Health – Difference or dysfunction?

When does a difference become a disease? In what circumstances is difference a good thing? Should we expect people who are divergent to conform to society’s norms?

These questions have pre-occupied philosophers and physicians for centuries, but it was only when psychiatry was recognised as a valid branch of medicine that systematic efforts were made to draw boundaries between normal behaviour and psychopathology. 

These days the “bible” of psychiatry is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. It first appeared in 1952 as a modestly sized document listing about 100 different diagnoses. Its purpose was to give clinicians and researchers clear definitions of conditions and to optimise treatment, development of drugs and public health planning.

At its last revision in 2013, the DSM had blown out to nearly a thousand pages and tripled the number of conditions identified as mental disorders. Over the years, many diagnoses have been removed, added, redefined, subcategorised or in some cases lumped together, and renamed (mostly to reduce stigma). 

While praised for its attempt to standardise diagnosis and treatment, there have also been concerns raised about arbitrary criteria and cut-offs for certain conditions, for example, how severe does low mood have to be before it qualifies as “major depressive disorder”? Also, are we inappropriately medicalising aspects of human distress and difference just because societies find them hard to cope with?

Although this process has sought to be evidence-based, there are no doubt influences from cultural and ideological factors as well. It’s important to note that this is an American document and many other countries prefer an international alternative published by WHO. 

All in all, DSM is considered to be a useful tool, particularly as it has an emphasis not just on diagnosis but on the impact of certain behaviours. Is the condition leading to distress or dysfunction, for the patient and others, or is there a risk of harm associated with it? This is the pragmatic point where a difference becomes a disorder. 

The reason why I got on to this is that I recently met someone who I felt might have a personality disorder (PD). It quickly became apparent that my understanding of this was hazy and needed an update. The briefest definition I could find was “the manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both.”

Since personality traits are on a continuum it is quite difficult to pin down what is meant by “extreme” and “significant” in this context. 

In practical terms, people with PD often have difficulty in sustaining relationships because of various maladaptive behaviours. They are sometimes clustered into (A) odd and eccentric personalities, (B) dramatic, impulsive, emotional personalities, and (C) fearful and anxious personalities.

In the DSM there are 10 different types of PD, of which the most commonly known are probably OCD and narcissism, words in common parlance now. It’s a big topic, so I’ll continue this another article.