Disorder and Deviance: Where to Draw the Boundaries?

Rashed and Bingham (2014) raise the question of whether psychiatry can distinguish between social deviance and psychiatry, and conclude that the “the limit of what society may be willing to accommodate – does not mark the beginning of illness” (254). This question is clearly important to consider, given that many critical of psychiatry have (incorrectly) emphasized that psychiatry is no more than a form of deviance control, and given that some practitioners of psychiatry have (inappropriately) subjected political deviants to medical treatments.

Rashed and Bingham review Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and DSM-5 definitions of mental disorder, and indicate that an evolutionary theoretic approach to defining dysfunction is problematic and should be replaced by an emphasis on distress. They then argue that socially caused distress can be distinguished from socially constitutive distress, that conditions in which distress is socially constituted should not be considered to be mental disorders, and that the appropriate level of response to some personality and sexual disorders is legal or perhaps political rather than medical.

This interesting piece raises a number of conceptual and scientific issues that deserve further consideration and clarification. I discuss in turn (1) the nature of linguistic categories, (2) the notion of dysfunction in mental disorder, (3) the nature of socially constituted distress, and (4) whether a number of key personality disorders (e.g., antisocial personality disorder) and sexual disorders (e.g., coercive paraphilic disorder, hypersexual disorder) should indeed be viewed as mental disorders.

Concepts of Mental Disorder

Proponents of what might be called a classical approach define disorders in terms of necessary and sufficient criteria (Stein 1991, 2008). The definition perhaps most relevant to this piece is Wakefield’s characterization of disorder as a harmful dysfunction (Wakefield 1992). Proponents of a more critical position argue, instead, that definitions of mental disorder differ from time to time and place to place (Stein 1991, 2008). Key for the current piece is the argument that psychiatry cannot, therefore, adequately differentiate mental disorder and other forms of deviance; this argument has been made by a broad range of critics of psychiatry in general, and of medicalization in particular.

Scientific work, however, increasingly emphasizes that linguistic categories are often continuous, with some exemplars typical and others atypical (Lakoff and Johnson 1999). Research has concluded that the linguistic category of birds, for example, is composed of typical exemplars such as robins (which fly) and atypical exemplars such as ostriches (which do not). A range of work in cognitive psychology, linguistics, artificial intelligence, and other branches of cognitive science has emphasized such continua (Stein 2007, 2013). Biologists are certainly able to classify species on the basis of phenotype, or increasingly, on the basis of genotype. At the same time, the concept of species is itself one that has fuzzy boundaries (Hey 2001).

Continua of categories and fuzziness of boundaries are relevant to formulating an approach to medical and psychiatric disorders (Stein et al. 2010). Typical disorders may be characterized by features such as the presence of a factor (often external) that disrupts internal homeostasis, the lack of responsibility of the individual for this disruption, and a social role that encourages medical treatment (rather than, say, legal sanction; Stein 2013). However, there are also atypical disorders, whether medical (such as macromastia, which may not involve disruption per se, but which may cause distress and impairment) or psychiatric (such as alcoholism, where the individuals do seem to need to take responsibility for their role in perpetuating the condition).

Mental Disorder and Dysfunction

Both the fourth and fifth editions of the DSM (DSM-IV and DSM-5) highlight the notion of dysfunction in their definitions of mental disorder. Stein et al. (2010) suggest the term ‘psychobiological dysfunction’ to emphasize the extent to which biological and psychological processes are intertwined. As alluded to, some authors have tried to define dysfunction in terms of necessary and sufficient criteria. Rashed and Bingham reference Bolton’s point (Bolton 2010) that psychological function includes both innate (evolved) and social (cultivated) components...