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Zagaria A, Zennaro A. A close look at sociality in DSM criteria. Soc Psychiatry Psychiatr Epidemiol 2024; 59:475-492. [PMID: 37932472 PMCID: PMC10944442 DOI: 10.1007/s00127-023-02568-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 09/28/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE The importance of sociality in psychology and psychotherapy is quite undisputed; however, this construct risks being underestimated in psychiatric nosography. The aim of the review was to assess the relevance of sociality in DSM 5 criteria. METHOD Sociality-laden criteria of 192 selected DSM categories have been identified through a textual grid. Second, the criteria have been classified into 6 categories, i.e., (1) Affiliation and Attachment (AA), (2) Social Communication (SC), (3) Perception and Understanding of Others (PUO), (4) Culture, (5) Clinical Significance Criterion (CSC) (6), and No Specific Construct (NSC). RESULTS 13% of all mental disorders mention AA in their criteria. 8.8% of all mental disorders mention SC; 8.8% of all mental disorders mention PUO in their criteria. 15% of all mental disorders mention culture in their criteria (exclusively ex negativo though). 40% of mental disorders mention non-specific sociality (NSC) in their criteria. CSC is mentioned in 85% of mental disorders. Personality disorders have the highest "concentration" of sociality mentions throughout the DSM categories. CONCLUSIONS The overall results suggest that DSM criteria offer a confused account of sociality. We believe that the descriptive approach is the underlying reason. We suggest that in the long run a theory-laden approach to sociality, informed by evolutionary insights about motivations, could be of help.
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Affiliation(s)
- Andrea Zagaria
- Department of Psychology and Cognitive Science, University of Trento, Corso Bettini, 31, 38068, Rovereto, TN, Italy.
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Amendola S. Chaos and confusion in Hikikomori research. Commentary on "The suitability of outing frequency as a definition of hikikomori (prolonged social withdrawal)". Front Psychiatry 2023; 14:1199359. [PMID: 37265557 PMCID: PMC10229764 DOI: 10.3389/fpsyt.2023.1199359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/24/2023] [Indexed: 06/03/2023] Open
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Brienza L, Zennaro A, Vitolo E, Andò A. Affective Neuroscience Personality Scale (ANPS) and clinical implications: A systematic review. J Affect Disord 2023; 320:178-195. [PMID: 36174784 DOI: 10.1016/j.jad.2022.09.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 08/29/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Affective neuroscience (AN) theory assumes the existence of seven basic emotional systems (i.e., SEEKING, ANGER, FEAR, CARE, LUST, SADNESS, PLAY) that are common to all mammals and evolutionarily determined to be tools for survival and, in general, for fitness. Based on the AN approach, the Affective Neuroscience Personality Scales (ANPS) questionnaire was developed to examine individual differences in the defined basic emotional systems. The current systematic review aims to examine the use of ANPS in clinical contexts attempting to define those behavioral elements associated with underlying stable personality traits. METHODS The systematic review was conducted following the PRISMA statements. PubMed and PsycInfo were used for research literature from March 2003 to November 2021. RESULTS Forty-four studies including ANPS were identified from 1763 studies reviewed. Sixteen studies met the inclusion criteria. LIMITATIONS The review comprised some papers with incomplete psychological assessments (e.g., lack of other measures in addition to the ANPS) and missing information (e.g., on the [sub]samples), which may affect the generalizability of findings. CONCLUSION Specific endophenotypes and/or patterns of emotional/motivational systems were found for several mental disorders. Specifically, endophenotypes emerged for the Depressive and Autism Spectrum Disorders, Borderline and Avoidant Personality Disorders, type I and II Bipolar Disorders, and the Obsessive-Compulsive Disorder. The endophenotypes can provide useful reflective elements for both psychodiagnosis and intervention. Overall, the current study may represent an attempt to contribute to the understanding of the basic emotional systems involved in the psychopathological manifestations identified by AN.
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Affiliation(s)
| | | | - Enrico Vitolo
- Department of Psychology, University of Turin, Turin, Italy.
| | - Agata Andò
- Department of Psychology, University of Turin, Turin, Italy
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Wakefield JC. Klerman's "credo" reconsidered: neo-Kraepelinianism, Spitzer's views, and what we can learn from the past. World Psychiatry 2022; 21:4-25. [PMID: 35015356 PMCID: PMC8751581 DOI: 10.1002/wps.20942] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In 1978, G. Klerman published an essay in which he named the then-nascent "neo-Kraepelinian" movement and formulated a "credo" of nine propositions expressing the movement's essential claims and aspirations. Klerman's essay appeared on the eve of the triumph of neo-Kraepelinian ideas in the DSM-III. However, this diagnostic system has subsequently come under attack, opening the way for competing proposals for the future of psychiatric nosology. To better understand what is at stake, in this paper I provide a close reading and consideration of Klerman's credo in light of the past forty years of research and reflection. The credo is placed in the context of two equally seminal publications in the same year, one by S. Guze, the leading neo-Kraepelinian theorist, and the other by R. Spitzer and J. Endicott, defining mental disorder. The divergences between Spitzer and standard neo-Kraepelinianism are highlighted and argued to be much more important than is generally realized. The analysis of Klerman's credo is also argued to have implications for how to satisfactorily resolve the current nosological ferment in psychiatry. In addition to issues such as creating descriptive syndromal diagnostic criteria, overthrowing psychoanalytic dominance of psychiatry, and making psychiatry more scientific, neo-Kraepelinians were deeply concerned with the conceptual issue of the nature of mental disorder and the defense of psychiatry's medical legitimacy in response to antipsychiatric criticisms. These issues cannot be ignored, and I argue that proposals currently on offer to replace the neo-Kraepelinian system, especially popular proposals to replace it with dimensional measures, fail to adequately address them.
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Affiliation(s)
- Jerome C Wakefield
- Center for Bioethics, School of Global Public Health, and Silver School of Social Work, New York University, New York, NY, USA
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Ouliaris C. Considering context: lessons from global mental health. Australas Psychiatry 2020; 28:210-212. [PMID: 31867984 DOI: 10.1177/1039856219889318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The development of international mental health has been characterised by the globalisation of Western psychiatric nosology that is arguably ill-suited to developing countries. This piece highlights the limitations of our current classification systems and explores how we may seek to overcome these limitations by considering the context in which symptoms present. CONCLUSION In developing a global model of psychiatric illnesses, it is important to emphasise contextual value judgements. Doing so welcomes integration of traditional models of care and encourages partnership across nations.
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Bredström A. Culture and Context in Mental Health Diagnosing: Scrutinizing the DSM-5 Revision. THE JOURNAL OF MEDICAL HUMANITIES 2019; 40:347-363. [PMID: 29282590 PMCID: PMC6677698 DOI: 10.1007/s10912-017-9501-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This article examines the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and its claim of incorporating a "greater cultural sensitivity." The analysis reveals that the manual conveys mixed messages as it explicitly addresses the critique of being ethnocentric and having a static notion of culture yet continues in a similar fashion when culture is applied in diagnostic criteria. The analysis also relates to current trends in psychiatric nosology that emphasize neurobiology and decontextualize distress and points to how the DSM-5 risks serving as an ethnic dividing line in psychiatry by making sociocultural context relevant only for some patients.
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Affiliation(s)
- Anna Bredström
- Institute for Research on Migration, Ethnicity and Society (REMESO/ISV), Linköping University, SE-601 74, Norrköping, Sweden.
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Micoulaud-Franchi JA, Quiles C, Masson M. Keep calm and carry on: Mental disorder is not more "organic" than any other medical condition. L'ENCEPHALE 2017; 43:491-494. [PMID: 28347522 DOI: 10.1016/j.encep.2017.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 10/19/2022]
Abstract
Psychiatry as a discipline should no longer be grounded in the dualistic opposition between organic and mental disorders. This non-dualistic position refusing the partition along functional versus organic lines is in line with Jean Delay, and with Robert Spitzer who wanted to include in the definition of mental disorder discussed by the DSM-III task force the statement that "mental disorders are a subset of medical disorders". However, it is interesting to note that Spitzer and colleagues ingeniously introduced the definition of "mental disorder" in the DSM-III in the following statement: "there is no satisfactory definition that specifies precise boundaries for the concept "mental disorder" (also true for such concepts as physical disorder and mental and physical health)". Indeed, as for "mental disorders", it is as difficult to define what they are as it is to define what constitutes a "physical disorder". The problem is not the words "mental" or "organic" but the word "disorder". In this line, Wakefield has proposed a useful "harmful dysfunction" analysis of mental disorder. They raise the issue of the dualistic opposition between organic and mental disorders, and situate the debate rather between the biological/physiological and the social. The paper provides a brief analysis of this shift on the question of what is a mental disorder, and demonstrates that a mental disorder is not more "organic" than any other medical condition. While establishing a dichotomy between organic and psychiatry is no longer intellectually tenable, the solution is not to reduce psychiatric and non-psychiatric disorders to the level of "organic disorders" but rather to continue to adopt both a critical and clinically pertinent approach to what constitutes a "disorder" in medicine.
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Affiliation(s)
- J A Micoulaud-Franchi
- Services d'explorations fonctionnelles du système nerveux, clinique du sommeil, CHU de Bordeaux, place Amélie-Raba-Leon, 33076 Bordeaux, France; USR CNRS 3413 SANPSY, CHU Pellegrin, université de Bordeaux, 33000 Bordeaux, France.
| | - C Quiles
- Pôle universitaire de psychiatrie adulte, centre hospitalier Charles-Perrens, 121, rue de la Béchade, 33076 Bordeaux cedex, France; Université Bordeaux Segalen, 146, rue Léo-Saignat, 33076 Bordeaux cedex, France
| | - M Masson
- Nightingale hospitals Paris, clinique du Château-de-Garches, 92380 Paris, France; Service hospitalo-universitaire, centre hospitalier Sainte-Anne, 75015 Paris, France
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Wakefield JC, Lorenzo-Luaces L, Lee JJ. Taking People as They Are: Evolutionary Psychopathology, Uncomplicated Depression, and Distinction between Normal and Disordered Sadness. EVOLUTIONARY PSYCHOLOGY 2017. [DOI: 10.1007/978-3-319-60576-0_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Much has changed since the two dominant mental health nosological systems, the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), were first published in 1900 and 1952, respectively. Despite numerous modifications to stay up to date with scientific and cultural changes (eg, exclusion of homosexuality as a disorder) and to improve the cultural sensitivity of psychiatric diagnoses, the ICD and DSM have only recently renewed attempts at harmonization. Previous nosological iterations demonstrate the oscillation in the importance placed on the biological focus, highlighting the tension between a gender- and culture-free nosology (solely biological) and a contextually relevant understanding of mental illness. In light of the release of the DSM 5, future nosological systems, such as the ICD 11, scheduled for release in 2017, and the Research Development Criteria (RDoC), can learn from history and apply critiques. This article aims to critically consider gender and culture in previous editions of the ICD and DSM to inform forthcoming classifications.
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Stein DJ, Hermesh H, Eilam D, Segalas C, Zohar J, Menchon J, Nesse RM. Human compulsivity: A perspective from evolutionary medicine. Eur Neuropsychopharmacol 2016; 26:869-76. [PMID: 26723168 DOI: 10.1016/j.euroneuro.2015.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 10/25/2015] [Accepted: 12/01/2015] [Indexed: 01/15/2023]
Abstract
Biological explanations address not only proximal mechanisms (for example, the underlying neurobiology of obsessive-compulsive disorder), but also distal mechanisms (that is, a consideration of how particular neurobiological mechanisms evolved). Evolutionary medicine has emphasized a series of explanations for vulnerability to disease, including constraints, mismatch, and tradeoffs. The current paper will consider compulsive symptoms in obsessive-compulsive and related disorders and behavioral addictions from this evolutionary perspective. It will argue that while obsessive-compulsive disorder (OCD) is typically best conceptualized as a dysfunction, it is theoretically and clinically valuable to understand some symptoms of obsessive-compulsive and related disorders in terms of useful defenses. The symptoms of behavioral addictions can also be conceptualized in evolutionary terms (for example, mismatch), which in turn provides a sound foundation for approaching assessment and intervention.
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Affiliation(s)
- Dan J Stein
- Department of Psychiatry, University of Cape Town, South Africa.
| | | | - David Eilam
- Department of Zoology, Tel-Aviv University, Israel
| | - Cosi Segalas
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Cibersam, University of Barcelona, Spain
| | - Joseph Zohar
- Department of Psychiatry, Chaim Sheba Medical Centre, Israel
| | - Jose Menchon
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Cibersam, University of Barcelona, Spain
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Wakefield JC. Diagnostic Issues and Controversies in DSM-5: Return of the False Positives Problem. Annu Rev Clin Psychol 2016; 12:105-32. [PMID: 26772207 DOI: 10.1146/annurev-clinpsy-032814-112800] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was the most controversial in the manual's history. This review selectively surveys some of the most important changes in DSM-5, including structural/organizational changes, modifications of diagnostic criteria, and newly introduced categories. It analyzes why these changes led to such heated controversies, which included objections to the revision's process, its goals, and the content of altered criteria and new categories. The central focus is on disputes concerning the false positives problem of setting a valid boundary between disorder and normal variation. Finally, this review highlights key problems and issues that currently remain unresolved and need to be addressed in the future, including systematically identifying false positive weaknesses in criteria, distinguishing risk from disorder, including context in diagnostic criteria, clarifying how to handle fuzzy boundaries, and improving the guidelines for "other specified" diagnosis.
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Affiliation(s)
- Jerome C Wakefield
- NYU Silver School of Social Work, New York University, New York, NY 10003.,Department of Psychiatry, NYU School of Medicine, New York University, New York, NY 10016;
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Wakefield JC, Schmitz MF. The harmful dysfunction model of alcohol use disorder: revised criteria to improve the validity of diagnosis and prevalence estimates. Addiction 2015; 110:931-42. [PMID: 25622535 DOI: 10.1111/add.12859] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 10/31/2014] [Accepted: 01/14/2015] [Indexed: 11/30/2022]
Abstract
AIMS To formulate harmful dysfunction (HD) diagnostic criteria for alcohol use disorder (AUD) and test whether they increase validity relative to standard DSM criteria, as evidenced by lowered prevalence, increased validator levels including service use, severity and family history and enhanced specificity. DESIGN DSM-IV AUD, DSM-IV dependence, DSM-5 AUD and HD AUD definitions were compared on eight validity related tests using nationally representative community data. SETTING United States. PARTICIPANTS National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) respondents, aged 18-54 years (wave 1, n = 29 673; wave 2, n = 24 244). MEASURES NESARC DSM-IV and DSM-5 criteria were taken from published studies. Whereas DSM-5 diagnosis requires any two AUD symptoms, HD criteria were constructed from NESARC items to require symptoms of both impaired-control dysfunction [withdrawal, drink to prevent/stop withdrawal, cannot stop/reduce drinking, or craving (wave 2 only)] and harm (sacrificed important activities, problems caring for home/family, job/school problems, health problems, psychological problems or problems with family/friends). Validators included service use, severity and family history, among others. Specificity was tested using a teen transient drinker criterion group. FINDINGS Compared with DSM-5 AUD (DSM-IV results were similar), HD criteria yielded lower prevalence (95% confidence intervals): HD life-time 6.7% (6.2, 7.2%), 1-year 2.3% (2.0, 2.5%); and DSM-5 life-time 38.2% (36.5, 39.9%), 1-year 12.4% (11.7, 13.1%). HD AUD was higher than DSM-5 on pathology validators, including: life-time alcohol-related service use: HD 41.0% (38.1, 43.9%), DSM-5 11.5% (10.7, 12.3%); severity (number of life-time alcohol symptoms): HD 20.8 (20.4, 21.2), DSM-5 10.6 (10.4, 10.8); and family history of alcohol problems: HD 50.1% (47.3, 52.9), DSM-5 32.8% (31.6, 34.0). HD criteria eliminated 83% of a DSM-5 teen transient drinker false-positives criterion group. CONCLUSIONS Prevalence estimates of alcohol use disorder are lowered and diagnostic validity improved when using 'harmful dysfunction' diagnostic criteria compared with standard DSM criteria, partly by reducing misdiagnosis of teenage transient drinkers.
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Affiliation(s)
- Jerome C Wakefield
- School of Social Work and Department of Psychiatry, New York University, New York, NY,, USA
| | - Mark F Schmitz
- School of Social Work, Temple University, Philadelphia, PA,, USA
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Global mental health and neuroscience: potential synergies. Lancet Psychiatry 2015; 2:178-85. [PMID: 26359754 DOI: 10.1016/s2215-0366(15)00014-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/07/2014] [Indexed: 02/05/2023]
Abstract
Global mental health has emerged as an important specialty. It has drawn attention to the burden of mental illness and to the relative gap in mental health research and services around the world. Global mental health has raised the question of whether this gap is a developmental issue, a health issue, a human rights issue, or a combination of these issues-and it has raised awareness of the need to develop new approaches for building capacity, mobilising resources, and closing the research and treatment gap. Translational neuroscience has also advanced. It comprises an important conceptual approach to understanding the neurocircuitry and molecular basis of mental disorders, to rethinking how best to undertake research on the aetiology, assessment, and treatment of these disorders, with the ultimate aim to develop entirely new approaches to prevention and intervention. Some apparent contrasts exist between these fields; global mental health emphasises knowledge translation, moving away from the bedside to a focus on health systems, whereas translational neuroscience emphasises molecular neuroscience, focusing on transitions between the bench and bedside. Meanwhile, important opportunities exist for synergy between the two paradigms, to ensure that present opportunities in mental health research and services are maximised. Here, we review the approaches of global mental health and clinical neuroscience to diagnosis, pathogenesis, and intervention, and make recommendations for facilitating an integration of these two perspectives.
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Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: a call for greater clarity and precision. Diabet Med 2014; 31:764-72. [PMID: 24606397 PMCID: PMC4065190 DOI: 10.1111/dme.12428] [Citation(s) in RCA: 274] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/20/2013] [Accepted: 03/04/2014] [Indexed: 01/05/2023]
Abstract
Studies have identified significant linkages between depression and diabetes, with depression associated with poor self-management behaviour, poor clinical outcomes and high rates of mortality. However, findings are not consistent across studies, yielding confusing and contradictory results about these relationships. We suggest that there has been a failure to define and measure 'depression' in a consistent manner. Because the diagnosis of depression is symptom-based only, without reference to source or content, the context of diabetes is not considered when addressing the emotional distress experienced by individuals struggling with diabetes. To reduce this confusion, we suggest that an underlying construct of 'emotional distress' be considered as a core construct to link diabetes-related distress, subclinical depression, elevated depression symptoms and major depressive disorder (MDD). We view emotional distress as a single, continuous dimension that has two primary characteristics: content and severity; that the primary content of emotional distress among these individuals include diabetes and its management, other life stresses and other contributors; and that both the content and severity of distress be addressed directly in clinical care. We suggest further that all patients, even those whose emotional distress rises to the level of MDD or anxiety disorders, can benefit from consideration of the content of distress to direct care effectively, and we suggest strategies for integrating the emotional side of diabetes into regular diabetes care. This approach can reduce confusion between depression and distress so that appropriate and targeted patient-centred interventions can occur.
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Affiliation(s)
- L Fisher
- University of California, San Francisco, San Francisco, CA
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Wakefield JC, Schmitz MF. How Many People have Alcohol Use Disorders? Using the Harmful Dysfunction Analysis to Reconcile Prevalence Estimates in Two Community Surveys. Front Psychiatry 2014; 5:10. [PMID: 24550847 PMCID: PMC3910138 DOI: 10.3389/fpsyt.2014.00010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 01/17/2014] [Indexed: 11/22/2022] Open
Abstract
Community prevalence rates of alcohol use disorders (AUDs) provided by epidemiological studies using DSM-based diagnostic criteria pose several challenges: the rates appear implausibly high to many epidemiologists; they do not converge across similar studies; and, due to low service utilization by those diagnosed as disordered, they yield estimates of unmet need for services so high that credibility for planning purposes is jeopardized. For example, two early community studies using DSM diagnostic criteria, the Epidemiologic Catchment Area Study (ECA) and the National Comorbidity Survey (NCS), yielded lifetime AUD prevalence rates of 14 and 24%, respectively, with NCS unmet need for services 19% of the entire population. Attempts to address these challenges by adding clinical significance requirements to diagnostic criteria have proven unsuccessful. Hypothesizing that these challenges are due to high rates of false-positive diagnoses of problem drinking as AUDs, we test an alternative approach. We use the harmful dysfunction (HD) analysis of the concept of mental disorder as a guide to construct more valid criteria within the framework of the standard out-of-control model of AUD. The proposed HD criteria require harm and dysfunction, where harm can be any negative social, personal, or physical outcome, and dysfunction requires either withdrawal symptoms or inability to stop drinking. Using HD criteria, ECA and NCS lifetime prevalences converge to much-reduced rates of 6 and 6.8%, respectively. Due to higher service utilization rates, NCS lifetime unmet need is reduced to 3.4%. Service use and duration comparisons suggest that HD criteria possess increased diagnostic validity. Moreover, HD criteria eliminate 90% of transient teenage drinking from disorder status. The HD version of the out-of-control model thus potentially resolves the three classic prevalence challenges while offering a more rigorous approach to distinguishing AUDs from problematic drinking.
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Affiliation(s)
- Jerome C. Wakefield
- Silver School of Social Work and Department of Psychiatry, School of Medicine, New York University, New York, NY, USA
| | - Mark F. Schmitz
- School of Social Work, Temple University, Philadelphia, PA, USA
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Wakefield JC. Wittgenstein's nightmare: why the RDoC grid needs a conceptual dimension. World Psychiatry 2014; 13:38-40. [PMID: 24497242 PMCID: PMC3918013 DOI: 10.1002/wps.20097] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Jerome C. Wakefield
- School of Social Work and Department of Psychiatry; New York University; New York NY 10003 USA
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Stein DJ. What is a mental disorder? A perspective from cognitive-affective science. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:656-62. [PMID: 24331284 DOI: 10.1177/070674371305801202] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Defining disease and disorder remains a key conceptual question in philosophy of medicine and psychiatry, and is currently a very practical matter for psychiatric nosology, given the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the upcoming International Classification of Diseases, 11th Revision. There have been advances in the cognitive-affective science of human categorization, and it is timely to consider implications for our understanding of the category of psychiatric disorder. The category of mental disorder has graded boundaries, and conditions within this category can be conceptualized using MEDICAL or MORAL metaphors. One key set of constructs used in MEDICAL metaphors relates to the notion of dysfunction, and it may, in turn, be useful to conceptualize such dysfunction in evolutionary terms. For typical disorders, it is relatively easy to agree that dysfunction is present. However, for atypical disorders, there may be considerable debate about the presence and extent of dysfunction. Rational arguments can be brought to bear to help decide whether particular entities should be included in our nosologies, and, if so, what their boundaries should be. However, it is appropriate that there should be ongoing debate on diagnostic validity, clinical utility, and other relevant facts and values, for cases that are difficult to decide. The perspective here can be illustrated using many nosological debates within the anxiety disorders and the obsessive-compulsive and related disorders, including the question of delineating normal from abnormal anxiety, of deciding whether anxiety is psychiatric or medical, and the debate about the optimal meta-structure for anxiety disorders.
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Affiliation(s)
- Dan J Stein
- Professor and Chair, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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First MB, Wakefield JC. Diagnostic criteria as dysfunction indicators: bridging the chasm between the definition of mental disorder and diagnostic criteria for specific disorders. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:663-9. [PMID: 24331285 DOI: 10.1177/070674371305801203] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
According to the introduction to the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, each disorder must satisfy the definition of mental disorder, which requires the presence of both harm and dysfunction. Constructing criteria sets to require harm is relatively straightforward. However, establishing the presence of dysfunction is necessarily inferential because of the lack of knowledge of internal psychological and biological processes and their functions and dysfunctions. Given that virtually every psychiatric symptom characteristic of a DSM disorder can occur under some circumstances in a normally functioning person, diagnostic criteria based on symptoms must be constructed so that the symptoms indicate an internal dysfunction, and are thus inherently pathosuggestive. In this paper, we review strategies used in DSM criteria sets for increasing the pathosuggestiveness of symptoms to ensure that the disorder meets the requirements of the definition of mental disorder. Strategies include the following: requiring a minimum duration and persistence; requiring that the frequency or intensity of a symptom exceed that seen in normal people; requiring disproportionality of symptoms, given the context; requiring pervasiveness of symptom expression across contexts; adding specific exclusions for contextual scenarios in which symptoms are best understood as normal reactions; combining symptoms to increase cumulative pathosuggestiveness; and requiring enough symptoms from an overall syndrome to meet a minimum threshold of pathosuggestiveness. We propose that future revisions of the DSM consider systematic implementation of these strategies in the construction and revision of criteria sets, with the goal of maximizing the pathosuggestiveness of diagnostic criteria to reduce the potential for diagnostic false positives.
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Affiliation(s)
- Michael B First
- Professor of Clinical Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York; Research Psychiatrist, Division of Clinical Phenomenology, New York State Psychiatric Institute, New York, New York
| | - Jerome C Wakefield
- Professor of Social Work, Silver School of Social Work, New York University, New York, New York; Professor of Psychiatry, Department of Psychiatry, School of Medicine, New York University, New York, New York
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Wakefield JC, First MB. Clarifying the boundary between normality and disorder: a fundamental conceptual challenge for psychiatry. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:603-5. [PMID: 24246429 DOI: 10.1177/070674371305801104] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jerome C Wakefield
- Professor of Social Work, Silver School of Social Work, New York University, New York, New York; Professor of Psychiatry, Department of Psychiatry, School of Medicine, New York University, New York, New York
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The DSM-5 debate over the bereavement exclusion: Psychiatric diagnosis and the future of empirically supported treatment. Clin Psychol Rev 2013; 33:825-45. [DOI: 10.1016/j.cpr.2013.03.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 03/29/2013] [Accepted: 03/29/2013] [Indexed: 10/26/2022]
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Abstract
Psychiatric nosology is widely criticized, but solutions are proving elusive. Planned revisions of diagnostic criteria will not resolve heterogeneity, comorbidity, fuzzy boundaries between normal and pathological, and lack of specific biomarkers. Concern about these difficulties reflects a narrow model that assumes most mental disorders should be defined by their etiologies. A more genuinely medical model uses understanding of normal function to categorize pathologies. For instance, understanding the function of a cough guides the search for problems causing it, and decisions about when it is expressed abnormally. Understanding the functions of emotions is a foundation missing from decisions about emotional disorders. The broader medical model used by the rest of medicine also recognizes syndromes defined by failures of functional systems or failures of feedback control. Such medical syndromes are similar to many mental diagnoses in their multiple causes, blurry boundaries, and nonspecific biomarkers. Dissatisfaction with psychiatric nosology may best be alleviated, not by new diagnostic criteria and categories, but by more realistic acknowledgment of the untidy landscape of mental and other medical disorders.
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