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IMPLICATIONS OF ACCOUNTS OF DISEASE FOR THE D.S.M.

Before examining the implications of accounts of disease for the D.S.M. it will beuseful to review the argument of this chapter so far. In this chapter I have argued that it is neither a sufficient nor a necessary condition for something to be a disease that there be an evolutionary dysfunction. That something is an evolutionary dysfunction is not a sufficient condition for it to be a disease because some evolutionary dysfunctions, for example plausibly homosexuality, do not harm the dysfunctioning individual and these dysfunctions are not diseases. As such,biologically-based accounts of disease must be rejected.

The claim that diseases are harmful dysfunctions, a claim that is implicit in the definition of disease included in the D.S.M., must also be rejected. This is because it is not even necessary that there be an evolutionary dysfunction for a condition to bea disease. Some diseases may increase the inclusive fitness of an organism and in such cases there may be a disease but no evolutionary dysfunction. Having rejected these accounts, I have argued for a new account of disease according to which for a condition to be a disease it is necessary and sufficient that it be a bad thing, that the sufferer be unlucky, and that it be potentially medically treatable.

If the definition of disease used by the D.S.M. must be rejected, what implications does this have for the D.S.M? Does it imply that the D.S.M. includes the wrong class of conditions? I suggest that the implications for the D.S.M. are limited. The D.S.M. committee employed an account of disease according to which a disease is a harmful dysfunction. I have argued that this is the wrong account of disease and that instead a condition is a disease if and only if it is a bad thing tohave, sufferers are unlucky, and it is potentially medically treatable. As they standthese two accounts of disease are quite different. However, it turns out that in orderto be practically useful the D.S.M. account has to be revised, and the revised versionis fairly close to the account I have been promoting. An account that claims that diseases are harmful dysfunctions is of little practical help in deciding whether particular conditions are diseases because in most cases we lack sufficient knowledge to know whether or not a condition is a dysfunction. As was seen in the earlier discussion of homosexuality, in many cases we just don’t know whether ornot a condition is biologically advantageous. As a result, the dysfunction part of theD.S.M. account can do little work. I suggest that in practice a condition is assumed to be a dysfunction if it is unusual and if it appears to be a biological orpsychological problem. These proxy criteria would have seemed attractive to the D.S.M. committee because it is often assumed that the majority will functionnormally and that an evolutionary dysfunction will manifest itself at the biologicalor psychological level. These criteria, it turns out, are very close to my criteria that those who suffer from a disease should be unlucky and that diseases should be potentially medically treatable. Thus in practice it is unlikely that the dysfunction criterion would have led the D.S.M. committee far astray.

The D.S.M. account and my own account both claim that diseases are bad things to have. I take it to be a consequence of this claim that one and the same biological condition can be a disease for some individuals and not for others (depending on whether it is a bad thing for the individual). At many points the D.S.M. takes the same line. Ego-dystonic homosexuality is a classic example of a condition that was only taken to be a disease so long as it was bad for the individual, although asdiscussed this diagnosis was dropped in 1987. Similarly, as we saw, the D.S.M.considers pedophilia to only be a disease when it is bad for the pedophile.

The account of disease used by the D.S.M. committee in practice, I suggest, was not far wrong. This being said, there may be reason to doubt the extent to which decisions to include particular conditions in the D.S.M. were influenced by accountsof disease. The A.P.A. archives contain files full of letters to and from the D.S.M-IIIcommittee. Many of these letters argue for the inclusion or exclusion of particular disorders. The archives contain letters arguing that disorders should be included because psychiatrists see patients with the condition, or that the condition is requiredfor insurance purposes, or that research on the condition is being carried out.However, there are no letters, either to or from the D.S.M. committee, that argue that conditions should be included because they are diseases or excluded because theyare not diseases. This suggests that accounts of disease may have been little used indeciding the conditions to be included in the D.S.M. As I have argued, during the1970s and 1980s, in public, the A.P.A. found defining “disease” a useful rhetoricalstrategy, but this is compatible with A.P.A. committees paying little attention toaccounts of disease behind closed doors.

During the 1990s the A.P.A. begun to lose interest in defining “disorder” evenfor rhetorical effect. I have suggested that psychiatrists became interested in defining“disorder” during the 1970s and 80s because they needed to defend themselves from the claims of the anti-psychiatry movement and because they wanted to determine whether homosexuality is pathological. These concerns were peculiar to a specific time in American history and by the late 80s had largely disappeared. Right on cuethe A.P.A. started to loose interest in defining “disorder”. The introductions to theD.S.M-IV and the D.S.M.-IV-TR include a definition of “disorder” but add “nodefinition adequately specifies precise boundaries for the concept ‘mental disorder’”and admit that “the definition of mental disorder that was included in D.S.M.-III andD.S.M.-III-R. is presented here because it is as useful as any other available definition”.80 These comments scarcely give the impression that the definition of“disorder” was considered of much importance by the committees responsible forthese editions of the D.S.M.

There are some signs that interest in defining “disorder” is once again increasing.In 2002 the A.P.A. published A Research Agenda for D.S.M.-V. This brings together a series of “white papers”, produced by committees of experts, that lay out some ofthe most pressing research problems for psychiatric classification. The first of these“white papers” is concerned with issues of basic nomenclature, and argues that arevised definition of “mental disorder” should be developed for inclusion in theD.S.M.-V. The committee think that such a definition is needed to justify why someconditions but not others are included in the D.S.M. in the face of “rising publicconcern about what is sometimes seen as the progressive medicalization of allproblem behaviours and relationships”.81 Once again defining “disorder” hasbecome a matter of political importance.

The A.P.A.’s interest in defining “disorder” varies with the political climate.However, I suggest that providing an account of disorder is always a matter ofimportance, whether this is recognised in particular periods or not. First, an account of disease can be helpful in determining which conditions should be considered to bediseases. As an example of a condition which has plausibly been wrongly includedin the D.S.M. take hypomania. Hypomanic episodes are characterised by a moodthat is “unusually good, cheerful, or high…The expansive quality of the mood disturbance is characterized by enthusiasm for social, interpersonal, or occupational interactions.”82 The person may have a decreased need for sleep and be moretalkative than normal. Hypomanic episodes are distinguished from manic episodes inthat there is no, or little, impairment in the person’s social or occupationalfunctioning, and there are no psychotic features. Quite simply, a hypomanic episodeis generally a great thing to experience. Many psychiatrists believe that it isimportant to record hypomanic episodes because if a depressed person has beenhypomanic in the past then this can have implications for their treatment. I have noquarrel with such claims. However, I suggest that hypomania in and of itself shouldnot be considered to be a disease because it is not a bad thing to have. Suchconclusions are of practical importance because many benefits and costs accrue tothose who are considered to suffer from a disease.

Second, it is important to develop an account of disease because this is relevantto the discussion of various ongoing social and political problems. Take, for example, the question of who should determine whether a condition is a disease.

Depending on the account of disease adopted different answers to this question willseem attractive. Boorse, for example, argued that whether a condition is a disease isa matter of biological fact. On such an account of disease it will seem appropriate for experts in biology to tell us which conditions are diseases. In contrast, I haveargued that whether a condition is a disease is in part a value-judgement. As doctorsare not experts in making value-judgements, it follows from my account that it not appropriate for them alone to have a say in deciding which conditions are diseases.Similarly, an account of disease will be of use in determining whether, and why,diseased people should be eligible for various benefits, or excused from wrong doing,although exploring such issues is beyond the scope of this book.

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