Drop the Disorder?

Critics advocating for the removal of the term ‘disorder’ in mental health settings argue that it stigmatises, patholoigises and discourages help seeking behaviours.  Proponents, on the other hand, contend that the term captures a collection of symptoms that are chronically distressing or impair daily functioning.  In this month’s blog, I explore these contrasting perspectives, define the term ‘disorder’ and share my thoughts on its strengths and limitations.  

Defining disorder

Derived from Latin and later adopted into French and English, ‘disorder’ can be understood to mean a being away or apart from (dis) order or arrangement (ordo/ordinis).  In mental health settings, it implies being away from what is considered normal, signifying a state of abnormality and dysfunction.  Abnormal Psychologists (e.g. Zimmerman) typically characterised disorders as states of persistent mental and emotional distress or an inability to function in daily life, as seen in conditions such as anxiety, depression or schizophrenia.  

In the context of PTSD, for instance, one could argue that abnormal or ‘disorder’ is a state of hemispheric imbalance, leading to intrusive symptoms, avoidance, persistent perceptions of threat, dissociation, and emotional dysregulation.  Neuroscience identifies the left hemisphere as responsible for analytical, logical, and language processing functions, while the right hemisphere governs creativity, imagination, and emotional processing.  Both must work collaboratively to function optimally.  When traumatic shock occurs, one explanation is that it causes hemispheric imbalance and PTSD symptoms.  A non-disordered or ‘normal’ brain then, is one that is balanced, which necessarily facilitates day to day functioning.  

Disorder, in this sense, signifies suffering – persistent distress and impairment, and a divergence away from optimal functioning.  Optimal mental health includes the ability to concentrate, recall information, problem solve, make decisions, regulate emotions, a healthy sense of self-worth and value, confidence, optimism, compassion, and the ability to engage in daily activities, for example.  

Why drop the disorder then?  

If we define disorder as a state of distress and impairment caused by hemispheric imbalance, to my mind, the term is not problematic.  So why is it controversial? 

Stigma

The term disorder is not exclusive to the mental health field.  As far back as the 14th to 18th centuries, it was predominantly applied in political and military contexts to refer to a lack of order, confusion, chaos.  In historical (and contemporary) legal settings, it also refers to threatening, abusive, or insulting words (i.e. Public Disorder Act). 

From the late 18th century onwards, individuals placed in asylums presenting with mania, melancholia, dementia, delusions, hallucinations, hysteria, and other conditions, were viewed in very negative ways.  Often, as dangerous, immoral, disruptive, or unfit for society.  Unfortunately, negative attitudes persist.  Recent research highlights enduring stereotypes that associate mental disorders with being ‘crazy’, ‘dangerous’, ‘weak’ or ‘incompetent’.  

Furthermore, the DSM appears to function as a legal entity by labelling certain criminal actions, such as the sexual abuse of children (i.e. acting on urges), as Pedophilic Disorder, even without a requirement for the presence of chronic distress or impairment.  This also appears to apply, to some degree, to antisocial personality disorder, which predominantly focuses on persons disregarding social norms and laws, although the presence of distress or impairment is an essential criterion.  

Thus, historical and contemporary negative attitudes, and the associations between disorder, crime and violence may fuel stigma and associated discrimination.  

Pathologising 

Another criticism is that the term ‘disorder’ implies abnormality or dysfunction.  While abnormal psychologists have claimed that this primarily refers to persistent distress/daily impairment, this does not appear to apply to the Diagnostical Statistical Manual’s (DSM) Pedophilic Disorder, which does not require any disclosure of actual distress.  Additionally, common associations with the term ‘abnormal’ include ‘unusual’, ‘deviant’, ‘freakish’, and ‘perverse’, making it questionable why such a term with such negative connotations would be used to describe patients that experience disabling chronic distress.  

Furthermore, the antipsychiatry movement contend that many mental disorders are natural responses to stressors of varying kinds, including socio-economic troubles, rather than an indicator of an inherent flaw in the individual.    This perception may stem from historical judgments combined with the way psychiatry has theorised and treated disorders – as brain defects, serotonin imbalances, or genetic predispositions, generally thought to be incurable.

Other criticisms include the construction of medical disorders such as ADHD, Autism, Grief Disorder, Personality disorder and many others, where diagnosis commonly leads to pharmaceutical interventions.  Some argue that this benefits the pharmaceutical industry rather than patients.  It’s difficult to disregard the latter especially since the medical profession has administered many drugs to patients, often with terrible side effects,  on the basis that a serotonin imbalance causes mental disorders, despite there being no evidence for this. 

Help seeking behaviours 

Many people with mental health difficulties don’t access services.  Those who do may encounter ignorance and discrimination.  Stigma plays a significant role in this.  However, so too does the DSM, not simply because it conflates distress with criminal activity, it also openly excludes people on the basis of its PTSD diagnostic criteria.  For example it stipulates exposure to extreme life threatening events as a necessary diagnostic component, despite evidence indicating that many suffer from chronic trauma symptoms in response to varying degrees of threat/harm.  Patients may not necessarily be denied access to care if presenting with distress, however they may get misdiagnosed and offered psychiatric medicines that attempt to manage symptoms rather than addressing the underlying cause.  

Conclusion 

While the term ‘disorder’ is not problematic in the sense that it reflects a deviation or moving away from optimal psycho-biological functioning, how it has been applied, the negative connotations associated with the term, its use in multiple settings, which conflates it with violent behaviour, is concerning.  A primary goal for mental health professionals is to offer the best possible care.  It’s difficult to see how this can be achieved given the criticisms outlined. A more inclusive approach would be to drop the term entirely.  The assessment process does not require the use of the term ‘disorder’ to identify severe and persistent symptoms of psychobiological distress or impairment.  Similar to physical health diagnosis, a reference to the condition, such as depression, anxiety, schizophrenia, bipolar, anorexia and so forth, suffice.   

I hope you found this article useful.  If you would like further information or for any other questions or queries then feel free to get in touch.  

Sadaf