Tuesday 23 August 2022

Dysfunction and the Definition of Mental Disorder

Today's post is by Anne-Marie Gagné-Julien. Anne-Marie is a postdoctoral fellow at the Biomedical Ethics Unit at McGill University and also affiliated with the École normale supérieure (ENS). She works on philosophy of psychiatry and medicine, social epistemology and epistemic injustice. Here, she discusses her recent paper on dysfunction and the definition of mental disorder. 

Anne-Marie Gagné-Julien

One big question in North-American psychiatry (at least) is the meaning of “mental disorder”. This is an issue that goes back to the 1960s-1970s when the discipline was the subject of heated debate. At that time psychiatry was under attack from all sides, but one of the most important criticisms was to show problems with one of its central concepts, “mental disorder”. One of the arguments was that the concept of mental disorder was not based on anything scientific or empirical and was therefore only a tool of social control to regulate social deviance (e.g., depression would not be a “real mental disorder”, but a behaviour socially disvalued in a productivist society).

Since this crisis that psychiatry encountered in the 1960s and 1970s, there has been a desire on the part of psychiatry to demonstrate that its concept of mental disorder was not just a tool of social control, but rather an objective and therefore scientific concept. In the face of these tensions, psychiatry has offered an official and formal definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM), stating that a mental disorder must not only be the result of a disagreement between the individual and society. Rather a condition must cause suffering/disability or have an impact on functioning, and it must be the result of an internal underlying dysfunction. This definition has remained more or less the same throughout the years, including in DSM-5 (2013). This was an attempt by psychiatry to counter the previous accusations of medicalization of mere social deviance.

One problem with this definition is that the DSM does not say what a dysfunction is, it simply postulates that a mental disorder should be explicable by the presence of a dysfunction (psychological, neurobiological, etc.). But this notion is what was supposed to ground the scientific and objective basis of the definition. So this might appear to be an incomplete endeavour. Many philosophers have found interest in this issue and have tried to develop accounts of “dysfunction” that would prove its objectivity and scientificity. So far however, most of these accounts have been seen as unsatisfying, since it seems that what a dysfunction is is often related to social and cultural values (e.g., we can identify some psychological or neurobiological processes related to symptoms of depression, but seeing depression or its symptoms as a dysfunction ultimately amounts to normative aspects such as suffering or harm).

My objective in the paper is to demonstrate that it is possible to think that the concept of mental disorder and the notion of dysfunction associated with it are indeed a reflection of our social and cultural norms, but that in spite of this influence, psychiatry can still claim to be a science (with certain modifications to its current practices). Based on recent work in feminist philosophy of science about what “objectivity” means, I claim that recognizing the influence of social and cultural values in psychiatry and on the notion of dysfunction does not mean that it ceases to be objective. If we adopt what is now called “social objectivity”, the notion of dysfunction could reflect social and cultural values, and therefore be value-laden, but also objective if the procedures through which psychiatry defines these concepts were amended. That is, if the DSM revision process was to become more inclusive, transparent, and open to criticisms from different actors in the way “mental disorder” is defined, it would enhance the objectivity of the concept.

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