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Psychol Med. 2010 November ; 40(11): 1759–1765. doi:10.1017/S0033291709992261.

What is a Mental/Psychiatric Disorder? From DSM-IV to DSM-V

Dan J. Stein, Katharine A. Phillips, Derek Bolton, K.W.M Fulford, John Z. Sadler, and
Kenneth S. Kendler

Introduction
DSM-III and DSM-IV have been praised for making a seminal contribution to patient care
and to the scientific study of psychiatric disorders by providing rigorous and reliable
diagnostic criteria for conditions such as major depressive disorder and social phobia. At the
same time, DSM-III and DSM-IV have been criticized for creating too many diagnostic
categories (van Praag, 2000) and for allowing the distinction between psychopathology and
normal psychological phenomena (e.g., sadness after a major stressful event, shyness in
social situations) to be eroded (Horwitz, V & Wakefield, 2007; Wakefield, Horwitz, &
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Schmitz, 2005). Both DSM-III and DSM-IV emphasized the difficulties inherent in drawing
a precise distinction between normality and psychopathology, and they provided a definition
of mental disorder that attempted to address this challenge (Spitzer & Endicott, 1978). This
issue is relevant not only to deciding whether or not a disorder should be in the nosology,
but whether or not the criteria for a particular disorder are optimal for defining the threshold
for caseness. As part of the process of developing DSM-V, researchers have explored again
the concept of mental disorder and emphasized the need for additional work in this area
(Rounsaville et al., 2002). In this editorial, we review the DSM-IV definition of mental
disorder and propose a number of changes.

DSM-IV Definition of Mental Disorder

DSM-IV notes that “… although this manual provides a classification of mental disorders, it
must be admitted that no definition adequately specifies precise boundaries for the concept
of ‘mental disorder.’ The concept of mental disorder, like many other concepts in medicine
and science, lacks a consistent operational definition that covers all situations. All medical
conditions are defined on various levels of abstraction--for example, structural pathology
(e.g., ulcerative colitis), symptom presentation (e.g., migraine), deviance from a
physiological norm (e.g., hypertension), and etiology (e.g., pneumococcal pneumonia).
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Mental disorders have also been defined by a variety of concepts (e.g., distress, dyscontrol,
disadvantage, disability, inflexibility, irrationality, syndromal pattern, etiology, and
statistical deviation). Each is a useful indicator for a mental disorder, but none is equivalent
to the concept, and different situations call for different definitions.”

DSM-IV goes on, however, to note that, “Despite these caveats, the definition of mental
disorder that was included in DSM-III and DSM-III-R is presented here because it is as
useful as any other available definition and has helped to guide decisions regarding which
conditions on the boundary between normality and pathology should be included in DSM-
IV. In DSM-IV, each of the mental disorders is conceptualized as a clinically significant
behavioral or psychological syndrome or pattern that occurs in an individual and that is
associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in
one or more important areas of functioning) or with a significantly increased risk of
suffering death, pain, disability, or an important loss of freedom. 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
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currently be considered a manifestation of a behavioral, psychological, or biological

dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual)
nor conflicts that are primarily between the individual and society are mental disorders
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unless the deviance or conflict is a symptom of a dysfunction in the individual, as described

above.”

Table 1 operationalizes the DSM-IV definition of mental disorder, in the standard format
used for the operationalization of clinical diagnoses.

Proposed DSM-V Definition of Mental/Psychiatric Disorder

Table 2 provides our suggested changes. Before going on to provide a rationale for each of
these changes, it is relevant to address the question of whether the term “mental disorder” is
optimal. “Mental” implies a Cartesian view of the mind-body problem – that mind and brain
are separable and entirely distinct realms, an approach that is inconsistent with modern
philosophical and neuroscience views (Fulford, Thornton, & Graham, 2006). The term
“psychiatric disorder” may be preferable insofar as it emphasizes that these conditions are
not purely “mental”, and that the line between “psychiatric disorder” and “other medical
disorders” is not a sharp one. However, the term “psychiatric” has been criticized for not
sufficiently connoting the extent to which entities are in fact psychobiological (instead, for
some, connoting an overly reductionistic biomedical model). Mental health clinicians other
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than psychiatrists have also voiced criticism of this term insofar as it may suggest
incorrectly that only psychiatrists are trained in the diagnosis and management of these
conditions (Spitzer & Williams, 1982). Such criticism may be sufficient to warrant retaining
“mental disorder”, and indeed the authors of this article could not come to a consensus on
this matter. One potential compromise is to recommend the awkward and perhaps
transitional term “mental/psychiatric”. A more conservative approach would be to retain the
term “mental disorder” in keeping with DSM-IV, but to emphasize in the text that these are
brain-mind disorders.

Criterion A
DSM-IV refers to a clinically significant behavioral or psychological syndrome or pattern
that occurs in an individual. However, the phrase “clinically significant” is in some ways
tautological here; its definition is precisely what is at stake when defining a mental disorder.
Other definitional criteria go on to tackle the meaning of clinical significance, and we
therefore suggest omitting the “clinically significant” phrase from criterion A. Nevertheless,
the phrase “clinically significant” is useful in defining a mental disorder, and we therefore
turn to it in criterion B.
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As alluded to earlier, the question has been raised of what is “mental” about mental
disorders (Fulford et al., 2006). In this regard, a practical issue that arises is the inclusion in
DSM-IV of symptoms and disorders that might be conceptualized as more neurological
(rather than behavioral or psychological) in nature (e.g., tic disorders, catatonia). It might be
argued that involuntary motoric movements (or lack of motoric movement) belong in a
classification of neurological disorders rather than mental/psychiatric disorders. However,
the constructs “voluntary” and “involuntary” arguably have fuzzy borders. Furthermore, the
term “behavioral” in criterion A could be considered to cover motoric symptoms that lie in a
border area between voluntary and involuntary, supporting the inclusion of conditions like
tic disorders in DSM-V.

Regarding the phrase “in an individual” in criterion A, there has been debate about whether
dysfunction in relationships should be classified as mental/psychiatric disorders (Heyman et
al, 2009). Although currently listed only as V codes (other conditions that may be a focus of

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clinical attention), such phenomena appear to have content validity, may be associated with
significant distress and impairment, and can be reliably diagnosed. Nevertheless, general
medical disorders invariably occur within individuals, and although there may be some
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reasons to stretch the construct of disorder to novel phenomena such as relationship

dysfunction, such an expansion would necessarily be contentious and therefore would
require particularly persuasive supporting data. We therefore suggest retaining the phrase
“occurs in an individual” at this time. (Notably, DSM-IV-TR includes the diagnosis of
Shared Psychotic Disorder, and does not specifically indicate that individuals with this
condition have an internal syndrome. It might therefore be relevant to clarify this point in
DSM-V).

Criterion B
DSM-IV notes that mental disorders are associated with distress, disability, or a significantly
increased risk of suffering death, pain, disability, or an important loss of freedom. It also
gives an example of distress and defines disability as impairment in one or more important
areas of functioning.

We recommend that distress and impairment in functioning be retained in criterion B.

Psychological distress is central to many mental disorders, especially those considered
“internalizing disorders” (such as depression and anxiety disorders). Including disability in
this criterion is needed to identify individuals who need treatment but whose symptoms may
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not cause them emotional distress. Indeed, it may be argued that distress and disability are
not merely associated with the symptoms of a disorder, but they are a result of the disorder,
and we suggest emphasizing this causal relationship (Wakefield, 1992; Spitzer et al., 1982).

The definition notes that disability consists of impairment in one or more important areas of
functioning; these areas include domains such as occupational, academic, social (including
interpersonal), and role functioning. (One set of disorders in DSM-IV-TR that might not, at
first glance, be considered to be characterized by distress or impairment are the paraphilias.
However, it could be said that symptoms of paraphilias reflect a disturbance in interpersonal
functioning). Because distress and impairment in functioning can vary in terms of degree
and severity (i.e., they are dimensional constructs), we suggest modifying these terms with
the phrase “clinically significant” to help differentiate impairment indicative of a disorder
from milder distress or difficulty in functioning which may not warrant clinical attention or
treatment.

This “clinical significance criterion” (Spitzer & Wakefield, 1999) has been subjected to
criticism when used as one of the operational criteria for individual disorders. One criticism
is that this criterion does not appear to be widely used in other areas of medicine and is
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difficult to operationalize (e.g., distress is a highly subjective construct). Nevertheless, we

would argue that medical disorders typically implicitly require a judgment that the condition
is distressing (e.g., painful) or impairing in some way. Given that we do not have objective
biomarkers that adequately define most psychiatric/mental disorders, the clinical
significance criterion remains useful in differentiating disorder from normality.

Regarding the phrase pertaining to “increased risk,” risk factors are important to bear in
mind and perhaps even to treat (indeed, the full title of the ICD-10 is “International
Classification of Disease and Health Related Problems,” with the latter phrase including risk
factors for disease such as hypertension); perhaps DSM-V should consider an analogous
extension to its title. A full consideration of this issue is beyond the scope of this editorial;
diagnosis and treatment of risk factors for psychiatric disorders is appropriately a
contentious area, where advantages and disadvantages must be carefully weighed. At the
same time, we would note that disorder and risk factors should not be conflated. The phrase

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“loss of freedom” can be derived from the concept of disability – i.e. disability involves one
or more losses of freedom (Wakefield, 1992). We therefore tentatively suggest simplifying
this criterion by omitting the phrase on risk and on loss of freedom for the sake of clarity.
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We recognize, however, that limiting the classification to deal with disorders only may well
be unduly restrictive.

Criterion C
DSM-IV notes that disorders must not be an expectable and culturally sanctioned response
to a particular event, for example, the death of a loved one. Although it may be difficult to
define the term “expectable,” it is important to retain an emphasis on exploring the context
of symptoms, and so we suggest retaining this term. Certainly, not all responses to common
stressors and losses are optimally conceptualized as disorders (even if clinical intervention is
useful for some of these responses), and we suggest clarifying the criterion to emphasize this
point.

Part of the context of symptoms, is their cultural context. We agree that it is important
therefore, in addition, to retain the idea that culturally sanctioned responses to events are not
considered a mental disorder. An example of this is expectable and culturally sanctioned
trance states in religious rituals, and we suggest adding this example in parentheses.

The example in DSM-IV of death of a loved one exemplifies the difficulty in reaching a
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judgment about what is expectable. The boundaries between normal and pathological
bereavement are complex and contentious (Kendler, Myers, & Zisook, 2008). Although
bereavement symptoms may be expectable (and culturally sanctioned), studies indicate an
association between such symptoms and distress/impairment, and that bereavement
symptoms can be modified by clinical intervention. Kendler and colleagues (2008) have
noted that the similarities between bereavement-related depression and depression related to
other stressful life events substantially outweigh their differences, results that are consistent
with a detailed review of the prior literature on this subject (Zisook & Kendler, 2007).

Along these lines, while it may be useful for clinicians to distinguish between common
response to stressors and losses (that are distressing, but likely to be self-limiting, without
high risk of persistent clinically significant distress or impairment) and mental/psychiatric
disorders (as defined here), common distressing reactions to common stressors and losses do
carry an incremental risk of complications, including the development of mental/psychiatric
disorders. Furthermore, people experiencing such normal responses may well present for
evaluation and treatment, and they may be helped by a brief intervention such as
psychotherapy and monitoring (so that once again, the ICD-10 title of “disease and health
related problems” has advantages).
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Criterion D
DSM-IV refers to behavioral, psychological or biological dysfunction. The term dysfunction
can be understood in a statistical way, meaning deviance from a statistical norm (Boorse,
1976), or in an evolutionary framework, meaning deviance from functioning as selected for
(Wakefield, 1992). Both of these so-called naturalist approaches are controversial in various
ways (Bolton, 2008). One problem with the evolutionary theoretic approach to defining
disorder, for example, is that it would involve speculative theoretical assumptions about
what syndromes did or did not represent a failure of evolutionary selected psychological or
behavioral mechanisms, which would adversely affect reliability of diagnosis.

An alternative way of understanding “dysfunction” is in terms of the consequences of the

syndrome, specifically that it leads to or is associated with distress and disability. A related
possibility is to define “dysfunction” as a functioning for the worse, a proposal which

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requires that the context of symptoms be closely examined and appraised against the
patient’s life values and goals (Fulford, 1999). Similarly, it has been argued that the notion
of “dysfunction” draws on particular metaphors of disorder; there is no algorithm that
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specifies fully the use of the term, rather appropriate use requires careful judgment (Stein,
2008). Certainly, as other authors have also pointed out (Horwitz, V et al., 2007), context is
a key issue in determining whether disorder is present (consider, for example, antisocial
behavior in the context of adolescent gangs in some urban areas, where it may be adaptive to
join a gang, but where this requires participating in a range of behaviors listed in the
diagnostic criteria for conduct disorder). A key aspect of context is the developmental stage
of the individual; the boundaries between function and dysfunction change over time, and
might also be viewed differently by different caregivers (e.g., parents versus teachers).
Another possibility is to use a different term, such as “disturbance”, rather than
“dysfunction,” as it is not associated with particular theories of function, and is used in some
diagnostic criteria sets. This would not, however, resolve the difficulties involved in
specifying appropriate use of the term.

The concept that a disturbance is behavioral, psychological, or biological may be taken to

imply that there are different levels or types of disturbance. There is a growing awareness of
the extent to which all behavior and psychology are dependent upon brain processes, and the
extent to which brain changes have complex behavioral and psychological effects. The term
“psychobiological” emphasizes the extent to which these different types and levels of
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dysfunction are intertwined in reality, and we therefore recommend incorporating it into the
criterion.

Criterion E
DSM-IV requires that deviant behavior and conflicts between the individual and society
should not be regarded as disorder, unless they can be shown to be a symptom of
dysfunction in the individual. This criterion is arguably not strictly necessary, in that
criterion D already indicates that there is dysfunction. Nevertheless, because of the
difficulties in specifying fully appropriate use of this term, and because psychiatric
diagnoses have been used for political purposes in the past and potential future misuse
cannot be ruled out, we suggest, as a precaution, retaining the first part of this criterion. To
simplify this criterion, we suggest deleting the second part of the DSM-IV definition
because the concept of dysfunction in the individual is already covered by prior criteria, and
addition of the word “solely” more succinctly conveys the intended point.

Criterion F and G
We suggest adding two more criteria to define an individual mental/psychiatric disorder.
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First, any disorder in DSM should have diagnostic validity (criterion F), on the basis of one
or more key validators (e.g., prognostic significance, evidence of psychobiological
disruption, or prediction of response to treatment). Although we conceptually require
psychobiological dysfunction (criterion D), in the absence of strong empirical evidence for
this, other evidence of diagnostic validity is needed. Evidence for diagnostic validity of
different conditions is variable, reflecting in part the amount of research that has been done
on each condition. DSM-IV had an Appendix for disorders requiring further research, this
provides a place for disorders with weaker validating evidence and may encourage such
validation; we would therefore argue for retaining such an appendix in DSM-V, and
possibly expanding it with poorly-validated DSM-IV categories.

Second, any disorder in DSM should have clinical utility (criterion G) (First et al., 2004).
That is, we suggest that receipt of a DSM-V diagnosis needs to convey something important
about that individual that is relevant in a treatment setting. Our diagnoses should “do work

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in the world” and provide useful information about individuals so classified (Kendler, 1990).
Diagnosis should facilitate the process of patient evaluation and treatment rather than hinder
it. In this regard, it is notable that considerations of clinical utility may vary from setting to
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setting; DSM-V requires a balancing of such considerations, so that optimal utility is

achieved across more specialized settings and primary care settings.

Criteria H, I, and J
DSM-IV usefully noted that no definition adequately specifies precise boundaries for the
concept of mental/psychiatric l disorder. A large philosophical literature supports this point
(Fulford et al., 2006; Stein, 2008), and we agree with the retention of this part of criterion H.
However, we would also add that no definition of which we are aware adequately specifies
precise boundaries for the concept of non-psychiatric medical disorder either.

Ongoing discussions address how best to organize the DSM classification. In criterion I, we
have noted that considerations about diagnostic validation and clinical utility should help
differentiate disorders from diagnostic “nearest neighbors.”

The issue of the value-laden nature of defining disorders has received a good deal of
attention in the philosophical literature (Fulford, 1989; Sadler, 2005; Bolton, 2008). We
suggest acknowledging in criterion J that values inform nosological decisions and specifying
that potential benefits should outweigh potential harms when considering whether to add a
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psychiatric disorder to, or delete a psychiatric disorder from, the nomenclature.

Conclusion
The explicit DSM-IV position that mental/psychiatric disorders cannot easily be precisely
operationally defined seems basically correct. On the other hand, the position of the DSM
process, that our classification system can improve over time as the scientific knowledge
base progresses, also seems correct. The situation in psychiatry is reminiscent of some other
areas of medicine, where there are also shifting boundaries between normality and
abnormality, with evidence-based changes made over time. It is also redolent of many areas
of biology, where there may be fuzzy boundaries between constructs (e.g., species), again
with evidence-based advances in classification made over time (Stein, 2008; Kendler, 2009).

Contrasting philosophical stances to a number of nosological issues have been identified

previously, for example contrasting objectivist and evaluativist, internalist and externalist,
entity and agent, and categorical and dimensional perspectives (Zachar & Kendler, 2007).
The approach taken here perhaps takes a middle course through some of these debates. For
example, we would argue that although gaps in current science mean that a descriptivist
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position is important (focusing on the symptoms and course of a disorder, rather than merely
on its underlying mechanisms), current understandings of psychobiology may usefully
inform certain nosological decisions. Disorders cannot be perfectly defined in necessary and
sufficient terms, and there are likely to be particularly robust disagreements about more
atypical categories. At the same time, disorders are more than mere “labels,” and progress
towards a more scientifically valid and more clinically useful nomenclature is possible.
Similarly, we hope that our proposals here, although not providing an absolute definition of
mental/psychiatric disorder, do help progress the debate towards a more scientifically valid
and more clinically useful definition.

Acknowledgments
We thank Dr Roberto Lewis-Fernandez and Dr Danny Pine for their comments on an earlier version of this
editorial.

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Table 1
DSM-IV Definition of Mental Disorder
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Features
A a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual
B is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of
functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom
C must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one
D a manifestation of a behavioral, psychological, or biological dysfunction in the individual
E neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are
mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual

Other Considerations
F no definition adequately specifies precise boundaries for the concept of “mental disorder”
G the concept of mental disorder (like many other concepts in medicine and science) lacks a consistent operational definition that
covers all situations
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Table 2
DSM-V Proposal for the Definition of Mental/Psychiatric Disorder
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Features
A a behavioral or psychological syndrome or pattern that occurs in an individual
B the consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more
important areas of functioning)
C must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally
sanctioned response to a particular event (for example, trance states in religious rituals)
D that reflects an underlying psychobiological dysfunction
E that is not solely a result of social deviance or conflicts with society
F that has diagnostic validity using one or more sets of diagnostic validators (e.g., prognostic significance, psychobiological
disruption, response to treatment)
G that has clinical utility (for example, contributes to better conceptualization of diagnoses, or to better assessment and treatment)

Other Considerations
H no definition perfectly specifies precise boundaries for the concept of either “medical disorder” or “mental/psychiatric disorder”
I diagnostic validators and clinical utility should help differentiate a disorder from diagnostic “nearest neighbors”
J when considering whether to add a psychiatric condition to the nomenclature, or delete a psychiatric condition from the
nomenclature, potential benefits (for example, provide better patient care, stimulate new research) should outweigh potential
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harms (for example, hurt particular individuals, be subject to misuse)

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