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Disorder and

Where to Draw the
Dan J. Stein

Keywords: mental disorder, definition, deviance, dys- personality and sexual disorders is legal or perhaps
function, distress political rather than medical.
This interesting piece raises a number of con-
ceptual and scientific issues that deserve further

ashed and Bingham (2014) raise the consideration and clarification. I discuss in turn
question of whether psychiatry can dis- (1) the nature of linguistic categories, (2) the no-
tinguish between social deviance and psy- tion of dysfunction in mental disorder, (3) the
chiatry, and conclude that the the limit of what nature of socially constituted distress, and (4)
society may be willing to accommodate does not whether a number of key personality disorders
mark the beginning of illness (254). This question (e.g., antisocial personality disorder) and sexual
is clearly important to consider, given that many disorders (e.g., coercive paraphilic disorder, hy-
critical of psychiatry have (incorrectly) emphasized persexual disorder) should indeed be viewed as
that psychiatry is no more than a form of deviance mental disorders.
control, and given that some practitioners of psy-
chiatry have (inappropriately) subjected political Concepts of Mental Disorder
deviants to medical treatments.
Proponents of what might be called a classical
Rashed and Bingham review Diagnostic and
approach define disorders in terms of necessary
Statistical Manual of Mental Disorders (DSM)-IV
and sufficient criteria (Stein 1991, 2008). The
and DSM-5 definitions of mental disorder, and
definition perhaps most relevant to this piece is
indicate that an evolutionary theoretic approach
Wakefields characterization of disorder as a harm-
to defining dysfunction is problematic and should
ful dysfunction (Wakefield 1992). Proponents of a
be replaced by an emphasis on distress. They then
more critical position argue, instead, that defini-
argue that socially caused distress can be distin-
tions of mental disorder differ from time to time
guished from socially constitutive distress, that
and place to place (Stein 1991, 2008). Key for
conditions in which distress is socially constituted
the current piece is the argument that psychiatry
should not be considered to be mental disorders,
cannot, therefore, adequately differentiate mental
and that the appropriate level of response to some
disorder and other forms of deviance; this argu-

2015 by The Johns Hopkins University Press

262 PPP / Vol. 21, No. 3 / September 2014

ment has been made by a broad range of critics Boltons point (Bolton 2010) that psychological
of psychiatry in general, and of medicalization in function includes both innate (evolved) and social
particular. (cultivated) components, and argue that a natural-
Scientific work, however, increasingly em- ist position fails. They instead focus on the notion
phasizes that linguistic categories are often con- that dysfunction leads to distress, although they
tinuous, with some exemplars typical and others also indicate their view that this position does not
atypical (Lakoff and Johnson 1999). Research has entail the denial of biology.
concluded that the linguistic category of birds, for Rashed and Bingham reference Stein et al.
example, is composed of typical exemplars such (2010) as defining dysfunction in terms of distress
as robins (which fly) and atypical exemplars such and indicate this is an alternative to a naturalist
as ostriches (which do not). A range of work in approach. However, this is just one possibility
cognitive psychology, linguistics, artificial intel- mentioned by these authors, who go on to say that
ligence, and other branches of cognitive science the notion of dysfunction draws on particular
has emphasized such continua (Stein 2007, 2013). metaphors of disorder and that no algorithm fully
Biologists are certainly able to classify species on specifies the term. Further, although dysfunction
the basis of phenotype, or increasingly, on the may not be reducible to any invariant psychologi-
basis of genotype. At the same time, the concept cal or biological mechanism (to use Rashed and
of species is itself one that has fuzzy boundaries Binghams phrase), scientists can investigate a
(Hey 2001). particular phenotype and provide reasonable argu-
Continua of categories and fuzziness of bound- ments as to whether or not dysfunction is present.
aries are relevant to formulating an approach to In a typical disorder, such as infection, this is in-
medical and psychiatric disorders (Stein et al. variably uncontroversial. In an atypical disorder,
2010). Typical disorders may be characterized by such as alcoholism, there may be disagreement
features such as the presence of a factor (often (with some scientists emphasizing a range of dis-
external) that disrupts internal homeostasis, the ruptions, including alterations in brain circuitry).
lack of responsibility of the individual for this dis- An increasingly relevant issue is situations when
ruption, and a social role that encourages medical there is evidence of dysfunction, but an absence
treatment (rather than, say, legal sanction; Stein of distress and/or impairment. In DSM-IV and
2013). However, there are also atypical disorders, DSM-5, tic disorders are unusual, in that there
whether medical (such as macromastia, which may is no mention of the clinical criterion (emphasiz-
not involve disruption per se, but which may cause ing distress and/or impairment); presumably it
distress and impairment) or psychiatric (such as is thought that tics themselves are indicative of
alcoholism, where the individuals do seem to need dysfunction. As brain imaging methods for de-
to take responsibility for their role in perpetuating tection of Alzheimers disease improve, the issue
the condition). of how to categorize cases where there are brain
abnormalities, but no distress or impairment, may
Mental Disorder and arise. Note, however, that already we know that
Dysfunction plaques and tangles can exist in the absence of
impairment, so that part of the answer may depend
Both the fourth and fifth editions of the DSM on whether intervention is helpful in such cases.
(DSM-IV and DSM-5) highlight the notion of Differentiating between risk and disorder is also
dysfunction in their definitions of mental disorder. a pertinent issue (Stein et al. 2010).
Stein et al. (2010) suggest the term psychobio-
logical dysfunction to emphasize the extent to Mental Disorder and Distress
which biological and psychological processes are
intertwined. As alluded to, some authors have tried Wakefield has emphasized that not all dysfunc-
to define dysfunction in terms of necessary and tion leads to harm, and that disorder requires the
sufficient criteria. Rashed and Bingham reference presence of harm (Wakefield 1992). Similarly,
Stein / Disorder Versus Deviance 263

Rashed and Bingham (2014) emphasize distress, and societal-level interventions are needed (Stein
but note that not all distress points to the presence et al. 2007).
of a mental disorder. The issue of differentiating
different kinds of distress is certainly difficult if Personality Disorders and
one discards the notion of dysfunction; a com- Sexual Disorders
prehensive psychiatric evaluation must assess the
individual in his or her context, and determine On the basis of their argument that conditions
whether responses to that context are functional in which distress is socially constituted should
or dysfunctional (Nesse and Stein 2012; Stein et not be considered to be mental disorders, Rashed
al. 2010). Similarly, it can be argued that psy- and Bingham indicate that the appropriate level of
chiatry needs to complement the focus of clinical response to some personality and sexual disorders
neuroscience on endophenotypes with a careful is legal or perhaps political, rather than medical.
assessment of the exophenotype (Stein et al. 2013), They argue, however, that in the case of antisocial
so avoiding the fundamental attribution error personality disorder and pedophilia, we should
(Ross, 1977). advocate not for acceptance, but perhaps for less
Rashed and Bingham distinguish between social medicalization. Although they indicate they have
causal (i.e., environmental risk factors, which im- insufficient space to speak to delusional disor-
pact on internal states, and require individual level der, it is perhaps relevant to note that, although
interventions) and social constitutive factors (e.g., some have persuasively emphasized the continua
when interpersonal relationships are pathological between normal thought processes and delusions
and require societal-level interventions). They (Reznek 2010), there are clear arguments in favor
argue that, when distress is socially constituted, of medicalizing delusional disorders.
then a mental disorder should not be judged to be The question of whether antisocial personality
present. They go on, however, to consider the situ- disorder is a mental disorder has previously been
ation of a woman in an abusive relationship, and debated (Stein 1996, 2000). Some antisocial traits
to indicate that even after this relationship ends, can be argued to be adaptive, rather than repre-
there may be enduring effects, such as negative sentative of disorder. At the same time, evidence
views of self, so that distress is no longer socially of disrupted cognitiveaffective processes, and
constituted. Thus, they acknowledge that there is associated changes in brain structure in ASPD,
a continuum between acute and chronic effects of support the argument that this is a disorder. Im-
harmful interpersonal relationships, with no clear portantly, such individuals may not always experi-
conceptual boundary or threshold dividing them. ence distress (whether socially caused or socially
Early abuse may, however, lead both to endur- constituted), but they may well have significant
ing negative internal states, and to increased risk impairment. Still, as in the case of alcoholism,
for future involvement in abusive relationships individuals with antisocial personality disorder
(Stein et al. 2005). Arguably there is not only a must take responsibility for their behaviors, which
continuum between acute and chronic effects of is one reason that antisocial personality disorder
abuse, but also a continuum between social causal can be viewed as an atypical disorder. Other
and social constitutive processes (and distress). A personality disorders need to be considered on
similar logic is seen in posttraumatic stress disor- a case-by-case basis, but it is notable that some
der (PTSD), where some view PTSD as a normal personality disorders overlap closely with related
response to abnormal events and requiring societal axis I conditions (Stein et al. 2004).
intervention, whereas others view PTSD in terms Past nosologies have described neat categories
of a dysfunction requiring individual interven- of various paraphilias. This arguably contrasts
tion. Arguably, disorders have both transitive with evidence that there is a wide continuum of
dimensions (they are socially constructed) and sexual behavior in healthy people, but that some
intransitive dimensions (they do involve dysfunc- have increased frequency/intensity of sexual desire,
tion), and in a case like PTSD both individual-level sometimes including multiple paraphilias (Kafka
264 PPP / Vol. 21, No. 3 / September 2014

1997). It is instructive to consider two sexual dis- Kafka, M. P. 1997. Hypersexual desire in males: An
orders proposed for DSM-5coercive paraphilic operational definition and clinical implications
disorder and hypersexual disorder. Coercive para- for males with paraphilias and paraphilia-related
disorders. Archives of Sexual Behavior 26:50526.
philic disorder proposes medicalizing a behavior
Knight, R. A. 2010. Is a diagnostic category for para-
that is and should not be tolerated (rape); this philic coercive disorder defensible? Archives of
seems flawed insofar as there is little evidence for Sexual Behavior 39:41926.
a specific dysfunction underlying rape (although Lakoff, G., and M. Johnson. 1999. Philosophy in the
there may be evidence of association with per- flesh: The embodied mind and its challenge to West-
sonality, sexual, or relationship problems; Knight ern thought. New York: Basic Books.
2010). Hypersexual disorder was not included Nesse, R. M., and D. J. Stein. 2012. Towards a genu-
inely medical model for psychiatric nosology. BMC
in DSM-5; this seems to be an error insofar as
Medicine 10:5.
patients with this condition are characterized by Rashed, M., and R. Bingham. 2014. Can psychiatry
dysfunction, distress, and impairment, even in the distinguish social deviance from mental disorder?
absence of conflict with society (Stein et al. 2001). Philosophy, Psychiatry, & Psychology 21, no.
Conclusion Reznek, L. 2010. Delusions and the madness of the
masses. Lanham: Rowfield & Littlefield.
Rashed and Bingham (2014) bravely attempt Ross, L. 1977. The intuitive psychologist and his short-
to draw a clear delineation between disorder and comings: Distortions in the attribution process. In
deviance, arguing that the limit of what society Advances in experimental social psychology 10, ed.
may be willing to accommodate does not mark L. Berkowitz,177220. New York: Academic Press.
Stein, D. J. 1991. Philosophy and the DSM-III. Com-
the beginning of illness. In my view, given that
prehensive Psychiatry 32:40415.
linguistic categories are characterized by graded . 1996. The philosophy of psychopathy. Perspec-
continua and fuzzy thresholds, and that judg- tives in Biology and Medicine 39:56980.
ments about the boundaries of both disorder . 2000. The neurobiology of evil: Psychiatric
and deviance are theory based and value laden, perspectives on perpetrators. Ethnicity & Health
we must accept that our current delineations are 5:30315.
imperfect, and attempt to improve progressively . 2007. Can the cognitive-affective sciences help
us rethink psychiatric nosology? Towards DSM-V
our appreciation and weighing of the relevant facts
and ICD-11. The World Journal of Biological Psy-
and values. Accepting that disorder and deviance chiatry: The official journal of the World Federation
lie on a continuum does not absolve us of this of Societies of Biological Psychiatry 8:21011.
responsibility, but it is consistent with a growing . 2008. Philosophy of psychopharmacology. New
corpus of scientific work on linguistic categories, York: Cambridge University Press.
and may help to explain a number of key relevant . 2013. What is a mental disorder? A perspective
phenomena (such as the stigmatization of atypical from cognitive-affective science. Canadian Journal
of Psychiatry. Revue Canadienne de Psychiatrie
medical disorders such as alcoholism, antisocial
personality disorder, and hypersexual disorder). Stein, D. J., D. W. Black, N. A. Shapira, and R. L. Spitzer.
2001. Hypersexual disorder and preoccupation with
Acknowledgments internet pornography. The American Journal of
Psychiatry 158:15904.
Dr. Stein is supported by the Medical Research Stein, D. J., B. H. Harvey, J. Uys, and W. Daniels. 2005.
Council of South Africa. Suffer the children: The psychobiology of early ad-
versity. CNS Spectrums 10:6125.
References Stein, D. J., C. Lund, and R. M. Nesse. 2013. Classifi-
Bolton, D. 2010. Conceptualisation of mental disorder cation systems in psychiatry: Diagnosis and global
and its personal meanings. Journal of Mental Health mental health in the era of DSM-5 and ICD-11.
19:32836. Current Opinion in Psychiatry 26:4937.
Hey, J., 2001. Genes, categories, and species: The evolu- Stein, D. J., Y. Ono, O. Tajima, and J. E. Muller. 2004.
tionary and cognitive causes of the species problem. The social anxiety disorder spectrum. The Journal of
New York: Oxford University Press. Clinical Psychiatry 65, Suppl 14:2733; quiz 346.
Stein / Disorder Versus Deviance 265

Stein, D. J., K.A. Phillips, D. Bolton, K. W. Fulford, J. Wakefield, J. C. 1992. Disorder as harmful dysfunction:
Z. Sadler, and K. S. Kendler. 2010. What is a men- A conceptual critique of DSM-III-Rs definition of
tal/psychiatric disorder? From DSM-IV to DSM-V. mental disorder. Psychological Review 99:23247.
Psychological Medicine 40:175965.
Stein, D. J., S. Seedat, A. Iversen, and S. Wessely. 2007.
Post-traumatic stress disorder: Medicine and politics.
Lancet 369:13944.
274 PPP / Vol. 21, No. 3 / September 2014

Department of Social and Cultural Analysis and for the Department of Psychiatry and Behavioral
the Department of Psychiatry. His writing and Sciences, Tulane University School of Medicine.
teaching is at the interface of medicine, psychiatry, He has an interest in applying conceptual issues
humanities, and cultural/disability studies. He is from philosophy to the theory and practice of
an Associate Editor for the Journal of Medical psychiatry. His recent publications have applied
Humanities and his recent books are devoted critical theory to an understanding of psycho-
to the role of narrative in clinical care. His cur- pharmacology; explored the impact of concepts
rent research is focused on the ways art, politics, of scientific authority on the psychiatric recovery
and spirituality impact narratives of flourishing movement; and developed a theory of normative
and disability. He can be contacted via email at validity for the science of psychiatric nosology. He can be contacted via email at douglasporter@
Peter Lucas is Senior Lecturer in Philosophy at
the University of Central Lancashire, Preston, UK, Mohammed Abouelleil Rashed is a Postdoc-
where he is Course Leader for the Universitys BA toral Research Fellow in Philosophy of Mental
Philosophy Program. His main philosophical inter- Health at the University of Pretoria. He obtained
ests lie at the interface of ethics, epistemology, and his doctorate from University College London and
post-Kantian European philosophy. In particular, masters in philosophy of mental disorder from
he is interested in the special ethical obligations Kings College London. He qualified as a medical
that arise, in professional ethics and more gener- doctor from Cairo University and trained in psy-
ally, from our shared capacity for self-knowledge. chiatry in the UK. Dr Rasheds research interests
He is the author of a number of articles and book include concepts of mental disorder and culture,
chapters in modern European philosophy, the spirit possession, and psychiatric ethics. He has a
philosophy of communication, and applied and number of publications exploring values, culture
professional ethics. His recent book Ethics and and psychiatric diagnosis. He can be contacted via
Self-Knowledge: Respect for Self-Interpreting email at:
Agents was published by Springer in 2011. He
can be contacted via email at Ilina Singh is Professor of Neuroscience & Soci-
ety at the University of Oxford, where she holds a
Joanna Moncrieff is a Senior Lecturer at joint appointment between the Department of Psy-
University of Central Lancashire and a practic- chiatry and the Department of Philosophy (Uehiro
ing psychiatrist. She is the Co-Chairperson of Centre. Her work examines the psychosocial and
the Critical Psychiatry Network, and author ethical implications of advances in biomedicine
ofmanybooks andarticles which present a critical and neuroscience for young people and families.
viewof psychiatric theory and practice in general, Recent projects include the ADHD VOICES proj-
andpsychiatric drug treatment in particular. She ect (; Neuroenhancement
can be contact via email at Responsible Research and Innovation (www.nerri.
eu); and the Urban Brain Project (www.urban-
Christian Perring is Professor of Philosophy at In w014, Professor Singh received
Dowling College, New York. He teaches a wide a Wellcome Trust Senior Investigator Award for a
variety of courses and does research in philosophy study entitled: Becoming Good: Early Intervention
of psychiatry. He is Editor of Metapsychology and Moral Development in Child Psychiatry. She
Online Reviews. He can be contacted via email can be contacted via email at ilina.singh@psych.

Douglas Porter is Medical Director of the Al- Dan J. Stein is Professor and Chair of the Depart-
giers Behavioral Health Center in New Orleans, ment of Psychiatry at the University of Cape Town,
Louisiana, and a Clinical Instructor of Psychiatry and Director of the Medical Research Council
About the Authors 275

(MRC) Unit on Anxiety and Stress Disorders. run by the British School of Osteopathy and vali-
He completed his undergraduate and medical dated by the University of Bedfordshire. He can
training at the University of Cape Town, his psy- be contacted via email at
chiatric residency and post-doctoral fellowship
in psychopharmacology at Columbia University, G. Scott Waterman is Professor of Psychiatry
and his doctoral dissertation in philosophy at the Emeritus at the University of Vermont College
University of Stellenbosch. He can be contacted of Medicine, where he also served for eight years
via email at as Associate Dean for Student Affairs.His schol-
arly work has involved neuroscience education,
Stephen Tyreman combines a long-standing os- philosophy of mind in medical discourse and
teopathic practice with an academic career in oste- practice, and philosophical problems in psychiatric
opathy that covers both the UK and Norway. His nosology. He is currently a Graduate Student in
academic interest is in philosophy of healthcare, History at the University of Vermont, studying
with a particular focus on professional identity, ideological commitment among American Com-
concepts of health, illness and disease in associa- munists during the Spanish Civil War. He can be
tion with complexity and uncertainty. He is course contacted via email at
leader for the professional doctorate in osteopathy
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