Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder

Abstract

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the occurrence of distress or disability, which may be dubbed the harm requirement, is taken to be merely usual, and thus not necessary: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for the general notion of mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others involving the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be (provisionally) maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified.

Do Feeding and Eating Disorders Fit the General Definition of Mental Disorder?

“…Among the diagnostic criteria of mental disorders, distress and disability can play at least three different roles (Amoretti and Lalumera 2019b). They can be used: (1) to make up for the current absence of relevant biomarkers or clinically useful measurements of severity, and thus to solve the threshold problem and distinguish between mental disorder and non-disorder, or between different mental disorders (this may be the case of anxiety disorders or neurocognitive disorders: these syndromes doubtless reflect a dysfunction, but it is unclear how one might assess their severity and establish the thresholds for demarcating normal and pathological anxieties, or mild and major neurocognitive disorders) 5 ; (2) to make up for the current lack of knowledge about the underlying dysfunction, and, again, to separate mental disorders from non-disorders (where the presence of a dysfunction is dubious, as with some paraphilic disorders, the harm criterion can provisionally be used to separate normal from pathological conditions); (3) to discriminate between those mental disorders that must be diagnosed and/ or medically treated and those mental disorders that should not (where the presence of a dysfunction is quite clear, as in the case of erectile disorder, the label of mental disorder should be applied; however, there might be good reasons not to diagnose or treat some of these conditions in practice, precisely when they are harmless).…”

Reconsidering harm in psychiatric manuals within an explicationist framework

“…The place of the notion of harm within manuals such as the Diagnostic Statistical Manual of Mental disorders (DSM-5, American Psychiatric Association 2013 ) and the International Classification of Diseases (ICD-10, World Health Organization 1992 ) is controversial. For instance, in DSM-IV harm was considered a necessary condition for something to be a mental disorder, while in DSM-5 harm is something that only usually and not necessarily accompanies behavioral, psychological or biological dysfunctions underpinning mental disorders (Amoretti and Lalumera 2019 ; Cooper 2013 ). Some authors are reluctant to accept this evolution of DSM’s definition of mental disorder (e.g.…”

“…Some authors are reluctant to accept this evolution of DSM’s definition of mental disorder (e.g. Cooper 2013 ; Telles‐Correia 2018 ), while others provide arguments to support it (Amoretti and Lalumera 2019 ).…”

Wherein is the concept of disease normative? From weak normativity to value-conscious naturalism

“…The conceptual shift Cooper concentrates on involves the concept of mental disorder 11 endorsed by the psychological and psychiatric community, and it was made explicit by the recent decision to modify the general definition of mental disorder contained in the introduction of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorder, DSM-5 (American Psychiatric Association, 2013 ) 12 . Specifically, in DSM-5, harm is no longer a necessary requirement for a condition being a mental disorder, but merely a “usually associated” feature that disorders may bring (Amoretti & Lalumera, 2019 ; Cooper, 2015b , 2020 ). Cooper briefly recalls that the harm criterion has reflected the social and scientific consensus since the Eighties, when homosexuality was eventually excluded from the psychiatric nosology precisely because it was admitted that it is not a harmful condition, and notices that such consensus is less firm than before.…”

“… 13 Arguably, this is a conceptual defect of the manual. In a recent paper Amoretti and Lalumera ( 2019 ) suggested that harm should be explicitly ‘unpacked’ for every DSM diagnostic category, to specify whether it is harm for the subject, his or her close acquaintances, or the society, and who can assess it. …”