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CHAPTER
Conceftions of Psychopathology:
A Socia Constructionist Perspective
James E. Maddux Jennifer T. Gosselin
George Mason University. Pepperdine University
Barbara A. Winstead
Old Dominion University
A textbook about a subject should begin with a clear definition of the subject. Unfortunately, in the case of a textbook on psychopathology, definition is difficult if not impossible. The definitions or conceptions of psychopathology and related terms such as mental disorder have been the focus of heated debate throughout the history of psychology and psychiatry, and the debate is far trom over (e.g, Gorenstein, 1984; Horwitz, 2002; Widiger, 1997). Despite many. variations, the debate has centered on a single overriding question-are psychopathology and related terms such as mental disorder and mental illness scientific terms that can be defined objectively and by scientific criteria or are they social constructions (Gergen, 1985) that are defined entirely by societal and cultural values? The goal.of this chapter is to address this
. question. Addressing it early is important because readers' views of everything they read in . the rest of this book will be influenced by their views on this question. A conception of psychopathology is not a theory of psychopathology (Wakefield, 1992a). A cOI1l(eption of psychopathology provides one definition of the term-it delineates which human' experiences are considered psychopathological and which are not. A conception of psychopathology does not try to explain the psychological phenomena that are considered pathological but instead tells us what psychological phenomena are considered pathological. and thus need to be explained. A theory of psychopathology, however, provides an expla n~tion of those psychological phenomena and experiences that have been identified by the conception as pathologicaL This chapter deals with conceptions of psychopathology. Theo ries and explanations can be found in a number of other chapters, including aU of those in part II. Understanding various conceptions of psychopathology is important for many reasons. As medical philosopher Lawrie Reznek (1987) said, "Concepts carry consequences~lassifying things one way rather than another has important implications for the way we behave towards I/i<·'¥/ff'··'"··iSUC!h (p. 1). In speaking ofthe importance of the conception of disease, Reznek wrote:
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The classification of a condition as a disease carries many important consequences. we inform
medical scientists that they should try to discover a cure for the condition. We inform benefactors that they should support such research: we direct medical care towards the condition, making it appropriate to treat the condition by medical means such as drug therapy. surgery, and so on. We inform our courts that it is inappropriate to hold people responsible for the manifestations of the condition. We set up early warning detection services aimed at detecting the condition in its early stages when it is still amenable to successful treatment. we serve notice to health insurance companies and national health services that they are liable to pay for the treatment of such a condition. Classifying a condition as a disease is no idle matter. (p. 1)
If we substitute the term psychopathology or mental disorder for the word disease in this paragraph, Reznek's message still holds true. How we conceive of psychopathology and related tenus has wide-ranging implications for individuals, medical and mental health professionals, government agencies and programs, and society at large.
TRADITIONAL CONCEPTIONS OF PSYCHOPATHOLOGY
Various conceptions of psychopathology have been offered over the years. Each has its merits and its deficiencies, but none suffices as a truly scientific definition.
Psychopathology· as Statistical Deviance
A common and common sense conception of psychopathology is that pathological psycholog ical phenomena are those that are abnormal or statistically deviant or infrequent. Abnormal literally means away from the norm. The word norm refers to what is typical or average. Thus, in this conception, psychopathology is viewed as deviation from psychological normality. One of the merits of this conception is its commonsense appeal. It makes sense to most people to use terms such as psychopathology and mental disorder to refer only to behaviors or experiences that are infrequent (e.g., paranoid delusions, hearing voices) and not to those that are relatively common (e.g., shyness, sadness following the death of a loved one). A second benefit of^ this conception is that it lends itself^ to accepted methods^ of^ measurement that give it at least a semblance of scientific respectability. The first step in using this conception scientifically is to determine what is statistically normal (typical, average). The second step is to determine how far a particular psychological phenomenon or condition deviates from statistical normality. This step is often accomplished by developing an instrument or measure that attempts to quantify the phenomenon and then assigns numbers or scores to people's experiences or manifestations of the phenomenon. Once the measure is developed, norms are typically established so that an individual's score can be compared to the mean or average score of some group of people. Scores that are sufficiently far from average are considered to be indicative of abnormal or pathological psychological phenomena. This process describes most tests of intelligence and cognitive ability and many commonly used measures of personality and emotion (e.g., the Minnesota Multiphasic Personality Inventory). Despite its commonsense appeal and its scientific merits, this conception presents problems. It sounds relatively objective and scientific because it relies on well-established psychometric methods for developing measures of psychological phenomena and developing norms. Yet, this approach leaves much room for subjectivity. Subjectivity first comes into play in the conceptual definition of the construct for which a measure is developed. A measure of any psychological construct, such as intelligence, must
6 MADDUX, GOSSELIN, WINSTEAD
Psychopathology as Maladaptive (Dysfunctional) Behavior
Most of us think of psychopathology as behavior and experience that are not just statistically abnormal but also maladaptive (dysfunctional). Normal and abnormal are statistical terms, but adaptive and maladaptive refer not to statistical norms and deviations but to the effectiveness or ineffectiveness of a person's behavior. If a behavior is effective for the person-if the behavior helps the person deal with challenge, cope with stress, and (l.ccomplish his or her goals-then we say the behavior is more or less adaptive. If the behavior does not help in these ways, or if the behavior makes the problem or situation worse, we say it is more or less maladaptive. Like the statistical deviance conception, this conception has commonsense appeal and is consistent with the way most laypersons use words such as pathology, disorder, and illness. Most people would find it odd to use these words to describe statistically infrequent high levels of intelligence, happiness, or psychological well being. To say that someone is pathologically intelligent or pathologically well-adjusted seems contradictory because it flies in the face of the commonsense use of these words. The major problem with the conception of psychopathology as maladaptive behavior is its inherent SUbjectivity. The distinction between adaptive and maladaptive, like the distinction between normal and abnormal, is fuzzy and often arbitrary. We have no objective, scientific way of making a clear distinction. Very few human behaviors are in and of themselves either adaptive or maladaptive; their adaptiveness and maladapativeness depends on the situations in which they are enacted and on the judgment and values of the observer. Even behaviors that are statistically rare and therefore abnormal are more or less adaptive under different conditions and more or less adaptive in the opinion of different observers. The extent to which a behavior or behavior pattern is viewed as more or less adaptive or maladaptive depends on a number of factors, such as the goals the person is trying to accomplish and the social norms and expectations of a given situation. What works in one situation might not work in another. What appears adaptive to one person might not appear so to another. What is usuaUy adaptive in one culture. might not be so in another. Even so-called normal personality involves a good deal of occasionally maladaptive behavior, for which you can find evidence in your own life and the lives of friends and relatives. In addition, people given personality disorder diagnoses by clinical psychologists and psychiatrists often can manage their lives effectively and do not always behave in disordered ways. Another problem with the psychopathological-equals-maladaptive conception is that deter minations of adaptiveness and maladaptiveness are logically unrelated to measures of statistical deviation. Of course, often we do find a strong relationship between the statistical abnormality of a behavior and its maladaptiveness. Many of the problems described in the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA],
- and in this textbook are both maladaptive and statistically rare. There are, however, major exceptions to this relationship. First, psychological phenomena that deviate from normal
or average are not all maladaptive. In fact, sometimes deviation from normal is adaptive and
healthy. For example, IQscores ofl30 and 70 are equally deviant from normal, but abnormally high intelligence is much more adaptive than abnormally low intelligence. Likewise, people who consistently score abnormally low on measures of anxiety and depression are probably happier and better adjusted than people who consistently score equally abnormally high on such measures. Second, maladaptive psychological phenomena are not all statistically infrequent and vice versa. For example, shyness is very common and therefore is statistically frequent, but shyness is almost always maladaptive to some extent, because it almost always interferes with a person's ability to accomplish what he or she wants to accomplish in life and relationships. This is not
CONCEPTIONS OF PSYCHOPATHOLOGY 7
. to. say that shyness is pathological but orily that it makes it difficult for some people to live full arid happy lives. The same is true of many of the problems with sexual functioning that are _·'.•. l .... A in the DSM as mental disorders.
rsy~hopathology as Distress and Disability · ~~~e conceptions of psychopathology invoke the notions of subjective distress and disability. Subjective distress refers to unpleasant and unwanted feelings such as anxiety, sadness, and anger. Disability refers to a restriction in ability (Os80riO, 1985). People who seek mental health treatment are not getting what they want out of life, and many feel that they are unable to do 1Nhat they would like to do. They may feel inhibited or restricted by their situation, their fears or ~motional turmoil, or by physical or other limitations. The individual may lack the necessary self-efficacy beliefs (beliefs about personal abilities), physiological or biological components, ~d/or sitUational opportunities to make positive changes (Bergner, 1997). Subjective distress and disability are simply two different but related ways of thinking about adaptiveness and maladaptiveness rather than alternative conceptions of psychopathol Although the notions of SUbjective distress and disability may help re~e our notion of i..· lllaladaptiveness, they do nothing to resolve the subjectivity problem. Different people define personal distress and personal disability in vastly different ways, as do different mental health pto.fessionals and those in different cultures. Likewise, people differ in how much distress or · djsability they can tolerate. Thus, we are still left with the problem of how to determine normal antl abnoIJllallevels of. distress and disability. As noted previously, the question "How much is too much?" cannot be answered using the objective methods of science. Another problem is that some conditions or patterns of behavior (e.g., sexual fetishisms, antisocial personality disorder) that are considered psychopathological (at least officially, ac
. cording to the DSM) are not characterized by SUbjective distress, other than the temporary distress that might result from social condemnation or conflicts with the law.
Psychopathology as Social Deviance Another conception views psychopathology as behavior that deviates from social or cultural norms. T¥s conception is sinlply a variation of the conception of psychopathology as abnor mality, except that in this case judgments about deviations from nom1ality are made informally · by people rather than formally according to psychological tests or measures. This copception also is consistent to some extent with common sense and common parlance. We tend to view psychopathological or mentally disordered people as thinking, feeling, and doing things that most other people do not do and that are inconsistent with socially accepted and culturally sanctioned ways of thinking, feeling, and behaving. The problem with this conception, as with the others, is its subjectivity. Norms for socially normal or acceptable behavior are not scientifically derived but instead are based on the values, beliefs, and historical practices of the culture, which determine who is accepted or rejected by a society or culture. Cultural values develop not through the implementation of scientific methods but through numerous informal conversations and negotiations among the people and institutions of that culture. Social norms differ from one culture to another, and therefore what is psychologically abnormal in one culture may not be so in another (See Lopez & Guarnaccia, this book). Also, norms of a given culture change over time; therefore, conceptions of psychopathology also change over time, often very dramatically, as evidenced by American society's changes over the past several decades in attitudes toward sex, race, and gender. For example, psychiatrists in the 1800s classified masturbation, especially in children and women, as a disease, and it was treated in some cases by clitoridectomy (removal of the clitoris), which
1. CONCEPTIONS OF PSYCHOPATHOLOGY 9
mechanisms and their natural functions. Wakefield states that "discovering what in fact is nat ural or dysfunctional may be extraordinarily difficult" (1992b, p. 236). The problem with this statement is that, when applied to human behavior, natural and dysfunctional are not proper ties that can be discovered; they are value judgments. The judgrOent that a behavior represents a dysfunction relies on ·the observation that the behavior is excessive andlor inappropriate under certain conditions. Arguing that these behaviors represent failures of an evolutionarily designed mental mechanisms (itself an untestable hypothesis because of the occult nature of mental mechanisms) does not relieve us of the need to make value judgments about what is excessive or inappropriate in what circumstances. These value judgments are based on so cial norms, not on scientific facts, an issue that we will explore in greater detail later in this chapter. Another problem with the HD conception is that it is a moving target. Recently, Wakefield modified the HD conception by saying that it refers not to what a mental disorder is but only to what most scientists th,ink it is. For example, he states that "My comments were intended to argue, not that PTSD [posttraumatic stress disorder] is a disorder, but that the lID analysis is capable of explaining why the symptom picture in PTSD is commonly judged to be a disorder" (1999, p. 390).
According to Sadler (1999), Wakefield's original goal was to "define mental disorders
prescriptively [and to] help us decide whether someone is mentally disordered or not. [However, his current view] avoids making any prescriptive claims, instead focusing on explaining the conventional clinical use of the disorder concept [and he] has abandoned his original task to be prescriptive and has now settled for being descriptive only, for example, telling us why a disorder is judged to be one" (pp. 433-434). Describing how people have agreed to define a concept is not the same as defining the concept in scientific terms, even if those people are scientists. Thus, Wakefield's revised lID conception simply offers another criterion that people (clinicians, scientists, and laypersons) might use to judge whether or not something is a mental disorder. But consensus of opinion, even among scientists, is not scientific evidence. Therefore, no matter how accurately this criterion might describe how some or most people define mental disorder, it is no more or no less scientific than other conceptions that also are based on how some people agree to define mental disorder. It is no more scientific than the conceptions involving statistical infrequency, maladaptiveness, or social norm violations. (See aiso Widiger, this book.)
CONTEMPORARY CONCEPTIONS: THE DSM DEFINmON OF MENTAL DISORDER
Any discussion of conceptions of psychopathology has to include a discussion of the most influential conception of all-that of the DSM. The DSM documents "what is currently un derstood by most scientists, theorists, researchers, and clinicians to be the predominant forms of psychopathology" (Widiger, this book). First published in 1952 and revised and expanded five times since, the DSM provides the organizational structure for virtually every textbook (including this one) on abnormal psychology and psychopathology, as well as almost every professional book on the ~ssessment and treatment of psychological problems. (See Widiger, this book, for a more detailed history of psychiatric classification and the DSM.) Just asa textbook on psychopathology should begin by defining its key term, so should a taxonomy of mental disorders. To their credit, the authors of the DSM attempted to do that. The difficulties inherent in attempting to define psychopathology and related terms is clearly
10 MADDUX, GOSSELIN, WINSTEAD
illustrated by the definition of mental disorder found in the latest edition of the DSM, the DSM-IV-TR (~A, 2000):
, .. a clinically ~ignificant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e,g., a painfol symptom) or disability (i,e" impainnent in one or more important areas offunctioning) or with a significantly increased risk ofsuffering death, pain, disability, or an important loss offreedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one, Whatever its original cause, it must currently be con sidered a manifestation ofa behaVioral, psycholOgical, or biolOgical dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily be tween the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfonction in the individual. as described above. (p, xxxi)
All of the conceptions of psychopathology described previously can be found to some extent in this definition-statistical deviation (i.e., not expectable); maladaptiveness, including distress and disability; social norms violations; and some elements of the harmful dysfunction conception (a dysfunction in the individual), although without the flavor of evolutionary theory. For this reason, it is a comprehensive, inclusive, and sophisticated conception and probably as good as, if not better than, any proposed so far. Nonetheless, it contains the same problems with subjectivity as other conceptions. For example, what is the meaning of clinically significant and how should clinical significance be measured? Does clinical significance refer to statistical infrequency, mal~daptiveness, or both? How much distress must people experience or how much disability must people exhibit before they are said to have a mental disorder? Who judges a person's degree of distress or disability? How do we determine whether a particular response to an event is expectable or culturally sanctioned? Who determines this? How does one determine whether deviant behavior or conflicts are primarily between the individual and society? What exactly does this mean? What does it mean for a dysfunction to exist or occur in the individual? Certainly a biological dysfunction might be said to be literally in the individual, but does it make sense to say the same of psychological and behavioml dysfunctions? Is it possible to say that a psychological or behavioral dysfunction can occur in the individual apart from the sociocultural and interpersonal milieu in which the person is acting? Clearly, the DSM's conception of mental disorder raises as many questions as do the conceptions it was meant to supplant.
CATEGORIES VERSUS DIMENSIONS
The difficulty inherent in the DSM conception of psychopathology and other attempts to distinguish between normal and abnormal or adaptive and maladaptive is that they are cat egorical models in which individuals are determined either to have or not have a disorder. An alternative. model, overwhelmingly supported by research, is the dimensional model. In the dimensional model, normality and abnormality, as well as effective and ineffective psy chological functioning, lie along a continuum; so-caned psychological disorders are simply extreme variants of normal psychological phenomena and ordinary problems in living (Keyes & Lopez, 2002; Widiger, this book). The dimensional model is concerned not with classifying people or disorders but with identifying and measuring individual differences in psychological phenomena such as emotion, mood, intelligence, and personal styles (e.g., Lubinski, 2000). Great differences among individuals on the dimensions of interest are expected, such as the
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developing a scientific definition and accept the idea that psychopathology and related terms cannot be defined through the processes that we usually think of as scientific. We have to stop struggling to develop a scientific conception of psychopathology and attempt instead to try to understand the struggle itself-why it occurs and what it means. We need to better understand how people go about trying to conceive of and define psychopathology and how and why these conceptions are the topic of continual debate and undergo continual revision. We start by accepting the idea that psychopathology and related concepts are abstract ideas that are not scientifically constructed but instead are socially constructed. To do this is to engage in social constructionism, which involves "elucidating the process by which people corne to de scribe, explain, or otherwise account for the world in which they live" (Gergen, 1985, pp. 3-4). Social constructionism is concerned with "examining ways in which people understand the world, the social and political processes that influence how people define words and explain events, and the implications of these d,efinitions and explanations-who benefits and who loses because of how we describe and understand the world" (Gergen, 1985, pp. 3-4). From this point of view, words and concepts such as psychopathology and mental disorder "are products· of particular historical and cultural understandings rather than ... universal and immutable cat egories of human experience" (Bohan, 1996, p. xvi). Universal or true definitions of concepts do not exist because these definitions depend on who does the defining. The people who define them are usually people with power, and so these definitions reflect and promote their interests and values (Muehlenhard & Kimes, 1999, p. 234). Therefore, "When less powerful people attempt to challenge existing power relationships and to promote social change, an initial bat tleground is often the words used to discuss these problems" (Muehlenhard & Kimes, 1999, p. 234). Because the interests ofpeopl,e and institutions are based on their values, debates over· the definition of concepts often become clashes between deeply and implicitly held beliefs about the way the world works or should work and about the difference between right and wrong. Such clashes are evident in the debates over the definitions of domestic violence (Muehlenhard & Kimes, 1999), child sexual abuse (Holmes & Slapp, 1998; Rind, Tromovich, & Bauserman, 1998), and other such terms. The social constructionist perspective can be contrasted with the essentialist perspective. Essentialism assumes that there are natural categories and that all members of a given category share important characteristics (Rosenblum & Travis, 1996). For example, the essentialist per spective views our categories of race, sexual orientation, and social class as objective categories that are independent of social or cultural processes. It views these categories as representing "empirically verifiable similarities among and differences between people" (Rosenblum & Travis, 1996, p. 2). In the social constructionist view, however, "reality cannot be separated from the way that a culture makes sense of it" (Rosenblum & Travis, 1996, p. 3). In social constructionism, such categories represent not what people are but rather the ways that people think about and attempt to make sense of differences among people. Social processes also deter mine what differences among people are more important than other differences (Rosenblum & Travis, 1996). Thus, from the essentialist perspective, psychopathologies and mental disorders are natural entities whose true nature can be discovered and described. From the social constructionist perspective, however, they are but abstract ideas that are defined by people and thus reflect their values~ultural, professional, and personal. The meanings of these and other concepts are not revealed by the methods of science but are negotiated among the people and institutions of society who have an interest in their definitions. In fact, we typically refer to psychological terms as constructs for this very reason-that their meanings are constructed and negotiated rather than discovered or revealed. The ways in which conceptions of such basic psychological constructs as the self (Baumeister, 1987) and self-esteem (Hewitt, 2002) have changed over
1. CONCEPTIONS OF PSYCHOPATHOLOGY 13
time and the different ways they are conceived by different cultures (e.g., Cross & Markus, 1999; Cushman, 1995; Hewitt, 2002) provide an example of this process at work. Thus "all categories of disorder, even physical disorder categories convincingly explored scientifically, are the product of human beings constructing meaningful systems for understandiing their world" (Raskin & Lewandowski, 2000, p. 20. In addition, because ''what it means to be a person is determined by cultural ways of talking about and conceptualizing personhood ... identity and disorder are socially constructed, and there are as many disorder constructions as there are cultures." (Neimeyer & Raskin, 2000, p. 6--7). Finally, "if people cannot reach the objective truth about what disorder really is, then viable constructions of disorder must compete with one another on the basis of their use and meaningfulness in particular clinical sitUations" (Raskin & Lewandowski, 2000, p. 26). From the social constructionist perspective, sociocultural, political, professional, and eco nomic forces influence professional and lay conceptions of psychopathology. Our conceptions of psychological normality and abnormality are not facts about people but abstract ideas that are constructed through the implicit and explicit collaborations of theorists, researchers, pro fessionals, their clients, and the culture in which all are embedded and that represent a shared view of the world and human nature. For this reason, mental disorders and the numerous diagnostic categories of the DSM were not discovered in the same manner that an archeolo gist discovers a buried artifact or a medical researcher discovers a virus. Instead, they were invented (see Raskin & Lewandowski, 2000, in Neimeyer & Raskin). By saying that mental disorders are invented, however, we do not mean that they are myths (Szasz, 1974) or that the distress of people who are labeled as mentally disordered is not real. Instead, we mean that these disorders do not exist and have properties in the same manner that artifacts and viruses do. Therefore, a conception Ofpsychopathology "does not simply describe and classify characteristics of groups Of individuals, but ... actively constructs a version of both normal and abnormal ... which is then applied to individuals who end up being classified as normal or abnormal" (Parker, Georgaca,Harper, McLaughlin, & Stowell-Smith, 1995, p. 93). Conceptions of psychopathology and the various categories of psychopathology are not mappings·of psychological facts about people. Instead, they are social artifacts that serve the same sociocultural goals as do our conceptions of race, gender, social class, and sexual orientation-those of maintaining and expanding the power of certain individuals and insti tutions and maintaining social order, as de~ed by those in power (Beall, 1993; Parker et aI., 1995; Rosenblum & Travis, 1996). As are'these other social constructions, our concepts of psychological normality and abnormality are tied ultimately to social values-in particular, the values of society's most powerful indiviquals, groups, and institutions-and the contextual rules for behavior derived from these values (Becker, 1963; Parker et al., 1995; Rosenblum & Travis, 1996). As McNamee and Gergen (1992) state: "The mental health profession is not politically, morally, or valuationally neutral. Their practices typically operate to sustain certain values, political arrangements, and hierarchies of privilege" (p. 2). Thus, the debate over the definition of psychopathology, the struggle over who defines it, and the continual revisions of the DSM are not aspects of a search for truth. Rather, they are debates over the definition of socially constructed abstractions and struggles for the personal, political, and economic power that derives from the authority to define these abstractions and thus to determine what and whom society views as normal and abnormal. These debates and struggles are described in detail by Allan l:Iorwitz in Creating Mental Illness (2002). According to Horwitz:.
The emergence and persistence of an overly.expansive disease model of mental illness was not accidental or arbitrary. The Widespread creation ofdistinct mental diseases developed in specific
I.' CONCEPTIONS OF PSYCHOPATHOLOGY 15
invasion ofa human organism by cholera germs carries with it no more the stamp of "illness" than does the souring of milk by other forms of bacteria. Out of his anthropocentric self-interest, man has chosen to consider as "illnesses" or "diseases" those natural circumstances which precipitate death (or the failure to function according to certain values). (p. 30)
If these statements are true of physical disease, they are certainly true of psychological disease or psychopathology. Like our conception of physical disease, our conceptions of psy chopathology are social constructions' that are grounded in sociocultural goals and values, particularly our assumptions about how people should live their lives and about what makes life worth living, (See also Lopez & Guamaccia, this book, and Widiger, this book.) This truth is illustrated clearly in the American Psychiatric Association's 1952 decision to include homosexuality in the first edition of the DSM and its 1973 decision to revoke its disease status (Kutchins & Kirk, 1997; Shorter, 1997). As stated by Wilson (1993), "The homosexu ality controversy seemed to show that psychiatric diaghoses were clearly wrapped up in social constructions of deviance" (p. 404). This issue also was 'in the forefront of the debates over post traumatic stress disorder, paraphilic rapism, and masochistic personality disorder (Kutchins & Kirk, 1997), as well as caffeine dependence, sexual compulsivity, low intensity orgasm, sibling rivalry, self-defeating personality, jet lag, pathological spending, and impaired sleep-related painful erections, all of which were proposed for inclusion in DSM-IV (Widiger & Trull, 1991). Others have argued convincingly that schizophrenia (Gilman, 1988), addiction (Peele, 1995), personality disorder (Alarcon ~t aI., 1998), and dissociative identity disorder (formerly mu tIP Ie personality disorder) (Spanos, 1996) also are socially constructed categories rather than disease entities, With each revision, our most powerful professional conception of psychopathology, the DSM, has had more and more to say about how people should live their lives and about what makes life worth living. The number of pages increased from 86 in 1952 to almost 900 in 1994, and the number of mental disorders increased from 106 to 297. As the scope of mental disorder has expanded with each DSM revision, life has become increasingly pathologized, and the sheer number of people with diagnosable mental disorders has continued to grow. Moreover, mental health professionals have not been content to label only obviously and blatantly dysfunctional patterns of behaving, thinking, and feeling as mental disorders. Instead, we have defined the scope of psychopathology to include many commonp.roblems in living. Consider some of the mental disorders found in the DSM-IY. Cigarette smokers have Nicotine Dependence. If you drink large quantities of coffee, you may develop Caffeine In toxication or Caffeine-Induced Sleep Disorder. If you have "a preoccupation with a defect in appearance" that causes "significant distress or impairment in ... functioning" (p. 466), you have a Body Dysmorphic Disorder. A child whose academic achievement is "substantially below that expected for age, schooling, and level of intelligence" (p. 46) has a Learning Dis order. Toddlers who throw tantrums have Oppositional Defiant Disorder. Not wanting sex often enough is Hypoactive Sexual Desire Disorder. Not wanting sex at all is Sexual Aversion Disorder. Having sex but not having orgasms or having them too late or too soon is an Or gasmic Disorder. Failure (for men) to maintain "an adequate erection ... that causes marked distress or interpersonal difficulty" (p. 504) is Male Erectile Disorder. Failure (for women) to attain or maintain "an adequate lubrication or swelling response ofsexual excitement" (p. 502) accompanied by distress is Female Sexual Arousal Disorder. The past few years have witnessed media reports of epidemics of internet addiction, road rage, pathological stock market day trading, and "shopaholism." Discussions of these new disorders have turned up at scientific meetings and in courtrooms. They are likely to find a
16 MADDUX, GOSSELIN, WINSTEAD
home in the next revision of the DSM if the media, mental health professions, and society at large continue to collaborate in their construction and if treating them and writing books about < them become lucrative. Those adopting the social constructionist perspective do not deny that human beings experi ence behavioral and emotional difficulties, sometimes very serious ones. They insist, however, that such experiences are not evidence for the existence of entities called mental disorders that then explain those behavioral and emotional difficulties. The belief in the existence of these entities is the product of the all-too-human tendency to socially constrUct categories in an attempt to make sense of a confusing world.
SUMMARY AND CONCLUSIONS
The debate over the conception or definition of psychopathology and related terms has been going on for decades and will continue, just as we will always have debates over the definitions of truth, beauty, justice, and art. Our position is that psychopathology and mental disorder are not the kinds of terms whose true meanings can be discovered or defined objectively by using the methods of science. They are social constructions-abstract ideas whose meanings are negotiated among the people and institutions of a culture and that reflect the values and power structure of that culture at a given time. Thus, the conception and definition of psychopathology always has been and always will be debated and always has been and always will be changing. It is not a static and concrete thing whose true nature can be discovered and described once and for all. By saying that conceptions of psychopathology are socially constructed rather than scientif ically derived, we are not proposing, however, that human psychological distress and suffering are not real or that the patterns of thinking, feeling, and behaving that society decides to label psychopathological cannot be studied objectively and scientifically. Instead, we are saying that it is time to acknowledge that science can no more determine the proper or correct conception of < psychopathology and mental disorder than it can determine the proper and correct conception of other social constructions such as beauty, justice, race, and social class. We can nonetheless use science to study the phenomena that our culture refers to as psychopathological. We can use the methods of science to understand a culture's conception of mental or psychological health and disorder, how this conception has evolved, and how it affects individuals and society. We also can use the methods of science to understand the origins of the patterns of thinking, feeling, and behaving that a culture considers psychopathological and to develop and test ways of modifying those patterns. Psychology and psychiatry will not be diminished by aCkllOwledging that their basic con cepts are socially and not scientifically constructed-any more than medicine is diminished by acknowledging that the notions of health and illness are socially constructed (Reznek, 1987), nor economics by acknowledging that the notions of poverty and wealth are socially con structed. Science cannot provide us with purely factual scientific definitions of these concepts. They are fluid and negotiated matters of value, not fixed matters of fact. As Lilienfeld and Marino (1995) have said:
Removing the imprimatur of science.. < would simply make the value judgments underlying these decisions more explicit and open to criticism. < • heated disputes would almost surely arise concern ing which conditions are deserving of attention from mental health professionals. Such disputes, however, would at least be settled on the legitimate basis of social values and exigencies, rather than on the basis of ill-defined criteria of doubtfol scientific status. (pp. 418--419)
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McNamee, S., &, Gergen, K. 1. (1992). Therapy as social construction. Thousand Oaks, CA: Sage.
Muehlehard, C. L., &, Kimes, L. A. (1999). The social construction of violence: The case of sexual and domestic
violence. Personality and Social Psychology Review, 3, 234-245. Neimeyer, R. A., &, Raskin, J. D. (2000). On practicing postmodem therapy in modem times. In R. A. Neimeyer &, 1. D. Raskin (&!s.), Constructions ofdisorder: Meanihg-makingframeworksfor psychotherapy (pp. 3-14). Washington, DC: American Psychological Association. Oatley, K., &, Jenkins, J. M. (1992). Human emotions: Function and dysfunction. Annual Review of Psychology, 43, 55-85. Ossorio, P. G. (1985). Pathology. Advances in Descriptive Psychology, 4, 151-201. Parker, t, Georgaca, E., Harper, D., McLaughlin, T., &, Stowell-Smith. M. (1995). Deconstructingpsychopathology. London:' Sage. Peele, S. (1995). Diseasing of America: How we allowed recovery zealots imd the treatment industry to convince us we are out of control. San Francisco: Lexington Books. Persons, 1. (1986). The advantages of studying psychological phenomena rather than psychiatric diagnosis. American Psychologist, 41, 1252-1260. ' Raskin, 1. D., &, Lewandowski, A. M. (2000). The construction of disorder as humatl enterprise. In R. A. Neimeyer &, J. D. Raskin (Eds.), Constructions of disorder: Meaning-making frameworks for psychotherapy (pp. 15-40). Washington, DC: American Psychological Association. Reznek, L. (1987). The nature ofdisease. London: Routledge &, Kegan Paul. Rind, B .• Tromovich, P., &, Bauserman, R. (1998). A meta-analytic examination of assumed properties of child sexual
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CHAPTER
4
Classification and 'Diagnosis:
Historical Development and
Contemporary Issues
Thomas A. Widiger
University of Kentucky
. dysfunctional, and maladaptive thinlcing, feeling, behaving, and relating are of sub concern to many different professions, the members of which will hold an equally array of beliefs regarding etiology, pathology, and intervention. It is imperative that persons be able to commlUlicate meaningfully with one another, The primary purpose official diagnostic nomenclature is to provide this common language of communication 1975; Sartorius et aI., 1993), diagnostic nomenclatures, however, can be exceedingly powerful, impacting sig many important social, forensic, clinical, and other professional decisions (SchWartz 2002Y. Persons think in terms of their language, and the predominant languages ps)rchiopalthc'lo·~~ are the fourth edition ofth~ American Psychiatric Association's (1994, Diagnostic and Statistical Manual ofMental Disorders (DSM-IV) and the tenth edition. World Health Organization's International Classification of Diseases (ICD-lO; 1992). these nomenclatures have a substantial iinpact on how clinicians, social agencies, and public conceptualize psychopathology. two languages, however, are not the final word. Interpreting DSM-IV or ICD-IO validated nomenclatures exaggerates the extent of their empirical support v:>cu..,,,,,,,Pincus, Widiger, Davis, & First, 1990).00 the other hand, DSM-IV and ICD-l 0 are lacking in credible or compelling empirical support. DSM-IV and ICD-IO contain many but they are also well-reasoned, scientifically researched, and well-documented nomen
."''''''lIlrf·'' that describe what is currently lUlderstood by most scientists, theorists, researchers,
clinicians to be the predominant variants of psychopathology (Nathan & Langenbucher, Widiger & Trull, 1993). This chapter will overview the DSM-IV diagnostic nomencla ture, beginning with historical backgrolUld, followed by a discussion of major issues facing "~ture revisions.
"" ..,ITL,-.n.TION AND DIAGNOSIS 65
"devoted to mental disorders (Kendell, 1975; Kramer, Sartorius, Jablensky, & Gulbinat, ", in recognition of the many psychological casualties of World War II and the &;n1na;ct of mental health professions. The UnitedBtates Public Health Service com :a committee, chaired by George Raines (with representations from a variety of and public health agencies), to develop a varilplt of the mental disorders section ", for use within the United States. The United States, as a member of the WHO, was use ICD-6, but modifications could be made to maximize its acceptance and utility
. the United States. The resulting nomenclature resembled closely the Veterans system developed by Brigadier General William Memiinger (brother to Karl 1963). Responsibility for publishing and distributing this nosology was given to , Psychiatric Association (1952) under the title Diagnostic and Statistical Manual. I }L~Ora'ers (hereafter referred to as DSM-I). , , was generally successful in obtaining acceptance, mainly because of its expanded including somatoform disorders, stress reactions; and personality disorders. How , New York State Department of Mental Hygiene, 'which had been influential in the of the Standard Nomenclature, continued for some time to use its own classifica also included narrative descriptions of each disorder to facilitate understanding 'consistent applications. Nevertheless, fundamental criticisms regarding the relia validity of psychiatric diagnoses were also raised (e.g., Zigler & Phillips, 1961). a widely cited reliability study by Ward, Beck, Mendelson, Mock, and Erbaugh ,\A.J.u".'",...,,,. that most of the poor agreement among psychiatrists' diagnoses was due , inadequacies ofDSM-I.. was less successful. The "mental disorders section [ofICD-6] failed to gain [inter
acceptance and eleven years later was found to be in official use only in Fiiuand, New
Peru, Thailand, and the United Kingdom" (Kendell, 1975, p. 91). The WHO therefore ISSlOlle)U a review by the English psychiatrist E,rwin Stengel. Stengel (1959) reiterated Vlne,""n"", of establishing an official nomenclature:
serious obstacle to progress in psychiatry is diffiCUlty of communication. Everybody who has the literature and listened to disc~ssions concerning mental illness soon discovers that' ",'tIi,hi(]'tri,~'t,~ even those apparently sharing the same basic orientation. often do not speak the language. They either use different terms for the same conqepts, or the same term for different ~(mr;;ep,ts, usually without being aware of it. It is sometimes argued that this is inevitable in the state ofpsychiatric knowledge, out it is doubtful whether this is a valid excuse. (Stengel. ~~ , ,
attributed the failure of clinicians to accept the me~tal disorders section of ICD-{) to nn:sellce of theoretical biases, cynicism regarding any psychiatric diagnoses (some theo perspectives opposed the use of any diagnostic terms), and the presence of abstract, inferential diagnostic criteria that hindered consistent, uniform applications by different
L'WLJ"-n and DSM-II
began on ICD-8 soon after Stengel's (1959) report (ICD-6 had been revised to ICD- 1955, but there were no revisions to the mental disorders). Considerable effort was made develop a system that would be used by all of the member countries of the WHO. The edition ofICD-8 was approved by the WHO in 1966 and became effective in 1968. A )tn])anl'oill glossary, in the spirit of Stengel's (1959) reconllnendations, was to be pUblished
66 WIDIGER
conjointly, but work did not begin on the glossary until 1967 and it was not completed until
- "This delay greatly reduced [its] usefulness, and also [its] authority" (Kendell, 1975, p. 95). In 1965, the American Psychiatric Association appointed a committee, chaired by Ernest M. Gruenberg, to revise DSM-I to be compatible with ICD-8 and yet also be suitable for Use , within the United States. The final version was approved in 1967, with pUQlication in 1968. The diagnosis of mental disorders, however, was receiving substantial criticism during this time (e.g., Rosenhan, 1973; Szasz,·1961). A fundamental problem continued to be the absence , of empirical support for the reliability, let alone the validity, of its diagnoses (e.g., Blashfield & Draguns, 1976). Researchers, however, took to heart the recommendations of Stengel (1959) by developing more specific and explicit criterion sets (Blashfield, 1984). The most influential of these efforts was produced by a group of neurobiologically oriented psychiatrists at Washington University in St.Louis. Their criterion sets generated so much interest that they were published separately in what has become one of the most widely cited papers in psychiatry (i.e., Feighner et aI., 1972). Research has since indicated that mental disorders can be diagnosed reliably and do provide valid information regarding etiology, pathology, course, and treatment (Nathan & Langenbucher, 1999).
ICD-9 and DSM-III By the time 'Feighner et al. (1972) was published, work was nearing completion on the ninth edition of the ICD. The authors of ICD-9 had dec;ided to include a glossary that would pro vide more precise descriptions of each disorder, but it was apparent that ICD-9 would not include the more specific and explicit criterion sets used in research (Kendell, 1975). In 1974, the American Psychiatric Association appointed a task force, chaired by Robert Spitzer, to revise DSM-II in a manner that would be compatible with ICD-9 but would also incorporate many of the current innovations in diagnosis. DSM-III was published in 1980 and was remark ably innovative, including (a) a multiaxial diagnostic system (most mental disorders were diag nosed on Axis I, personality and specific developmental disorders were diagnosed on Axis II, medical disorders on Axis nI, psychosocial stressors on Axis rv, and level of functioning on Axis V), (b) specific and explicit criterion sets for all but one of the disorders (schizoaffective), (c) a substantially expanded text discussion of each disorder to facilitate diagnosis (e.g., age at onset, course, complications, sex ratio, and familial pattern), and (d) rer,noval ofterms (e.g., neurosis) that appeared to favor a particular theoretical model for the disorder's etiology or pathology (Spitzer, Williams, & Skodol, 1980).
DSM-III-R
A disadvantage of DSM-III was that errors in criterion sets were as specific and explicit as the diagnostic criterion sets, and a number of such errors were soon apparent (e.g., panic disorder could not be diagnosed in the presence of a major depression). "Criteria were not entirely clear, were inconsistent across categories, or were even contradictory" (APA, 1987, 'p. xvii). The American Psychiatric Association therefore authorized the development of a revision to DSM-III to correct these errors. Fundamental revisions were to be tabled until work began on ICD-lO. However, it might have been unrealistic to expect the authors of DSM-III-R to confine their efforts to refinement and clarification, given the impact, success, and importance of DSM-III. '
The impact ofDSM-III has been remarkable, Soon after its publication, it became widely accepted in the United States as the common language of mental health clinicians and researchers for
