ORIGINAL ARTICLE

The concept of mental disorder and the DSM-V

MASSIMILIANO ARAGONA

Chair of Philosophy of Psychopathology, Sapienza University, Rome, Italy

In view of the publication of the DSM-V researchers were asked to discuss the theoretical implications of the definition of mental disorders. The reasons for the use, in the DSM-III, of the term disorder instead of disease are considered. The analysis of these reasons clarifies the distinction between the general definition of disorder and its implicit, technical meaning which arises from concrete use in DSM disorders. The characteristics and limits of this technical meaning are discussed and contrasted to alternative definitions, like Wakefield’s harmful/dysfunction analysis. It is shown that Wakefield’s analysis faces internal theoretical problems in addition to practical limits for its acceptance in the DSM-V. In particular, it is shown that: a) the term dysfunction is not purely factual but intrinsically normative/evaluative; b) it is difficult to clarify what dysfunctions are in the psychiatric context (the dysfunctional mechanism involved being unknown in most cases and the use of evolutionary theory being even more problematic); c) the use of conceptual analysis and commonsense intuition to define dysfunctions leaves unsatisfied empiricists; d) it is unlikely that the authors of the DSM-V will accept Wakefield’s suggestion to revise the diagnostic criteria of any single DSM disorder in accordance with his analysis, because this is an excessively extensive change and also because this would probably reduce DSM reliability. In conclusion, it is pointed up in which sense DSM mental disorders have to be conceived as constructs, and that this undermines the realistic search for a clear-cut demarcation criterion between what is disorder and what is not.

Key words: classification, nosology, nosography, phenomenology, conceptualization, theoretical construct, mental dysfunction.

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INTRODUCTION In view of the publication of the DSM-V 2002). According to Rounsaville et al. (2002, researchers were solicited to contribute to the p.3) “the most contentious issue is whether discussion on possible changes (Kupfer et al., disease , illness , and disorder are scientific 2002). Among the basic nomenclature biomedical terms or are sociopolitical terms problems to be addressed in view of the that necessarily involve a value judgment”. In DSM-V, the first under discussion was “how effect, this is one fundamental philosophical to define mental disorder” (Rounsaville et al., problem underlying discussions on diagnostic

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systems. It should be stressed that a b) Once introduced has the term disorder discussion on the definition of mental acquired a specific, technical meaning? disorders can be focused at various levels of c) Why the DSM-V Agenda considers the abstraction. general definition of mental disorder in At the most general level, which considers need of revision? different approaches in different cultural d) May new definitions solve current contexts, a culture or society may formulate a problems? psychiatric condition in seven general ways e) Are new definitions in accordance with the (Fabrega 2005, p.224): theoretical basic principles of the DSM? 1) medical/naturalistic phenomenon; After having discussed these questions at this 2) spiritual/religious phenomenon; third level, the reader will be driven to their 3) malevolent/villainous phenomenon; implication for the upper level. Accordingly, 4) nonauthentic or malingered/fictive pheno- the final part of the paper will focus on some menon; philosophical problems arising when a strict 5) phenomenon attributed to external unwar- criterion sharply discriminating mental disorder rantable attack; from non disordered conditions is proposed; in 6) phenomenon attributed to a warrantable this context, the relativity of such a distinction punishment for wrongdoing; will be highlighted. 7) a phenomenon resulting from faulty habits or moral predicaments. THE CONSTRUCTION OF MENTAL At an intermediate level, internal to the “DISORDER” AS A TECHNICAL TERM Western culture, there are different general In order to understand why the DSM-III views about what constitute a disease (in its used the term “disorder” the nosological debate general sense, which enclose mental of the early Seventies should be considered. In disorders). Under the influence of the work of particular, studies such as the famous United Albert et al. (1988), these general views may States-United Kingdom Diagnostic Project be grouped as follows: (Kendell et al., 1971) introduced the 1) nominalism: a disease is what a profession fundamental problem of diagnostic low inter- or society labels as such; rater reliability. If different clinicians labelled 2) social idealism: deviation from the social the same patients with different diagnoses, then ideal of health; the minimal basis for any scientific activity 3) statistical: deviation from the statistical (namely, the use of technical words to mean the norms; same things/phenomena) was at risk. 4) realism: lesion and/or dysfunction of a Accordingly, nosographists worked on biological organ or system. improving reliability and, following some of At the same level is Rounsaville et al.’s Hempel’s suggestions (Hempel 1965; Schwartz (2002) work, which considers: and Wiggins 1986), they introduced in the 1) sociopolitical; classification operative diagnostic criteria 2) biomedical; aimed to provide a framework for comparison 3) combined biomedical and sociopolitical; of data gathered in different centres and to 4) ostensive types of definition of “disease or promote communication between investigators disorder”. (Feighner et al., 1972). It should be stressed The present paper will start focusing on a that the study of Feighner et al., which can be third level, internal to psychopathology, considered as the most direct forerunner of the trying to answer to questions such as the DSM-III, used the words illness , diagnostic followings: category , disorder , clinical picture , syndrome , a) Why the DSM authors decided to use the psychiatric condition as synonyms. term “disorder”?

2 DIAL PHIL MENT NEURO SCI 2009;2(1): 1-14 According to Klerman (1984) the DSM-III using general terms such as “syndrome or resulted from the felicitous union between the pattern” and “behavioural or psychological”, group of St. Louis (the authors of Feighner’s avoiding to define what is meant with criteria) and the psychometric and statistical “clinically significant” and, according to skills of Spitzer and Endicott in New York. In Rounsaville et al. (2002, p.3), failing “to define the transition form Feighner’s criteria to or explain the crucial term dysfunction ”, the DSM-III diagnoses, an apparently little but DSM renounced to specify exactly what a relevant change was the use of the term mental disorder was. Nevertheless, this was the “disorder” instead of illness or syndrome. price it had to pay in order to be widely This reflected a significant change in basic accepted, and it indubitably realised it. philosophical assumptions which, in turn, At this point, the next question to consider is: depended from changed needs. Feighner’s despite its non-specific general definition, can criteria were mainly focused on improving we ascribe to the term “disorder” a specific, reliability and admitting research data as the technical meaning? Here we need to shift from only ones allowed to guide diagnostic the explicit aforementioned definition to the decisions. This project was conceived within implicit meaning of mental disorders as it a neo-kraepelinian frame that considered emerges from their concrete use. An analysis of mental pathologies in accordance with the current crisis of the DSM classification medical pathologies. This explains why they system (Aragona, 2006) focused on the used synonymously words such as illness, following specific characteristics of mental syndrome and disorder (and also the reason disorders as they are used in the DSM: why they considered laboratory tests and 1) Descriptive approach . According to the family aggregation among their diagnostic atheoretical model, the great majority of DSM criteria). mental disorders are based on the phenomenal Compared to Feighner’s criteria, the DSM-III description of clinical manifestations had to be more careful because among its (symptoms or behaviours). Thus, mental primary goals there was its acceptability disorders usually differ from illnesses or among clinicians working in all mental diseases because within the biomedical context settings and believing in different theoretical these last two concepts are usually based on views about the etiology of psychopatho- etiopathogenesis while disorders (like logical conditions. Accordingly, a descriptive, syndromes) are based on phenomenal “atheoretical” approach was adopted together descriptions. with operative diagnostic criteria. As a 2) Use of explicit “operative” diagnostic consequence, it is likely that the term criteria . Any DSM mental disorder is “disorder” was used instead of illness or characterized by a defined set of diagnostic disease because they risked to be felt as too criteria, each with a clear, explicit definition of much medical-oriented, linked to a biological its satisfaction criteria. Once the clinician has theory about etiology. On the contrary, the controlled that the patient’s characteristics term disorder was enough general and effectively fit with those enlisted in the “atheoretical” to be widely accepted. Indeed, diagnostic criteria, the diagnosis becomes the DSM-III adopted a general definition of automatic. This characteristic discriminates “mental disorder” as a clinically significant mental disorders from classical typologies in behavioural or psychological syndrome or which the diagnostic act largely relied on the pattern that occurs in an individual and that is subjective judgment of the clinician that was associated with present distress or disability, requested to decide how much the concrete and which reflects a psychological or case was similar to the ideal typology. In the biological dysfunction in the individual case of typologies, the clinicians had to judge if (American Psychiatric Association, 1980). By the concrete patient was enough similar to the

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ideal type described in the psychiatric manual, in medical classification (Jablensky 1999). On while in the case of DSM disorders, the the contrary, the concept of disorder as it physician can only decide if the enlisted emerges from the way it was effectively used in phenomena are present or not. In fact, the the single DSM disorders is specific, and here diagnostic rules are not under his power, its distinction from the concept of disease, considering that the authors of the DSM have typology and psychopathological syndrome is decided them a-priori and the clinician is only clear-cut. expected to apply them. 3) Lack of a hierarchical ordering of SHOULD THE GENERAL DSM symptoms . With the exclusion of rare DEFINITION OF “MENTAL DISORDER” exceptions,1 DSM mental disorders do not BE CHANGED? consider qualitative differences among The previous paragraph showed that the symptoms. Indeed, all the symptoms listed in strategy of the DSM-III to define the term the symptomatological criterion (usually mental disorder generically while using named A) are equivalent. This point traces a stringent diagnostic criteria was successful: distinction from classical psychopathological both main goals of wide acceptability and syndromes, which were based on Bleuler’s increased reliability were achieved. What has it qualitative hierarchical distinction of funda- changed in the meanwhile? Why the authors of mental from accessory symptoms (Vella and the DSM-V Agenda consider the general Aragona, 2000). definition of mental disorder unsatisfactory and 4) Use of polythetic criteria with quantitative in need of revision? What are the current diagnostic thresholds. With the exception of a diagnostic problems that such a change in the few DSM-III monothetic disorders, the vast definition should resolve? majority of DSM-III disorders and all the Rounsaville et al. (2002, p.3) talk of “rising disorders of DSM-III-R and subsequent public concern about what is sometimes seen as versions were defined polythetically. In short, the progressive medicalization of all problem polythetic definitions are based on a list of behaviors and relationships” and accordingly characteristics all of which are possessed by they regard as “desirable that DSM-V should, if some members of the category, but none of at all possible, include a definition of mental which is possessed by every member of the disorder that can be used as a criterion for class. In the diagnostic field, there is a list of assessing potential candidates for inclusion in symptoms possessed by some patients with a the classification, and deletions from it”. This given disorder, none of which is fundamental. last remark is in line with Wakefield’s (1992) Hence, polythetic diagnostic criteria are early critique to the DSM-III-R concept of linked to the above mentioned lack of mental disorder which failed to validly hierarchical distinctions among symptoms distinguish disorders from non-disorders. Thus, and to the requirement of a quantitative the current diagnostic problem that a new clear diagnostic threshold (presence of a minimal general concept of mental disorder should help number of symptoms, independently from to solve is that of overdiagnosis. their quality). As an example, the symptoma- This problem arose from the evaluation of the tological criterion of the DSM mental results of two major epidemiological studies; disorders is often formalized as “X (or more) namely, the Epidemiologic Catchment Area of the following Y symptoms have to be (ECA; Robins and Regier, 1991) that used present”. DSM-III diagnoses and the National In conclusion, the general DSM definition of Comorbidity Survey (NCS; Kessler et al., disorder is a category “all-embracing”, with 1994) that used DSM-III-R disorders. Both no clear correspondence with either the surveys reported prevalence rates for psychia- concept of disease or the concept of syndrome tric disorders that many critics considered

4 DIAL PHIL MENT NEURO SCI 2009;2(1): 1-14 much too high (for example, about 30% of effect on false positives and false negatives are interviewed met criteria for at least one practical ones, which can be empirically tested, mental disorder). This higher-than-expected on the other side the last remark that what is prevalence, rather than producing new needed is a coherent and valid redefinition of pressure for greater mental health funding to mental disorders is a theoretical claim that respond to the discovered unmet need, led needs to be addressed at the level of conceptual critics to attack the DSM system itself, analysis. accused to be overly inclusive (Wakefield and Having rejected the clinically significance Spitzer 2002, pp.31-32). criterion as well as other ad hoc , case by case As a consequence, the DSM-IV Task Force strategies to address the overdiagnosis problem, decided to add a clinical significance criterion Wakefield and First (2003) suggested to adopt to the definitions of many disorders in the Wakefield’s harmful-dysfunction analysis to DSM-IV (namely half of all Axis I and Axis reformulate the DSM general definition of II disorders). When additional criteria of mental disorders. The next paragraph will focus clinical significance were applied post hoc to on this proposal. the ECA and NCS data, prevalence rates of overall mental and substance use disorders WAKEFIELD ’S HARMFUL /DYSFUNCTION showed approximately a 30% drop (Narrow et ANALYSIS al., 2002). However, this prevalence reduction Wakefield (1992) proposed to consider a was still considered unsatisfactory, because mental disorder as a harmful dysfunction, only partially successful in eliminating false where “harm” is a normative concept anchored positives (Kendell 2002, p.5) and because in social values and “dysfunction” is intended adding a significance criterion ad hoc was to be a factual concept referred to the failure of considered likely to eliminate some true cases a mechanism to perform its natural function. of mental disorder, rising false negatives rates Additionally, the dysfunction is a derangement (Wakeflield and Spitzer 2002, p.37). in a naturally selected mechanism whose Moreover, it was argued that the elimination existence or structure has to be explained via its of mild disorders from the DSM-V was a evolutionary history. This definition is the serious risk, because mild disorders are often expression of a two-stage picture of mental along a continuum of progression from a mild disorders, which claims that dysfunctions are to a more severe form of psychopathology, the purely factual basis of the diagnosis, and and because effective treatment of mild that a normative evaluation of its consequences disorders might prevent a substantial must follow in order to decide if such a proportion of future serious disorders (Kessler dysfunction is (or is not) a disorder. et al., 2003). Finally, it was stressed that In order to be accepted as the basic definition lowering the prevalence rates is not what of mental disorder in the DSM-V, the harmful- counts in redefining disorders, because this dysfunction definition should prove: should be done “in a way that is conceptually a) to be unmoved by philosophical critiques on coherent and valid” (Wakefield and Spitzer its conceptual plausibility; 2002, p.33). b) to be supported from available research data; Accordingly, Wakefield and Spitzer (2002, c) to be in accordance with the DSM require- p.33) “proceed on the assumption that ments; progress in diagnostic validity can be made d) to be of concrete aid in the solution of the only if there is a clear understanding of the overdiagnosis problem, without worsening relationships between disorder and the prior well-established DSM achievements. concepts of dysfunction, disability and Let we start from the philosophical point. As distress”. While objections to the clinical seen, Wakefield’s analysis is based on a two- significance criterion based on its expected stage picture grounded on the idea that purely

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normative and purely factual components can little is known about the cerebral mechanisms be sharply distinguished. No doubt that underlying basic psychological functions […] feeling sick, asking for a doctor, doing for it to be possible in most cases to do more something that the society disvalues as than infer the probable presence of a biological “crazy” are relevant factors in the definition dysfunction” (Rounsaville et al., 2002, pp.5-6). of what counts as mental disorder, and that Wakefield tries to escape this obvious limit many authors would agree that they are suggesting that the only relevant dysfunctional intrinsically normative.2 What is more mechanisms are those possessed “in virtue of difficult to accept is the idea that dysfunctions how human beings are designed by evolution” are “purely factual”. (Wakefield and First, 2003, p.36), but this use A first critique on this point is that a term like of evolutionary theory is even more dysfunction is intrinsically normative: it is problematic. First of all, it was stressed that already operating an intrinsic idea that a “the phylogenetic trajectory of human putative mechanism does not works properly cognition is difficult, if not impossible, to as it ought to, and that this different way to ascertain” (McNally 2001). Moreover, it was function is evaluated as negative (as a bad noted that this definition of dysfunction (as a way to function). Moreover, a second critique failure of an organ or mechanism to perform considers the way Wakefield presents the natural function for which it had been dysfunctions; for example, Fulford and designed by natural selection): Thornton (2007, p.161) stress that “by liberally employing terms like “failure”, “implies the existence of purpose-driven Wakefield shows that his definition of evolutionary processes resulting in pre-ordained, fixed structures and functions, presumably located dysfunction also has an underlying value side within the human brain. This view ignores the fact as well as the fact side he presents us with. that natural selection is an opportunistic process, […] Wakefield is able to present his not guided by purpose or design, and that its definition of “dysfunction” fact-side up, while general outcome is an increasing inter-individual all the time it is the hidden value-side that is variability […] Lastly, the assumption that neural systems within the human brain perform fixed doing the (logical) work”. cognitive or emotional functions pre-ordained by Besides these critiques on the intrinsic values natural selection ignores two widely accepted involved in the concept of dysfunction, a pieces of evidence from evolutionary biology and major problem for Wakefield is to define neuroscience: first, that some highly specialized exactly what he really means with human cognitive functions (e.g. reading or writing) evolve by piggy-backing on earlier, more primitive “dysfunctions”; here, philosophical and adaptive mechanisms, and are therefore neutral vis- empirical concerns merge together. The à-vis reproductive fitness; and secondly, that the general DSM-IV-TR definition of mental individual brain is a neural plasticity machine, in disorder was able to escape this problem, the sense that it constructs its own internal because in that context the term dysfunction cognitive architecture in post-natal development, in an activity-dependent manner, interacting with its could be defined generically leaving the environment. Thus, the thresholds of vulnerability atheoretical criteria untouched. This is not the to dysfunction of any causes vary individually to an case of Wakefield’s dysfunctions: having extent that would make the discernment of a made mental dysfunctions the necessary breakdown in a “natural function” implausible” requirement for the diagnosis of mental (Jablensky, 2007, pp.157-158). disorder, their use must rely on a clear knowledge and definition of what they are. In a similar way, it was stressed that many Wakefield’s definition is weak on this point mental functions are not direct evolutionary for two reasons: first, in most cases the adaptations, but rather by-products of adapta- dysfunctional mechanism involved is not tions which are, per se, adaptively neutral known. Accordingly, “the problem is that too (Lilienfeld and Marino, 1995), and that “natural function may not be actual function. The

6 DIAL PHIL MENT NEURO SCI 2009;2(1): 1-14 existence of many traits may be explained not atheoretical requirement of the DSM. by the increased fitness they confer but by Wakefield (1997b, p.644) seems to renounce to evolutionary conservatism. […] some ask for the abandonment of this position in physical and psychological human traits may favour of a theoretically oriented classification best be explained by the fact that they based on evolutionary theory. On the contrary, conferred some adaptive advantage on an he claims that his etiological assumption about evolutionary ancestor of ours rather than on the dysfunction of an internal mechanism “is us” (Gold and Kirmayer, 2007, p.165). not theory-laden in a sense that would Hence, if evolutionary theory is not enough to undermine DSM-IV’s theory neutrality”, thus enucleate dysfunctions, how should it be trying to let his analysis accepted into the done? Wakefield clearly stresses that our atheoretical frame of the DSM. How is it ignorance of the details of evolution is not an possible? Let we consider one typical impediment because we all have a folk Wakefield’s example: “Conduct Disorder must intuition that makes it “obvious from surface be caused by an internal dysfunction of some features” when underlying mechanisms are mechanism involved in socialization, empathy, functional or dysfunctional (Wakefield, or other prosocial behaviour” (Wakefield 1997a, p.256). Namely it is this idea, that we 1997b, p.644). Here there are two possible should be able to say when someone’s alternative interpretations: at one side, if taken psychological functions are not working in its stronger sense, the etiological assumption properly as designed just on the base of should refer to the dysfunction of a precise commonsense evaluation of surface features, mechanism. This would imply the rejection of that Murphy (2006, p.45) directly rejects: “It the DSM atheoretical requirement together with is not a priori that all causes of mental even stronger consequences: if we describe a disorder are failures to perform an evolved precise mechanism, then we know it, and in a function, nor that we can figure this out via diagnostic context this means that we know the knowledge of folk psychology”. physiopathology of the pathological condition Accordingly, Wakefield is in trouble when an under investigation. accurate determination of what are properly In turn, if we know its physiopathology we do mental dysfunctions is requested, since for the not need anymore to found the determination of majority of mental disorders neither the this pathological condition on descriptive mechanisms underlying the supposed dys- psychopathology. As a consequence, we would functions nor their evolutionary pathways are have no more a disorder (descriptively-based) sufficiently known. Thus, he gives only a but a disease (based on the physiopathology general draft of it while he uses commonsense that underlines symptoms). intuition as the final arbiter of what really However, Wakefield’s analysis cannot help in counts as dysfunctional. Critics easily this task because, as seen above, he admits that attacked his view on this point, claiming that the actual mechanisms of his dysfunctions are conceptual analysis and commonsense unknown and no precise causal mechanism is intuition should be rejected as a source of described. Accordingly, only the other possi- authority (Murphy, 2006, p.61) and asking for bility remains; namely, to refer to dysfunctional an empirically based analysis of what a mechanisms in a weaker sense, without any disorder is. definite indication of the specific mechanism Having considered some of Wakefield’s involved (dysfunctions as inferred, hypothe- harmful/dysfunction analysis shortcomings, sized entities). In this case talking of the failure we turn now to the effect it could be expected of a mechanism involved in socialization and on the process of making the DSM-V. The empathy means nothing more that Conduct first point to be considered now is the Disorder is characterized by difficulties in relationship between this analysis and the socializing and feeling empathy.

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This formulation respects the DSM-IV theory meaningful, generalizable research. We would be neutrality but it is suspect that dysfunctions back where we are with (another) change of name” are nothing more that a different way to say (Bolton, 2007, pp.164-165). the same things, thus their utility being in In sum, reliability would decrease, and question. Wakefield himself appears to be conscious of Another point to be considered is about this (at least in the case of his rules aimed to possible effects of Wakefield’s suggestions on exclude symptoms caused by a normal reaction reliability. In order to solve the overdiagnosis to environmental stressors). Coherently, he problem he recommended to introduce claims that “reliability purchased at the cost of environmental qualifiers in diagnostic criteria validity is no bargain” and he declares himself (Wakefield 1997b). For example, in major ready to sacrifice at least part of DSM depression a criterion might be: “the achievements on reliability: “increases in symptoms are not simply a proportional and validity are not only compatible with but appropriate response to negative life sometimes require decreases in reliability” circumstances or events” (Wakefield and (Wakefield 1997b, p.646). This position has Spitzer 2002). Could a similar criterion be many merits; indeed it is clear and, above all, it adopted without decreasing DSM reliability? is the result of a serious analysis of one of the The answer is not, the introduction of rules main problems of the DSM (namely, that the aimed to exclude symptoms caused by a excessive focus of the DSM on reliability led to normal reaction to environmental stressors a simplistic definition of symptoms which are would surely decrease reliability, because it often insufficient as valid indicators of would be very difficult to find clear and disorder). Nevertheless, would the authors of consensual definition/description of what is the DSM-V agree to introduce new criteria if exactly to be intended as normal reaction, they are likely to reduce reliability? It is a proportional and appropriate response and so shared view that DSM-III success was mainly on. Moreover, reliability would also be due to its ability to improve reliability. Thus, it seriously jeopardized due to Wakefield’s can be easily predicted that the authors of the evolutionary approach: DSM-V will be very cautious on the risk of

“To establish that a condition is a disorder in the decreasing reliability. sense of Wakefield’s analysis, we would have to Finally, the last point to be considered is that of establish, or at least have a consensus about, the practical effects of the adoption of whether it arose because of or at least involved Wakefield’s suggestions. Despite his claim for “failure of a natural mechanism to function as the substitution of the DSM-IV general designed in evolution”. But as opposed to what? Behavioral scientists working in an evolutionary definition of mental disorders with his harmful- theoretic framework have suggested that failure of dysfunction definition, Wakefield appears function in Wakefield’s sense as a pathway to conscious that this would have limited practical harmful conditions can be contrasted with, for effects unless it is accompanied with conse- instance, evolutionary design/current environ- quential changes of the various diagnostic mental mismatch, or maladaptive learning. If these are the kinds of intended contrasts, we need criteria: “false positives can occur if the criteria to wait until the science has been done to establish sets for specific disorders do not conform to the which types or sub-types of problems are requirements of the definition” (Wakefield and “genuine disorders” in the sense of Wakefield’s First, 2003, p.33). analysis, and which are not. And in the meantime, Accordingly, his harmful-dysfunction defini- during what might be a long wait, we would need another name for the problems, not disorders tion of disorder should “provide guidance on (which in this scenario we are interpreting in how to construct diagnostic criteria sets for Wakefield’s sense), but perhaps, for instance, individual disorders” (Wakefield and First, mental health problems , the criteria for which 2003, p.24). This coherent consequence from would have to be reliable enough for us to do the general definition of disorder to the changes

8 DIAL PHIL MENT NEURO SCI 2009;2(1): 1-14 of diagnostic criteria for specific disorders is reducing the role of the subjective judgment of among the major strengths of Wakefield’s the single evaluator). It should be stressed that proposal, tracing a distinction from ad hoc in view of the DSM-V researchers were alerted adoption of exclusion clauses aimed at single that changes in diagnostic criteria have many known cases of overdiagnosis. However, how possible disadvantages that need to be changes in individual disorders should be considered (Rounsaville et al., 2002, pp.10-11). done? And, would the authors of the DSM-V Thus, it is likely that this conservative approach be inclined to accept this kind of changes? will refuse to accept too many small changes Practically, added criteria should indicate how (at least one for any specific disorder, if disproportionate a response is to environ- Wakefield’s suggestion must be followed mental triggers; alternatively, they should coherently), especially if they are too subjective signal when a reaction occurs without and as a consequence they risk to decrease appropriate eliciting stimuli or, on the reliability. contrary, when a normal response does not Accordingly, the authors of the DSM-V could occur despite the occurrence of the specific more easily accept to introduce only the general circumstances under which such a response Wakefield’s definition of disorder (as a harmful was waited; finally, when possible they dysfunction) in the introduction of the DSM-V should identify what is supposed to be going (something in the same direction was already wrong in the involved mechanism (Wakefield done for the DSM-IV, albeit partially). This and First, 2003). Suitable examples are “the general change would be easier because it symptoms are not simply a proportional and would change only the generic definition of appropriate response to negative life disorder, without any change of the single circumstances or events” (Wakefield and diagnostic criteria (which are the core of the Spitzer 2002, p.38) or “antisocial behavior DSM system). However, as discussed above does not necessarily indicate Conduct this strategy would have no effect on the Disorder if it is simply the result of peer overdiagnosis problem, thus failing to solve pressure or a rational decision in a threatening one of the main current classification problems. or deprived environment” (Wakefield 1997b, p.644). It is undeniable that by stressing this DISCUSSION point Wakefield has the merit of having The present paper considered one of the solicited a reflection on contextual judgments basic nomenclature problems that were that any good clinicians should consider in his regarded as in need of discussion in view of the anamnesis. DSM-V, namely “how to define mental However, how might it be made operative in disorder” (Rounsaville et al., 2002). order to be accepted for DSM-V criteria? In the first part of the script it was shown that Who must decide what should be intended for the DSM concept of mental disorder is two- disproportionate? When should a response to faced. At one side, in the introduction of the a living situation be considered exaggerated, diagnostic manual there is a generic definition and who decides what is exaggerated? Who of disorder, which slightly changed in knows when stimuli are appropriated? How subsequent versions but without increasing its many specific circumstances are known that specificity. It was argued that, intentionally or in normal conditions invariably elicit a given not, the very fact that this general definition response? Are rational decisions always was non-specific helped the DSM-III in one of synonymous of normal decisions? All this its primary aims: namely, wide acceptability questions involve clinicians’ subjective among clinicians working in all mental settings, choices that are at the antipodes of the DSM independently from their views on the etiology operative diagnostic criteria (as seen above, of mental disorders (a more defined concept of expressly designed to increase reliability by mental disorder was at risk to unmask

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etiological beliefs and thus to be more Finally, classic psychopathological syndromes difficult to be accepted). On the other side, it were based on qualitative distinctions of was shown that in the DSM-III the term fundamental from accessory symptoms, while “disorder” acquired a specific, technical disorders are a kind of syndrome whose meaning, implicitly arising from its concrete symptoms are not hierarchically differentiated use (from the way the single mental disorders (in the case of disorders the approach is were categorized by means of operative quantitative and polythetic, being essentially diagnostic criteria). based on diagnostic thresholds). Accordingly, the specific definition of mental In the last paragraphs it was shown that one of disorder might be conceived as “a categorial the main problems soliciting for a conceptual concept based on the description of some revision of the definition of mental disorder mental phenomena which are (usually without was the pragmatic problem of overdiagnosis. qualitative differences or hierarchies among Wakefield’s harmful-dysfunction definition them) explicitly enlisted in polythetic was then considered and the first point that operative diagnostic criteria”. Onset, course, needs to be addressed now is that his time frequency of the symptoms and characterization of a “mental disorder” is very exclusion rules for other disorders are among different from that emerged from the above the other criteria considered in the operative discussed historically-grounded conceptual “diagnostic mechanism” whose final principal analysis of mental disorders as technical terms goal was to significantly increase diagnostic specifically linked to the DSM nosography. reliability. Wakefield swings ambiguously between a very Another point of interest that emerged from general meaning of disorder as “a broader term the analysis of mental disorders was that their that covers both traumatic injuries and specific concept was markedly different from diseases/illnesses, thus being closer to the other categorial concepts such as diseases, overall concept of medical pathology” typologies and classic psychopathological (Wakefield, 2007, p.150) and a restricted syndromes. In fact, medical diseases “are now meaning based on the necessary requirement of defined at a more fundamental level than their a dysfunction plus a negative judgment on the syndrome and are distinguished from one harmful effects of having that dysfunction. In another by fairly well-established differences the first case the term is used generically as in pathology or etiology” (Kendell and equivalent to medical pathology and it cannot Jablensky 2003, p.9), while usual mental escape the critique of Jablenski (2007) that disorders (e.g. schizophrenia and bipolar medical doctors practice medicine and treat disorder) are descriptive concepts that illnesses without neither using nor needing an officially say nothing about possible overarching and universal definition of mechanisms underlying symptoms. disorder. In the second case the requirement, if Moreover, classical typologies were, taken seriously, is so strict that it would according to Jaspers’ work on Idealtypes , provide (as Wakefield intended to) a mainly diagnosed through a subjective demarcation criterion to sharply divide “real” decision following the comparison of the disorders from problems in living that involve concrete clinical case to the ideal typology. “a normal though problematic reaction to On the contrary, operative diagnostic criteria stressful environmental conditions” (Wake- were designed to mechanically guide the field, 2007, p.153). clinicians to the diagnosis (in this last case the Here the question is: do we really need a rigid physician was only allowed to decide if the demarcation criterion? And also, what kind of enlisted phenomena were present or not, the entity would be a mental disorder if diagnostic rules being not under his power but Wakefield’s proposal has to be followed? a-priori decided by the authors of the DSM). Wakefield is very critical with the authors of

10 DIAL PHIL MENT NEURO SCI 2009;2(1): 1-14 the DSM, but he shares with their back where we are with (another) change of neokraepelinian view a common obsession, name”, notes Bolton (2007, p.165)); namely that of reducing psychiatry to a c) finally, a third possibility would be the self- branch of medicine. When this means that confinement of clinical psychiatry into a psychiatry (like medicine) must be founded smaller field of action, reducing its activities to on the scientific method, there is nothing to a sort of clinical neuropsychology (focusing disagree about it. The problems arise when only to symptoms due to brain and cognitive this position is not only a methodological one, lesions/dysfunctions), leaving out the cure for but in addition it takes for granted that it must the most part of current psychiatric problems to add a positive content (in this case the claim other disciplines (for instance, psychology).3 that mental disorders must be dysfunctions). Psychiatrists could reasonably ask: Why should As a consequence of this position, it might be we scotomize living problems if they are asked: responsible of psychic sufferance that can be First, if mental disorders are characterized on successfully treated? Bearing in mind that the basis of a dysfunction (that is, in Wakefield claims that his harmful/dysfunction medicine, on a physiopathological level), analysis should be accepted because it is a what kind of difference would remain solution for the overdiagnosis problem, a point between the concept of “disorder” and that of of general interest is whether psychiatry should “disease” (which, as seen above, is a medical consider the overdiagnosis problem as an diagnostic category based on the knowledge internal, theoretical problem, or rather as an of its etiology and/or physiopathology)? Why external bias (due to the interests of the should we still need a concept of disorder if it American insurance companies to reimburse can be completely reduced to that of disease? less treatments by simply denying to many Second, clinical psychiatrists do not treat only subjects in therapy the status of mental psycho-organic diseases, but also syndromes sufferer). in which a dysfunction is unknown and those In any case, in the present work it was shown in which the sickness is related to living that Wakefield’s suggestion will be probably problems. Possible consequences of such a discarded for pragmatic reasons (unwanted rigid demarcation criterion could be: decrease of reliability and need of too much a) the paradoxical situation that if a classical changes in the diagnostic criteria of any single psychiatric disorder is not found to be based DSM disorder); hence, genuine or not, the on any known dysfunction, it is ipso facto a overdiagnosis problem is unlikely to be solved non-psychiatric condition. Today, this would by using Wakefield’s analysis simply because involve all the classical “endogenous the authors of the DSM-V probably will not psychoses”, which are diagnosed only on the accept to reformulate any diagnostic criteria set basis of descriptive features, as well as many in accordance with his suggestion. other psychiatric disorders enlisted in the Another point of philosophical relevance DSM. Should they be deleted from any arising from a comparison of the different psychiatric classification? concepts of “disorder” discussed herein is the b) alternatively, psychiatrists could continue following: the harmful dysfunction analysis is to consider useful to diagnose these proposed as a hybrid position (partly factual conditions; hence, this would lead to the and partly normative) although as Fulford and restriction of the term mental disorder to the Thornton (2007) clearly show, it is the concept cases meeting the harmful/dysfunction of dysfunction which is at the basis of requirement and the ex novo creation of a new Wakefield’s concept of disorder. name for those clinical conditions that still Having asserted the factual status of his need a psychiatric treatment but cannot fulfil concept of dysfunction, and in turn the Wakefield’s restrict criteria (“We would be dysfunction being the core of his concept of

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disorder, Wakefield appears to assert an criteria sets for new disorders, but should be used to objectivist position on mental disorders. On guide revisions of the existing criteria sets as well” (First, 2007, p.159). the contrary, the historical reconstruction of the emergence of the concept of mental Intended to support Wakefield’s proposal, this disorder as a technical implicit term specific writing clearly shows that mental disorders are of the DSM points in a very different constructed in accordance to theoretical direction; from this last perspective the positions in order to overcome practical concept of disorder emerges in a particular problems and to pursue concrete goals. place (North America), in a particular era (the Therefore, the construction of mental disorders second half of the Twentieth Century), in a being implicitly admitted even by the particular cultural milieu (the encounter of supporters of the harmful/dysfunction analysis, neokraepelinian and neo-empiricist psychia- an objectivist question like “what really is a trists) and in reply to particular challenges mental disorder?” appears to be senseless. By (above all the unreliability of psychiatric the same token even the question that implicitly nosography and related discredit: see on this underlies the overinclusion problem, that is Aragona, 2006). From this point of view, “what (who) is normal and what (who) is thus, mental disorders are constructions mentally disordered?” should be reconsidered, (although seeing a concept as constructed being significantly influenced by what is does not mean necessarily that it was invented conceived as normal and what is thought to be and that it has nothing to do with nature and a mental pathology in our society and in our reality but simply that our “worldmaking” era. Researchers aware of the relativity of this activity is involved as a relevant factor). distinction would be less prone to look for a Hence, the contrast is between objectivist and unique a-historical definition of disorder and constructivist accounts of the meaning of would probably agree that in the diagnostic “mental disorder”. activity what is decisive in order to say that However, it should be noted that the someone is in a pathological condition is objectivist position cannot avoid implicit clinical significance. constructivism when proposes (as Wakefield In turn, clinical significance will widely vary in does) to actively change the DSM diagnostic relation to social and scientific factors criteria in order to decrease the prevalence of (treatment availability included), and we should mental disorders in epidemiological studies (a not expect to find a unique and definitive pragmatic need, indeed). In this context it is definition of clinical significance, valid in any paradigmatic the following quotation of one case, in any culture and in any period of time.4 of the most important supporters of the Accordingly, clinical significance cannot be a harmful-dysfunctional analysis (co-author of solution in the search of a demarcation a significant paper on this position (Wakefield criterion; it means nothing in se , being only and First, 2003) and, above all, one of the another way to express the mere fact that most influential persons in the DSM-V clinicians have to judge whether a subject is board): healthy and does not need any treatment or

“Given that there are certainly at least some cases pathological and in need of treatment. of individuals whose lives have been ruined by an Factors that influence this technical (but still inability to control their sexual impulses, the issue subjective) judgment may be a parte objecti is not whether compulsive sexual behaviour can (patient’s features of uttered experiences or ever be considered a disorder, but instead how to behaviours) and a parte subjecti (clinician’s tailor the criteria set for compulsive sexual behaviour disorder so that it falls within the ideas/knowledge and emotional reaction to definition of mental disorder […] Thus, the patient’s characteristics), as well as technical aforementioned harmful dysfunction analysis (e.g. treatment availability), social and cultural should not just be applied in the construction of influences. Therefore, much work on the

12 DIAL PHIL MENT NEURO SCI 2009;2(1): 1-14 general categories that drive/bias this clinical (4) On this particular point there are no obvious judgment would be appreciated. differences with Wakefiled who writes: “a dysfunction only qualifies as a disorder if it causes harm over the threshold of clinical significance, and judgements that a Endnotes condition is negative or harmful are irretrievably (1) For example, the criteria for major depression place culturally relative” (Wakefield, 2006). However, its two symptoms, depressed mood and loss of interests or assumption that basic dysfunctions are always the same pleasure, at a different level of importance, even if and that the thing that varies is only the judgment on its neither is necessary for the diagnosis. harmfulness (Wakefield, 2007) does not consider at all (2) Although someone could question whether a that culture often shapes the form of the disorder itself, sentence like “I feel sick” could also be seen as a fact, not only the reaction to it. Further etnopsychiatric studies thus challenging also the idea of “purely normative” are needed to consider in more detail Wakefield’s characteristics. shortcomings on this point. (3) It should be noted that psychiatry and psychology are now intertwined and strictly collaborate in the Corresponding Author : treatment of psychic problems. On the contrary, in the Massimiliano Aragona hypothesis discussed herein they would divorce, Insegnamento di Filosofia della Psicopatologia focusing on two completely separate kinds of entity Università Sapienza, Facoltà di Filosofia, Stanza 203 (psychiatric disorders and living difficulties). Some via Carlo Fea 2, 00161 Rome, Italy clinicians will probably find this demarcation unsound, Tel.: +39-339-7119021 given the usual interplay between mental functions and e-mail: [email protected] living and environmental conditions. Copyright © 2009 by Ass. Crossing Dialogues, Italy

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