Abstract

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.3 (2003) 265-266 [Access article in PDF] Definition Is Limited and Values Inescapable Richard Mullen THIS IS A welcome paper that lays bare some of the presumptions of those who seek to determine the status of psychiatric disorder. At different times debate on the subject reflects stigma, prejudice, needs for coherent categorization, and occasionally just antipsychiatric resentment. As Pickering hints, much philosophical argument may be selected to support a position already chosen.The article illustrates that the likeness argument is insufficient to demonstrate that mental disorders are or are not disorders in any other more profound sense. Similarly perhaps, if a debate were conducted about whether or not a bony fracture, hypertension, obesity, or bacterial infection were real illnesses, the likeness argument might be unfruitful. This is perhaps unsurprising; notions of health and illness, mental or physical, are largely abstractions. In psychiatry, so-called symptoms are themselves abstract classifications of incompletely articulated mental phenomena far more diverse than the definitions and criteria to be found in a diagnostic manual.Argument by analogy is always limited. If my car has a flat tire, the car will be dysfunctional or disordered. Its loss of performance will be the symptoms of the flat tire, which is the lesion. It is a problem quickly diagnosed and treated. If convenient, I suppose my car could have been said to be ill, but this would not lead to any particular insights into the nature of cars, mechanics, health, or anything else.A variety of concepts can be contained within terms such as illness,disease, and disorder. They include the clinicopathological approach (the disease is the organic lesion), the disease is deviance approach, disease as distress, and approaches that consider disease—particularly mental disorder—as largely socially constructed. None may resolve the questions that Pickering raises, but recognizing that our terms are not always precise or used consistently is part of formulating the problem more clearly. For the most part clinical psychiatry (and the rest of medicine) has no difficulty in properly identifying most of our patients as disordered or ill. The fact that there are some borderline instances, difficult to classify either way, does not invalidate the classification.Consideration of whether or not the features of a disorder can in themselves determine whether or not a person is disordered is timely for two reasons. As stigma about (some) psychiatric disorder lessens, and opportunities for complaint and compensation expand, an era of self-definition as mentally disordered has arrived. How are mental health practitioners to respond to someone whose mental distress appears not to be clinically significant, but who demands access to the sick role? Also of current concern for clinical psychiatry is widespread pressure to define as disordered those persons whose antisocial behavior brings them into conflict with society. Professional recognition that definitions of mental disorder are inadequate, or rather incomplete, [End Page 265] may be valid. Worryingly, there are others who are willing to define it for us.Both major international systems of classification of mental disorder offer definitions of mental disorder that turn on what is to be meant by clinical significance or clinically recognizable. In the current Diagnostic and Statistical Manual, mental disorder implies "clinically significant impairment or distress," and criteria for specific disorders mostly including a comment about "clinically significant distress or impairment in social, occupational, or other important areas of functioning" (APA 2000, 8). In the International Classification of Disease, disorder is used to imply "existence of a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal function" (WHO 1992, 5). It seems that no definition of mental disorder is adequate for all purposes. Seeking to improve existing definitions by further defining the terms used quickly becomes an exercise in pedantry, far removed from practical utility.Pickering mentions as an example the "symptom" of delusions. Available definitions are widely recognized as incomplete or otherwise unsatisfactory (David 1999). This leads to debate about what the individual elements within the definition precisely mean. However in practice delusions are identified with remarkably high reliability (WHO 1973...