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Psychiatry Online

  • July 01, 2024 | VOL. 181, NO. 7 CURRENT ISSUE pp.565-686
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What Is Mental Disorder? An Essay in Philosophy, Science, and Values

  • KENNETH S. KENDLER M.D. ,

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Imagine you are a member of the admissions committee for DSM-V. Your set of applications include night-eating syndrome, hoarding, racism, and Internet addiction. It is your job to decide if these are “real” psychiatric disorders worthy of inclusion in DSM-V. By what criteria would you decide if these applications represent a true mental disorder versus a non-disordered “problem of living” or social deviance?

In this thought-provoking book, clinical psychologist and philosopher Derek Bolton asks whether it is possible to develop a single clear definition of mental disorder to which such a committee could refer. Perhaps surprisingly, he reaches a negative conclusion, writing, “there is no natural, principled boundary between normal and abnormal conditions of suffering” (p. 194).

Much of Bolton’s book critiques the naturalist approach to mental illness. This idea—probably a comfortable one to many readers of this journal—is that there exists in the real world a clear distinction between mental health and disorder. All we have to do is be smart enough to find it and define it clearly. He evaluates several approaches to naturalist definitions of psychiatric disorders. However, he spends the most time on the influential work of Jerry Wakefield, which emphasizes an objective dysfunction of an evolved mental process, the consequences of which cause harm to the individual. At the risk of oversimplification, Bolton suggests that in principle it is just too hard to know what represents a dysfunction of an evolved mental system. Since Homo sapiens evolved in a social milieu, and many of our mental functions develop in an intertwined manner from both genetic and environmental factors, trying to distinguish social from evolutionary dysfunction may be inherently impossible. Problems could also arise when an evolved system is not really dysfunctional, but the environment has changed so dramatically that its impact has become harmful (perhaps an underlying explanation for the obesity epidemic). He argues that Wakefield, rather than trying to make the difficult determination of what functions have evolved for what purpose, actually uses a rough “understandability” measure when, for example, he argues that conduct disorder should not be applied to children growing up in some inner-city neighborhoods where gang membership might be adaptive or that depression should not be diagnosed when it occurs after a major loss. Bolton also examines and rejects the concept that mental disorders represent the breakdown of meaningful connections. With regard to the important issue of the abuse of psychiatry, as occurred in the former Soviet Union, he concludes that is more a task for governments and judicial systems than for psychiatric diagnostic manuals.

Ultimately, Bolton opts for a harm-based approach to defining what should go into our diagnostic manuals. That is the point of greatest consensus for all stakeholders in the business of mental health. He dislikes the term “disorder,” because in many of these syndromes, mental life remains ordered and meaningful.

I suspect most readers, like myself, will find this book a bit disturbing. We would much prefer a comfortable and neat and tidy solution to this boundary problem. Given the current ascendancy of the biological psychiatric paradigm, many of us want to ground ourselves in our physician identity and see ourselves as treating “real” biological disorders that can be cleanly and decisively separated from problems of living and social deviance. Bolton tries hard to puncture this comfortable belief system.

Bolton writes well, with only a modest amount of “philosophy-speak.” My main gripe is the book is not concise. Many of his well-developed arguments are repeated several times in different forms. I also think he underestimates the striking differences across disorders in seeking generic solutions to definitional questions about mental disorders.

I began this book with only a modest knowledge of the relevant literature and a rather naive sense that with a bit of “hard thinking,” we could come up with a clear, defensible definition of mental disorders. Upon completion, I no longer believed as such and have a much deeper appreciation of the subtlety and complexity of this definitional question. Did Bolton convince me the problem is intractable? Not quite, but my naiveté has surely been laid to rest.

Who should read this book? This book will be of most value to those who, because of their clinical or research work (or because they are contributing to current revisions of DSM and ICD manuals), are really interested in the problem of defining the boundaries of psychiatric illness. While it is not the easiest of reads, such individuals will be amply rewarded for their efforts. This book might be of interest to a wider group of individuals, from the fields of both mental health and philosophy, who want to see a good example of analytic philosophy being applied with skill and scholarship to a difficult real-world problem that really matters.

Book review accepted for publication July 2008 (doi: 10.1176/appi.ajp.2008.08060944).

Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.

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What Is Mental Disorder? An Essay in Philosophy, Science, and Values

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2008, American Journal of Psychiatry

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What is Mental Disorder? An essay in philosophy, science, and values

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What is Mental Disorder? An essay in philosophy, science, and values

Introduction

  • Published: February 2008
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The effects of mental disorder are apparent and pervasive, in suffering, loss of freedom and life opportunities, negative impacts on use of education, work satisfaction and productivity, complications in law, institutions of healthcare, intensive scientific research into causes and cures and so on. Suffering, loss of functioning, and perceived threat are among the personal and social experiences that can lead to mental health services. Once the problems are brought to the attention of mental health services and mental disorder is diagnosed, a range of possible outcomes is licensed, including offer of treatment, funding and perhaps, depending on severity and other circumstances, paid leave from work due to illness, possible shame and stigma, and in extreme cases compulsory admission to hospital, or acceptance of no or diminished responsibility in the Courts. Mental health professionals engage with the problems inside institutional structures using manuals for diagnosis and providing treatments that are increasingly required to be backed by scientific evidence of effectiveness. The social and institutional outcomes of assigning a diagnosis are important topics for social scientific theory and research. However, earlier in the chain of events and consequences are the social manifestations of mental disorder, open for all to see, and most importantly the personal and interpersonal effects, experienced by the people with the problems, their families and friends.

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National Collaborating Centre for Mental Health (UK). Common Mental Health Disorders: Identification and Pathways to Care. Leicester (UK): British Psychological Society (UK); 2011. (NICE Clinical Guidelines, No. 123.)

Cover of Common Mental Health Disorders

Common Mental Health Disorders: Identification and Pathways to Care.

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  • Cite this Page National Collaborating Centre for Mental Health (UK). Common Mental Health Disorders: Identification and Pathways to Care. Leicester (UK): British Psychological Society (UK); 2011. (NICE Clinical Guidelines, No. 123.) REFERENCES.
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I Saw My Anxiety Reflected in ‘Inside Out 2.’ It Floored Me.

In a way that’s both cathartic and devastating, Pixar’s latest portrays how anxiety can take hold, our critic writes.

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A still from the movie “Inside Out 2” shows the character of Anxiety — an orange cartoon with big eyes and frayed hair — waving to other animated characters.

By Maya Phillips

At the climax of Pixar’s “Inside Out 2,” Riley, a freshly pubescent teen with a gaggle of new personified emotions, becomes so overwhelmed with anxiety that she has a panic attack.

In the theater, I whispered to my friend that I’d forgotten to bring my panic attack medication. I’d said it as a joke — but at the sight of this anxious animated teenager, my whole body’s choreography changed. My muscles tensed. I pressed my right palm down hard to my chest and took a few deep yoga breaths, trying to cut off the familiar beginnings of an attack.

This depiction of how quickly anxiety can take hold was overwhelming. I saw my own experiences reflected in Riley’s. “Inside Out 2” felt personal to me in a way that was equally cathartic and devastating: It’s a movie that so intimately understands how my anxiety disorder upends my everyday life.

“Inside Out 2” picks up two years after the 2015 film “Inside Out,” as Riley is about to start high school. With puberty comes a group of new emotions, led by Anxiety. A manic orange sprite voiced by Maya Hawke, Anxiety bumps out the old emotions and inadvertently wreaks havoc on Riley’s belief system and self-esteem as she tries to manage the stress of a weekend hockey camp.

When an emotion takes over in the “Inside Out” movies, a control board in Riley’s mind changes to that feeling’s color; Anxiety’s takeover, however, is more absolute. She creates a stronghold in Riley’s imagination, where she forces mind workers to illustrate negative hypothetical scenarios for Riley’s future. Soon, Riley’s chief inner belief is of her inadequacy; the emotions hear “I’m not good enough” as a low, rumbling refrain in her mind.

I’m familiar with anxiety’s hold on the imagination; my mind is always writing the script to the next worst day of my life. It’s already embraced all possibilities of failure. And my anxiety’s ruthless demands for perfection often turn my thoughts into an unrelenting roll-call of self-criticisms and insecurities.

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COMMENTS

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  25. REFERENCES

    Gill SC, Butterworth P, Rodgers B, et al. Validity of the mental health component scale of the 12-item Short-Form Health Survey (MCS-12) as measure of common mental disorders in the general population. Psychiatry Research. 2007;152:63-71.

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