Diagnostic Validity and the Definition of Mental Disorder: A Program for Conceptually Advancing Psychiatry

Abstract

Unlike the first 2 editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I1 and DSM-II,2 respectively), DSM-III,3 for the first time, included a definition of mental disorder in its introduction. The brief definition was derived from a much longer and more elaborate definition of mental disorder, along with a definition of the broader category of medical disorder, earlier put forward by Robert Spitzer and Jean Endicott.4 Spitzer's inclusion of an analysis of mental disorder in DSM-III was largely motivated by his desire to intellectually justify the manual's controversial elimination of ego-syntonic homosexuality from disorder status in 1973. The DSM-III acknowledged (as has every edition since) that the concept of mental disorder has inherent limitations of precision and will have fuzzy rather than precise boundaries ([t]here is no satisfactory definition that specifies precise boundaries for the concept 'mental disorder'3, p 5), but noted that this is also true for such concepts as physical disorder and mental and physical health.3, p 5-6 However, the DSM-III maintained that, despite the limitations, the definition of disorder needed to be made explicit because it impacted decisions about whether conditions were included in the manual: it is useful to present concepts that have influenced the decision to include certain conditions in DSM-III as mental disorders and to exclude others.3, p 6 The definition required that, for a condition to be considered a mental disorder, it must cause harm in the form of distress or impairment of social functioning, and it must be due to a dysfunction (that is, something having gone wrong with some psychological mechanism) inside the person.In fact, there is no evidence-and Spitzer has never claimed-that the specific DSM-III definition of mental disorder was explicitly consulted in deliberations to decide what to include in DSM-III, except perhaps as an idea in the agile head of Robert Spitzer as he guided the DSM-III revision process. Nevertheless, intuitions about what is and is not a disorder that were captured in Spitzer's analysis were throughout the DSM-III deliberations. Should a bereavement exclusion be incorporated into the major depressive disorder (MDD) diagnostic criteria? Is racism a mental disorder? Is marital incompatibility a mental disorder? What belongs in the V codes that list nondisordered, problematic conditions for which clinicians are often consulted (for example, parent-child conflict and occupational challenges)? All these and many more fundamental questions and decisions depended on intuitions derived from the meaning of the concept of disorder.Essentially the same definition of mental disorder remained in the DSM introduction over the following editions, with minor revisions intended to address specific problems. For example, in DSM-III-R,5 the DSM-III concept of harm (defined as actual distress or disability) was expanded to include the risk of developing distress, disability, death, or loss of freedom. This change was partly designed (misguidedly, we would argue, but that is another story) to allow diagnosis of ego-syntonic pedophilia based on the harm of the risk of potentially being imprisoned owing to the illegality of sexual activity with a child. However, as far as one can tell, a lack of systematic application of the definition of disorder to the formulation of the diagnostic criteria in the manual has been the rule across editions. According to the introduction to DSM-III-R, when a diagnostic proposal involved dropping a category from the DSM-III classification (e.g., Ego-dystonic Homosexuality) or adding a new diagnosis to the classification (e.g., Late Luteal Phase Dysphoric Disorder), it was asked, Does the proposed category meet the requirements of the DSM-III definition of mental disorder?5, p xxi Thus the definition's use was again limited to the very narrow set of issues concerned with eliminating or introducing categories. …