The editorial by Stein et al. (Reference Stein, Phillips, Bolton, Fulford, Sadler and Kendler2010) proposes several changes to the DSM-IV definition of mental disorder. We would like to give a brief comment on their proposal.
Stein et al. rightly emphasize that context is a key issue in determining whether disorder is present. The inclusion of common stressors and losses in criterion C implies clinicians to evaluate and judge whether responses are expectable or not, in order to dissuade them from pathologizing normal problems of life. We welcome the expansion of this criterion and the sensitivity for context it presupposes. We wonder, however, whether the inclusion of criterion D (presence of ‘underlying psychobiological dysfunction’) does add anything substantial and is not vulnerable to similar criticisms as have been levelled against the use of this term in the DSM-IV. One main point of criticism has been the circular definition of dysfunction in the Introduction of DSM-IV. Dysfunctions are defined in terms of the clinical syndromes of which they are supposed to be the underlying determinants (Fulford, Reference Fulford2000).
Stein et al. are aware of the different approaches to the concept of dysfunction (statistical, evolutionary, in terms of clinical consequences or of brain abnormalities) and – wisely – do not make a choice. By doing so, however, their proposal runs the risk of reinforcing the lack of clarity of the DSM-IV definition of disorder and of suggesting more than can be accounted for on scientific grounds.
We think it helpful to make a distinction between ‘real’ underlying dysfunctions (brain abnormalities, basic psychological disturbances; in short, dysfunction 2) and dysfunctions at the clinical level (affective instability, thought disorder, inability to maintain stable relationships, and so on; dysfunction 1) (Glas, Reference Glas1994). For the majority of psychiatric disorders we lack a ‘scientific’ concept of dysfunction (dysfunction 2) (Murphy, 2006). However, to view dysfunction 1 as criterion for disorder would just circularly redefine criterion A and B (syndrome, leading to distress or disability) as dysfunction (criterion D). Therefore, our criticism of Stein et al.'s proposal is twofold: (1) they insufficiently distinguish type 1 dysfunctions (clinical) from type 2 dysfunctions (scientific); and (2) the type 2 dysfunctions they suggest as criterion are at best assumptions at the present moment. It would be wise to skip criterion D from the list of ‘features’ and add it to the list of ‘other considerations’. Otherwise, the Stein et al. proposal would lead to the same conceptual confusion as the current DSM-IV use of the term dysfunction.
At the clinical level expectable and culturally sanctioned responses (criterion C) as well as psychological distress and disability (criterion B) are inextricably bound to a context in which social norms and values co-determine whether disorder is present (Sadler, Reference Sadler2005). Two other criteria require that there exists a behavioural or psychological syndrome in the individual (criterion A) that ‘reflects an underlying psychobiological dysfunction’ (criterion D). How are psychobiological dysfunctions (type 2) related to the clinical level of psychological distress and disability (type 1 dysfunctions)? The authors state that distress and disability are consequences of a syndrome and that dysfunction underlies the syndrome. The authors point out that dysfunction cannot be understood in purely naturalistic terms. We could add that even in the definition of blood levels of sodium, potassium or pharmacological agents we implicitly refer to a life-world in which certain states of affairs are negatively valued and others not. We agree with this position, but would like to emphasize two additional points.
First, if there is no value-free definition of dysfunction (contra; Wakefield, Reference Wakefield1992), we should be more explicit about the way in which we apply socio-cultural norms in the distinction between normality and pathology. The DSM-V would do a great job if it would provide for the conceptual and procedural framework for the inclusion of such norms. It would also bring psychiatry closer to the social sciences and to socio-critical approaches of the interaction between psychiatry and society.
Second, the fact that we will probably never be able to formulate a purely objective concept of dysfunction does not make the search for such ‘underlying’ dysfunctions (mechanisms; determinants) fruitless. On the contrary, we think that the effort to find such dysfunctions is critical for the development of psychiatry, provided that the distinction between the two types of dysfunctions is maintained. Recognition of values does not preclude conceptual distinction and refinement!
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The editorial by Stein et al. (Reference Stein, Phillips, Bolton, Fulford, Sadler and Kendler2010) proposes several changes to the DSM-IV definition of mental disorder. We would like to give a brief comment on their proposal.
Stein et al. rightly emphasize that context is a key issue in determining whether disorder is present. The inclusion of common stressors and losses in criterion C implies clinicians to evaluate and judge whether responses are expectable or not, in order to dissuade them from pathologizing normal problems of life. We welcome the expansion of this criterion and the sensitivity for context it presupposes. We wonder, however, whether the inclusion of criterion D (presence of ‘underlying psychobiological dysfunction’) does add anything substantial and is not vulnerable to similar criticisms as have been levelled against the use of this term in the DSM-IV. One main point of criticism has been the circular definition of dysfunction in the Introduction of DSM-IV. Dysfunctions are defined in terms of the clinical syndromes of which they are supposed to be the underlying determinants (Fulford, Reference Fulford2000).
Stein et al. are aware of the different approaches to the concept of dysfunction (statistical, evolutionary, in terms of clinical consequences or of brain abnormalities) and – wisely – do not make a choice. By doing so, however, their proposal runs the risk of reinforcing the lack of clarity of the DSM-IV definition of disorder and of suggesting more than can be accounted for on scientific grounds.
We think it helpful to make a distinction between ‘real’ underlying dysfunctions (brain abnormalities, basic psychological disturbances; in short, dysfunction 2) and dysfunctions at the clinical level (affective instability, thought disorder, inability to maintain stable relationships, and so on; dysfunction 1) (Glas, Reference Glas1994). For the majority of psychiatric disorders we lack a ‘scientific’ concept of dysfunction (dysfunction 2) (Murphy, 2006). However, to view dysfunction 1 as criterion for disorder would just circularly redefine criterion A and B (syndrome, leading to distress or disability) as dysfunction (criterion D). Therefore, our criticism of Stein et al.'s proposal is twofold: (1) they insufficiently distinguish type 1 dysfunctions (clinical) from type 2 dysfunctions (scientific); and (2) the type 2 dysfunctions they suggest as criterion are at best assumptions at the present moment. It would be wise to skip criterion D from the list of ‘features’ and add it to the list of ‘other considerations’. Otherwise, the Stein et al. proposal would lead to the same conceptual confusion as the current DSM-IV use of the term dysfunction.
At the clinical level expectable and culturally sanctioned responses (criterion C) as well as psychological distress and disability (criterion B) are inextricably bound to a context in which social norms and values co-determine whether disorder is present (Sadler, Reference Sadler2005). Two other criteria require that there exists a behavioural or psychological syndrome in the individual (criterion A) that ‘reflects an underlying psychobiological dysfunction’ (criterion D). How are psychobiological dysfunctions (type 2) related to the clinical level of psychological distress and disability (type 1 dysfunctions)? The authors state that distress and disability are consequences of a syndrome and that dysfunction underlies the syndrome. The authors point out that dysfunction cannot be understood in purely naturalistic terms. We could add that even in the definition of blood levels of sodium, potassium or pharmacological agents we implicitly refer to a life-world in which certain states of affairs are negatively valued and others not. We agree with this position, but would like to emphasize two additional points.
First, if there is no value-free definition of dysfunction (contra; Wakefield, Reference Wakefield1992), we should be more explicit about the way in which we apply socio-cultural norms in the distinction between normality and pathology. The DSM-V would do a great job if it would provide for the conceptual and procedural framework for the inclusion of such norms. It would also bring psychiatry closer to the social sciences and to socio-critical approaches of the interaction between psychiatry and society.
Second, the fact that we will probably never be able to formulate a purely objective concept of dysfunction does not make the search for such ‘underlying’ dysfunctions (mechanisms; determinants) fruitless. On the contrary, we think that the effort to find such dysfunctions is critical for the development of psychiatry, provided that the distinction between the two types of dysfunctions is maintained. Recognition of values does not preclude conceptual distinction and refinement!
Declaration of Interest
None.