alternative constructions within the general medical model, more or less distinct from the western biomedical approach. The medical model in psychiatry has also been extended, or transformed, by the incorporation of psychological and psychosocial models. There is no single, fixed standard to use for judging whether medicalization is better or worse in absolute terms, once naturalist approaches to mental disorder are given up. There are however various pragmatic criteria by which different approaches can be compared: on how well they solve particular kinds of problem and in what respects. Regardless whether we think that there is an absolute fact of the matter to which these constructions correspond or fail to correspond, these pragmatic criteria are what is available to us in practice for comparative purposes.

Chapter.  20470 words. 

Subjects: Psychiatry

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