The Nature of Mental Disorder: Disease, Distress, or Personal Tendency?

Reading the Diagnostic and Statistical Manual (DSM)’s attempt to define ‘mental disorder’ as presented in Rashed and Bingham’s interesting article (2014), immediately reveals it as a tautology. A ‘mental disorder’ is a ‘behavioral or psychological syndrome’ causing ‘clinically significant distress or disability’ that ‘reflects an underlying psychobiological dysfunction,’ the definition goes. Biological dysfunctions have not been established, however, nor have any ‘underlying’ psychological processes. Many philosophers, Wittgenstein and his followers among them, would argue that it makes no sense to postulate ‘underlying psychological processes’ in any case, as if the mind could be separated off from the individual’s behavior and expressions (Malcolm 1988). Even if it did, these processes remain as hypothetical as the ever-changing biological theories about the origins of various psychological ‘symptoms.’ Without the proven existence of separate and distinct foundational processes, however, the definition of mental disorder can be boiled down to saying that a dysfunction—behavioral or psychological syndrome associated with distress or disability—is a reflection of a dysfunction. Similarly, although individual diagnoses purport to provide an explanation for the behavioral symptoms that are said to constitute them, they are in fact nothing but labels for those behaviors (Pilgrim 2005).

The paradigm ushered in by the DSM-III was based on the aspiration that the biological abnormalities underlying different mental disorders would shortly be identified. Hence, the DSM-III “organized symptoms into discrete disease entities with the expectation that the organic bases of these entities would be discovered” (Whooley and Horwitz 2013, 79). Because these biological dysfunctions have not been forthcoming, however, the ‘psychological’ had to be tacked on. But what does ‘psychological dysfunction’ actually mean? Should it be considered a ‘mental disorder,’ and if so what implications does this have? Rashed and Bingham accept the notion that dysfunction can be usefully referred to as mental disorder in some circumstances, and set out to differentiate when it should be referred to as such, and when not. Their critique hinges on the idea of ‘intrinsic distress.’

First, they equate dysfunction with distress; however, these concepts are clearly not co-extant. People may neglect themselves and act in other ways that compromise their safety and survival without necessarily being distressed. Having set up distress, rather than dysfunction, as the necessary characteristic of mental disorders, Rashed and Bingham then differentiate between intrinsic distress, which is ‘to do with . . . [the individual’s] inner state’ and cannot be addressed by modifying the environment, and extrinsic distress. The latter is a reaction to social circumstances or conditions and can be resolved by altering these.

The term ‘intrinsic distress’ could assume various meanings, however, and it is useful to explore these and their implications further. The examples provided by Rashed and Bingham refer to familiar bodily conditions such as angina. So one possible meaning of ‘intrinsic’ could be a bodily or biological dysfunction. In other words, like the DSM’s original ambition, on this account, mental disorders are conceptualized as brain diseases waiting to be identified. A definition of this sort allows the usual corollaries of having a disease to be applied without contention, such as the excusal of responsibility for the consequences of the disease, and the expectation that the sufferer will submit to whatever measures are deemed necessary to remove the disease. If this is what the authors mean, however, it is not clear what added value the concept of ‘intrinsic distress’ confers, except that, like the DSM’s addition of the ‘psycho’ to the notion of ‘biological dysfunction,’ it allows the concept of mental disorder as inferred brain disease to persist in the absence of any evidence of specific biological abnormalities.

There is another way of understanding the term ‘intrinsic,’ however, which leads to quite different conclusions. In my view, this position is a useful way of characterizing the situations we currently refer to as ‘mental disorders,’ but it is not clear that this alternative meaning of ‘intrinsic’ does the work that Rashed and Bingham wish it to do.

An ‘intrinsic’ state could...