The concept of mental disorder: diagnostic implications of the

harmful dysfunction analysis

ABSTRACT
The concept of mental disorder is at the foundation of psychiatry as a medical
discipline, at the heart of scholarly and public disputes about which mental conditions
should be classified as pathological and which as normal suffering or problems of living,
and has ramifications for psychiatric diagnosis, research, and policy. Although both
normal and disordered conditions may warrant treatment, and although psychiatry
arguably has other functions beyond the treatment of disorder, still there exists
widespread concern that spurious attributions of disorder may be biasing prognosis and
treatment selection, creating stigma, and even interfering with normal healing processes.
However, no consensus exists on the meaning of "mental disorder". The upcoming
revisions of the DSM-IV and ICD-10 offer an opportunity to confront these conceptual
issues and improve the validity of psychiatric diagnosis.
I approach this problem via a conceptual analysis that asks: what do we mean
when we say that a problematic mental condition, such as adolescent antisocial behavior,
a child's defiant behavior toward a parent, intense sadness, intense worry, intense
shyness, failure to learn to read, or heavy use of illicit drugs, is not merely a form of
normal, albeit undesirable and painful, human functioning, but indicative of psychiatric
disorder? The credibility and even the coherence of psychiatry as a medical discipline
depends on there being a persuasive answer to this question. The answer requires an
account of the concept of disorder that generally guides such judgments.
Among existing analyses of "mental disorder", a basic division is between value
and scientific approaches. As Kendell put it: "The most fundamental issue, and also the
most contentious one, is whether disease and illness are normative concepts based on
value judgments, or whether they are valuefree scientific terms; in other words, whether
they are biomedical terms or sociopolitical ones" (1). I have proposed a hybrid account,
the "harmful dysfunction" (HD) analysis of the concept of mental disorder (2-8).
According to the HD analysis, a disorder is a harmful dysfunction, where "harmful" is a
value term, referring to conditions judged negative by sociocultural standards, and
"dysfunction" is a scientific factual term, referring to failure of biologically designed
functioning. In modern science, "dysfunction" is ultimately anchored in evolutionary
biology and refers to failure of an internal mechanism to perform one of its naturally
selected functions.
In this article, I explore the consider- able explanatory power of the HD analysis
for understanding the distinction between mental disorder and other problematic mental
conditions. I also illustrate the implications of the analysis for assessing the validity of
DSM and ICD diagnostic criteria, and for understanding some of the conceptual
challenges in applying diagnostic criteria across cultures, using the example of
transplantation of DSM criteria to Taiwan.
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WHY PSYCHIATRY CAN'T ESCAPE THE CONCEPT OF

MENTAL DISORDER
 The diagnostic criteria of the DSM and the ICD are currently the primary arbiters
of what is disordered vs. nondisordered in most clinical practice and research. But they
are clearly not conceptually final arbiters. The criteria are regularly revised to make them
more valid in indicating disorder and to eliminate false positives, implicitly recognizing
that "errors" in the criteria are possible. Moreover, both the popular press and critics
within the mental health professions challenge the validity of the criteria in picking out
mental disorder, and these disputes do not seem entirely arbitrary, but rather often seem
to appeal to an underlying shared notion of disorder. Indeed, professionals often classify
conditions using the "not otherwise specified" category, which requires a sense of what
is and is not a disorder independent of specific diagnostic criteria.
Granting the common observation that there is no "gold standard" laboratory test
or physiological indicator for mental disorders and that current criteria are fallible, it
might still be asked: why must we grapple with the elusive concept of disorder itself
when there are so many empirical techniques for identifying disorders? The reality is
that all of the tests that are commonly used to distinguish disorder from nondisorder rest
on implicit assumptions about the concept of disorder; otherwise, it is not clear whether
the test is distinguishing disorder from nondisorder, one disorder from another disorder,
or one nondisordered condition from another. Common tests of validity such as
statistical deviance, family history/genetic loading, predictive validity, Kendell's
discontinuity of distribution, factor analytic validity, construct validity, syndromal co-
occurrence of symptoms, response to medication, Robins and Guze criteria, Meehl's
taxometric analysis, and all other such guides can identify a valid construct and separate
one such construct from another. But whether the distinguished constructs are disorder
versus nondisorder goes beyond the test's capabilities. Every such test is equally satisfied
by myriad normal as well as disordered conditions. Even the currently popular (in the
U.S.) use of role impairment does not inherently distinguish disorder from nondisorder
(and for this reason is generally avoided by the ICD), because there are many normal
conditions, from sleep and fatigue to grief and terror, that not only impair routine role
functioning but are biologically designed to do so. It only seems as though these various
kinds of empirical criteria provide a stand-alone standard for disorder, because they are
used within a context in which disorders - in some background conceptual sense - are
already implicitly and independently inferred to exist, and the issue is simply to
distinguish among disorders or to distinguish disorder from normality. This essential
background assumption itself depends on the concept of disorder being deployed
independently of the specific empirical test. Thus, there is no substitute for the concept
of mental disorder as the ultimate standard. None of our empirical approaches work
without a warrant in a conceptual analysis of disorder.
A further reason why we must rely on the concept of disorder is the lack of
definitive etiological understanding of mental disorder and the consequent theoretical
fragmentation of psychiatry, and thus the decision in the DSM and the ICD to provide
theory-neutral criteria for diagnosing disorders. Etiological theory (e.g., return of the
repressed, irrational ideas, serotonin deficit) would generally provide ways to distinguish
disorder from nondisorder in a more developed science. The need to rely for now on
theory-neutral criteria means that the concept of disorder itself, which is to some extent
shared by various theories, offers the best way of judging whether a theory-neutral
diagnostic criteria set picks out disorders rather than normal conditions (i.e.,
is conceptually valid) (2). Theory-neutral criteria work to the extent that they adhere to
an implicit understanding of disorder versus nondisorder that is shared across most
theoretical perspectives and allows a provisional basis for shared identification of
disorders for research purposes.
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ASSUMPTIONS UNDERLYING THE ANALYSIS OF MENTAL

DISORDER
The HD analysis departs from two observations: first, the concept of "disorder"
has been around in physical medicine and applied to some mental conditions for
millennia and is broadly understood by lay people and professionals; and, second, a
central goal of an analysis of "mental disorder" is to clarify and reveal the degree of
legitimacy in psychiatry's claims to be a truly medical discipline rather than, as
antipsychiatrists and others have claimed, a social control institution masquerading as a
medical discipline. The approach to defining "mental disorder" that seems most relevant
to the latter goal is a conceptual analysis of the existing meaning of "disorder" as it is
generally understood in medicine and society in general, with a focus on whether and
how this concept applies to the mental domain. The claim of psychiatry to be a medical
discipline depends on there being genuine mental disorders in the same sense of
"disorder" that is used in physical medicine. Any proposal to define "mental disorder" in
a way unique to psychiatry that does not fall under the broader medical concept of
disorder would fail to address this issue. Part of the challenge in resolving this issue is
that the medical concept of disorder is itself subject to ongoing dispute. The HD analysis
is aimed at addressing this challenge.
Because the analysis here ultimately concerns the general concept of disorder as
applied to both mental and physical conditions, examples from both mental and physical
domains are used to test the analysis. I use "internal mechanism" as a general term to
refer both to physical structures and organs as well as to mental structures and
dispositions, such as motivational, cognitive, affective, and perceptual mechanisms.
Some writers distinguish between "disorder", "disease", and "illness"; I focus on
"disorder" as the broader term that covers both traumatic injuries and diseases/illnesses,
thus being closer to the overall concept of medical pathology.
I focus on the question of what makes a mental condition a disorder; I do not
address how to delineate mental versus physical disorders. For present purposes, mental
processes are simply those like emotion, thought, perception, motivation, language, and
intentional action. There is no intended Cartesian implication about any special
ontological status of the mental; it is just an identified set of functions and processes.
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THE VALUE COMPONENT OF "DISORDER"

As traditional value accounts suggest, a condition is a mental disorder only if it is
harmful according to social values and thus at least potentially warrants medical
attention. Medicine in general, and psychiatry in particular, are irrevocably value-based
professions. "Harm" is construed broadly here to include all negative conditions.
 Both lay and professional classificatory behaviors demonstrate that the concept of
mental disorder contains a value component. For example, inability to learn to read due
to a dysfunction in the corpus callosum (assuming that this theory of some forms of
dyslexia is correct) is harmful in literate societies, but not harmful in preliterate societies,
where reading is not a skill that is taught or valued, and thus not a disorder in those
societies. Most people have what physicians call "benign anomalies", that is, minor
malformations that are the result of genetic or developmental errors but that cause no
significant problem, and such anomalies are not considered disorders. For example,
benign angiomas are small blood vessels whose growth has gone awry, leading them to
connect to the skin, but, because they are not harmful, they are not considered disorders.
The requirement that there be harm also accounts for why simple albinism, heart
position reversal, and fused toes are not generally considered disorders, even though
each results from an abnormal breakdown in the way some mechanism is designed to
function. Purely scientific accounts of "disorder", even those based on evolutionary
function as is the analysis below (9-11), fail to address this value component.
In the DSM and ICD diagnostic criteria, the symptoms and clinical significance
requirement generally ensure harm and that the condition is negatively valued. The
dispute remains about whether "mental disorder" is purely evaluative or contains a
significant factual component that can discriminate a potential domain of negative
conditions that are disorders from those that are nondisorders.
There are many negative conditions that are not disorders, and many of them
contain symptoms and are clinically significant in that they cause distress or role
impairment (e.g., grief). The distinction between disorders and nondisorders thus seems
to depend on some further criterion.
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THE FACTUAL COMPONENT OF "DISORDER"

Contrary to those who maintain that a mental disorder is simply a socially
disapproved mental condition (12,13), "mental disorder" as commonly used is just one
category of the many negative mental conditions that can afflict a person. One needs an
additional factual component to distinguish disorders from the many other negative
mental conditions not considered disorders, such as ignorance, lack of skill, lack of
talent, low intelligence, illiteracy, criminality, bad manners, foolishness, and moral
weakness.
Indeed, both professionals and laypersons distinguish between quite similar
negative conditions as disorders versus nondisorders. For example, illiteracy is not in
itself considered a disorder, even though it is disvalued and harmful in our society, but a
similar condition that is believed to be due to lack of ability to learn to read because of
some internal neurological flaw or psychological inhibition is considered a disorder.
Male inclinations to aggressiveness and inclination to sexual infidelity are considered
negative but not generally considered disorders because they are seen as the result of
natural functioning, although similar compulsive motivational conditions are seen as
disorders. Grief is seen as normal, whereas similarly intense sadness not triggered by
real loss is seen as disordered. A pure value account of "disorder" does not explain such
distinctions among negative conditions.
 Moreover, we often adjust our views of disorder based on cross-cultural evidence
that may go against our values. For example, U.S. culture does not value polygamy, but
we judge that it is not a failure of natural functioning, thus not disordered, based partly
on cross-cultural data.
The challenge, then, is to elucidate the factual component. Based on common
usage in the literature, I call this factual component a "dysfunction". What, then, is a
dysfunction? An obvious place to begin is with the supposition that a dysfunction
implies an unfulfilled function, that is, a failure of some mechanism in the organism to
perform its function. However, not all uses of "function" and "dysfunction" are relevant.
The medically relevant sense of "dysfunction" is clearly not the colloquial sense in
which the term refers to failure of an individual to perform well in a social role or in a
given environment, as in assertions like "I'm in a dysfunctional relationship" or
"discomfort with hierarchical power structures is dysfunctional in today's corporate
environment". These kinds of problems need not be individual disorders. A disorder is
different from a failure to function in a socially or personally preferred manner precisely
because a dysfunction exists only when something has gone wrong with functioning, so
that a mechanism cannot perform as it is naturally (i.e., independently of human
intentions) supposed to perform.
Presumably, then, the functions that are relevant are "natural functions", about
which concept there is a large literature (12-27). Such functions are frequently attributed
to inferred mental mechanisms that may remain to be identified, and failures labeled
dysfunctions. For example, a natural function of the perceptual apparatus is to convey
roughly accurate information about the immediate environment, so gross hallucinations
indicate dysfunction. Some cognitive mechanisms have the function of providing the
person with the capacity for a degree of rationality as expressed in deductive, inductive,
and means-end reasoning, so it is a dysfunction when the capacity for such reasoning
breaks down, as in severe psychotic states.
The function of a mechanism is important because of its distinctive form of
explanatory power; the existence and structure of the mechanism is explained by
reference to the mechanism's effects. For example, the heart's effect of pumping the
blood is also part of the heart's explanation, in that one can legitimately answer a
question like "why do we have hearts?" or "why do hearts exist?" with "because hearts
pump the blood". The effect of pumping the blood also enters into explanations of the
detailed structure and activity of the heart. Talk of "design" and "purpose" in the case of
naturally occurring mechanisms is just a metaphorical way of referring to this unique
explanatory property that the effects of a mechanism explain the mechanism. So,
"natural function" can be analyzed as follows: a natural function of an organ or other
mechanism is an effect of the organ or mechanism that enters into an explanation of the
existence, structure, or activity of the organ or mechanism. A "dysfunction" exists when
an internal mechanism is unable to perform one of its natural functions (this is only a
first approximation to a full analysis; there are additional issues in the analysis of
"function" that cannot be dealt with here (8,21,24)).
The above analysis applies equally well to the natural functions of mental
mechanisms. Like artifacts and organs, mental mechanisms, such as cognitive, linguistic,
perceptual, affective, and motivational mechanisms, have such strikingly beneficial
effects and depend on such complex and harmonious interactions that the effects cannot
be entirely accidental. Thus, functional explanations of mental mechanisms are
sometimes justified by what we know about how people manage to survive and
reproduce. For example, a function of linguistic mechanisms is to provide a capacity for
communication, a function of the fear response is to avoid danger, and a function of
tiredness is to bring about rest and sleep. These functional explanations yield ascriptions
of dysfunctions when respective mechanisms fail to perform their functions, as in
aphasia, phobia, and insomnia, respectively.
"Dysfunction" is thus a purely factual scientific concept. However, discovering
what in fact is natural or dysfunctional (and thus what is disordered) may be difficult and
may be subject to scientific controversy, especially with respect to mental mechanisms,
about which we are still largely ignorant. This ignorance is part of the reason for the high
degree of confusion and controversy concerning which conditions are really mental
disorders. However, functional explanations can be plausible and useful even when little
is known about the actual nature of a mechanism or even about the nature of a function.
For example, we know little about the mechanisms underlying sleep, and little about the
functions of sleep, but circumstantial evidence persuades us that sleep is a normal,
biologically designed phenomenon and not (despite the fact that it incapacitates us for
roughly onethird of our lives) a disorder; the circumstantial evidence enables us to
distinguish some normal versus disordered conditions related to sleep despite our
ignorance.
Obviously, one can go wrong in such explanatory attempts; what seems
nonaccidental may turn out to be accidental. Moreover, cultural preconceptions may
easily influence one's judgment about what is biologically natural. But, often one is
right, and one is making a factual claim that can be defeated by evidence. Functional
explanatory hypotheses communicate complex knowledge that may not be so easily and
efficiently communicated in any other way.
Today, evolutionary theory provides the best explanation of how a mechanism's
effects can explain the mechanism's presence and structure. In brief, those mechanisms
that had effects on the organism that contributed to the organism's reproductive success
over enough generations thereby increased in frequency and hence were "naturally
selected" and exist in today's organisms. Thus, an explanation of a mechanism in terms
of its natural function may be considered a roundabout way of referring to a causal
explanation in terms of natural selection. Since natural selection is the only known
means by which an effect can explain a naturally occurring mechanism that provides it,
evolutionary explanations presumably underlie all correct ascriptions of natural
functions. Consequently, an evolutionary approach to mental functioning (7,24) is
central to an understanding of psychopathology.
One might object that what goes wrong in disorders is sometimes a social function
that has nothing to do with natural, universal categories. For example, reading disorders
seem to be failures of a social function, because there is nothing natural or designed
about reading. However, illiteracy involves the very same kind of harm as reading
disorder, yet it is not considered a disorder. Inability to read is only considered indicative
of disorder when circumstances suggest that the reason for the inability lies in a failure
of some brain or psychological mechanism to perform its natural function. There are
many failures of individuals to fulfill social functions, and they are not considered
disorders unless they are attributed to a failed natural function.
 If one looks down the list of disorders in the DSM, it is apparent that by and large
it is a list of the various ways that something can go wrong with the seemingly designed
features of the mind. Very roughly, psychotic disorders involve failures of thought
processes to work as designed; anxiety disorders involve failures of anxiety- and fear-
generating mechanisms to work as designed; depressive disorders involve failures of
sadness and loss-response regulating mechanisms; disruptive behavior disorders of
children involve failures of socialization processes and processes underlying conscience
and social cooperation; sleep disorders involve failure of sleep processes to function
properly; sexual dysfunctions involve failures of various mechanisms involved in sexual
motivation and response; eating disorders involve failures of appetitive mechanisms, and
so on. There is a certain amount of nonsense in the DSM and criteria are often overly
inclusive. However, the vast majority of categories are inspired by conditions that even a
lay person would correctly recognize as a failure of designed functioning.
When we distinguish normal grief from pathological depression, or normal
delinquent behavior from conduct disorder, or normal criminality from antisocial
personality disorder, or normal unhappiness from adjustment disorder, or illiteracy from
reading disorder, we are implicitly using the "failure-of-designedfunction" criterion. All
of these conditions - normal and abnormal - are disvalued and harmful conditions, and
the effects of the normal and pathological conditions can be quite similar behaviorally,
yet some are considered pathological and some not. The natural-function criterion
explains these distinctions.
It bears emphasis that even biological conditions that are harmful in the current
environment are not considered disorders if they are considered designed features. For
example, the taste preference for fat is not considered a disorder, even though in today's
foodrich environment it may kill you, because it is considered a designed feature that
helped us to obtain needed calories in a previous food-scarce environment. Higher
average male aggressiveness is not considered a mass disorder of men even though in
today's society it is arguably harmful, because it is considered the way men are designed
(of course, there are aggressiveness disorders; here as elsewhere, individuals may have
disordered responses of designed features).
In sum, a mental disorder is a harmful mental dysfunction. If the HD analysis is
correct, then a society's categories of mental disorder offer two pieces of information.
First, they indicate a value judgment that the society considers the condition negative or
harmful. Second, they make the factual claim that the harm is due to a failure of the
mind to work as designed; this claim may be correct or incorrect, but in any event
reveals what the society thinks about the natural or designed working of the human
mind.
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IMPLICATIONS OF THE HD ANALYSIS FOR VALIDITY OF

DIAGNOSTIC CRITERIA
One of the disadvantages of pure social- constructivist views of mental disorder,
like antipsychiatric views, is that they offer no place to stand from which to critique
current diagnostic criteria and to improve their validity. Once one has a conceptual
analysis of disorder that offers a "place to stand" in evaluating whether diagnostic
criteria identify disorders, one can consider whether current criteria get the intended
distinction right. A distinction central to an adequate assessment is whether the client's
problem is a mental disorder or a problem in living that involves a normal though
problematic reaction to stressful environmental conditions. The way we think about a
case may influence the treatment we think most appropriate, so that, for example,
thinking of a client's condition as a mental disorder tends to suggest that something is
wrong internally and that the locus of intervention should be the client's mental
functioning rather than the client's relationship to the environment. There are many other
potentially harmful effects of such misclassification as well, ranging from stigma to
confusing research results about etiology and treatment when disordered and
nondisordered clients are mixed together.
The international use of DSM-style symptom-based criteria to diagnose mental
disorder raises two basic challenges. The first is that symptom-based criteria themselves,
even as used within the U.S., fail to take context into account and thus fail to adequately
identify conditions due to dysfunctions. Criteria are consequently often too broad and
incorrectly include normal reactions under the "disorder" category. Here are three brief
examples from earlier work of mine (6,28).

Major depressive disorder

The DSM-IV criteria for major depressive disorder contain an exclusion for
uncomplicated bereavement (up to two months of symptoms after loss of a loved one are
allowed as normal) but no exclusions for equally normal reactions to other major losses,
such as a terminal medical diagnosis in oneself or a loved one, separation from one's
spouse, the end of an intense love affair, or loss of one's job and retirement fund.
Reactions to such losses may satisfy DSM-IV diagnostic criteria but are not necessarily
disorders. If one's reaction to such a loss includes, for example, just two weeks of
depressed mood, diminished pleasure in usual activities, insomnia, fatigue, and
diminished ability to concentrate on work tasks, then one's reaction satisfies DSM-IV
criteria for major depressive disorder, even though such a reaction need not imply
pathology any more than it does in bereavement. Clearly, the essential requirement that
there be a dysfunction in a depressive disorder - perhaps one in which loss-response
mechanisms are not responding proportionately to loss as designed - is not adequately
captured by DSM-IV criteria (29,30).
Because of these flaws, the epidemiological data on prevalence of depression can
be misleading, yielding potentially inflated estimates of the social and economic costs of
depression. Based on international epidemiological studies using symptom-based
criteria, the World Health Organization (WHO) has publicized the apparently immense
costs of depression. However, the claimed enormity of this burden relative to other
serious diseases, and the consequent influence on priorities, may result from the failure
to distinguish depressive disorders from normal sadness. The WHO calculations of
disease burden are extremely complex, but arise from two basic components: the number
of people who suffer from a condition and the amount of disability and premature death
the condition causes. The first component of burden, the frequency of the condition,
derives from symptombased definitions that estimate that 9.5% of women and 5.8% of
men suffer from depression in a 1-year period. The second component, disability, is
ordered into seven classes of increasing severity, stemming from the amount of time
lived with a disease weighted by the severity of the disease. The severity scores come
from consensual judgments of health workers from around the world that are applied to
all cases of the disease. Depression is placed in the second most severe category of
illness, behind only extremely disabling and unremitting conditions such as active
psychosis, dementia, and quadriplegia, and is considered comparable to the conditions of
paraplegia and blindness. This extreme degree of severity assumes that all cases of
depression share the depth, chronicity, and recurrence that are characteristic of the severe
conditions that health workers see in their practices. But, the epidemiological studies
encompass everyone who meets symptom criteria, a group that, due to the possible
confounding of normal sadness with disorder, may be heterogeneous to a greater degree
than clinical patients would indicate, yielding an invalid overall estimation of disease
burden. Unraveling these confusions could lead to a more optimal distribution of WHO's
health resources.

Conduct disorder
The DSM-IV diagnostic criteria for conduct disorder allow the diagnosis of
adolescents as disordered who are responding with antisocial behavior to peer pressure,
threatening environment, or abuses at home (31). For example, if a girl, attempting to
avoid escalating sexual abuse by her stepfather, lies to her parents about her whereabouts
and often stays out late at night despite their prohibitions, and then, tired during the day,
often skips school, and her academic functioning is consequently impaired, she can be
diagnosed as conduct disordered. Rebellious kids or kids who fall in with the wrong
crowd and who skip school and repetitively engage in shoplifting and vandalism also
qualify for diagnosis. However, in an acknowledgment of such problems, there is a
paragraph included in the "Specific culture, age, and gender features" section of the
DSM-IV text for conduct disorder which states that "consistent with the DSM-IV
definition of mental disorder, the conduct disorder diagnosis should be applied only
when the behavior in question is symptomatic of an underlying dysfunction within the
individual and not simply a reaction to the immediate social context". If these ideas had
been incorporated into the diagnostic criteria, many false positives could have been
eliminated. Unfortunately, in epidemiological and research contexts, such textual
nuances are likely ignored.

Social phobia
Whereas social phobia is a real disorder in which people can sometimes not
engage in the most routine social interaction, current criteria allow diagnosis when
someone is, say, intensely anxious about public speaking in front of strangers. But, it
remains unclear whether such fear is really a failure of normal functioning or rather an
expression of normal range danger signals that were adaptive in the past, when failure in
such situations could lead to ejection from the group and a consequent threat to survival.
This diagnosis seems potentially an expression of American society's high need for
people who can engage in occupations that require communicating to large groups
(32,33).
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IMPLICATIONS OF THE HD ANALYSIS FOR CROSS-

CULTURAL USE OF DIAGNOSTIC CRITERIA
 A second problem that arises in the use of symptom-based diagnostic criteria is
specific to the international context: due to local cultural conditions, the symptomatic
expression of a dysfunction, or the symptomatic indicators of dysfunction versus
normality, or the values that determine that a condition is negative, may vary for a great
number of reasons. To illustrate this problem, I return to each of the above diagnostic
categories and suggest how additional problems might occur in using the DSM criteria
for these disorders in the context of Taiwanese society.

Depression
The classic finding is that Asian populations express their depression through an
"idiom of distress" that focuses on somatic complaints rather than more mental DSM
symptoms (34,35). This poses a challenge in applying DSM criteria. However, the data
suggest that, if asked, Asian populations do often report the DSM-type symptoms as
well, so that this may be an issue of self-presentation rather than actual variation in the
symptomatic expression of a dysfunction. Another issue concerns gender expectations:
in Taiwan (especially among older generations), even more than in the U.S., the woman
is expected to have primary responsibility for the home, which can be constraining. Folk
understanding of female versus male nature tends to allow for a large amount of normal
expression of depressive-like misery expressed by women as part of their "natural" life
situation and innate tendencies. Different expectations apply to males. Thus, especially
in applying DSM criteria to some older women, there might be a challenge in deciding
whether the symptoms indicate a disorder (as they might in the U.S.) or are just a
culturally sanctioned normal response to difficult circumstances.

Conduct disorder
In Taiwanese society, expectations and supervision of some children and
adolescents appear to be more demanding and more rigid than in the U.S.. In some cases,
this is because of the academic testing system, in which a youth's entire future may
depend on his or her performance on a single test. These factors could affect the
interpretation of antisocial behavior in several ways. For example, early misbehavior
could more frequently be a normal response to excessive family pressure. On the other
hand, some children may not express inherent antisocial tendencies until a later age than
would be typical in U.S., because of the greater constraints of the Taiwanese cultural
environment. It is also possible that Taiwanese hold a culturally implicit theory of
adolescent development that is less accepting of youthful misbehavior as normal than is
the American implicit theory, leading to overpathologization.

Social phobia
DSM-IV criteria for social phobia require anxiety only about social interactions
with unfamiliar people. One can be perfectly comfortable with one's family and with
those one knows, but still be diagnosed with social phobia if he feels anxious in certain
situations with strangers (e.g., public speaking). There may be a strong cultural loading
here that poses challenges for the Taiwanese diagnostician. These criteria are influenced
by American culture's belief in individuality, independence from family, and open
interactions of unfamiliars. In contrast, some Taiwanese, at least of older generations,
may have been socialized to think primarily of the family as a safe haven and to see
unfamiliar people as requiring more caution. The DSM-IV criteria may potentially
pathologize what might be considered normal among Taiwanese given local
socialization. It should be emphasized that these observations may apply more to older
Taiwanese.
As these examples suggest, the HD analysis allows much room for crosscultural
variation in diagnosis due to many nuanced sources not limited to culture-specific
syndromes. However, the HD analysis also reflects the reality that cultures, whatever
their values, cannot construct disorders from whole cloth; a culture is only correct in
labeling a condition it considers undesirable as a disorder if the condition involves a
failure of biologically designed functioning. Thus, cultures can be wrong about whether
a condition is a disorder or normal, as Victorian physicians were wrong to think that
clitoral orgasm was a disorder, ante-bellum confederate U.S. physicians were wrong to
think that slaves who ran away from their slavery were disordered, and some cultures in
which schistosomiasis is endemic are wrong to think that its symptoms are part of
normal functioning.
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CONCLUSIONS
Careful attention to the concept of mental disorder that underlies psychiatry
suggests that, contrary to various critics, there is indeed a coherent medical concept of
mental disorder in which "disorder" is used precisely as it is in physical medicine. Once
this concept is made explicit, it offers a "place to stand" in evaluating whether current
symptombased DSM and ICD diagnostic criteria are accomplishing their goal of
identifying psychiatric disorders as opposed to normal problematic mental conditions. I
have argued that there is a long way to go in this regard. I suggest that the upcoming
revisions of both manuals create a formal mechanism for reviewing each diagnostic
criteria set for possible conceptual flaws leading to false positives, so that psychiatric
diagnosis need not be afflicted by manifest weaknesses that are apparent to the press and
the lay public yet go ignored by the profession.
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ACKNOWLEDGEMENT
I am grateful to Prof. Eva Lu for helpful discussions of Taiwanese culture, on
which I based my speculations. It should be cautioned that my characterizations are my
responsibility alone and may well represent a distortion or stereotype, for which I
apologize ahead of time.