PHILOSOPHY

What is mental disorder?

a detailed phenomenology of symptoms (description of abnormal

mental states) and classification into syndromes. They also inevitably assumed (presumed as familiar), the language and concepts
of medicine, and in particular, the great paradigms and discoveries
of 19th century medicine that illnesses and other major medical
conditions are caused by diseases or lesions, involving more or
less catastrophic destruction of relevant bodily tissue. While these
assumptions were part of what psychiatry inherited from medicine, a new (related) psychological paradigm arose at the same
time: mental processes (unconscious ones) could mimic the effect
of neurological lesions, producing intrusive, apparently senseless
disruptions of normal functioning. This new psychoanalytic
paradigm was one of several new psychological approaches to
abnormal mental states; the other most famous being the conditioning model, in which abnormal behaviours are held to be learnt
by normal learning principles applying to unfortunate coincidences. The medical model in psychiatry (while it remains wedded
to the paradigms of 19th century medicine) has a clear idea of
illness/disorder and its distinctness from normal functioning. The
parallel psychological model in psychiatry had and remains with
no such idea: characteristically it links abnormal functioning to
normal, meaningful psychological processing, and finds the same
distortions of reality as are implicated in abnormal functioning in
the population at large.1
In brief, and simplifying, the medical approach had mental
illness/disorder as axiomatic, while the psychological approach
undermined the idea. In contrast with those two in-house
approaches, a third approach, the sociological, disqualifies it.
The sociological approach to the conditions identified by
psychiatry emerged in full force in conflict with the medical
model in the 1960s, with key contributions from writers such as
Foucault, Szasz, Laing, Goffman and Rosenhan. In broad terms,
the criticism was that mental illness/disorder e or what is
labelled as mental illness/disorder e is really social deviance,
deviance from social/moral norms of the dominant group, and
that psychiatry mistakes these social/moral norms for medical
norms, social disorder for medical disorder. This criticism of
medical psychiatry was often combined with the characteristically psychological view that the problems pathologized by
psychiatry were in fact meaningful. Sociological critiques of
psychiatry have continued2 and have been recently reviewed and
updated by Horwitz.3
The sociological and psycho-sociological critiques of the
1960s laid major charges against mainstream psychiatry and its
medical model: that it medicalized and pathologized what were
essentially socially defined and meaningful problems. At their
most profound, as in Foucault,4,5 these criticisms were levelled
not so much at psychiatry as at society at large. Most of the
explicit debate about the concept of mental disorder since the
1960s has revolved around the question of whether mental
disorder attributions really do rest on some hard, natural,
medical fact or whether they are rather merely an expression of
social norms and values. Candidates for such a natural (nonsocial) fact are, first, statistical abnormality, and second, failure
of a psychological mechanism to function as it has been designed
to do e selected for e in evolution. The biostatistical theory of
dysfunction proposed by Boorse6,7 is interesting and important
but the details are difficult to work out and it has few
adherents.1,8,9

Derek Bolton

Abstract
The question of definition of mental disorder and the related question of
its boundaries have been, and remain, of crucial importance in many
contexts. Two approaches were evident from the beginnings of modern
psychiatry approximately 100 years ago: the medical and the psychological models, differing in several critical respects, particularly on whether
or not psychiatric conditions are meaningful and understandable, and
the related question of whether or not the abnormal is clearly differentiated from the normal. A third approach, the sociological, emphasized the
strong connexion between so-called mental disorder and social deviance,
and appeared forcefully in the 1960s as critiques of mainstream psychiatry. These controversial issues remain alive, sharpened by major changes
since the 1960s, particularly the development of medications for common
mental health problems and the development of care in the community
for severe mental health problems.

Keywords boundaries; definition; mental disorder; mental illness

Contexts in which the question arises

The question of what mental disorder is can be raised in various
contexts for various purposes:
! people in trouble, ending up consulting a psychiatrist or other
mental health professional, can ask what a mental disorder is
and the professional should be prepared to give a helpful answer
! clinician experts responsible for textbooks such as the standard diagnostic manuals need to know why a condition is
included as a mental disorder and why another is not, or why
a condition that is not currently counted as a mental disorder
should make an appearance in the next edition
! those responsible for public health and service provision need
to know what the illnesses are and how much they occur in
the population
! health (illness) research funders need to know what to fund
! and criminal law requires some understanding of why mental
disorder should provide excuse in some circumstances.
In brief, the question of mental disorder pervades many
contexts, raises many issues, and is many-sided and complex. It
is accordingly dealt with in diverse literatures, within and outside
of psychiatry, recently reviewed by the present author.1

Medical, psychological and sociological approaches

Our contemporary notion of mental illness or mental disorder has
origins in the beginnings of contemporary psychiatry approximately a century ago. The pioneer psychiatrists attended to

Derek Bolton PhD is a Professor of Philosophy and Psychopathology at

the Institute of Psychiatry, Kings College London and Honorary
Consultant Clinical Psychologist at the South London & Maudsley NHS
Foundation Trust, UK. Conflicts of interest: none declared.

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PHILOSOPHY

Approach to definition in terms of evolutionary theory

ethnic minority groups reflect social exclusion rather than medical

disorder.2 A related problem is whether traits that are normal in
the population are being pathologized, for example shyness as
social anxiety,20 and high levels of exploratory behaviour especially in boys as ADHD.21 An update in such contemporary criticisms that psychiatry is pathologizing the normal is the
observation that rates of prescribing of psychotropic medication
are accelerating, and that advertising and other promotion by the
pharmaceutical industry has a major role in this.
Another contemporary concern, again echoing the 1960s
critiques of psychiatry, is the extent to which psychiatry and
mental health services are in the business of social control e
control of social deviance e rather than healthcare of the patient.
Since the 1960s, and especially over the last few decades following
the closure of the asylums, this problem has been both amplified
and clarified, with the focus on compulsory treatment of people
with serious mental illness in the community, and on the
management of people with anti-social personality disorder.
Management of risk to others, as well as to the patient, has become
an increasingly prominent discourse in mental health policy, and
hence in mental health law and NHS operational procedures,
giving rise to many questions about the impact on patient care and
the role of psychiatry and mental health services generally.22e24

The approach to defining illness/disorder that has dominated the

field since the 1970s has been in terms of evolutionary theory,
particularly in the version proposed by Jerome Wakefield.8e10
Wakefields analysis has come to be called the harmful
dysfunction analysis and it can be stated briefly along the
following lines: A mental disorder is a harmful disruption of
a natural function, where natural function is to be understood
in terms of functioning in the way designed (selected for) in
evolution. According to this approach, negative social evaluation
is necessary for a condition to be a disorder. This has the
consequence that conditions can change from being (considered
as) disorders to being (considered as) normal, and vice versa,
depending on the prevailing social norms. In this sense, its
inclusion in the definition is consistent with the social
constructionist anti-psychiatry critiques of the 1960s. On the
other hand, Wakefield emphasizes that his approach puts
a definite limitation on what legitimately counts as a mental
disorder, namely that it has to involve, as a necessary condition,
a failure of a natural psychological/behavioural function.
Wakefields analysis has been subject to much criticism in the
literature. Criticisms include that it has a limited or oversimplified approach to evolutionary psychology,11,12 that it
implies modularity in mental architecture that may not apply to
some mental disorders,13 that it presupposes an unviable
distinction between what is natural and what is social in mental
functioning,1 and in terms of utility, that it makes diagnosis of
mental disorder a speculative and unreliable hypothesis that is
unsuited for both clinical and research purposes.14

Conclusions
In conclusion, the question of definition of mental disorder and the
related question of its boundaries has been, and remains, of crucial
importance in many contexts. Two approaches were evident from
the beginnings of modern psychiatry approximately 100 years ago:
the medical and the psychological models, differing in several
critical respects, particularly on whether or not psychiatric
conditions are meaningful and understandable, and on whether or
not the abnormal is clearly differentiated from the normal. A third
approach, the sociological, emphasizing that strong connexion
between so-called mental disorder and social deviance appeared
forcefully in the 1960s critiques of mainstream psychiatry. These
issues remain alive, sharpened by major changes since the 1960s,
particularly the closure of asylums and the development of care in
the community, and the development of medications for common
mental health problems.
A

Approach to definition in the diagnostic manuals

The standard manuals for psychiatric diagnosis, the ICD-1015 and
the DSM-IV16 both have definitions of mental disorder (op.cit. p.5
and pp. xxiexxii, respectively). Both definitions emphasize the
harm associated with mental disorders, distress and/or disability
and the need to distinguish mental disorder from social deviance.
Robert Spitzer has written extremely helpful papers explaining
the background and rationale of the definition of disorder which
appeared first in the DSM-III,17,18 which survives pretty much
unchanged in DSM-IV, and which will presumably survive in
some form in the pending DSM-V. The psychiatric diagnostic
manuals have it exactly right in emphasizing in their definitions
of mental disorder, the fundamental reality and rationale of
psychiatry and mental health services generally, the fact that
people come to the clinic with distress and disability seeking help
getting on with their lives. No sociological critique, whatever
other insights it offers, should lose sight of this reality.

REFERENCES
1 Bolton D. What is mental disorder? An essay in philosophy, science
and values. Oxford: Oxford University Press, 2008.
2 Kutchins H, Kirk SA. Making us crazy. DSM e the psychiatric bible and
the creation of mental disorders. New York: Free Press, 1997.
3 Horwitz AV. Creating mental illness. Chicago & London: University of
Chicago Press, 2002.
4 Foucault M. Madness and civilisation: a history of insanity in the Age
of Reason. Trans. by R Howard of abridged version of Folie et
deraison. Histoire de la folie a` lage classique [Paris: Librairie Plon,
1961]. London: Tavistock, 1965. Reprinted Routledge 1997.
5 Foucault M. History of madness. English translation of Histoire de la
folie a` lage classique, Paris, Gallimard, 1972. London: Routledge,
2006.
6 Boorse C. What a theory of mental health should be. J Theory Soc
Behav 1976; 6: 61e84.

Current controversies
That said, various controversies certainly remain about the definition and boundaries of mental disorder. Our current controversies are closely related to those identified in the 1960s
critiques, for example on the question whether psychiatry is illegitimately pathologizing normal, meaningful states. There is
current concern for example that normal life suffering is being
pathologized as depressive disorder,19 and that typically higher
rates of diagnosable mental disorders among the poor and in

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PHILOSOPHY

7 Boorse C. A rebuttal on health. Biomedical ethics reviews. In:

Humber James F, Almeder Robert F, eds. What is disease? Totowa,
NJ: Humana Press, 1997. p. 1e134.
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10 Wakefield JC. Mental disorder as a black box essentialist concept.
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13 Murphy D. Psychiatry in the scientific image. Cambridge, MA: MIT
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manuals. World Psychiatry 2007; 6: 164e5.
15 World Health Organization. The ICD-10 classification of mental and
behavioural disorders: clinical descriptions and diagnostic guidelines.
Geneva: World Health Organization, Division of Mental Health, 1992.
16 American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 4th edn. Washington, DC: American Psychiatric
Association, 1994.

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17 Spitzer RL, Endicott I. Medical and mental disorder: proposed

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19 Horwitz AV, Wakefield JC. The loss of sadness. How psychiatry
transformed normal sorrow into depressive disorder. New York:
Oxford University Press, 2007.
20 Lane C. Shyness: how normal behavior became a sickness.
Yale University Press, 2007.
21 Timimi S. Pathological Child Psychiatry and the Medicalization of
Childhood. Hove: Brunner-Routledge, 2002.
22 Kent County Council. Report of the independent inquiry into the
care and treatment of Michael Stone. Available at: http://www.kent.
gov.uk/publications/council-and-democracy/michael-stone.htm;
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