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WHY DEFINE “DISORDER”?

Whether a condition is considered a mental disorder often has social, economic, andethical implications. As such, debates that hinge on whether some condition shouldbe considered a disorder are commonplace in both medicine and popular culture.Are psychopaths evil or sick? Should health insurance pay for the treatment ofnicotine addiction? Is it right for shy people to take character-altering drugs? Allthese debates may be seen to depend on whether the conditions are disorders, anddeveloping an account of disorder may be hoped to help us in addressing suchquestions. For many individual philosophers and physicians this has been sufficientmotivation to attempt to produce an account of disorder. Questions concerning thestatus of particular conditions have always been with us, however, and yet it is onlyin the 1970s that the American Psychiatric Association (from now on the A.P.A.)seriously began to try and define “mental disorder”. Why did the A.P.A. becomeinterested at this particular time?

One possible answer should be dismissed from the outset. Prior to the D.S.M.-IIIthe A.P.A. produced classifications of mental disorders without ever producing adefinition of “mental disorder”. Retrospectively commentators have often seen theabsence of a definition in the earlier classification systems as a strange deficiency.

How, they have asked, can one classify mental disorders without knowing whatmental disorders are? The implication is that it is a logical requirement for ascientific classification system to contain a definition of its domain. Thesecommentators suggest that the lack of a definition in the D.S.M.-I and D.S.M.-II isjust one example of the ways in which these classification systems were deficientfrom a scientific point of view. As psychiatric classification became scientific theyclaim that it was inevitable that a definition of “mental disorder” would come to beincluded in the D.S.M.

That this response is mistaken, however, can be seen when it is remembered thatmost scientific classification systems do not explicitly define their domain. TheInternational Classification of Diseases, for example, gives no definition of“disease”. Similarly, taxonomies of the flora and fauna of particular areas do notnormally start off by saying what they mean by living thing. Clearly it is quitepossible to produce a classification without the domain being explicitly defined. It isthe presence of a definition of “disorder” in the D.S.M.-III, rather than its absence inearlier editions, that is unusual.

I will argue that the A.P.A. became interested in producing a definition of“mental disorder” in the 1970s for political reasons. Understanding these reasonssheds light on much that otherwise seems odd in the debates over “disorder” – why it is that interest in the question has ebbed and flowed, and why it is that so manydiscussants have been obsessed by the case of homosexuality, for example. It willalso illustrate exactly why it is that defining “disorder” can be important.During the 1970s the A.P.A. was under heavy attack from two quarters: On theone hand, “anti-psychiatrists” challenged the legitimacy of psychiatry as a branch ofmedicine. On the other, gay activists protested at homosexuality being classified as amental disorder. Defining “mental disorder” was rhetorically useful for the A.P.A. inboth these battles.4 Armed with the “right” definition, it could show that mentaldisorders are medical disorders, and determine whether homosexuality ispathological.

First, the anti-psychiatrists: In the early 1970s the anti-psychiatry movement wasin full swing. The anti-psychiatrists were a diverse group, united only in theirdistrust of psychiatry. They argued on various different grounds that mental illness isprofoundly unlike physical illness, and that therefore psychiatry is only dubiously abranch of medicine. Thomas Szasz, in particular, was a serious irritation toAmerican psychiatry at this time. Szasz was a trained psychiatrist, and publishedregularly in respectable and widely read outlets such as the New York Times. Heclaimed that psychiatric patients don’t suffer from diseases but are rathermalingerers, social misfits, and people with problems in living.5 Correspondingly,psychiatrists should not be classed with medical doctors but are rather, at best,expensive agony aunts or, at worst, agents of social control.

Against the background of such attacks, in 1973, at the same time as setting up aTask Force to revise the D.S.M., the A.P.A. set up a Task Force to define the term“mental illness”.6 It was hoped that the definition produced could be used in thepreamble to the D.S.M.-III. Considerable effort was put into defining “mentalillness”, as can be seen from the fact that a special session at the annual A.P.A.meeting was dedicated to the issue. Various contributors were invited to discuss theproposed definitions from the perspectives of psychoanalysis, law, medicalinsurance and sociology. Other discussants were asked to consider possibleimplications for the individual patient, and for the interface of psychiatry with otherbranches of medicine and psychology.7 Unfortunately the A.P.A. archives do nothold a copy of the definition produced. Still, that such effort was expended in anattempt to defend psychiatry from the attacks of the anti-psychiatry movement ismade clear by the organiser’s expressed satisfaction that the Task Force hadmanaged to “avoid an overly broad definition of mental disorders that would viewall individual and social unrest or problems in living as psychiatric illness, and at thesame time justify the designation of mental disorders as a subset of medicaldisorders.”8 The phrase “problems in living” had been popularised by Szasz, and I suggest that its use here indicates that the A.P.A. was seeking to refute his claims inparticular.

At around the same time the A.P.A. was coming under attack from gay rightsgroups who wanted homosexuality removed from the D.S.M.9 Gay rights protestersmobbed the1970 A.P.A. annual meeting inSan Francisco, shouting down speakerswith whom they disagreed and disrupting much of the meeting.

 Throughout 1971and 1972 the activists continued to protest against the A.P.A. position. RobertSpitzer, who would later become chairman of the D.S.M.-III committee, becameinvolved in the debates and found defining “disorder” to be a useful way ofdefending his stance on homosexuality.10 Spitzer suggested that homosexuality perse is not a disorder but that a diagnosis should be included for homosexuals whoexperience distress concerning their sexual orientation. Such a proposal waspolitically useful because it found some middle ground between those whoconsidered homosexuality to be a mental disorder and those who considered it anormal variant of human sexuality. To defend his claim, Spitzer formulated adefinition of “mental disorder” that he claimed was satisfied by all the disorders inthe D.S.M.-II with the exception of homosexuality. According to Spitzer’s definitiona condition can only be a mental disorder if it causes distress or disability. As manyhomosexuals experience no distress or disability, homosexuality in and of itselfcannot be a disorder.

However, those people who are distressed about their sexualorientation can be considered to suffer from a disorder and are appropriately treatedby psychiatrists. Spitzer’s position came to be adopted by the A.P.A. in 1973, whenhomosexuality was removed as a diagnosis from the D.S.M.-II and “SexualOrientation Disorder”, a diagnosis for homosexuals who are unhappy about beinggay, was added. On becoming chairman of the D.S.M.-III Task Force, Spitzerreturned to his definition repeatedly to defend decisions to include or omitconditions from the classification system.11 In due course, a version of Spitzer’sdefinition came to be included in the introduction of the D.S.M.-III.

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