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.

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.

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.

Placing symptoms in context: the role of contextual criteria in reducing false positives in Diagnostic and Statistical Manual of Mental Disorders diagnoses.

PURPOSE: The Diagnostic and Statistical Manual of Mental Disorders (DSM) definition of mental disorder requires that symptoms be caused by a dysfunction in the individual; when dysfunction is absent, symptoms represent normal-range distress or eccentricity and, if diagnosed as a mental disorder, are false positives. We hypothesized that because of psychiatry's lack of direct laboratory tests to distinguish dysfunction from normal-range distress, the context in which symptoms occur (eg, lack of imminent danger in a panic attack) is often essential to determining whether symptoms are caused by a dysfunction. If this is right, then the DSM diagnostic criteria should include many contextual criteria added to symptom syndromes to prevent dysfunction false positives. Despite their potential importance, such contextual criteria have not been previously reviewed. We, thus, systematically reviewed DSM categories to establish the extent of such uses of contextual criteria and created a typology of such uses. RESULTS: Of 111 sampled categories, 68 (61%) used context to prevent dysfunction false positives. Contextual criteria fell into 7 types: (1) exclusion of specific false-positive scenarios; (2) requiring that patients experience preconditions for normal responses (eg, requiring that individuals experience adequate sexual stimulation before being diagnosed with sexual dysfunctions); (3) requiring that symptoms be disproportionate relative to circumstances; (4) for childhood disorders, requiring that symptoms be developmentally inappropriate; (5) requiring that symptoms occur in multiple contexts; (6) requiring a substantial discrepancy between beliefs and reality; and (7) a residual category. CONCLUSIONS: Most DSM categories include contextual criteria to eliminate false-positive diagnoses and increase validity of descriptive criteria. Future revisions should systematically evaluate each category's need for contextual criteria.

Should prolonged grief be reclassified as a mental disorder in DSM-5?: reconsidering the empirical and conceptual arguments for complicated grief disorder.

The proposed changes to DSM-5 will create new categories of mental disorder (referred to here generically as Prolonged Grief Disorder'' [PGD]) to diagnose individuals experiencing prolonged intense grief reactions to the loss of a loved one. Individuals could be diagnosed even if they have no depressive or anxiety symptoms but only symptoms typical of grief (e.g., yearning, avoidance of reminders, disbelief, feelings of emptiness). The main challenge for such proposals is to establish that the proposed diagnostic criteria validly discriminate a genuine psychiatric disorder of grief from intense normal grief. With this test in mind, I evaluate the soundness of four empirical arguments and one conceptual argument that have been put forward to support such proposals: (1) PGD has discriminant validity because distinctive, pathognomonic symptoms distinguish it from normal grief; (2) PGD has discriminant validity because it identifies grief symptoms that are of greater absolute severity than in normal grief; (3) PGD has predictive validity because it implies a chronic, interminable process of grieving, thus a derailment of the normal process of grief resolution; (4) PGD has predictive validity because it predicts negative mental and physical health outcomes unlikely in normal grief; and (5) PGD has conceptual validity because grief is analogous to a wound or, alternatively, lengthy grief is analogous to a wound that does not heal. Upon close examination, each of these arguments turns out to have serious empirical or conceptual deficiencies. I conclude that the proposed diagnostic criteria for PGD fail to discriminate disorder from intense normal grief and are likely to yield massive false-positive diagnoses. Consequently, the proposal to add pathological grief categories to DSM-5 should be withdrawn pending further research to identify more valid criteria for diagnosing PGD.

Recurrence of depression after bereavement-related depression: evidence for the validity of DSM-IV bereavement exclusion from the Epidemiologic Catchment Area Study.

The DSM-IV diagnostic criteria for major depressive disorder exclude bereavement-related depressive episodes that are brief and lack certain severe symptoms and are thus better explained as normal grief responses. However, the DSM-5 Task Force proposes to eliminate this exclusion because of a lack of evidence that such episodes differ relevantly from standard major depression. Using the two-wave longitudinal Epidemiologic Catchment Area Study, we compared 1-yr depression recurrence rates at wave 2 of four groups at wave 1 baseline: (1) those with no history of depressive disorder (n = 18,239), (2) those who had only lifetime excludable bereavement-related depression (n = 25), (3) those with brief-episode (≤ 2 months duration) lifetime standard depressive disorder (n = 446), and (4) those with nonbrief lifetime standard depressive disorder (n = 581). The recurrence rate in the excludable-depression group (3.7%) was not significantly different from the no-history group (1.7%) but was significantly and substantially lower than in the brief and nonbrief standard depression groups (14.4% and 16.2%, respectively). These findings confirm findings reported by Mojtabai (Arch Gen Psychiatry 68:920-928, 2011) using a different data set and time frame and thus substantially strengthen the support for the validity of bereavement exclusion and for its preservation in the DSM-5.

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.

Did narrowing the major depression bereavement exclusion from DSM-III-R to DSM-IV increase validity?: evidence from the National Comorbidity Survey.

The DSM's major-depression "bereavement exclusion" eliminates bereavement-related depressive episodes (BRDs) from diagnosis unless they are "complicated" by prolonged duration or certain severe symptoms. The exclusion was substantially narrowed in DSM-IV to decrease false-negative diagnoses, but the impact of this change remains unknown. We divided BRDs in the National Comorbidity Survey into uncomplicated versus complicated categories using broader DSM-III-R and narrower DSM-IV exclusion criteria. Using 6 pathology validators (symptom number, melancholic depression, suicide attempt, interference with life, medication for depression, and hospitalization for depression), we compared the validity of the 2 exclusion criteria sets using 2 tests: (1) which criteria set yielded less pathological uncomplicated cases or more pathological complicated cases; (2) which yielded the largest separation between uncomplicated and complicated pathology levels. Results of both tests indicated that the narrower DSM-IV criteria substantially decreased the exclusion's validity. These results suggest caution regarding the current proposal to eliminate the bereavement exclusion in DSM-5.

Misdiagnosing normality: Psychiatry's failure to address the problem of false positive diagnoses of mental disorder in a changing professional environment.

BACKGROUND: In psychiatry's transformation from primarily an asylum-based profession to a community-oriented profession, false positive diagnoses that mistakenly classify normal intense reactions to stress as mental disorders became a major challenge to the validity of psychiatric diagnosis. The shift to symptom-based operationalized diagnostic criteria in DSM-III further exacerbated this difficulty because of the contextually based nature of the distinction between normal distress and mental disorder, which often display similar symptoms. The problem has particular urgency because the DSM's symptom-based criteria are often applied in studies and screening instruments outside of the clinical context and by non-mental-health professionals. AIMS: To consider, through selected examples, the degree of concern, systematicity and thoroughness - and the degree of success - with which recent revisions of the DSM have attended to the challenge of avoiding false positive diagnoses. METHOD: Conceptual analysis of selected criteria sets, with a focus on possible counterexamples to the claim that DSM criteria imply disorder. RESULTS: Psychiatry has so far failed to systematically adjust its diagnostic practices to confront the problem of false positives. Flaws in criteria, which can be recognized immediately by lay people, remain unaddressed or are addressed on a hit-or-miss random basis years after the flaw has been introduced, even though the issue is purely conceptual and is not sensitive to any new research information.

Addiction from the harmful dysfunction perspective: How there can be a mental disorder in a normal brain.

Is addiction a medical disorder, and if so, what kind of disorder is it? Addiction is considered a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Critics argue that the brain changes result instead from normal neuroplasticity and learning in response to the intense rewards provided by addictive substances, thus addiction is not a disorder but rather a series of normal-range if problematic choices. Relying on the harmful dysfunction analysis of medical disorder to evaluate disorder versus nondisorder status, I argue that even if one accepts the critics' reinterpretation of NIDA's brain evidence and rejects the brain disease account, the critics' conclusion that addiction is not a medical disorder but is rather a matter of problematic nondisordered choice does not follow. This is because there is a further possible account of addiction, the evolutionary "hijack" view, that holds that addiction is due to the availability of substances and stimuli that were unavailable during human species evolution and that coopt certain brain areas concerned with human motivation, creating biologically undesigned peremptory desires. I argue that if the hijack theory is correct, then it opens up the possibility that addiction could be a true motivational medical disorder for which there is no underlying neurological-level dysfunction. Finally, I explore the implications of this account for how we see the social responsibility for addiction and how we attempt to control it.

Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey.

CONTEXT: Symptoms of intense bereavement-related sadness may resemble those of major depressive disorder (MDD) but may not indicate a mental disorder. To avert false-positive diagnoses, DSM criteria for MDD exclude uncomplicated bereavement of brief duration and modest severity. However, the DSM does not similarly exempt depressive reactions to other losses, even when they are uncomplicated in duration and severity. OBJECTIVE: To test the validity of the DSM exclusion of uncomplicated depressive symptoms only in response to bereavement but not in response to other losses. DESIGN: Community-based epidemiological study. PARTICIPANTS: From the National Comorbidity Survey (NCS) of 8098 persons aged 15 to 54 years representative of the US population, we identified individuals who met MDD symptom criteria and whose MDD episodes were triggered by either bereavement (n = 157) or other loss (n = 710). Intervention We divided the bereavement and other loss trigger groups into uncomplicated and complicated cases by applying the NCS algorithm for uncomplicated bereavement to the reactions to other losses. We then compared uncomplicated bereavement and uncomplicated reactions to other losses on a variety of disorder indicators and symptoms. MAIN OUTCOME MEASURES: Nine disorder indicators, as follows: number of symptoms, melancholic depression, suicide attempt, duration of symptoms, interference with life, recurrence, and 3 service use variables. RESULTS: Episodes of uncomplicated depression triggered by bereavement and by other loss have similar symptom profiles and are not significantly different for 8 of 9 disorder indicators. Moreover, uncomplicated reactions, whether triggered by bereavement or other loss, are significantly lower than complicated reactions on almost all disorder indicators. CONCLUSION: The NCS data do not support the validity of uniquely excluding uncomplicated bereavement but not uncomplicated reactions to other losses from MDD diagnosis.

Little Hans and the thought police: the 'policeman fantasies' as the first reported supervisory transference fantasies.

The 'policeman fantasies' in Freud 's case of Little Hans, famous for being Freud 's most direct evidence for specifically sexual oedipal desire by Hans for his mother, are reconsidered. The Hans case is the first recorded instance of psychoanalytic supervision, and recent studies suggest that it is common for patients in supervised treatment to experience fantasies about the supervisor. It is argued that the policeman fantasies are the first recorded instances of such transference fantasies about psychoanalytic supervision and the patient-therapist-supervisor triangle. The explanatory power of this interpretation is supported by the nuances of the features of the fantasies themselves, as well as by the context in which they occurred that might serve as 'day residues'. Moreover, this interpretation provides an answer to the central mystery of the two fantasies, which goes unaddressed by Freud 's oedipal interpretation: Who is the policeman?

Saving PTSD from itself in DSM-V.

Papers in this special issue of the Journal of Anxiety Disorders concern critical issues and core assumptions that underlie the diagnostic construct of posttraumatic stress disorder. Rather than addressing specific points raised in these papers, we consider the issues and their implications for redefining PTSD and associated disorders in the DSM-V. Specific proposals are advanced to tighten definitional criteria for traumatic events and posttraumatic symptoms. We believe the more stringent criteria express the intent of the PTSD category and will promote more effective research on whether that intent was legitimate or based on misconceptions.

Attachment and sibling rivalry in Little Hans: the fantasy of the two giraffes revisited.

Freud's interpretation of Little Hans's "phantasy of the two giraffes" is pivotal to his oedipal analysis that Hans has inchoate desires for sexual intercourse with his mother. Bowlby argued that Freud's focus on his oedipal theory led him to ignore preoedipal attachment-related factors that have equal plausibility in explaining the clinical data. However, Bowlby did not attempt to apply the attachment perspective to the interpretation of Hans's fantasies that form the core of the case material. A microanalysis of Hans's giraffe fantasy and the evidence used to support Freud's claims about it yields an attachment-based sibling rivalry account arguably of greater explanatory power than the oedipal account. Consistent with Bowlby's hypothesis, the evidence suggests that Hans's giraffe fantasy is about the sibling rivalry triangle involved in caregiver attachment access, rather than (or in addition to) the oedipal triangle. The issue of multiple levels of meaning and the methodological challenges raised by multiple determination is also considered. The giraffe fantasy's attachment-theoretic explanation encourages a rethinking of this classic case and strengthens Bowlby's claim that the case is fruitfully viewed from an attachment perspective.

Max Graf's "Reminiscences of Professor Sigmund Freud" revisited: new evidence from the Freud archives.

Recently derestricted Freud Archive interviews with Max and Herbert Graf and Herbert's wife shed new light on Max Graf's article, "Reminiscences of Professor Sigmund Freud," published in The Psychoanalytic Quarterly in 1942. To explain discrepancies between the interviews and the earlier article, the author postulates that, in the article, Max Graf purposely distorted or omitted certain details in order not to reveal Herbert's identity as "Little Hans" (Freud 1909). The interviews place incidents reported in the article in a new and more complex light, and also underscore the intensely personal nature of the intellectual development of the psychoanalytic movement.

Little Hans and attachment theory: Bowlby's hypothesis reconsidered in light of new evidence from the Freud Archives.

Bowlby (1973), applying attachment theory to Freud's case of Little Hans, hypothesized that Hans's anxiety was a manifestation of anxious attachment. However Bowlby's evidence was modest; Hans was threatened by his mother with abandonment, expressed fear of abandonment prior to symptom onset, and was separated from his mother for a short time a year before. Bowlby's hypothesis is reassessed in light of a systematic review of the case record as well as new evidence from recently derestricted interviews with Hans's father and Hans in the Freud Archives. Bowlby's hypothesis is supported by multiple additional lines of evidence regarding both triggers of separation anxiety preceding the phobia (e.g., a funeral, sibling rivalry, moving, getting his own bedroom) and background factors influencing his working model of attachment (mother's psychopathology, intense marital conflict, multiple suicides in mother's family) that would make him more vulnerable to such anxiety. Bowlby's hypothesis is also placed within the context of subsequent developments in attachment theory.

Severity of complicated versus uncomplicated subthreshold depression: New evidence on the "Monotonicity Thesis" from the national comorbidity survey.

BACKGROUND: "Complicated" subthreshold depression (CsD) includes at least one of six pathosuggestive "complicated" symptoms: >6 months duration, marked role impairment, sense of worthlessness, suicidal ideation, psychotic ideation, and psychomotor retardation. "Uncomplicated" subthreshold depression (UsD) has no complicated features. Whereas studies show that complicated (CMDD) versus uncomplicated (UMDD) major depression differ substantially in severity and prognosis, UsD and CsD severity has not been previously compared. This study evaluates UsD and CsD pathology validator levels and examines whether the complicated/uncomplicated distinction offers incremental concurrent validity over the standard number-of-symptoms dimension as a depression severity measure. METHODS: Using nationally representative community data from the National Comorbidity Survey, seven depression lifetime history subgroups were identified: one MDD screener symptom (n=1432); UsD (n=430); CsD (n=611); UMDD (n=182); and CMDD with 5-6 symptoms (n=518), 7 symptoms (n=217), and 8-9 symptoms (n=291). Severity was evaluated using five concurrent pathology validators: suicide attempt, interference with life, help seeking, hospitalization, and generalized anxiety disorder. RESULTS: CsD validator levels are substantially higher than both UsD and UMDD levels, and similar to mild CMDD, disconfirming the "monotonicity thesis" that severity increase with symptom number. Complicated/uncomplicated status predicts severity, and when complicatedness is controlled, number of symptoms no longer predicts validator levels. LIMITATIONS: Diagnoses were based on respondents' fallible retrospective symptom reports during a lay-administered structured interview, which may not yield diagnoses comparable to clinicians' assessments. CONCLUSION: CsD is more severe than UsD and comparable to mild MDD. Complicated status more validly indicates depression severity than the standard number-of-symptoms measure.