On the heels of my criticism of Seligman’s portrayal of psychology as the science of mental disease, it seems appropriate to address the question What is a Mental Disorder? This is a hot issue right now because the Diagnostic and Statistical Manual of Mental Disorders is in the process of making a major revision, from IV-R to V. In that regard, authors are considering some significant changes to the definition of mental disorder. The definition is a crucial issue for mental health professionals and society in general for many different reasons, including who has access to care and how we think about the nature of the human condition. Given the complex nature of the issues and the fragmentation and conceptual confusion in psychology (and, yes, psychiatry), it should not come as a surprise that there is much confusion and controversy regarding what exactly constitutes a mental disorder. (See, for example, this article by Gary Greenberg).
Here are some basic questions regarding the definition of a mental disorder:
Where is the line between normal variation and pathology? Are mental disorders categorically different or are do they simply exist at the extremes of a continuum?
Does having a mental disorder say anything about one’s character or should it be completely separated from that, and thus the individual should not be judged or stigmatized? What if the disorder is a personality disorder? Doesn’t that, by definition, say the structure of a person’s character is a problem?
Are mental disorders natural kinds that can be objectively specified or are they entirely the result of social values and the cultural construction of what is normal (i.e., different values will lead to different conceptions of what is a mental disorder)?
Are mental disorders essentially like other disease or illnesses in medicine or are they a fundamentally different kind of condition?
This last question is particularly important from the vantage point of psychiatry relative to other mental health professions. Psychiatrists are, of course, medical doctors, and there is thus much pressure for psychiatry to perceive mental disorders as akin to other medical conditions. Yet many mental health professionals, like professional psychologists, counselors, social workers, and marriage and family therapists are neither trained in medicine nor inclined to want to reduce the problems they see to dysfunctional biology.
If you wonder whether this issue has real consequences, check out an open letter about the upcoming DSM revisions from the Division of Humanistic Psychology. The essence of the letter is the concern about medicalizing human problems and suffering and framing the nature of mental disorders in a biologically reductionistic way. (By the way, I signed the petition).
One of my earliest articles (here in word form finalHD) grounded in the unified theory was on the question of what is a mental disorder and focused especially on the issue of whether mental disorders were of the same essential kind as other biological diseases. My answer was that some mental disorders are likely reducible to (neuro) biological dysfunction that produces harmful consequences. Consider, for example, a rather obvious case like Alzheimer’s disease. Other highly likely candidates for what I call mental diseases are autism, schizophrenia, severe cases of OCD, Bipolar 1.
On the flip side, there are many mental disorders that cannot be reduced to or understood in terms of biological malfunction. Instead, these conditions are maladaptive psychological behaviors (often of a cyclical nature) that result in excessive (or clinically significant) levels of distress and dysfunction for the individual and/or society. (The value of the article for me was affirmed when I received a call out of the blue from Bob Spitzer, primary author of the DSM III and IV and told me he thought the analysis was convincing).
I have explored the nature of disorder in some depth via the construct of depression. In an article arguing that we should consider depression a state of behavioral shutdown, I pointed out how different portrayals result in radically different notions of what the term depression means.
“To get a flavor for why depression might mean different things to different researchers and how those different meanings might carry different sociopolitical implications, imagine two different television commercials. The first begins with an attractive woman isolating herself at a party. Everyone else appears to be having a good time, yet she stands in the background, ostensibly gripped in the throes of a seemingly inexplicable sadness. The cultural milieu is of upper middle class suburbia. A soft voice inquires and informs, “Have you experienced periods of depressed mood? Have you lost interest in things you used to enjoy? Do you feel tired, guilty, ineffective or hopeless? Depression is an illness. Ask your doctor about new antidepressant treatments available.” The implicit message of this commercial is clear. When people are suffering from depression, something has gone wrong with the physiology of the brain.
“Now imagine a different commercial. This one begins with an impoverished woman getting slapped by her husband. Her three children are having difficulties in school. Her husband controls her, and she has little in the way of social support. She recently immigrated to the United States and cannot get a job because she only speaks a little English. She frequently faces prejudice and racism. The voice overlay asks, “Have you been feeling down or depressed, guilty or hopeless? Have you lost interest in things you usually enjoy? Depression is an illness. Ask your doctor about new antidepressant treatments available.” Somehow the “depression as disease” message in this commercial is less convincing.”
I teach my doctoral students that depression is a state of behavioral shutdown. That behavioral shutdown needs to be placed in the developmental historical context to determine its nature. I further argue that, given the nature and context of the shutdown, we can further consider whether depression should be thought of as a normal reaction (in the case of extreme loss, humiliation, or chronic traumatization), part of a vicious psychological cycle (some stress or loss results in maladaptive shutting down which results in further problems and the failure to effectively adapt to the environment) or depressive diseases (when the shutdown is pervasive and occurs independent of context or changes in the environment).
This is a complicated construct with many possible threads and implications and I welcome thoughts, questions, or additional issues to be considered.