Disorder and

Deviance:
Where to Draw the
Boundaries?
Dan J. Stein

Keywords: mental disorder, definition, deviance, dys- personality and sexual disorders is legal or perhaps
function, distress political rather than medical.
This interesting piece raises a number of con-
ceptual and scientific issues that deserve further

R
ashed and Bingham (2014) raise the
question of whether psychiatry can dis-
tinguish between social deviance and psy-
chiatry, and conclude that the the limit of what
society may be willing to accommodate does not
mark the beginning of illness (254). This question
is clearly important to consider, given that many
critical of psychiatry have (incorrectly) emphasized
that psychiatry is no more than a form of deviance
control, and given that some practitioners of psy-
chiatry have (inappropriately) subjected political
deviants to medical treatments.
Rashed and Bingham review Diagnostic and
Statistical Manual of Mental Disorders (DSM)-IV
and DSM-5 definitions of mental disorder, and
indicate that an evolutionary theoretic approach
to defining dysfunction is problematic and should
be replaced by an emphasis on distress. They then
argue that socially caused distress can be distin-
guished from socially constitutive distress, that
conditions in which distress is socially constituted
should not be considered to be mental disorders,
and that the appropriate level of response to some
consideration and clarification. I discuss in turn
(1) the nature of linguistic categories, (2) the no-
tion of dysfunction in mental disorder, (3) the
nature of socially constituted distress, and (4)
whether a number of key personality disorders
(e.g., antisocial personality disorder) and sexual
disorders (e.g., coercive paraphilic disorder, hy-
persexual disorder) should indeed be viewed as
mental disorders.
Concepts of Mental Disorder
Proponents of what might be called a classical
approach define disorders in terms of necessary
and sufficient criteria (Stein 1991, 2008). The
definition perhaps most relevant to this piece is
Wakefields characterization of disorder as a harm-
ful dysfunction (Wakefield 1992). Proponents of a
more critical position argue, instead, that defini-
tions of mental disorder differ from time to time
and place to place (Stein 1991, 2008). Key for
the current piece is the argument that psychiatry
cannot, therefore, adequately differentiate mental
disorder and other forms of deviance; this argu-

2015 by The Johns Hopkins University Press

262 PPP / Vol. 21, No. 3 / September 2014
ment has been made by a broad range of critics
of psychiatry in general, and of medicalization in
particular.
Scientific work, however, increasingly em-
phasizes that linguistic categories are often con-
tinuous, with some exemplars typical and others
atypical (Lakoff and Johnson 1999). Research has
concluded that the linguistic category of birds, for
example, is composed of typical exemplars such
as robins (which fly) and atypical exemplars such
as ostriches (which do not). A range of work in
cognitive psychology, linguistics, artificial intel-
ligence, and other branches of cognitive science
has emphasized such continua (Stein 2007, 2013).
Biologists are certainly able to classify species on
the basis of phenotype, or increasingly, on the
basis of genotype. At the same time, the concept
of species is itself one that has fuzzy boundaries
(Hey 2001).
Continua of categories and fuzziness of bound-
aries are relevant to formulating an approach to
medical and psychiatric disorders (Stein et al.
2010). Typical disorders may be characterized by
features such as the presence of a factor (often
external) that disrupts internal homeostasis, the
lack of responsibility of the individual for this dis-
ruption, and a social role that encourages medical
treatment (rather than, say, legal sanction; Stein
2013). However, there are also atypical disorders,
whether medical (such as macromastia, which may
not involve disruption per se, but which may cause
distress and impairment) or psychiatric (such as
alcoholism, where the individuals do seem to need
to take responsibility for their role in perpetuating
the condition).
Mental Disorder and
Dysfunction
Both the fourth and fifth editions of the DSM
(DSM-IV and DSM-5) highlight the notion of
dysfunction in their definitions of mental disorder.
Stein et al. (2010) suggest the term psychobio-
logical dysfunction to emphasize the extent to
which biological and psychological processes are
intertwined. As alluded to, some authors have tried
to define dysfunction in terms of necessary and
sufficient criteria. Rashed and Bingham reference
Boltons point (Bolton 2010) that psychological
function includes both innate (evolved) and social
(cultivated) components, and argue that a natural-
ist position fails. They instead focus on the notion
that dysfunction leads to distress, although they
also indicate their view that this position does not
entail the denial of biology.
Rashed and Bingham reference Stein et al.
(2010) as defining dysfunction in terms of distress
and indicate this is an alternative to a naturalist
approach. However, this is just one possibility
mentioned by these authors, who go on to say that
the notion of dysfunction draws on particular
metaphors of disorder and that no algorithm fully
specifies the term. Further, although dysfunction
may not be reducible to any invariant psychologi-
cal or biological mechanism (to use Rashed and
Binghams phrase), scientists can investigate a
particular phenotype and provide reasonable argu-
ments as to whether or not dysfunction is present.
In a typical disorder, such as infection, this is in-
variably uncontroversial. In an atypical disorder,
such as alcoholism, there may be disagreement
(with some scientists emphasizing a range of dis-
ruptions, including alterations in brain circuitry).
An increasingly relevant issue is situations when
there is evidence of dysfunction, but an absence
of distress and/or impairment. In DSM-IV and
DSM-5, tic disorders are unusual, in that there
is no mention of the clinical criterion (emphasiz-
ing distress and/or impairment); presumably it
is thought that tics themselves are indicative of
dysfunction. As brain imaging methods for de-
tection of Alzheimers disease improve, the issue
of how to categorize cases where there are brain
abnormalities, but no distress or impairment, may
arise. Note, however, that already we know that
plaques and tangles can exist in the absence of
impairment, so that part of the answer may depend
on whether intervention is helpful in such cases.
Differentiating between risk and disorder is also
a pertinent issue (Stein et al. 2010).
Mental Disorder and Distress
Wakefield has emphasized that not all dysfunc-
tion leads to harm, and that disorder requires the
presence of harm (Wakefield 1992). Similarly,

Rashed and Bingham (2014) emphasize distress,
but note that not all distress points to the presence
of a mental disorder. The issue of differentiating
different kinds of distress is certainly difficult if
one discards the notion of dysfunction; a com-
prehensive psychiatric evaluation must assess the
individual in his or her context, and determine
whether responses to that context are functional
or dysfunctional (Nesse and Stein 2012; Stein et
al. 2010). Similarly, it can be argued that psy-
chiatry needs to complement the focus of clinical
neuroscience on endophenotypes with a careful
assessment of the exophenotype (Stein et al. 2013),
so avoiding the fundamental attribution error
(Ross, 1977).
Rashed and Bingham distinguish between social
causal (i.e., environmental risk factors, which im-
pact on internal states, and require individual level
interventions) and social constitutive factors (e.g.,
when interpersonal relationships are pathological
and require societal-level interventions). They
argue that, when distress is socially constituted,
then a mental disorder should not be judged to be
present. They go on, however, to consider the situ-
ation of a woman in an abusive relationship, and
to indicate that even after this relationship ends,
there may be enduring effects, such as negative
views of self, so that distress is no longer socially
constituted. Thus, they acknowledge that there is
a continuum between acute and chronic effects of
harmful interpersonal relationships, with no clear
conceptual boundary or threshold dividing them.
Early abuse may, however, lead both to endur-
ing negative internal states, and to increased risk
for future involvement in abusive relationships
(Stein et al. 2005). Arguably there is not only a
continuum between acute and chronic effects of
abuse, but also a continuum between social causal
and social constitutive processes (and distress). A
similar logic is seen in posttraumatic stress disor-
der (PTSD), where some view PTSD as a normal
response to abnormal events and requiring societal
intervention, whereas others view PTSD in terms
of a dysfunction requiring individual interven-
tion. Arguably, disorders have both transitive
dimensions (they are socially constructed) and
intransitive dimensions (they do involve dysfunc-
tion), and in a case like PTSD both individual-level
Stein / Disorder Versus Deviance 263
and societal-level interventions are needed (Stein
et al. 2007).
Personality Disorders and
Sexual Disorders
On the basis of their argument that conditions
in which distress is socially constituted should
not be considered to be mental disorders, Rashed
and Bingham indicate that the appropriate level of
response to some personality and sexual disorders
is legal or perhaps political, rather than medical.
They argue, however, that in the case of antisocial
personality disorder and pedophilia, we should
advocate not for acceptance, but perhaps for less
medicalization. Although they indicate they have
insufficient space to speak to delusional disor-
der, it is perhaps relevant to note that, although
some have persuasively emphasized the continua
between normal thought processes and delusions
(Reznek 2010), there are clear arguments in favor
of medicalizing delusional disorders.
The question of whether antisocial personality
disorder is a mental disorder has previously been
debated (Stein 1996, 2000). Some antisocial traits
can be argued to be adaptive, rather than repre-
sentative of disorder. At the same time, evidence
of disrupted cognitiveaffective processes, and
associated changes in brain structure in ASPD,
support the argument that this is a disorder. Im-
portantly, such individuals may not always experi-
ence distress (whether socially caused or socially
constituted), but they may well have significant
impairment. Still, as in the case of alcoholism,
individuals with antisocial personality disorder
must take responsibility for their behaviors, which
is one reason that antisocial personality disorder
can be viewed as an atypical disorder. Other
personality disorders need to be considered on
a case-by-case basis, but it is notable that some
personality disorders overlap closely with related
axis I conditions (Stein et al. 2004).
Past nosologies have described neat categories
of various paraphilias. This arguably contrasts
with evidence that there is a wide continuum of
sexual behavior in healthy people, but that some
have increased frequency/intensity of sexual desire,
sometimes including multiple paraphilias (Kafka
264 PPP / Vol. 21, No. 3 / September 2014
1997). It is instructive to consider two sexual dis-
orders proposed for DSM-5coercive paraphilic
disorder and hypersexual disorder. Coercive para-
philic disorder proposes medicalizing a behavior
that is and should not be tolerated (rape); this
seems flawed insofar as there is little evidence for
a specific dysfunction underlying rape (although
there may be evidence of association with per-
sonality, sexual, or relationship problems; Knight
2010). Hypersexual disorder was not included
in DSM-5; this seems to be an error insofar as
patients with this condition are characterized by
dysfunction, distress, and impairment, even in the
absence of conflict with society (Stein et al. 2001).
Conclusion
Rashed and Bingham (2014) bravely attempt
to draw a clear delineation between disorder and
deviance, arguing that the limit of what society
may be willing to accommodate does not mark
the beginning of illness. In my view, given that
linguistic categories are characterized by graded
continua and fuzzy thresholds, and that judg-
ments about the boundaries of both disorder
and deviance are theory based and value laden,
we must accept that our current delineations are
imperfect, and attempt to improve progressively
our appreciation and weighing of the relevant facts
and values. Accepting that disorder and deviance
lie on a continuum does not absolve us of this
responsibility, but it is consistent with a growing
corpus of scientific work on linguistic categories,
and may help to explain a number of key relevant
phenomena (such as the stigmatization of atypical
medical disorders such as alcoholism, antisocial
personality disorder, and hypersexual disorder).
Acknowledgments
Dr. Stein is supported by the Medical Research
Council of South Africa.
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274 PPP / Vol. 21, No. 3 / September 2014
Department of Social and Cultural Analysis and
the Department of Psychiatry. His writing and
teaching is at the interface of medicine, psychiatry,
humanities, and cultural/disability studies. He is
an Associate Editor for the Journal of Medical
Humanities and his recent books are devoted
to the role of narrative in clinical care. His cur-
rent research is focused on the ways art, politics,
and spirituality impact narratives of flourishing
and disability. He can be contacted via email at
BL466@nyu.edu
Peter Lucas is Senior Lecturer in Philosophy at
the University of Central Lancashire, Preston, UK,
where he is Course Leader for the Universitys BA
Philosophy Program. His main philosophical inter-
ests lie at the interface of ethics, epistemology, and
post-Kantian European philosophy. In particular,
he is interested in the special ethical obligations
that arise, in professional ethics and more gener-
ally, from our shared capacity for self-knowledge.
He is the author of a number of articles and book
chapters in modern European philosophy, the
philosophy of communication, and applied and
professional ethics. His recent book Ethics and
Self-Knowledge: Respect for Self-Interpreting
Agents was published by Springer in 2011. He
can be contacted via email at Plucas1@uclan.ac.uk
Joanna Moncrieff is a Senior Lecturer at
University of Central Lancashire and a practic-
ing psychiatrist. She is the Co-Chairperson of
the Critical Psychiatry Network, and author
ofmanybooks andarticles which present a critical
viewof psychiatric theory and practice in general,
andpsychiatric drug treatment in particular. She
can be contact via email at j.moncrieff@ucl.ac.uk
Christian Perring is Professor of Philosophy at
Dowling College, New York. He teaches a wide
variety of courses and does research in philosophy
of psychiatry. He is Editor of Metapsychology
Online Reviews. He can be contacted via email
at cperring@yahoo.com
Douglas Porter is Medical Director of the Al-
giers Behavioral Health Center in New Orleans,
Louisiana, and a Clinical Instructor of Psychiatry
for the Department of Psychiatry and Behavioral
Sciences, Tulane University School of Medicine.
He has an interest in applying conceptual issues
from philosophy to the theory and practice of
psychiatry. His recent publications have applied
critical theory to an understanding of psycho-
pharmacology; explored the impact of concepts
of scientific authority on the psychiatric recovery
movement; and developed a theory of normative
validity for the science of psychiatric nosology.
He can be contacted via email at douglasporter@
cox.net
Mohammed Abouelleil Rashed is a Postdoc-
toral Research Fellow in Philosophy of Mental
Health at the University of Pretoria. He obtained
his doctorate from University College London and
masters in philosophy of mental disorder from
Kings College London. He qualified as a medical
doctor from Cairo University and trained in psy-
chiatry in the UK. Dr Rasheds research interests
include concepts of mental disorder and culture,
spirit possession, and psychiatric ethics. He has a
number of publications exploring values, culture
and psychiatric diagnosis. He can be contacted via
email at: m.rashed@alumni.ucl.ac.uk
Ilina Singh is Professor of Neuroscience & Soci-
ety at the University of Oxford, where she holds a
joint appointment between the Department of Psy-
chiatry and the Department of Philosophy (Uehiro
Centre. Her work examines the psychosocial and
ethical implications of advances in biomedicine
and neuroscience for young people and families.
Recent projects include the ADHD VOICES proj-
ect (www.adhdvoices.com); Neuroenhancement
Responsible Research and Innovation (www.nerri.
eu); and the Urban Brain Project (www.urban-
brainlab.com). In w014, Professor Singh received
a Wellcome Trust Senior Investigator Award for a
study entitled: Becoming Good: Early Intervention
and Moral Development in Child Psychiatry. She
can be contacted via email at ilina.singh@psych.
ox.ac.uk
Dan J. Stein is Professor and Chair of the Depart-
ment of Psychiatry at the University of Cape Town,
and Director of the Medical Research Council

(MRC) Unit on Anxiety and Stress Disorders.
He completed his undergraduate and medical
training at the University of Cape Town, his psy-
chiatric residency and post-doctoral fellowship
in psychopharmacology at Columbia University,
and his doctoral dissertation in philosophy at the
University of Stellenbosch. He can be contacted
via email at dan.stein@uct.ac.za
Stephen Tyreman combines a long-standing os-
teopathic practice with an academic career in oste-
opathy that covers both the UK and Norway. His
academic interest is in philosophy of healthcare,
with a particular focus on professional identity,
concepts of health, illness and disease in associa-
tion with complexity and uncertainty. He is course
leader for the professional doctorate in osteopathy
About the Authors 275
run by the British School of Osteopathy and vali-
dated by the University of Bedfordshire. He can
be contacted via email at s.tyreman@bso.ac.uk
G. Scott Waterman is Professor of Psychiatry
Emeritus at the University of Vermont College
of Medicine, where he also served for eight years
as Associate Dean for Student Affairs.His schol-
arly work has involved neuroscience education,
philosophy of mind in medical discourse and
practice, and philosophical problems in psychiatric
nosology. He is currently a Graduate Student in
History at the University of Vermont, studying
ideological commitment among American Com-
munists during the Spanish Civil War. He can be
contacted via email at Scott.Waterman@uvm.edu
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