The concept of mental disorder

Clinical Psychology
Clinical Psychology


Even though the concept of mental illness is essential to theory and practice in the medical and psychological field of mental health, there is no agreed-on definition of the concept among specialists and the number of comprehensive analyses on the different ways mental disorder is defined are scarce. The paper is a conceptual analysis of the concept of mental disorder and of the manner in which it influences specialists who use it in their practice and individuals who suffer from a mental condition. The purpose of this work is to review the underlying difficulties of constructing a generally accepted and correctly structured definition of mental disorder and the possible negative outcomes of expanding the notion of mental disorder in the realm of normal human behaviours and experiences. Thus, this paper tries providing a better understanding of the complexity of the concept of mental disorder and also that it will draw attention to the necessity of a balanced approach in interpreting this concept.


Table of Contents:

1. Introduction

2. Mental disorder: the boundary between normality and abnormality

3. The concept of mental disorder: Five models of interpretation

3.1 The behaviourist model

3.2 The biological model

3.3 The psycho-analytic model

3.4 The anti-psychiatric movement

3.5 The anthropological model

4. Current issues regarding the concept of mental disorder

5. Conclusions


1. Introduction

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the mental disorder is a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual that is associated with a painful symptom or an impairment in one or more areas of functioning or with significantly increased risk of suffering death, pain, disability or loss of freedom. The mental disorder is a manifestation of a behavioural, psychological or biological dysfunction in the individual, not simply a deviant behaviour from a cultural or religious perspective [1].

The concept of mental disorder has a lengthy history. From the earliest medical texts in ancient Greece to the present DSM, it has been studied, analyzed, discussed, rejected and treated. Initially, the term commonly used was insanity, an old word that defines mental alienation in its psychotic forms and that nowadays is only used in sociology and anthropology [2].

Why is reviewing the definition of the concept of mental disorder so important? History shows that the way we regard a concept has wide and profound effects on people. Throughout history, mental disorder has been defined at different times as imbalance of the bodily fluids, demonic possession, alienation or disorganization of the conscious psyche, depending on the cultural values present in society at each moment in time and on the medical and scientific progress attained until then [3]. Each definition determined a different way of treating those who were suffering from mental disorders. Current views on this concept determine the way society and governments treat those mentally disordered, diagnostic practices and the course of future research in this area.

The first section of this paper focuses on the boundary between normality and abnormality.

When discussing mental disorder, one must first define mental health and normality and abnormality. These concepts are determined by the relation between the environment and the person, which depends both on biological mechanisms and on social and cultural expectations. The analysis of normality, health and illness has to start from specifying the content of these notions, as their semantic boundaries are predisposed to synonyms that can alter their correct understanding.

The ambiguity that usually accompanies these notions can have practical consequences for everyday life. Living a good quality life involves having a good knowledge of what it means to be healthy and normal. For example, a balanced appreciation of the working capacity and the potential level of disability of individuals are essential for obtaining the necessary medical and social assistance. This would not be possible without solid reference criteria for what constitutes normality [4].

The second section of this paper presents several different models of interpretation of the concept of mental disorder. Defining mental disorder is a difficult task as the definitive causes behind most mental disorders are still unknown. Finding a consensus on this subject across cultures and among different psychopathological orientations is further being complicated by the fact that there are many different ways of interpreting health, disease and the human psyche. The criteria describing mental disorders have to be descriptive rather than etiological in order for them to gain the acceptance of clinicians of varying allegiances who thus can feel that all factions are on a level playing field in using the theory-neutral definitions.

The third section of this paper tackles present issues concerning the concept of mental disorder. The need to create a reliable system of classification in which different specialists would generally arrive at the same diagnosis based on the same information has created other problems, like an abandonment of contextual criteria in diagnosing mental disorder and a rise in the number of those who are presumably suffering from mental conditions.[1] A condition cannot be seen as a disorder just on the basis of its social undesirability or strictly on the basis of the presence of harmful symptoms. Both cultural values and the universal functional design of internal mechanisms must enter into definitions of mental disorder.

The paper ends with a set of conclusions on the topic of mental disorder and suggestions for further analysis and research that could lead to positive changes in the way mental disorder is defined.


2. Mental disorder: the boundary between normality and abnormality

The human being is an infinite and fathomless reality both in its spiritual essence and its material corporality. Despite this, its functional organized structure can be perceived from different perspectives and described in various ways. The human psyche has two main components: a biological part and a psychological one. The body and the reflexive consciousness are shaped by social and cultural factors to form a person. Every individual is unique, presenting specific particularities in perception, attitude, thinking, reaction, emotions, desires and behaviour, which make him both similar and different from everyone else. [3] The discussion concerning normality and abnormality automatically involves taking into consideration both the uniqueness of each human being and the common characteristics of all humans.

When we talk about normality and abnormality, we refer to norms, statistics, rules and laws. Health and disease are particular subjects whereas normality and abnormality are general concepts. Abnormality can be positive or negative. Positive abnormality is represented by exceptional humans, geniuses, who are abnormal in the sense that their talents and capabilities are above the norm.

There are three types of norms that sit at the basis of how normality is defined [3]:

1. The statistical norm: the more frequent a phenomenon is, the more it will be seen as something normal. While this type of norm can appear to be very objective, it is not in itself enough to help medicine define normality. Some morbid phenomena can be encountered frequently without being seen as something normal. However, in psychiatry, recognizing the most frequent attitudes and behaviours for a culture in a specific moment in time, represents a reference context for deviant manifestations.

2. The ideal norm: each culture has certain ideals regarding what it means to be normal which are expressed through prescriptive statements. Each community has standards when it comes to how a person should behave, which are perpetuated through educational models, religious laws and myths found in literature. Evidently, this is the type of normality that could never be attained; its role is mainly to provide an ideal that regulates the life of the community.

3. The functional norm: reflects the way in which the person can fulfil his or her functional role in society. According to this norm, a person is seen as normal if it is able to correctly fulfil the functions pertaining to its role, thus avoiding to negatively impacting the rest of the community.

Normal functioning is not just mere statistical commonality, because some disorders, like atherosclerosis, can be statistically normal” in a population, while still being disorders, while some normal variations can be quite rare. Its important to also make the distinction between social desirability and social values. The DSM acknowledges that an individual can be deviant or can have a nature that is in conflict with the current values of society without being disordered. In the medical sense, the demarcation line between what we consider normality and disorder is the difference between biologically designed functioning and the failure of such functioning, which we call dysfunction. If a bodily organ functions the way it was biologically design to do and how it was design to do it, like the heart pumping blood or the kidneys eliminating waste, they are considered to work normally. A disorder appears when an organ is unable to accomplish the function for which it was biologically designed.

In the same way, from a psychological point of view, the mind is made up of specific mechanisms that are designed to respond in specific ways to environmental challenges.

Psychological processes have natural functions for which they were naturally selected and in the establishment of their proper functionality, context plays an important role. For example, fear responses are supposed to appear in dangerous situations and not in safe ones. Dysfunctions appear when these mechanisms don't operate the way they are designed to do [1]. External events can so deeply affect individuals that they trigger internal dysfunctions.

It is important to note that not all disorders have physiological causes. Psychological or social factors can also lead to dysfunctions. It is possible for mental disorders to not be described as malfunctions in the physiological machinery but as malfunctions at the mental level. A computer software can malfunction while its hardware is working properly. Thus, the software of the mind can stop functioning properly without any underlying physiological cause. Any disorder can have a vast number of biological, psychological and social causes behind it [1].

All definitions of normality and pathology derive from local concepts that cannot be generalized across cultures. What some cultures view as depression, others view as normal sadness. Local cultural definitions constitute what is normal or pathological in each society. Every cultures meanings shape philosophical attitudes and personality tendencies. Disorder, according to this view, consists of whatever a culture defines as negative behaviour. Culture refers to customs, symbols, beliefs, values and norms that individuals within a group share and which makes them different from other groups. What is considered to be disorder must be analyzed within the terms of each particular cultural group [5].

Normality is often used as a synonym for health, but in fact it has a much wider sphere.

Normality refers to norms and to statistical average, while health is placed above the norm and refers to the quality of life. Normality is part of the area of remedial medicine but health is part of the area of preventive medicine. The notion of health is connected to corporality and somatic aspects, while normality is mostly used to refer to mental psychical aspects [4].

From a somatic point of view, the individual can be ill or healthy, while from a psychopathological point of view, he can he can be normal or abnormal. The idea of mental disorder has entered the common knowledge and vocabulary much later in history and the scientific categorization of mental disorders was achieved much later than physical diseases, therefore the language used to refer to notions pertaining to mental health is relatively new. Nowadays, the human being is considered a bio-psychosocial being of a complexity that requires a multidisciplinary approach in order to be fully understood [4].


3. The concept of mental disorder: Five models of interpretation

The mental disorder is a process marked by disharmony, by a level oscillation and by a disorganization of the psychological life of the person. The psyche can become ill just like the body.

A mental disorder has the same evolution like a physical disease: a cause, a clinical description, a certain evolution and a specific reaction to treatment [3]. However, there is no unanimously accepted definition of mental disorder or mental health. The causes of most mental disorders have not yet been discovered and between normality and pathology there is a vast area of disharmonies that cannot be considered mental illnesses [4].

In this section, five different models of interpretation of the concept of mental disorder will be presented. Each of them reveals a different perspective and shows the complexity involved in trying to define mental disorder.


3.1 The behaviourist model

In the behaviourist approach, the view on mental disorder is that all behaviour is the outcome of learning processes and therefore no mental disorder can actually exist. [1] Both abnormal and normal behaviours are gained and maintained through identical mechanisms by following the general laws of learning. Behaviourists reject any kind of internal cause as the ultimate cause of a specific behaviour. For them, behaviour is a result of environment influence and it's extremely important to analyze the abnormal behaviour in order to determine the environmental variables that correlate with this type of behaviour [6].

This position has led to the development of a series of techniques called cognitive therapy that can help eliminate the behaviours considered deviant, pathological and undesirable. Based on very precise rules and involving a continuous monitoring, these techniques are focused solely on the symptoms displayed by patients in their exterior behaviour. Behaviourists consider that the disappearance of the symptom after the use of cognitive therapy validates their theoretical position.

On the other hand, for those opposing the behaviourist approach, the external symptom is simply a sign of an internal conflict. This sign represents the easiest way the patient has found to partially solve that conflict. Therefore, treating just the symptom doesnt affect in any way the real cause behind it. The disappearance of the symptom that was the target of the techniques simply leads to the appearance of a new symptom which is usually even more disorganizing in the human psyche than the first. This phenomenon is known as symptom substitution [6].

In 1963, Arthur W. Staats proposes a new behavioural approach of disorders [7]: abnormal behaviour is seen as an incorrect behaviour determined by the gaps present in the educational process of the individual, by the incorrect control of the stimulus and by inadequate enforcing systems. Behavioural gaps prevent a person from correctly adapting to its social and physical environment. For example, in the case of schizophrenia, Staats considers that a person suffering from this disorder has gaps in its emotional-motivational system caused by the fact that he or she has never learned how to give intense positive emotional responses at certain stimuli previously experienced during their lifetime.

Therefore, learning the background of a patient is especially important because it is there the learning conditions that may have caused gaps can be identified. Staats has a dynamic and interactive vision over abnormality. An abnormal behaviour is produced by the environment and at the same time, the same behaviour influences the environment [7].


3.2 The biological model

The biological model of mental disorder emphasizes the influence of the morphological modifications of the nervous system in the genesis of mental disorders. The idea that mental disorders have an organic basis is not new, having been discussed as early as the 19th century when Wilhelm Griesinger wrote about mental disorders originating at the level of the nervous system, as an organic lesion, even if this lesion cannot always be discovered. He was followed by Emil Kraepelin, who applied to mental conditions a classical medical model that examined the symptoms, the course and the prognosis of disorders, in order to define distinct physical pathologies [3]. He placed psychiatry within a biomedical framework that considered mental disorders as mental manifestations of physical brain pathologies and created categories of disorders that he hoped would one day be confirmed through the identification of anatomical lesions [1]. Kraepelins work is seen as the highlight of the organics approach.

The biological approach further evolved into two main directions: psychobiology, developed by

Adolf Meyer, and organ-dynamic psychology, introduced by Henry Ey. Meyer developed his own approach towards mental disorders that focused on the personality and the capacity of the person to respond to adaptative challenges. He emphasized a contextual approach, called bio-psychosocialand reconceptualised mental disorders as impairments in the ability to respond to everyday problems. In his view, each persons unique predispositions, environmental circumstances and life experiences produced their respective conditions. Therefore, disorders were in fact maladaptative reactions that appeared as a result of a combination of social conditions and psychological predispositions, from the interactions that occurred between individual organisms and their environments [6].

Meyer claimed that mental disorders must be understood in terms of reactions and adjustments and held to a clear distinction between normal and disordered reactions, the later being identified as excessive and disproportionate. Every individual should be taken as a whole, in his psychobiological complexity. He rejected the idea that a mental disorder can be the result of either just a cerebral lesion or just a result of the environment, claiming that both causes are always present. His theories had an important influence on the development of the first DSM in the United States of America [1].


3.3 The psycho-analytic model

Sigmund Freud and his followers emphasized the psychological aetiology of all mental disorders and their continuity with normal functioning. Freud's approach of studying mental disorders was revolutionary as he sought to understand pathological symptoms in terms of unconscious mental processes rather than in terms of organic aetiologies. He wanted to show causes that were most of the time purely psychogenic, without mentioning any physical causes. Therefore, the focus was on identifying the underlying unconscious causes of mental disorders, like repressed desires or psychological conflicts. In his view, these were the ones that maintained the symptoms. Moreover, in the psychoanalytical view, the boundary between normality and disorder was blurred by the fact that psychoanalysis viewed the psychodynamics that underlie mental disorders as continuous with the psychodynamics present in normality [1].


3.4 The anti-psychiatric movement

The immense progress in medicine during the last two decades is evident in psychiatry in the development of the description and classification of mental illnesses, in the interpretation of the etio-pathological mechanisms and psychopathological significations and the innovations of psychopharmacology. Despite its exceptional methodological and scientific progress, psychiatry is still regarded as the most controversial medical field.

The anti-psychiatry movement, founded in 1957 by Thomas Szasz, questions the reality of mental disorders. Szasz declared, before technological progress made it possible to prove the contrary, that there are no mental disorders because disorders require physical lesions [1]. He considered that mental disorders are simply a myth and defined insanity as a social phenomenon.

Szasz believed that the society imposes a definition of what is considered abnormal and this definition is used to oppress those who are labelled as being mentally ill.

The psychiatrist is in this sense an instrument of oppression, the enforcer of societys notion of normality and an accomplice in defending the notion of normality that is created by society. His role is to make sure that everyone submits to the established order in the society according to the existing definitions of normality and abnormality. Szasz claimed that those we label as mentally ill have in fact much to teach us and he saw psychosis as a means towards a more profound self- discovery if it is allowed to follow its own course of development [2].

Initially, the anti-psychiatric movement helped reveal the importance of the sociological analysis and of the socio-genetic position in the determination of the causes of mental illnesses. However, in time, this movement started challenging mental health institutions and psychiatrists, who have become the target of accusations of violence and discrimination against those who are brandedas mentally ill. Anti-psychiatrists havent managed to be coherent and methodical in their endeavours and to provide new models in exchange for those they consider to be wrong, thus becoming an antiscientific and anti-medical movement that goes against the best interests of society. The reality of mental illness, organic and transcultural correlations, the suffering and alienation that those who are mentally ill experience and their real need of help are the truths on which psychiatry and psychopathology operate in an efficient way [8].


3.5 The anthropological model

Anthropologists claim that distinctions between normal and abnormal functioning are purely cultural and therefore arbitrary [1]. During the last years, the emphasis of the anthropological model has been on cultural relativism and on the power of cultural meaning systems to shape human experience, in the detriment of studying the underlying universal structures across cultures that could show common factors in the suffering of all disordered people. Anthropologists currently promote the idea that the concept of mental illness used in the Western world should not be imposed upon other cultures, where mental disorders are perceived differently. They have embraced a relativistic view according to which there is no way to apply a concept of disorder or normality beyond local cultural practices.

However, there are some universals of human nature due to humanitys common heritage and these play an important role in identifying normal and disordered conditions. Even if a concept is socially constructed, what the concept refers to is a reality. Cultures shape the particular ways a disorder is manifested but the disorder that is shaped is a universal problem. Therefore, not all definitions of normality and pathology should be viewed as culturally relative. Further development of the concept of dysfunction is a crucial step in the study of how a dysfunction interacts with cultural meanings and in the differentiation between normality and abnormality, which should lead to the establishment of stronger universal concepts regarding these notions [1].


4. Current issues regarding the concept of mental disorder

The latest editions of the DSM and the International Statistical Classification of Diseases and Related Health Problems (ICD) brought important contributions under the right assumption that there are genuine mental disorders in the strict medical sense. However, these psychiatric diagnostic manuals tend to inappropriately make social problems medical and not pay enough attention to context. Large numbers of people that are having normal human responses to various stressors are mistakenly diagnosed as disordered. The researchers conducting major epidemiological studies ove the past decades have ignored this problem, resulting in high prevalence rates of disordered people that many find unbelievable [1].

It is difficult to state exactly where the line between dysfunction and normality is to be drawn because the boundary is fuzzy. Symptoms are not enough to differentiate between a mental disorder and normality, the context of an individual and cultural and social values should be taken into account. There is a need both to recognize the complexity of conceptualizing mental disorder and for psychiatry and psychopathology to rest on firmer logical foundations [9].

An example of the current problems that arise due to flawed definitions of the mental disorder concept is the diagnosis of depression. Depression became in the 1980s the signature diagnosis of contemporary psychiatry. Allan Horwitzs work [1] in the sociology of stress led him to believe that many of the conditions that sociologists studied were similar to those that psychiatry classified as Major Depression under the criteria of DSM-IV. They were not disorders but normal human response to stressful social circumstances. Normal sadness, sadnesswith cause” is caused by experiences of loss or other painful circumstances. When there is an obvious cause of distress, the response to such normal reactions would be to offer support, to help the person cope with the loss and find a way to move on, not diagnose the sadness as mental disorder.

Mental illness has a life of its own” – patients perceive it as something foreign, out of themselves. The condition is isolated from the actual circumstances of life. The symptoms in and out of themselves are not qualitatively different from what an individual might experience after a major life disruption. The absence of an appropriate context for symptoms indicates a disorder. [1]

Depression without cause” is a medical disorder distinguished by normal sadness by the fact that the symptoms occurred despite there being no appropriate reason for them in the persons circumstances. When there are disproportional reactions to actual events, they can be assumed to stem from an internal dysfunction that requires professional attention.

The confusion is caused by the fact that this pathological condition displays the same kind of symptoms associated with intense normal sadness: insomnia, social withdrawal, loss of appetite, lack of interest in usual activities and so on. Horwitz is convinced that there are depressive conditions that are truly disordered, but there is a conceptual problem in psychiatry regarding the notion of mental disorder that leads to the misdiagnosis of depression.

The definition of mental disorder has both clinical and scientific importance. A simple definition can have substantial consequences as the society at large relies on psychiatric expertise. During the 1960s and the 1970s, there was wide criticism regarding the unreliability of psychiatric diagnosisM (different psychiatrists would diagnose differently the same person presenting the same symptoms).

Therefore, in the 1980s the DSM began to use lists of symptoms to establish clear definitions for every disorder. These DSM definitions have become the authoritative arbiter of what is considered mental disorder. These abstract definitions are the foundation of the entire mental health research and treatment industry and they have important practical consequences for individuals.

The sphere of definitional concepts is closely connected to the realm of power relations within society and its institutions. There are social factors, more than just logical ones that determine how a concept is actually exploited and deployed. During the last recent years, there has been a pressure to lower the number of symptoms that are considered sufficient criteria for diagnosing a disorder.

The fact that the concept of mental disorder contains a degree of ambiguity allows different groups to exploit it in ways that suit their own interests. For some institutions or people, a concept of mental disorder that generates high rates of pathology is advantageous, while there are other groups that gain from attacking the very existence of mental disorders in the way they are defined by clinical diagnostic instruments. The profession of psychiatry has been a beneficiary of a definition that allows it to label and treat as disorders problems that were previously nonmedical.

All professions strive to enlarge the area under their control and whenever the label of mental disorder is attached to a condition, the medical profession is the one that has claim of jurisdiction over it [1].

Those conducting research also have much to gain from this type of expansion. They can argue more persuasively for increased funding on the basis that a certain disorder is becoming more prevalent in the population. By transforming social problems into medical ones, it becomes easier to acquire funds, because in todays political climate, it is far more likely that support will be given to preventing a disease than to confronting controversial social problems [1].

Certain institutions like the World Health Organization have at the top of their agenda the destigmatization of mental disorders, which invariably leads to the expansion of the notion of mental illness to such an extent that it encompasses an ever-growing part of the population. By lowering the boundary between normality and abnormality, they hope to achieve a greater acceptability of mental disorders in the society at large.

Pharmaceutical companies, which provide medication for mental disorders, also earn profits from the enlargement of the concept of mental disorder. They are the major sponsors of research projects and advocacy groups regarding mental disorders, which in turn promote the benefits of using medication as treatments for various mental ailments. Their advertisements tend to blur the boundary between normality and disorder in order to attract large numbers of consumers.

Individuals who suffer also contribute to this state of affairs. By discovering that identifying their symptoms as those of treatable illnesses enables them to get medical help and financial benefits, and because some of them believe that the quality of their lives can actually be improved by taking certain medication, they contribute significantly to reducing the gap between normality and pathology. Such individuals can find satisfaction in embracing an image of victim because they create a socially acceptable account for their problems and gain release from taking responsibility for them [1].

The official label of mental disorder can offer access to services that may come as a relief to those who actually suffer from it, or it can lead to unnecessary stigma and rejection for those who dont. People may be undertaking unnecessary treatment and thus exacerbating and prolonging certain symptoms. A diagnosis of mental illness can make it more difficult to obtain life or health insurance, can prevent getting a job, can become a negative factor in considerations during divorce proceedings over the custody of a child, can disqualify people from participating in clinical trials for new medications, etc. [1].

The act of defining, diagnosing and treating mental disorder requires courage and responsibility. Anyone discussing the concept of mental disorder has to take into account both social constructivism and biological essentialism. The distinction between normality and disorder in biological factors while at the same time keeping social factors in mind represents the most balanced approach [9].

One of the most balanced definitions of mental disorder has been proposed by Wakefield (1992) and it is called harmful dysfunction definition [10]. Based on two criteria, it states that the term dysfunction is used as in something that has gone wrong with some internal mechanisms ability to perform one of its biologically designed functions and this dysfunction must be harmful for the individual. Of course, cultural values play an important role in defining what type of dysfunction is considered harmful. A collection of symptoms indicates a mental disorder only when it meets both of these criteria [1].


5. Conclusions

Human health is a context which defines the normality of the individual. Health is a state of balance between the biological and psychic dimensions of a person, between the internal perspective and the external one. A healthy state involves a dynamic perspective which shows the normal ways of functioning of the person at different age levels, its capacity for development, maturity and adaptation to reactive and stressful situations [3].

During the last recent years, there has been a growing interest towards the dysfunctions and disabilities that are at the border between pathology and certain unpleasant emotions like anxiety,  fear, sadness and indifference. The growing concern in modern society for mental health, seen not only as a fundamental component of general health, but also as a key element of continuous happiness and welfare, has led to the continuous development of the area of research in psychiatry and psychology [8]. The more the perspective of solutions for mental health problems widens, the more the traditional boundaries of mental illness are enlarged. Daily problems which in the past were seen as belonging to other spheres of life are now being regarded as possible medical problems. The view today is that taking care of ones mental health can provide solutions for many different personal and social problems.

However, the increasing incorporation of traumatic human suffering into the sphere of medicine presents the risk of reducing it to a mere technical problem. Generally, those involved in the research of normality and health are specialized in identifying and treating illness, therefore their image on what constitutes health and normality may be skewed. [8] Doctors seem more eager than ever to diagnose new forms of mental conditions and the pharmaceutical companies are quick to create new medication for them. With the same desire for expansion, psychotherapists of diverse therapeutic orientations are becoming more creative in how they are handling these new challenges.

Both the tendency to diagnose normal human suffering as mental disorder and the anti- psychiatric movement that renegates mental illness as a condition that requires specialized treatment are extremes that need to be avoided.

Todays main necessary adjustments in the mental health field are to formulate a clear definition of the concept of mental disorder that allows for a balanced approach in the diagnosis of mental conditions, to put ethics before the attraction of ever expanding jurisdiction, to take into consideration each cultural and social context and to reduce medical control over normal aspects of human life. The promotion of mental health remains the best way of preventing mental disorders, even in the absence of a clear consensus over the definition of a mental disorder.


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