Diagnosing DSM-IV--Part II: Eysenck (1986) and the essentialist fallacy

Beyond Conceptual Analysis: Social Objectivity and Conceptual Engineering to Define Disease

In this article, I side with those who argue that the debate about the definition of "disease" should be reoriented from the question "what is disease" to the question of what it should be. However, I ground my argument on the rejection of the naturalist approach to define disease and the adoption of a normativist approach, according to which the concept of disease is normative and value-laden. Based on this normativist approach, I defend two main theses: (1) that conceptual analysis is not the right method to define disease and that conceptual engineering should be the preferred method and (2) that the method of conceptual engineering should be implemented following the principles of Alexandrova's account of social objectivity in the context of the definition of disease.

Klerman's "credo" reconsidered: neo-Kraepelinianism, Spitzer's views, and what we can learn from the past

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.

Harm as a Necessary Component of the Concept of Medical Disorder: Reply to Muckler and Taylor

Wakefield's harmful dysfunction analysis asserts that the concept of medical disorder includes a naturalistic component of dysfunction (failure of biologically designed functioning) and a value (harm) component, both of which are required for disorder attributions. Muckler and Taylor, defending a purely naturalist, value-free understanding of disorder, argue that harm is not necessary for disorder. They provide three examples of dysfunctions that, they claim, are considered disorders but are entirely harmless: mild mononucleosis, cowpox that prevents smallpox, and minor perceptual deficits. They also reject the proposal that dysfunctions need only be typically harmful to qualify as disorders. We argue that the proposed counterexamples are, in fact, considered harmful; thus, they fail to disconfirm the harm requirement: incapacity for exertion is inherently harmful, whether or not exertion occurs, cowpox is directly harmful irrespective of indirect benefits, and colorblindness and anosmia are considered harmful by those who consider them disorders. We also defend the typicality qualifier as viably addressing some apparently harmless disorders and argue that a dysfunction's harmfulness is best understood in dispositional terms.

Genotype-Environment Correlation and Its Relation to Personality - A Twin and Family Study

The aim of the study was to examine the Family and School Psychosocial Environment (FSPE) questionnaire in relation to a possible genotype-environment correlation and genetic mediation between the FSPE variables and personality variables, assessed by the Junior Eysenck Personality Questionnaire. A sample of 506 Swedish children aged 10-20 years from 253 families were recruited via the Swedish state population and address register and SchoolList.Eu. The children were divided into 253 pairs: 46 monozygotic twin pairs, 42 dizygotic twin pairs, 140 pairs of full siblings and 25 pairs of half-siblings. The behavioral genetic analysis showed that both FSPE factors, Warmth and Conflicts, may be partly influenced by genetic factors (suggesting genotype-environment correlation) and that nonadditive genetic factors may mediate the relationship between FSPE factors and psychoticism/antisocial personality (P). An indication of a special shared monozygotic twin environment was found for P and Lie/social desirability, but based on prior research findings this factor may have a minor influence on P and L. P and L were negatively correlated, and the relationship seems to be partly mediated by nonadditive genetic factors. Nonshared environment and measurement errors seem to be the most influential mediating factors, but none of the cross-twin cross-dimension correlations suggest a common shared environmental mediating factor.

Diagnostic Issues and Controversies in DSM-5: Return of the False Positives Problem

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.

DSM-5, psychiatric epidemiology and the false positives problem

The revision effort leading to the publication of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was flawed in process, goals and outcome. The revision process suffered from lack of an adequate public record of the rationale for changes, thus shortchanging future scholarship. The goals, such as dimensionalising diagnosis, incorporating biomarkers and separating impairment from diagnosis, were ill-considered and mostly abandoned. However, DSM-5's greatest problem, and the target of the most vigorous and sustained criticism, was its failure to take seriously the false positives problem. By expanding diagnosis beyond plausible boundaries in ways inconsistent with DSM-5's own definition of disorder, DSM-5 threatened the validity of psychiatric research, including especially psychiatric epidemiology. I present four examples: increasing the symptom options while decreasing the diagnostic threshold for substance use disorder, elimination of the bereavement exclusion from major depression, allowing verbal arguments as evidence of intermittent explosive disorder and expanding attention-deficit/hyperactivity disorder to adults before addressing its manifest false positives problems.

The biostatistical theory versus the harmful dysfunction analysis, part 1: is part-dysfunction a sufficient condition for medical disorder?

Christopher Boorse's biostatistical theory of medical disorder claims that biological part-dysfunction (i.e., failure of an internal mechanism to perform its biological function), a factual criterion, is both necessary and sufficient for disorder. Jerome Wakefield's harmful dysfunction analysis of medical disorder agrees that part-dysfunction is necessary but rejects the sufficiency claim, maintaining that disorder also requires that the part-dysfunction causes harm to the individual, a value criterion. In this paper, I present two considerations against the sufficiency claim. First, I analyze Boorse's central argument for the sufficiency claim, the "pathologist argument," which takes pathologists' intuitions about pathology as determinative of medical disorder and conclude that it begs the question and fails to support the sufficiency claim. Second, I present four counterexamples from the medical literature in which salient part-dysfunctions are considered nondisorders, including healthy disease carriers, HIV-positive status, benign mutations, and situs inversus totalis, thus falsifying the sufficiency claim and supporting the harm criterion.

Dysfunction as a factual component of disorder

The harmful dysfunction (HD) analysis holds that disorder, mental or physical, requires harm, a value criterion, and dysfunction, a factual criterion referring to failure of a mechanism to perform a naturally selected function. Houts' arguments that the HD analysis does not offer an adequate factual account of dysfunction are examined and shown to be invalid. For example, his claim that the HD analysis confuses function with purpose, a value concept, ignores the analysis'account of function in terms of the value-free notion of effect-explanation; and his argument that functions imply norms (e.g., what mechanisms are 'supposed to' do) falsely assumes that such norms are evaluative. The HD analysis of function is analogous in logical structure to the functional analyst's factual behavioral notion of function. Houts' value account of disorder is inconsistent with people's classificatory judgments, as his own examples demonstrate.

Evolutionary history versus current causal role in the definition of disorder: reply to McNally

The harmful dysfunction (HD) analysis (Wakefield, American Psychologist 47 (1992a) 373) asserts that "disorder" means "harmful dysfunction", where "harm" is a value concept anchored in social values and "dysfunction" is a factual concept referring to failure of a mechanism to perform a natural function. Additionally, the HD analysis claims that a mechanism's natural functions are its naturally selected effects. McNally (Behaviour Research and Therapy (2000) pp. 309-314) argues to the contrary that "dysfunction" is a value concept referring to negative failures of function, that "function" refers to current causal roles and not evolutionarily designed causal roles, and that "disorder" consequently means "harmful failure of a mechanism to perform a valued current causal role." I reply by showing that McNally's proposals lack the HD analysis's power to explain common judgments about function, dysfunction, and disorder. "Dysfunction" cannot be a negative value concept because many dysfunctions are positive or neutral; "function" cannot refer to current causal roles because many current causal roles are not functions and some functions are not current causal roles; and "disorder" cannot refer to harmful failures of current causal roles because that definition allows almost any negative condition whatever to be a disorder and thus fails to explain the distinctions we make between disorder and non-disorder.

Somatic treatment of psychotic depression: review and recommendations for practice

The diagnosis, classification, and course of psychotic major depression (PMD) is considered with regard to its status as a distinct syndrome. Several factors, especially biological markers, suggest, although as yet do not confirm, that PMD is distinct from nonpsychotic major depression (NPMD), particularly for the purposes of treatment. This article provides a critical review of somatic treatments for PMD, with attention to problems of inadequate treatment, as well as underused and more recently introduced treatments. The somatic treatment options reviewed include (1) combined antidepressant (AD) and antipsychotic (AP) therapy with tricyclic antidepressants (TCAs) and typical APs; (2) electroconvulsive therapy (ECT); (3) amoxapine; (4) selective serotonin reuptake inhibitors (SSRIs), alone and in combination; (5) several atypical APs, alone and in combination; (6) mood stabilizers and anticonvulsants; and (7) some experimental treatments and surgery. A comprehensive treatment algorithm (heuristic) is presented, which draws on some previous guidelines and the critical review. This heuristic is conservative in its aims, but forward-looking in its recommendations. The status of the TCA plus typical AP regime is challenged as the default first-line treatment, and preferable alternatives are discussed. ECT has been shown to be at least as effective in short-term treatment and should be considered more frequently, especially in severe presentations and as a maintenance treatment. Some single compounds should be considered as first-line monotherapies in less severe cases. For cases in which combined AD+AP regimes are instituted, SSRIs and atypical APs should be used before older classes of drugs are considered. These recommendations aim to minimize the number of treatments used and unwanted effects experienced.

Fifty years of psychiatric nomenclature: reflections on the 1943 War Department Technical Bulletin, Medical 203

War Department Technical Bulletin, Medical 203 is presented in historical context as the first psychodynamic nomenclature. The history of Medical 203 is presented to show how Medical 203 was adapted to become DSM-I. Medical 203 then is compared and contrasted to DSM-IV to illustrate how changes in the modern DSMs have led to an 800% increase in the number of psychiatric diagnoses over the last half century. The role of critical history is emphasized in evaluating those changes and in speculating about the next 50 years of psychiatric nomenclature.

Philosophy of science and the progressiveness of the DSM's theory-neutral nosology: response to Follette and Houts, Part 1

Follette and Houts [Follette, W. C., Houts, A. C. (1996). Models of scientific progress and the role of theory in taxonomy development: a case study of the DSM. Journal of Consulting and Clinical Psychology, 64, 1120-1132] argue on philosophy-of-science grounds that the DSM's theory-neutral nosology is scientifically unprogressive because of its growing number of categories and lack of a unifying explanatory theory. They suggested replacing the DSM by competing theory-laden diagnostic manuals. I argue: (1) the ways things can go wrong with the mind are inherently diverse, so a unified theory of mental disorders is unlikely; (2) the claim that an increase in categories is inconsistent with scientific progress is empirically false; (3) the claim that the DSM's new categories expand the domain of disorder is largely false; (4) progress in a theoretically fragmented field requires a shared theory-neutrally defined domain; (5) theory-neutral diagnosis and integration of etiological theories is preferable for now to competition among theory-based diagnostic manuals; (6) philosophy of science supports use of a theory-neutral nosology for now.

The concept of disorder as a foundation for the DSM's theory-neutral nosology: response to Follette and Houts, Part 2

Follette and Houts [Follette, W. C., Houts, A. C. (1996). Models of scientific progress and the role of theory in taxonomy development: a case study of the DSM. Journal of Consulting and Clinical Psychology, 64, 1120-1132] argue that 'mental disorder' and 'function' are value concepts that offer no scientific basis for the DSM's theory-neutral nosology or for distinguishing disorders from other behavioral problems. They also claim that the DSM presupposes a biological theory of etiology, thus is not really theory-neutral. They recommend replacing the DSM by theory-laden diagnostic manuals. I argue: (1) DSM criteria do not imply a biological model of disorder, (2) 'mental disorder' and 'function' have scientific content that allows one to distinguish disorder from nondisorder, (3) the evolutionary 'harmful dysfunction' analysis of disorder [Wakefield, J. C. (1992a). The concept of mental disorder: on the boundary between biological facts and social values. American Psychologist, 47, 373-388] coherently demarcates disorder from nondisorder, (4) the proposed behaviorist alternative to the DSM illustrated by the articles in Follette's special section [Follette, W. C. (Ed.) (1996a). Special section on the development of theoretically coherent alternatives to the DSM system. Journal of Consulting and Clinical Psychology, 64, 1117-1201] is incoherent because it does not distinguish disorder from nondisorder.

Diagnosing DSM-IV--Part I: DSM-IV and the concept of disorder

In this first article in a two-article series, I diagnose' a problem with DSM-IV, specifically, the overinclusiveness of its diagnostic criteria. Using the harmful dysfunction analysis of the concept of disorder (Wakefield, 1992a, American Psychologist, 47, 373-388) as a framework, I argue that DSM-IV criteria for many diagnostic categories fail to satisfy the analysis' dysfunction' requirement, that is, the criteria do not distinguish harmful conditions due to internal dysfunctions from harmful conditions that are nondisordered 'problems in living'. The overinclusiveness problem, I suggest, can be partly dealt with by giving up purely symptomatic criteria and contextualizing diagnosis to take into account the relationship between triggering causes and resulting symptoms. In Part II (Wakefield, 1997, Behaviour Research and Therapy, 35, 651-665, I examine Eysenck's (1986, Contemporary directions in psychopathology: Toward the DSM-IV) proposal for a dimensional diagnostic system to supplant DSM-IV.