Who Owns the Concept of Psychiatric Disorder? Miriam Solomon (bio) About ten years ago, I participated in a consensus process on migraine nomenclature (Young et al., 2012, p. 12). Participants used a modified Delphi technique to explore their views about what migraine is. Candidate concepts included an illness, disease, syndrome, condition, disorder, or susceptibility. Initially, there was a wide range of views about which concept best fits our concept of migraine. Migraine—in common with many psychiatric disorders—is poorly understood by neuroscience. On scientific grounds, participants thought that "susceptibility" and "syndrome" describes our current knowledge well. However, participants were concerned that terms like "susceptibility" and "syndrome" could lead to migraine not being taken seriously enough by both physicians and the public. They also rejected the term "disorder" on the grounds that it evokes the concept of psychiatric disorder, which they judged to be both stigmatizing and misleading. In the end, participants agreed that the concept "disease" is the most appropriate for migraine, because it gives migraine necessary credibility. This is important for generating funds for research, educating the public, and educating health care providers. I was impressed with the fact that pragmatic concerns to have migraine taken seriously and to avoid stigmatization outweighed epistemic interests in the scientific accuracy of the term chosen. A panel of migraine experts, other healthcare professionals, academics, and patients judged that it was more important for migraine to be classified in a way that would lead to its being taken more seriously. They also judged that it was important to classify migraine in a way that avoids stigmatization. Although the term "disease" is sometimes said to be reserved for conditions with known etiology, this scientific constraint is not applied strictly. I remembered this experience when I began thinking about what falls under the concept of psychiatric disorder. It is important to consider both the scientific meaning of psychiatric disorder (insofar as such a meaning can be discerned) and the pragmatic consequences of including (and excluding) a condition in the category of psychiatric disorders. I am grateful to Claire Pouncey and Jerome Wakefield for their thoughtful comments, which I think help to bring into focus what is at stake in our different positions. Both Pouncey and Wakefield are concerned that I am playing Lewis Carroll's Humpty Dumpty with the concept of psychiatric disorder in seeking to broaden it to include the concept of psychological injury. On [End Page 349] their views, the meaning of "psychiatric disorder" is fixed and to be discovered through conceptual investigation of current practice. In addition, according to Pouncey, the term "psychological injury" is already taken by the legal profession, and not available for other uses, such as the use that I suggest. Pouncey and Wakefield have conservative approaches to the language of psychiatric disorder. This is in accord with "ordinary language" philosophical methodology, which aims to elucidate the current meanings of terms rather than to track them over time or to recommend changes in meaning. Pouncey and Wakefield (as well as many others) think that it is a conceptual error to treat grief as a psychiatric disorder. For Pouncey, the core meaning of disorder is "not normal," and for Wakefield, the core meaning of psychological disorder is "harmful dysfunction." They see my suggestion of including "psychological injury" in the category of psychiatric disorder as a conceptual error because they think that it is contrary to the core meaning of the terms. They also think that my suggestion is pragmatically unnecessary, because Pouncey thinks that grief therapy can be covered under the "adjustment disorder" code and Wakefield recommends that grief therapy should be covered by a "Z-code." I take Pouncey and Wakefield's criticisms seriously. If they were right about "core meanings," then my own suggestions about how to let the meaning of "psychiatric disorder" change would be playing Lewis Carroll's Humpty Dumpty or, as Wittgenstein might put it derisively, "language on a holiday." However, I do not agree with their conservatism about concepts. It is ill-suited for giving an account of concepts that change over time, as well as ill-suited for concepts that would be improved by making changes in them. I do think...