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  • Conceptualization of a Mental DisorderA Clinical Perspective
  • Gary J. Gala (bio) and Sarah L. Laughon (bio)
Keywords

Mental disorder, DSM-5, heterogeneity, clinician, prototype theory, definition, disturbance, synthetic concept, exemplar

The paper by Bergnar and Bunford in this edition of Philosophy, Psychiatry, & Psychology (2017) is a sophisticated examination of a central question that has lacked consensus in the philosophy of psychiatry, namely, what is “the key aspect of the meaning of this fundamental term, mental disorder” (Bergner & Bunford, 2017, p. 26)? To settle this question, the authors use an empirical approach by surveying graduate students in clinical psychology. In this way, they attempt to invoke the Wittgensteinian method of determining the meaning of a term by seeing how it is used. The empirical results, the authors argue, serve as strong evidence in support of the position that the term ‘mental disorder’ designates disability and not any kind of behavior per se. We agree that disability is a core feature of mental disorders. We applaud an empirical approach to the philosophy of psychiatry. From our perspective, as clinicians, psychiatry is a field of science and, although guided by theory, those theories are ultimately accountable to the court of empirical investigation.

Nevertheless, we would like to raise three areas of concern for the authors that we hope will help the authors to further their project. We mention the concerns here and then explore them briefly below. First, we are worried that the degree of heterogeneity across mental disorders makes the search for a single essentialist definition that will encompass all disorders akin to the search for the Holy Grail. Second, in clinical medicine, we believe the pursuit of a complete general definition is pragmatically trumped by inquiries into the etiology of a disorder. Third, the authors cash out disability as a lack of control. However, lack of control is itself problematic and does not suffice to cover the forms of disability noted across the spectrum of mental disorders.

To elaborate on our first concern, that is, the search for a general definition, one of us has recently demonstrated a significant mathematical heterogeneity within certain mental disorders (Olbert, Gala & Tupler, 2014). For example, two people can meet criteria for Major Depressive Disorder and share no common symptoms.1 A cursory review of the table of contents of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reveals a wide range of types of disorders, including thought, cognitive, mood, and disorders, that are in fact defined by [End Page 41] their behavior, namely, a subset of the paraphilias. Because of this heterogeneity both within and across disorders, we do not believe an essentialist definition is possible. We believe instead that an exemplar or prototype definition is all that can be achieved, even in theory because of this heterogeneity. George Graham recognizes

that the concept of a mental disorder has uncontroversial or prototypical instances of application or exemplars, as they may be called. An uncontroversial instance or exemplar is a case that competent and clinically informed observers or qualified judges agree (or at least currently widely agree) is a mental disorder.

(Graham, 2014, p. 25)

We do not believe that the authors have adequately argued for an essentialist and against a prototype theory of mental disorders.

Furthermore, the authors of the DSM-5 note that

the primary purpose of the DSM-5 is to assist trained clinicians in the diagnosis of their patients’ mental disorders as part of a case formulation assessment that leads to a fully informed treatment plan for each individual.

(American Psychiatric Association [APA], 2013, p. 19)2

They do not require that necessary and sufficient criteria be met to correctly apply the term ‘mental disorder.’ In fact, the authors of DSM-5 explicitly state that,

the symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in these brief summaries.

(APA, 2013, p. 19)

Therefore, in a manual that was developed for clinical use, an essentialist definition of a mental disorder does not seem to us to be necessary.

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