Aliquando Non Nocere: The Exclusion of Values from the Definition of Mental Disorder Proposed for DSM-5

Rowan Hildebrand-Chupp hildebrr@reed.edu

Table of Contents/Summary
1. Introduction (pg. 3) The proposed definition changes the distress and disability criterion, which has been the core of the DSM definition of mental disorder for over 30 years.

2. Conceptual Analysis of the Proposed Definition (pg. 5) The proposed definition precludes the distress and disability criterion from playing any conceptual role, instead making the presence of dysfunction the only conceptually necessary requirement.

3. Applying Harmful Dysfunction to the Proposed Definition (pg. 9) The harmful dysfunction analysis suggests that the proposed definition excludes the harm component from playing any independent conceptual role altogether.

4. The Conceptual Rationale for the Removal of Disability (pg. 11) The arguments in favor of removing the distress and disability criterion ultimately rely on the conceptual distinction between symptoms and consequences of symptom. This distinction may guide research, but it is not empirically research.

5. The Conceptual Purpose of the Harm Component (pg. 19) Mental disorder is a hybrid theoretical-practical concept, and the harm component addresses the practical side: treatment, research, stigma, etc.

6. The View on Practical Concerns behind the Removal of Disability (pg. 21) Those arguing for the removal of the distress and disability criterion have denigrated concerns over treatment and stigma as unscientific, but the distinction between symptoms and consequences is itself a pragmatic one, meant to prioritize research and deemphasize treatment within the DSM.

7. Evaluating the Proposed Definitions Impact on Etiological Research (pg. 25) 1

The removal of the distress and disability criterion is meant to enable a biological reductionist etiological paradigm, but that research either cannot be reconciled with the DSM criteria, requires more extensive changes to the DSM, or represents a fundamentally flawed paradigm.

8. Evaluating the Proposed Definitions Impact on Treatment (pg. 28) The removal of the distress and disability criterion is design to reduce the pressure on the DSM criteria to accurately represent treatment need, but the DSM is better served integrating those concerns into the criteria, just as will be done with the etiological research on dysfunction.

9. The Origin and Structure of the Distress and Disability Criterion (pg. 34) The distress and disability criterion was originally created to fight the stigma and provide a conceptual basis for the removal of homosexuality by allowing individuals who do not suffer generalized impairment some amount of input in nosological decisions.

10. Dysfunction and the Proposed Definitions Standard of Harm (pg. 38) Because our understanding of dysfunction is greatly limited, by defining dysfunction as the standard of harm the proposed definition will inevitably lead to a dangerous, covert entanglement of empirical findings and value judgments.

11. The Proposed Definitions Inability to Prevent Stigmatization (pg. 41) The removal of the distress and disability criterion removes any conceptual rationale for the prevention of stigma. The proposed definition could be used to justify the reclassification of exclusive same-sex sexuality as a disorder, the labeling of all transgender people with a disorder, and the wholesale pathologization of womens sexuality.

12. Conclusion (pg. 48) It makes sense for the classification of mental disorder created and used in the United States to prioritize individual freedom more strongly than an international classification might, and overall the benefits of removing the distress and disability criterion are ultimately not worth the potential consequences.

13. Suggested Changes to the Proposed Definition of Mental Disorder (pg. 50) I discuss several potential alternatives to the proposed definition that would address the problem of stigma in various ways

Introduction The definition of mental disorder currently proposed for DSM-5 would be the most dramatic change to the definition in over 30 years. The revision ends the requirement of distress or disability, which has been at the center of the DSMs definition of mental disorder since the definitions inception. This move represents a stark divergence from the definitions that were previously proposed during the DSM-5 process. Its arrival at such a late stage of the DSM-5 process, too, gives reason for intense scrutiny. Unfortunately, despite the definitions important role as conceptual foundation for the DSM, the rationale for the proposed definition has not been thoroughly analyzed in the literature and potentially major issues have been ignored. The distress and disability criterion (DDC) is described in the first part of the DSM-IV definition of mental disorder: Each of the mental disorders is conceptualized as a clinically significant syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (DSM-IV-TR) These requirements were condensed and added to the diagnostic criteria of many disorders in DSM-IV in the form of the clinical significance criterion (CSC) 1, which requires (sometimes with slight alterations) that the condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (DSM-IV-TR). The terms disability, impairment, and functional impairment are all used interchangeably to refer to the level of overall functioning in

Usage note: Because the term clinical significance criterion (CSC) is widely used to refer specifically to the criterion that is included within the diagnostic criteria, I defer to that usage in those situations. However, in all other cases I use the term distress and 3

broad domains relevant to everyday living. This contrasts with the concept of dysfunction, which generally refers to the breakdown in lower-level biological or psychological function. Although the rationale published on the DSM-5 website for the change mistakenly refers to an outdated definition from earlier in the DSM-5 process, a paper published in A Research Agenda for DSM-V argued in favor of removing the DDC from the DSM entirely (Lehman, Alexopoulos, Goldman, Jeste, & stn, 2002). More recently, there was a forum in the journal World Psychiatry on that proposal (Ustun & Kennedy, 2009), and the DSM-5 Impairment and Disability Assessment Study Group put out a White Paper detailing why and how to carry out that proposal (American Psychiatric Association., 2010). None of these papers specifically call for the definition currently proposed, but their list of goals are clearly aligned with it: the removal of the DDC from the definition of mental disorder, the removal of the CSC from all diagnostic criteria, and the removal of any remaining language suggesting a requirement of functional impairment. As such, I rely on these papers for information on the rationale behind the proposed definition. The proposed definition effectively creates a new standard for what conditions should be considered disorders by removing the distress and disability criterion. However, the full conceptual impact of this change has not been explored, and the papers arguing for the removal of the DDC have repeatedly taken the distinction between symptoms and impairment for granted. I will analyze the nature of this change and demonstrate that it is a shift in the DSMs prioritization of practical concerns, enabling research and deemphasizing the role of treatment need in diagnosis. However, the

original purpose of the distress and disability criterion was actually to reduce stigma, and its removal puts marginalized groups in danger of being stigmatized by the DSM in the future. Overall, the potential consequences of removing the distress and disability criterion are not worth the meager benefits it might provide. Conceptual Analysis of the Proposed Definition The revision to the DSM-IV-TR definition of mental disorder proposed for DSM5 represents a substantial shift in emphasis between the DDC and the dysfunction requirement. This change is reflected in the definitions first section (the sentences are numbered for easy reference later): (1) A Mental Disorder is a health condition characterized by significant dysfunction in an individuals cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. (2) Some disorders may not be diagnosable until they have caused clinically significant distress or impairment of performance. (American Psychiatric Association., 2012) The dysfunction requirement from past DSM definitions remains, and it has been moved to the front of the definition and described more fully. Because the lack of a description for the dysfunction component had previously limited its conceptual and practical impact, Sentence 1 greatly increases the importance of the dysfunction requirement. At the same time, Sentence 2 significantly diminishes the importance of the DDC by describing its role as tentative and narrow. To determine the exact nature of the shift, it is necessary to analyze the exact language of Sentence 2: Some disorders may not be diagnosable until they have caused clinically significant distress or impairment of performance. First, Sentence 2 only applies to Some disorders, but it gives no indication of which disorders the DDC should be applied to. Second, the DDC may apply Sentence 2 only describes a

potential requirement that arises in a limited but undefined range of situations. Third, the disorders may not be diagnosable until they have satisfied the DDC, implying that the DDC does not actually play a role in systematically determining what a disorder is but merely when some disorders may be diagnosed. For example, if a new disorder were proposed, the DDC would not be relevant in determining whether it should or should not be a disorder. The DDC is required only in some situations, only potentially, and only in practice. It has been completely stripped of its conceptual role.2 Statement 2 is presumably influenced by the current state of the rest of the DSM-5 proposals. DSM-IV included the CSC in the diagnostic criteria for around 70 percent of the disorders (Lehman et al., 2002), and Statement 2 implies that the DDC may be necessary only for those disorders that feature the CSC. However, it would be more accurate to use the phrase Most disorders may not be over Some disorders may not be because the CSC is still used in a large percentage of the disorders proposed for DSM-5. The Impairment and Disability Assessment Study Group predicted that removing impairment from the diagnostic criteria would be difficult: We agree the DSM should be a living document. Changes can be managed in incremental steps and we aim to produce a strategy that can be realized as progress Some of the following recommendations will be met prior to the publication of the DSM-5, and some will continue after its publication as part of the living document. (American Psychiatric Association., 2010, p. 6) Although the Impairment and Disability Assessment Study Group have not been successful at their efforts to removal the CSC from many of the DSM-5 criteria, they have managed to influence the DSM-5 definition of mental disorder. It appears ending
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Because it is so unclear, if interpreted loosely Statement 2 could be read as maintaining a conceptual role for the DDC in a certain situations, but the lack of any indication of when it does become conceptually necessary results in an essentially identical outcome the DDC is no longer relevant. 6

the distress and disability criterions conceptual influence within the definition is meant to provide the foundation for removing the clinical significance criterion from the diagnostic criteria in the future. However, this move makes no sense conceptually, and whatever strategic benefit it may provide toward the removal of the DDC comes at the cost of undermining the conceptual validity of the DSM as a whole. The DSM-IV explicitly states that the CSCs creation is based in the definition of mental disorder: The definition of mental disorder in the introduction to DSM-IV requires that there be clinically significant impairment or distress. To highlight the importance of considering this issue, the criteria sets for most disorders include a clinical significance criterion This criterion helps establish the threshold for the diagnosis of a disorder in those situations in which the symptomatic presentation by itself (particularly in its milder forms) is not inherently pathological and may be encountered in individuals for whom a diagnosis of mental disorder would be inappropriate. (DSM-IV-TR, pg. 8) In situations where the symptoms listed in the criteria do not already lead to distress or disability, the CSC makes up the difference to ensure that the definition of mental disorder is followed in every diagnosis. It was not created based on empirical evidence; its impact was not even measured until after the publication of DSM-IV (Wakefield, Schmitz, & Baer, 2010). The clinical significance criterion fundamentally relies on the distress and disability criterion if that conceptual requirement is ended, then the CSC is intrinsically illogical, as it no longer reflects what is considered pathological or the situations in which a mental disorder exists. Statement 2 does not define the concept of mental disorder; if it is taken to reference the CSC, it merely (inaccurately) describes some of the contents of the DSM. If the role of a definition of mental disorder is to provide a conceptual guide for the classification of mental disorders, this tactic effectively leaves the DSM wandering blind.

When someone asks, Why does the clinical significance criterion exist? the answer is no longer: Because the definition of mental disorder requires distress or disability. In DSM-5, the answer will be: Because the definition of mental disorder says that the clinical significance criterion might sometimes be included. This is a clever way to undermine any future attempts to defend the CSC, but it only achieves this by attacking the validity of a large number of diagnostic categories in DSM-5. The second section is almost identical to the corresponding section of the definition in DSM-IV. However, it is redundant and provides no additional conceptual information: (3) A mental disorder is not merely an expectable or culturally sanctioned response to a specific event such as the death of a loved one. (4) Neither culturally deviant behavior (e.g., political, religious, or sexual) nor a conflict that is primarily between the individual and society is a mental disorder unless the deviance or conflict results from a dysfunction in the individual, as described above. (American Psychiatric Association., 2012) Statement 3 merely states that an expectable or culturally sanctioned response to a specific event is not a logically sufficient condition. Statement 4, while somewhat more substantial in previous definitions, is completely redundant here because it is entirely dependent on Statement 1.3 Therefore, the presence of a dysfunction as described in Statement 1 is the only conceptually necessary requirement within the proposed definition of mental disorder Applying the Harmful Dysfunction Analysis to the Proposed Definition

However, if the DDC were restored in some form, there is an important distinction between the phrase is a symptom of a dysfunction, which was used in previous DSM definitions, and results from a dysfunction. The former allows for situations where someone has a dysfunction, but it doesnt directly cause the deviance or conflict, while the latter implies a much looser causal relationship between the two. 8

The focus on dysfunction echoes Jerome Wakefields harmful dysfunction analysis (1992a), and his conceptual work has been cited in supporting the removal of the distress and disability criterion (e.g., Lehman et al., 2002). Because Wakefield has approached harmful dysfunction as the ur-definition of mental disorder, the definition from which many other definitions can be derived (see 1992b; 1993), it should be useful to apply his definition in order to learn more about the conceptual framework of the proposed definition. He has championed the concept of dysfunction for the past 20 years, so it is reasonable to believe that his analysis would be relevant at the moment when dysfunction is poised to become the only conceptual requirement in the proposed definition. Wakefield defines dysfunction as the inability of some internal mechanism to perform its natural function, which is very similar to the way the DSM-5 proposal describes dysfunction as reflect[ing] a disturbance in the psychological, biological, or developmental processes underlying mental functioning (American Psychiatric Association., 2012; Wakefield, 1992a, p. 384). There is a set of processes underlying (i.e., constituting) mental functioning (i.e., the set of natural functions present in humans). A dysfunction occurs when these process are disturbed (i.e., when they are unable to perform those functions) 4. In his framework, the dysfunction represents the factual component of mental disorder it is an objective concept that can be understood empirically.
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The absence of language regarding evolutionary design in the proposed definition is not a significant departure from Wakefields conceptual framework. While he does argue that evolution theory provides the most accurate account of natural functions based on current empirical evidence, he also states that this is merely an elaboration on the precise nature of the concept of natural function, which has a conceptual history dating back far before evolutionary theory was developed (Wakefield, 1999a, p. 375) 9

However, there is an important conceptual difference between the proposed definitions definition of dysfunction and the harmful dysfunction definition of dysfunction: the proposed definition specifies a range of dysfunctions, those involving mental functioning, as relevant. Presumably the discrepancy is due to the fact that Wakefields definition is not actually limited to mental disorders but is meant to define all disorders (Wakefield, 1999a, p. 376).5 In his view, a dysfunction at any hierarchical level can satisfy the requirement, unless the dysfunction serves another function (e.g., a defense mechanism) (Wakefield, 1999b). The proposed definition, on the other hand, implies that any dysfunction in psychological, biological, or developmental processes only satisfies the requirement if it leads to a dysfunction at the level of cognitions, emotions, or behaviors. Wakefield has identified the DDC as one application of the harm component (Wakefield, 1992a, p. 381). According to his harmful dysfunction analysis, a condition satisfies the harm requirement if the condition causes some harm or deprivation of benefit to the person as judged by the standards of the persons culture (Wakefield, 1992a, p. 384). The harm component represents the role of values in the concept of mental disorder, and the precise nature of the harm is intentionally left undefined because values dictate the standards of harm that are used in any given context (Wakefield, 1995). Additionally, disorder is a cause-effect concept, in that it requires that the dysfunction cause an effect that is judged to be harmful (Wakefield, 1997a). The proposed definition echoes that structure, stating that some disorders, characterized only by the presence of a

It is possible that one of the reasons for his approach is to focus on the factual nature of dysfunction and avoid the problem of drawing distinctions between types of dysfunctions that could be considered socially constructed. 10

dysfunction, may not be diagnosable until they have caused clinically significant distress or impairment (emphasis added). However, as demonstrated, the DDC is no longer conceptually necessary according to the proposed definition. A harmful dysfunction analysis of the framing of Statement 2 suggests two possibilities: the harm component has been conceptually excluded entirely, or all dysfunctions occurring in cognitions, emotions, or behaviors have been deemed harmful. The end result is basically the same in either case. The former interpretation asserts that the concept of mental disorder is purely factual and transcends values, while the latter interpretation acknowledges that defining a mental disorder using only dysfunction is to consider what ought to be considered a disorder as completely in line with is considered a dysfunction. The proposed definition of mental disorder implies that value judgments about harm distinct from factual judgments about natural functions are unnecessary or unwanted. The proposed definition denies the harm component and the value judgments it represents any independent conceptual role. The Conceptual Rationale for the Removal of Disability What is the conceptual rationale given for this change? The answer lies, first, in the differentiation of symptoms and disability: Diagnostic information can conceptually be separated into two components: psychiatric symptoms experienced by the patient that are produced by dysfunctions in biological or psychological processes, and the effects of these symptoms on the patients ability to perform important functions, called functional impairment. Although they are certainly related and intercorrelated, these two domains are not equivalent. A patient can experience relatively pronounced symptoms that result in little or no functional impairment; conversely, a patient can have rather severe functional impairment with relatively few psychiatric symptoms. (Lehman et al., 2002, p. 201, emphasis in original)

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In this view, a dysfunction causes symptoms, which in turn cause impairment. They are both causally linked to a dysfunction, and they are related and intercorrelated. However, if symptoms are more directly causally linked to dysfunctions than functional impairment is, symptoms could be considered more central to the concept of mental disorder than functional impairment. Although the harmful dysfunction analysis does not assign any conceptual importance to symptoms, this interpretation of the dysfunction component is at least plausible. Because dysfunction is the factual component of the concept of mental disorder, an empirical assessment is required in order to judge the conceptual validity (according to the dysfunction component) of the distinction between psychiatric symptoms and functional impairment. The existence of a significant objective distinction between symptoms and impairment is based on three interconnected arguments: symptoms have a more restricted range of causes, symptoms exist at a lower causal level, and other disorders are not defined by impairment. Ustun and Kennedy tie all three of these arguments together simultaneously: Theoretically, the severity of an illness is dependent on its development, spread, or the depth of dysfunction it causes in body systems. Disability is an outcome of the underlying disease in a given environment, concerning what activities people can do in terms of activities. For example, the severity of tuberculosis depends on factors such as the virulence of the bacteria, or the spread of the disease in the body, whereas disability depends on whether the patient with tuberculosis can work, go to school or carry out other daily activities. (Ustun & Kennedy, 2009, pp. 83-84) The first argument views symptoms as the direct effects of biological processes occurring in body systems, while impairment is a result of those same factors inherently confounded with social or environment influences (American Psychiatric Association., 2010, p. 2, emphasis added). The second argument is mostly implied, as all of the papers

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supporting the removal of the DDC outline conceptual models describing different levels, with biological processes at the bottom and impairment at the top. For example, the White Paper describes Level A as underlying neural structures and processes, Level B as reported and observed mental functions, and Level C as performance of activities (American Psychiatric Association., 2010, p. 2). The implication is that pushing past Level C to Level B is necessary to get to Level A, the ultimate cause of the disorder, i.e. the dysfunction. The comparisons between mental disorders and other medical disorders are used to provide examples for the other two arguments; for example, the white paper points out that someone with the symptoms of the flu who does not experience distress or disability still has the flu. The overarching goal of this framework is for mental disorders to be defined purely in terms of pathophysiological states. Lehman et al. describe what they will look like: These might take the form of an anatomical or cellular defect, a physiochemical laboratory abnormality, or even a genetic defect. Once it is possible to define a mental disorder based on the identification of its underlying pathology, then it would surely make sense to follow the course of other medical conditions and have the presence of disorder be based solely on pathology and not on the effect this pathology exerts on the individuals functioning. (Lehman et al., 2002, p. 208) If the end goal is to define mental disorders without any reference to psychological states whatsoever, clearly the DDC represents a roadblock. However, the psychiatric symptoms also present a similar limitation they are not as conceptually central as the underlying pathology, either. This biological reductionist model claims that there is a significant gap between the causal factors that affect psychiatric symptoms and the causal factors that affect functional impairment. One example of this argument is the assumption that

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environmental factors primarily affect disability and not symptoms. This model also claims that different causal levels will have greatly disproportionate causal influence: all mental disorders are ultimately caused by a small number of causal factors at the biological level, and any causal influence assigned to factors that exist at higher levels is actually the result of latent variables at the biological level. However, the available research does not support the tenets of the biological reductionist view that underlie the distinction between symptoms and impairment. Kendler describes the large body of research that casts doubt on the tenets of the biological reductionist view (Kendler, 2005). Research supports the etiological role of first-person mental processes and cultural processes, even though those arguing for the removal of the DDC seek to replace phenomenology with biological measures and view environmental effects as confound[s]. Even more importantly, basic underlying biological mechanisms interact heavily with environmental effects. Despite Ustun and Kennedys (2009) emphasis on the difference between body systems and environmental factors, Kendler dismisses the assumption that all biological risk factors operate through physiological inside-the-skin pathways, instead pointing out the role of outside-the-skin pathways that alter the probability of exposure to high-risk environments (Kendler, 2005, p. 437) The view of etiology as a line of one-to-one causal relationships that should always be studied at the lowest level of causality possible is also deeply problematic (Kendler, 2005; Kendler, Zachar, & Craver, 2011). Genetic research suggests a pattern of many-to-many causal links, as some genetic factors predispose a wide range of disorders based on other factors while a wide range of DNA variants can predispose an

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individual disorder. Kendler argues, This pattern of many-to-many causal links is more compatible with pluralistic than with monistic reductive etiological models (Kendler, 2005, p. 437). Furthermore, because there are so many different causal factors all interacting in extremely complex ways, their ultimate value and scientific fruitfulness are unlikely to bear any strong relationship with where on the causal chain (or, more realistically, network) they sit (Kendler, 2005, p. 438). In other words, the explanatory power of any given causal link is not necessarily correlated with its depth within the system. Of course, because all mental disorders (as do all mental phenomena) ultimately exist at the biological level, the biological reductionist view may be accurate from a purely theoretical perspective. The evidence, however, does not provide support for the conceptual claim that distinctions drawn at levels far above the biological processes will represent significant distinctions at the most basic biological level. The full understanding of a mental disorder entirely at the biological level would require a model so overwhelmingly complex that any distinction between symptoms and consequences would be irrelevant. An example is useful to demonstrate this point. The white paper attempts to demonstrate that distinguishing between symptoms and consequences is difficult but not impossible using the example of the avoidance of stimuli caused by a phobia: Avoidance is a symptom of a dysregulated fear-circuitry system that often has a direct consequence upon participation in society (i.e. a disability). The amount of phobic avoidance is likely to correlate with the amount of disability, such that persons with agoraphobia are likely to be more disabled than the persons with a specific phobia of dogs. Thus, it may appear as if avoidance and disability are one and the same thing. However, two individuals with the same degree of phobic avoidance may have different degrees of disability. For example, avoidance of air travel may be very disabling for someone whose job requires air travel and yet

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have little disabling influence for someone whose job does not. (American Psychiatric Association., 2010, p. 5) In other words, if two avoidance symptoms can be identical while having greatly disparate effects at the level of impairment, and the dysfunction exists in the fearcircuitry system, disability is conceptually unnecessary. However, the same argument can be made regarding the avoidance symptom. Imagine someone has a negative experience with an airplane at a young age and subsequently develops a phobia of air travel. By chance, that person moves to the remote countryside and never flies on an airplane or even perceives any stimuli related to airplanes (e.g., a picture of one) for the rest of their life. They possess a phobia, but they have no memory of the experience, and they have no avoidance symptom at all in fact, they appear to have no symptoms whatsoever. However, theoretically with a sufficiently advanced understanding of the biological processes underlying phobias, it would be possible to diagnose someone with a phobia who had never experienced a phobic response, much less developed phobic avoidance. They would still have a dysfunction, however, in the same way that it is possible to develop a specific allergy but not experience symptoms until many years later (or even never). Interestingly, Lehman et al use a similar example to demonstrate the irrationality of the CSC (Lehman et al., 2002, p. 208). They point to the fact that the ICD would classify someone with a phobia of snakes living in New York City (and therefore does not interact with snakes) as having a disorder, but the DSM would not. This situation is taken as self-evidently ridiculous, but

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the biological reductionist concept of dysfunction that they deploy implies that the current state of psychiatric classification is equally ridiculous. 6 It is important to note that the definition proposed for DSM-5 does not define mental disorder in accordance with the biological reductionist framework that inspired it. It specifically requires that the dysfunction manifest at the psychological level, which can result from psychological, biological, or developmental processes, implying a more pluralistic perspective on etiology. This also skirts two of Wakefields conceptual arguments against removing the DDC (Wakefield, 2009; Wakefield et al., 2010). He pointed out that some dysfunctions do not cause any negative effects, but the proposed definition requires that dysfunctions exist at the psychological level (which would, for example, exclude symptomless phobias). The proposed definition dodges another of Wakefields criticisms by allowing for the possibility of dysfunctions occurring at the level of functional impairment (e.g., an impairment in the evolutionarily designed ability to take care of offspring). The proposed definition does not make a distinction between psychiatric symptoms and functional impairment. In addition, it is not a factual distinction that inevitably follows from the concept of dysfunction. Therefore, the relative conceptual centrality of symptoms over impairment cannot be justified on the grounds that removing the DDC is inevitable in order to understand the etiology of mental disorders. That begins to explain why Wakefield himself is not actually in support of removing the DDC, even

Obviously, there is an important practical (but not theoretically necessary) difference: we rely on descriptive symptoms to understand mental disorders because of our current lack of etiological understanding, but we may not necessarily need to rely on impairment. I discuss the issue of practical concerns in the next section, because an analysis of those arguments requires the use of the harm component. 17

though his conceptual work has been cited repeatedly in the papers arguing for that proposal. In a paper authored by Spitzer and Wakefield (1999) that has been cited extensively, they take issue with the way the CSC has been applied, but they do not argue against the inclusion of the CSC altogether. Their main conceptual issue is that the CSC represents an overall lack of attention toward the cause of a condition, the presence or absence of a dysfunction. They believe that the CSC, designed to address what they call the threshold problem of symptomatic severity, and the concept of dysfunction have separate roles to play: A solution to the threshold problem need not be the same as a solution to the dysfunction problem, and the solution of each of these problems could vary from diagnosis to diagnosis. (Spitzer & Wakefield, 1999, p. 1858) The CSC does not address the dysfunction problem, and as a result they believe the CSC has limited usefulness. However, they do not believe that addressing dysfunction necessarily replaces the need for the CSC, either. This fits with the overall thesis of Wakefields work: when determining whether a condition is a mental disorder, the cause of a condition is much more important than the descriptive effects that make up the condition (see Wakefield, 2007, 2010a; Wakefield, 2010b). The harmful dysfunction definition of mental disorder reflects this unambiguously. Wakefield states that, at least conceptually, in order for a condition to be considered a disorder, a dysfunction only needs to cause a single harmful effect (Wakefield, 1997a). That dysfunction may represent a large sequence of causal processes all interacting with each other across a large number of hierarchical functions, but it takes only one of its effects to be judged as harmful for that dysfunction to become a disorder.

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Differentiating between the effects of dysfunctions and their relative importance, setting useful standards and cutoffs these are problems for the harm component. Applying the Harm Component to the Debate over Disability The conceptual rationale for the dysfunction component is fairly self-evident: the concept of mental disorder is inevitably based on some notion of how people function normally. What, then, is the conceptual motivation for the harm component? Why are values necessary at all, if mental disorder can be defined in purely factual terms based on the concept of dysfunction? Wakefield has written surprisingly little on harm, in contrast to the long stream of papers describing the nature of dysfunction and its importance, but he has mentioned the foundation of harm: Disorder is a practical as well as a theoretical concept - it is part of medicine, not physics or biology - and practical effects like harm, while not fitting easily into any nomological essentialist scheme, are in fact crucial to our judgments of who is and is not disordered. (Wakefield, 1997a, p. 660) He is very circumspect concerning exactly which practical effects are relevant. Nevertheless, his distinction between biology and medicine, theory and practice, implies that disorders are conceptually linked with the need for treatment. Societies judge certain conditions ways of being to be harmful and therefore seek to eliminate them (Wakefield, 2010a). When they also view them as caused by a dysfunction, they seek to treat them medically (though the attribution of other causes can lead to other approaches, e.g., religious, legal). All other practical concerns that one might seek to address with their conceptualization of mental disorder stem from this: research that will lead to improved treatments, stigma due to the expectation of change, etc. Purely theoretical concepts are applied practically as they come to fruition, just as an increased understanding of physics can open up new technological possibilities. In

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contrast, a hybrid theoretical-practical concept like mental disorder cannot wait for the science to provide clear answers before developing practical applications, because the people who are suffering cannot wait. As a result, the harm component also is meant to address epistemological limitations in the understanding of dysfunctions. To put it another way, a diagnostic category defined by a set of symptoms is an attempt to delineate a condition caused by a dysfunction, but it will always represent a judgment of harm. That explains why Wakefield argued against removing the DDC on epistemological grounds, stating [In some situations] role failure, though itself not a biological dysfunction, is the only way to infer that there is an underlying dysfunction (Wakefield, 2009, p. 98). The harm component should not be interpreted as a claim that the diagnosis of mental disorder always demands treatment, or that stigma is never acceptable, etc. Instead, the point is that mental disorders do have important practical ramifications, and all applications of the harm component represent a particular way of prioritizing those concerns. Values (influenced by cultural context) determine what conditions are considered undesirable and what standards are used to make those judgments (Wakefield, 2007). In a purely theoretical/conceptual sense, every application of the dysfunction component will be identical, but applications of the harm component vary greatly. This approach is not a radical social constructionist (or postmodern) position, as Kendler writes: The application of increasingly rigorous empirical methods to the evaluation of nosologic proposals will provide many important benefits At the same time, we need to guard against exaggerating the potential impact of science on our nosology. Many important nosologic questions in psychiatry are fundamentally nonempirical There is a danger that this process will degenerate into pseudoscience, in which we pretend to be objective and empirical when, in

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reality, we are making informed value judgments. (Kendler, 1990, p. 672, emphasis in original) In other words, classifications of mental disorders must negotiate between the empirical evidence concerning dysfunctions (or lack thereof) and the competing sets of values that influence the prioritization of various practical realities. For example, should a set of symptoms reflect a category that is useful for treatment or useful for genetic research? To reject the need to consider practical concerns is itself to prioritize a certain set of practical concerns (often related to research) over others. Similarly, adhering to a rigid sciencepolitics conceptual dichotomy that closes our eyes to the political dimension will not make us immune to abuses, nor will it keep our science pristine (Schacht, 1985, p. 516). The View on Practical Concerns behind the Removal of Disability Those arguing in favor of removing the DDC repeatedly and blatantly fall into the exact traps that Kendler and Schacht warn of. The White Paper contains one egregious example: It is noteworthy that these objections and concerns [over treatment and stigma] are not primarily scientific in nature, but rather fall at the interface of the profession and broader society In contrast, it can be argued on scientific grounds that the validity of DSM diagnostic criteria would be improved by removing the CSC from the diagnosis of mental disorder, thereby restricting criteria to manifestations of symptoms and excluding manifestations of their consequences. (American Psychiatric Association., 2010, p. 4, emphasis added) The harmful dysfunction analysis demonstrates that the debate over the DDC and the CSC is based in practical, not scientific concerns values, not facts. Those in favor of removing the DDC take the practical distinction they make between symptoms and impairment as a given at every turn, using it to frame the findings of large bodies of research, concealing its practical basis as an empirical one. There is nothing sinister about arguing in favor of a certain set of practical interests. However, it is very deceptive to

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label other stances not primarily scientific in nature while describing what Kendler would call an informed value judgment as made on scientific grounds. Lehman et al. make a similar rhetoric move in their discussion of these practical concerns. They acknowledge these concerns, but in a very strange way: The lack of a severity threshold would allow almost everyone to qualify for the diagnosis of a mental disorder (e.g., a mood or anxiety disorder not otherwise specified). Were there lesions, there would be less doubt about there being a disease, but the question of treatability and clinical significance would remain. If resources were unlimited and there was no stigma associated with having a mental disorder, there would not be the debate about caseness for the mental disorders. But resource limits and stigma abound, and so the debate has importance. (Lehman et al., 2002, p. 210) The authors state that if the practical concerns were not actually concerns, there would not matter. That is true and it is about as meaningful as the statement, If no one ever possessed a dysfunction, no one would be diagnosed. Merely bringing up that possibility implies that these concerns are somehow less important, and reinforces the idea that the concept of mental disorder is only muddled by these practical concerns. In the next paragraph, one would expect them the authors to wade into said debate over what severity cut-offs for diagnosis. Instead, they admit the importance of clinical significance but using the distinction between caseness and diagnosis they actually deny the importance of those concerns: Intellectually it is important not to confuse the potential significance of conditions below the current threshold for severity and caseness with the current need to limit the boundaries of mental illness Just as it is intellectually critical to remain open to the idea that there may be clinically significant conditions (e.g., genotypes) that impose no current distress or disability, it is equally critical to accept that a threshold for distress and disability may be required by the current realities of scarcity and restrictions on services and treatments. (Lehman et al., 2002, pp. 210-211)

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How can a threshold allow for diagnosis where there is no current distress and disability while simultaneously using standards of distress and disability to handle those other practical concerns? Although Lehman et al. never explicitly state it, it is clear what solution they are proposing. They seek to move treatment concerns out of diagnosis: As attention turns toward defining clinical significance as a means to establish priorities for who receives treatment, it is important to recognize that it may be used as a key criterion for determining who gains access to mental health care and what services they will receive. (Lehman et al., 2002, p. 211, emphasis added) Attention is turning because the authors are arguing it should turn the 3rd person here covers up the implied statement, As we move to end the relationship between diagnosis and treatment . Clinical significance already is used to determine who receives treatment, because it influences diagnosis, which informs treatment. Although they admit that the debate has importance, Lehman et al. do not believe that those issues are important enough to handle them using the DSMs diagnostic criteria. All of the arguments that those arguing for the removal of the DDC are practical in nature, based on a specific set of values and priorities, just as the harmful dysfunction analysis would suggest. These practical concerns include aiding certain programs of research, protecting psychiatrys role in informing public policy, and harmonizing the DSM with the ICD. These are legitimate concerns aiding research and improving treatment. However, those in favor of removing the DDC sometimes overstate the severity of the specific problems. They are often driven by priorities that are drastically in opposition with the practical reality, and it some cases removing the DDC would not actually solve the problems they raise. Furthermore, with a more honest framing of the

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debate as over practical matters, the drawbacks of removing the DDC can finally be weighed against the benefits. Removing the DDC is meant to shift the practical concerns addressed by the DSM. The goal is to make the DSM better suited for biological research into etiology by shifting some of the focus on treatment to a separate classification for functional impairment, the ICF. In other words, some of the practical concerns that the DSM currently tries to address, such as determining treatment need, would be shifted elsewhere, allowing the DSM itself to become more amenable to etiological research that is not immediately relevant to treatment. There are two major concerns motivating this change. On the one hand, biological researchers and others involved with the DSM generally agree that the DSM classification does not correspond to any underlying biological mechanisms and therefore is not well suited for such research (Frances & Widiger, 2012; Hyman, 2010; R. Kendell & Jablensky, 2003; Kendler, 2005; Phillips et al., 2012a, 2012b). On the other hand, there are worries over the bottomless pit of treatment need implied by the high prevalence rates generated by the DSM diagnostic criteria (Mechanic, 2003; Regier, 2003; Regier et al., 1998). The former aspect of the DSM makes it useless for or even impedes a research paradigm that is often considered the key to the dramatic advances in knowledge needed in order to reclassify mental disorders based on etiology instead of descriptive features. The latter aspect of the DSM fundamentally threatens the ability for the DSM to inform public policy, and even the perceived legitimacy of the DSM overall. The removal of the DDC lowers the DSMs overall threshold of harm. This is true both conceptually and in practice. Conceptually, any dysfunction in mental functioning

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could be considered harmful and therefore a mental disorder by the proposed definition. In practice, the CSC does generally set a higher standard of harm than that of the symptoms themselves a condition has to have a more intense harmful effect in order for it to be considered a disorder (Beals et al., 2004; Narrow, Rae, Robins, & Regier, 2002). Presumably, the proposed definition could increase the likelihood of a dysfunction being sufficient for clinical diagnosis (reducing false negatives). Evaluating the Proposed Definitions Impact on Etiological Research If the goal is to understand the underlying dysfunction at the level of pathophysiological states (Lehman et al., 2002), then every level that is shaved off the DSM criteria pushes the biological researchers using those criteria a little closer to that goal. However, they are limited by the current state of understanding about mental disorders they still rely on descriptive features, psychological syndromes, to orient their research. In contrast, the current state of knowledge does allow for the possibility of making some distinction between symptoms and impairment. Simply removing the CSC would help this goal. Therefore, it would be useful for the purposes of biological research into etiology to distinguish between symptoms and impairment because it removes one set of complicating variables, one source of noise. However, assuming this goal is worthwhile, any benefit it might have would be trivial in the face of the overwhelming limitations that the DSM poses for biological research. Kendell and Jablensky (2003) argue that the DSM is not suited for some types of research that depend on the validity of the diagnostic categories. They put forth a different solution: The widespread use of a single definition has many advantages, but researchers must be free to use other definitions if they wish, if only because that is how the

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shortcomings of the standard definition are most likely to be overcome. (R. Kendell & Jablensky, 2003, p. 11) Several others have reiterated this approach (Phillips et al., 2012a, 2012b). Pierre summarizes the views of those who believe the DSM has nothing to offer, stating, A new DSM-5 needs etiologic discoveries, but etiologic discoveries do not need a new DSM (Phillips et al., 2012b). Along these lines, First has trumpeted the Research Domain Criteria Project as the likely next step toward a diagnostic classification based on etiology. The RDoC project has goals similar to those behind the removal of the DDC but takes an entirely different tactic: The RDoC project is not intended to function as a diagnostic classification system in the way that the DSM and ICD do. Unlike the DSM, ICD, and other medical classifications, which are designed to exhaustively describe and delineate the different ways that psychiatric patients might present symptomatically in terms of conceptually high-level concepts such as disease or disorder, the RDoC project is primarily a research framework to assist researchers in relating the fundamental domains of behavioral functioning to their underlying neurobiological components. (Phillips et al., 2012b) As Kendell and Jablensky argued, the utility of any given classification will vary depending on the purpose it is being used for, and the RDoC is an example of the kind of classification useful for biological research into etiology. Because the DSM has such a large influence on funding, Hyman takes the opposite approach, seeking a large restructuring of the DSM in order to make it more flexible for the purposes of biological research (Hyman, 2010). He believes that reliability has been overemphasized, though the large proliferation of categories and the arbitrary symptom severity and duration cut-off. Though the DSM categories are not supported by genetic research whatsoever, they have become reified seen as objectively valid disease entities. His overarching goal is to reduce the dominating position of the

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diagnostic categories and their criteria by any means possible because he sees problems for etiological research as a result of the fundamental structure of the DSM: The problems that have emerged within the DSM paradigm (based on operationalized criteria that define a large number of categorical disorders) cannot be fixed by tinkering with existing criteria sets or by adding or subtracting diagnoses at the margins. Given the early state of the science, however, the kind of changes I would prescribe for the DSM-V are not replacing old flawed guesses with new guesses about disorder definitions. I believe that the most useful modifications will be those that invite scientists to move beyond currently reified diagnoses in order to provide the information that will lead, ultimately, to a valid classification. (Hyman, 2010, p. 171, emphasis added) His diagnosis of the DSM suggests that slightly altering the language of the DSM is a band-aid for a problem that requires intensive surgery. One of Hymans proposals is to switch to dimensional criteria that would allow researchers more flexibility. In Wakefields conceptual language, the standard of harm needed for the diagnosis of a disorder, i.e. the level and number of symptoms that would be relevant for biological research, could be set much lower than would be clinically viable. While DSM-5 is gaining a dimensional component, it will still strongly lean on categorical classification. Hyman also suggests restructuring the categories in ways that would legitimize research that transcended diagnostic categories. He criticizes the CSC, but he also admits, Although guided by data, the selection of thresholds for diagnosis and treatment is a matter of policy (Hyman, 2010, p. 164). Finally, the epistemological realities of etiological research, explicated by Kendlers (2005) arguments against biological reductionism, represent fundamental problems with the overall strategic approach behind removing the DDC. If dysfunctions can only be understood by incorporating many different variables existing at many different causal levels, the race to the bottom strategy may actually hinder the very

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etiological research it is meant to help (see also Ghaemi, 2009). While studying mental disorders at the lower causal levels will be useful to some extent, it is unlikely that [psychological, cultural, etc.] forces that shape psychopathology can be efficiently understood at the level of basic brain biology (Kendler, 2005, p. 436). Researchers will need to use different lenses in order to study different causal links, and the focus needs to be on integrating those findings rather than striving to understand the entire picture with one methodology and paradigm. There are clearly disagreements over what approach will be most useful for biological researchers. Some believe that the DSM can be safely ignored, while others argue for the necessity of large structural changes. Some believe that biological research will ultimately be the source of the much-needed shift away from descriptive to etiological classification, while others believe that the picture will be too complex for biological research to provide a piece of the puzzle big enough to bring on that shift. Everyone agrees, however, that the lists of symptoms in the DSM do not draw distinctions that exist at the biological level and the DSM criteria hamper etiological research. Engaging in furniture rearranging, in Frances words (Phillips et al., 2012b), making slight changes to the diagnostic criteria, will not help significantly with these problems. Evaluating the Proposed Definitions Impact on Treatment The other significant problem that the removal of the DDC attempts to address is the determination of treatment need. Because the diagnosis of a disorder does imply, to some extent, a need for treatment, the high prevalence rates that have been generated by epidemiological studies using the DSM-III and DSM-IV criteria have raised many

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eyebrows (Mechanic, 2003; Regier et al., 1998). While those high rates could be read as evidence supporting the importance of mental health issues, some policy makers have seen them as evidence that the DSM classification of mental disorders is not valid and cannot be used as a basis for health care spending. It is no surprise, then, that one of the goals of removing the DDC listed in the White Paper is To increase parity between mental and other health diagnosis (American Psychiatric Association., 2010). Using the DSM and the ICF in combination (i.e., assessing disorder and disability separately) when determining the level of treatment need would emphasize that, in the words of the Associated Text attached to the proposed definition of mental disorder, the diagnosis of a mental disorder is not equivalent to a need for treatment (American Psychiatric Association., 2012) That could, in turn, lessen worries about political pressure over high prevalence rates. The CSC was actually created in DSM-IV in part to bring down presumably inflated prevalence rates, but they remain high (Narrow et al., 2002). In some cases, the CSC is redundant, having no impact on prevalence rates (Wakefield et al., 2010). More restrictive interpretations of the CSC (i.e. even higher standards of harm) could be applied to bring down these rates further, but that method appears to have rapidly diminishing returns and probably results in many false negatives (Beals et al., 2004). That may be explained by the widely acknowledged tautological aspect of the CSC: clinically significant distress or impairment can be interpreted simply as a level of distress or impairment that would indicate disorder (Spitzer & Wakefield, 1999). Furthermore, even though it brings down prevalence rates somewhat, from a political perspective the CSC highlights the role of treatment need in determining diagnosis, which may

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negatively impact the perception of the DSMs ability to objectively judge treatment need. Although the other criticisms are centered exclusively on the clinical significance criterion, the way that the distress and disability criterion frames the concept of mental disorder has the same potential effect as the CSC on psychiatrys perceived authority. In light of these concerns, it is not surprising that those concerned with the interface between psychiatry and public policy sought another solution (Narrow, Kuhl, & Regier, 2009). Their solution mirrors the one put forth by etiological researchers like Kendell and Jablensky (2003) - study the variables (e.g., impairment) that are especially relevant in determining the level of treatment need elsewhere (Lehman et al., 2002). Using different criteria allows more control over what standard of harm should be used to determine caseness, rather than incorporating those concerns into the standard of harm used to determine diagnosis. In turn, it also is meant to enable a specific research approach the study of disability and the relationship between disorder and disability by allowing for more refined measures of functional impairment. In short, the proposed definition is meant to move judgments of harm (as separate from dysfunction) out of diagnosis and place them entirely within the realm of treatment decisions. The important difference between this proposal and the proposal of Kendell and Jablensky is that the latter never suggested that etiology, the study of dysfunctions, should be scrubbed from the DSM criteria as much as possible. It is entirely possible to study disability outside of the research framework of the DSM, develop more refined measures, and then incorporate them into the DSM, just as biological research into etiology is being carried out using other research framework in the hopes of developing criteria that are more firmly based in the concept of dysfunction. Neither disability nor

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dysfunction nor has been well defined or operationalized within the DSM. They both have been considered tautological, and the proposed definition of mental disorder does not end the tautological aspect of dysfunction (Wakefield, 1992a, p. 380): the functions that should be considered under the umbrella of mental functioning remain undefined. In other words, the removal of distress and disability is a conceptual decision regarding harm, not an inevitable consequence of the lack of research. Furthermore, as Wakefield has argued, epistemological limitations sometimes require a reliance on functional impairment in diagnosis. (Wakefield, 2009) There is also much reason to suggest that this change would actually reduce the amount of research on disability as it relates to mental disorder. The DSM criteria do exert a strong influence over research, especially in the realm of treatment efficacy. As a result, if functional impairment were removed from the DSM, many researchers would have less incentive to include those variables in their treatment research. While Lehman et al (2002) point to the research showing mental disorders to be one of the worlds leading causes of disability as a sign of the importance of removing the DDC, the same finding could be interpreted as a sign of the importance of keeping it. In addition, there are several other factors making the political aspects of the problem less salient (Regier, 2003). First, research suggests that treatment underutilization is the norm (Druss et al., 2009; Lehman, 2009), and some of the overdiagnosis due to high prevalence rates is probably corrected by patient self-selection (although many patients are certainly deprived of needed care). Second, managed care has largely taken over the issue of determining treatment need, for better or worse. Third, it is not clear conceptually how high the rates should be: it is entirely possible that

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depressive episodes are the common cold of mental health, for example. Overall, there are many other ways to reframe the problem of high prevalence rates, and it is not necessarily as serious as it appears at first glance. There is no indication that psychiatry will lose significant political influence by keeping the DDC in the DSM. The harmonization of the DSM and the International Classification of Diseases (ICD) is another one of the primary motivations for removing the DDC (Ustun & Kennedy, 2009). The ICD is actually a family of classifications designed for different users. The ICD-10 Clinical Descriptions and Diagnostic Guidelines (ICD-10-CDDG) forms the conceptual core of the ICD, but it primarily features general descriptions of the various disorders (Jablensky, 2009). The ICD-10 Diagnostic Criteria for Research (ICD-10-DCR) is more similar in form to the DSM, in that it contains sets of operationalized diagnostic criteria. Research suggests that small differences between the language of the ICD-10-DCR and the DSM-IV may lead to large differences in concordance rates (Andrews, Slade, & Peters, 1999). Furthermore, many of the differences appear to have no obvious conceptual basis (First, 2009). The concern is that the discordance hampers international research collaboration, because although the World Health Organization uses the ICD exclusively, the DSM is used far more frequently in the United States (and is also sometimes used elsewhere in place of the ICD). One significant source of discordance between the two classifications is on the question of impairment. The ICD-10-DCR specifically mentions that it excludes interference with social role performance from the diagnostic criteria as much as possible, and unlike many of the DSM-IV disorders it does not possess a clinical significance criterion. Instead, the International Classification of Functioning is meant to

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address these issues. However, the ICD-10-CDDG, used more often for clinical practice, does state that it uses the term disorder to imply the existence of a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal functions (pg. 11). Furthermore, functional impairment still persists in the diagnostic criteria of many ICD-10-DCR disorders, and though those working on revising the ICD have vowed to remove the remaining traces from ICD-11 (Ustun & Kennedy, 2009), the DSM-5s failure to achieve that goal makes that seem unlikely. Regardless, substantial conceptual differences between the two classifications may actually have a positive effect on research. Kendell argues this point: If there are to be differences, however, let them be substantial. That would at least provide the research community with a choice between two genuinely different alternatives The worst outcome of all would be for the DSM-IV and the ICD10 to be littered with trivial differences in phraseology and casual differences in the way in which different groups of disorders are subdivided and defined, none of which are rooted in important conceptual differences. (1991, p. 299) Although First (2009) marked the CSC as a casual difference in his review of the discrepancies between the DSM and ICD, that is certainly up for debate. Furthermore, the existence of important differences between the two helps, as Jablensky (2009) notes, to highlight the provisional nature of many nosological concepts and their arbitrary definitions and, as Kendell (1991) states even more strongly, to remind nave residents and practitioners that there is nothing God-given or immutable about the categories and definitions of their official nosology. Considering that the proposed definition implies that the symptoms listed in the DSM represent true dysfunctions, despite the worries over reification and the etiological validity of DSM criteria, this is particularly important.

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Finally, one of the major criticisms of the CSC is that it excludes risk factors (Lehman et al., 2002). Of course, changing the CSC to include risk, rather than removing it entirely, would solve that problem, though it would almost certainly damage reliability. Furthermore, the DSM-IV definition of mental disorder explicitly includes the risk of harm it is the proposed definition that excludes them! By requiring that the dysfunction manifest at the level of cognitions, emotions, and behaviors, the proposed definition excludes dysfunctions that exist only at the biological level and have not yet caused dysfunctions at the psychological level. Removing the DDC does nothing to address this issue. Additionally, this is somewhat of a solution in search of a problem, because the current state of knowledge cannot adequately predict risk for the most part (as evidenced by move of Psychosis Risk Syndrome to the section of conditions requiring more research). The Origin and Structure of the Distress and Disability Criterion In the words of Lehman (2009, p. 90), Why have we felt the need to confound diagnosis and functional impairment in the DSM in the first place? Throughout the discussion of this proposed change and the literature involving the CSC, the origin of the distress and disability criterion has been apparently forgotten. It has mistakenly been attributed over and over again to the attempts to narrow the diagnostic criteria to only capture those who experience a need for treatment (e.g., American Psychiatric Association., 2010; Lehman, 2009; Lehman et al., 2002; Ustun & Kennedy, 2009). While the clinical significance criterion was added to many diagnoses in DSM-IV in order to combat the high prevalence rates that had been generated by the DSM-III diagnoses, the

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use of distress and impairment within the definition of mental disorder predates even DSM-III. In reality, the distress and disability criterion was created and used as the basis of the removal of homosexuality from DSM-II in 1973. The resolution, written by Robert Spitzer and passed by the APA, explicitly used that criterion as a rationale for the change: For a mental or psychiatric condition to be considered a psychiatric disorder, it must regularly cause subjective distress or regularly be associated with some generalized impairment in social effectiveness or functioning. With the exception of homosexuality all of the mental disorders in DSM-II fulfill either of these two criteria. (Stoller et al., 1973, p. 1215) That definition of mental disorder formed the core of the definition in DSM-III and onward. Spitzer described several benefits of the change: ending the use of an unnecessary label of sickness, demonstrating that psychiatrists are not merely agents of social control, and removing one of the justifications for the denial of civil rights (Stoller et al., 1973, p. 1216). The motivation for the creation of the distress and disability criterion was the end of the stigmatization of an oppressed group. Because it represents a standard of harm, it is possible to reverse-engineer the DDC by analyzing the value commitments it represents. The distress criterion reflects two simultaneous value judgments regarding the role of individual freedom. First, the distress criterion is an acknowledgement that an individuals need for treatment should be incorporated into the concept of mental disorder. In his discussion of sexual orientation disturbance, the diagnosis given to gay men and lesbians experiencing distress, Spitzer writes: These people have a psychiatric condition, whether or not they seek professional help. By creating a new category, sexual orientation disturbance, we will be applying a label only to those homosexuals who are in some way bothered by their sexual orientation, some of whom may come to us for help. We will no

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longer insist on a label of sickness for individuals who insist that they are well and who demonstrate no generalized impairment in social effectiveness. (Stoller et al., 1973, pp. 1215-1216) Similar to the definition proposed for DSM-5, Spitzer repeatedly emphasizes that treatment and diagnosis are not synonymous, but he also points to the exclusion of those who insist that they are well, i.e. do not seek treatment, as a sign of psychiatrys legitimacy. By describing diagnosis as a label of sickness and the importance of applying that label only to those who are bothered, Spitzer implicitly identifies both the stigmatizing effect of diagnosis in general and the need to balance that effect with the positive effects of treatment when making nosological decisions. At the same time, Spitzers distress component indirectly incorporated individual values into diagnosis. By relying on subjective distress, his definition allows for the subjective framing of ones own distress. After all, many of the gay liberation activists fighting the pathologization of their sexual orientation described the emotional suffering they experience as a result of being gay, but they did not consider being gay as a disorder because they conceptualized that suffering as a result of societal pressure (e.g., Stoller et al., 1973)7. In fact, without gay rights activists fighting for the idea that Gay is Good and identifying the system of homophobic oppression, many more gay and lesbian individuals would have still experienced distress and attributed it to their sexual orientation, and the distress criterion would then have been a reason to keep the diagnosis in the DSM. In effect, the distress criterion relied on the external influence of gay rights activists to influence the values of gay men and lesbians and encourage them to view
7

This is one of examples of the distinction I mentioned earlier (p. 8) between the proposed definition and the previous DSM definitions. The distress is not a symptom of being gay, but one could claim that it results from being gay. That is an important difference in causal attribution. 36

their sexual orientation as positive and their distress as caused by society. In other words, the distress criterion incorporated into the nosological fabric of the DSM the ideas that individual freedom should be respected and that individuals (and their communities) should have some influence in the determining whether or not they have a disorder. At the same time, the freedom of the individual was balanced against the needs of society and the knowledge of clinicians through the impairment criterion. Because individuals cannot always be relied upon to properly judge their own needs and their impact on others, there still needed to be a way for others to judge whether an individual had a disorder. Hence, the focus on social effectiveness or functioning represents the interests of society as a whole. However, by specifying that the impairment had to be generalized, Spitzer implicitly put judgments based on functioning to a higher standard (it is worth noting that the subjective distress need not be generalized). He defended this decision by arguing that many conditions that might be negatively culturally valued would need to be included in the DSM otherwise, including revolutionary behavior and religious fanaticism (Stoller et al., 1973, p. 1215). Importantly, Spitzer identified individual political and religious freedom as needing protection from the classification of mental disorders, and so he narrowed the role of harm (in Wakefields conceptualization) by making the impairment standard more stringent. Ultimately the 1973 definition of disorder represented a fundamental balance between the value of individual freedom and the value of social cohesion, with emphasis on the former. In the situations where the stigmatization of diagnosis is most harmful, those situations where individuals are not distressed by their condition, it must cause widespread impairments in their functioning in order to be considered a disorder. The

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DSM-III definition dropped the requirement of generalized impairment and instead required distress or impairment in one or more important areas of functioning, somewhat lowering the standard but still requiring that the areas are important. However, in line with the DDCs original focus, the CSC defined those areas broadly, requiring distress or impairment in social, occupational, or other important areas of functioning. This delicate balance has formed the core of the DSMs standard of harm until now. Dysfunction and the Proposed Definitions Standard of Harm The creation of the dysfunction requirement was the other important change Spitzer made to the definition of mental disorder in DSM-III, but it was left undefined and buried within the definition. Wakefields harmful dysfunction pulled the dysfunction component out, dusted it off, and defined it as based on the concept of natural function. He argued that natural functions were functions that had been created by evolutionary processes. As a result, the functions must have possessed adaptive value at some point in evolutionary time. Though Wakefield saw dysfunction as a purely factual concept, he admitted in his paper introducing harmful dysfunction that discovering what in fact is natural or dysfunctional may be extraordinarily difficult (1992a, p. 383). Many have criticized the epistemological limitations of Wakefields conceptualization of dysfunction (Bergner, 1997; Lilienfeld & Marino, 1995; Sadler & Agich, 1995). Wakefield has also pointed out that many other criticisms that appear ontological, against the existence of the concept itself, are actually epistemological (Wakefield, 1999a). Though he has downplayed the significance of the epistemological problem (Wakefield, 1995, 1997b), he actually referenced it himself when arguing

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against the removal of the DDC (Wakefield, 2009)8. As discussed previously, the harm component addresses the epistemological problem because, in practice, all disorders as defined in the DSM are judgments of harm that are striving to also represent dysfunctions informed value judgments. Because it relies so heavily on the concept of dysfunction, these criticisms apply to the proposed definition, also. One of the most common critiques, inextricably linked to the epistemological problem, of the concept of dysfunction is that it is covertly value-laden (Sadler & Agich, 1995). Wakefield has argued that the concept of dysfunction is not intrinsically valueladen, but, because it is a black box essentialist concept, functions with prototypical valued effects form the basis for our current understanding of dysfunction (Wakefield, 1999b). He has argued that describing something as a dysfunction is not a value judgment because it refers to actual processes that exist in the world (Wakefield, 1995). The implication, however, is that an incorrect judgment of dysfunction is a value judgment. As Wakefield has pointed out, this occurred in the Victorian era regarding masturbation and in the United States during slavery regarding drapetomania. In other words, any given judgment of dysfunction is only value-free if it is accurate, and, because there is very little known about the influence of evolution on psychological functioning, there is a high risk that the judgment of a dysfunction will actually be a value judgment appearing as an objective claim. As noted, Wakefields conceptualization of dysfunction is not identical to that of the proposed definition, which states that a mental disorder is characterized by

A full discussion of Wakefields contradictory framing of harm is outside of the scope of this commentary, but overall in striving to demonstrate the conceptual value of dysfunction he has deemphasized the role of harm in much of his writing. 39

significant dysfunction in an individuals cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning (American Psychiatric Association., 2012). The proposed definition specifically requires a mental dysfunction, and unlike Wakefield it does not define what functions constitute mental functioning. Additionally, the proposed definitions dysfunction component also represents its judgment of harm, because for a definition to be included in the DSM, i.e. a practical context, it can no longer be judged based on purely conceptual grounds. The harm component cannot be excluded because the definition will be used to inform real-world changes to the classification of mental disorders in the future. As a result, although the conceptualizations of dysfunction are very similar conceptually, the proposed definition is substantially different in practice. In previous DSM definitions, the condition must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction. The definition proposed for DSM-5, on the other hand, states that mental disorders are characterized by significant dysfunction. In other words, the DSM-5 definition of mental disorder claims that all the disorders within it actually are dysfunctions the preliminary nature of the judgment is not emphasized. Furthermore, by representing the only standard of harm, there is no other way to determine whether a given condition is a disorder. All such judgments are entirely dependent on the current state of knowledge regarding dysfunctions, even though they are not described in those terms. Leaving mental functioning undefined covers up the gap in knowledge even further. In Wakefields conceptualization the emphasis on evolution is a red flag to many that it is not necessarily

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understood at the present time. The proposed definition contributes to the already pervasive problem of the reification of the DSM categories as real disease entities. This is a recipe for disaster. The DSM definition of mental disorder no longer provides any protection against the use of science as a cover for values, because it pretends to no longer represent a value judgment at all. It is not a coincidence the requirement of significance, which had previously only applied to the DDC, has been added to the dysfunction component it is a small attempt to lift up the standard of harm that has been greatly lowered. In Wakefields view, significance is irrelevant any given condition is either caused by a dysfunction or it is not, similar to the way Kendell and Jablensky describe the concept of validity. As a result, any condition that is deemed to be caused by a significant dysfunction could be considered a disorder. Wakefield himself has stated that some of the worst excesses of psychiatry have been committed based on false views of dysfunction, but he views that as all the more reason to develop more accurate views of dysfunction. The way that it has been applied within the proposed definition, however, enables exactly those same situations, where value judgments and empirical findings become fused in a cover of legitimacy that is difficult to unravel. The Proposed Definitions Inability to Prevent Stigmatization The proposed definitions standard of harm not only enables a destructive merging of value judgments and empirical claims in the future, but also has the potential to undo many of the DSMs current value commitments. Although the epistemological problem is one key reason to use a separate standard of harm, there are other important situations where the concept of dysfunction is insufficient. Even if we possessed perfect

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understanding of dysfunction, there would still be some dysfunctions that I believe the DSM should not consider a disorder. According to the definition of mental disorder proposed for DSM-5, the following disorder would be absolutely conceptually justified for inclusion in DSM-6 or DSM-7: Diagnostic criteria for Hypoactive Heterosexual Desire Disorder A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies about and desire for sexual activity with a member of the opposite sex B. Persistent or recurrent sexual/erotic thoughts or fantasies about and desire for sexual activity with a member of the same sex exclusively (or predominantly) C. The lack of heterosexual desire and presence of homosexual desire must coincide for a minimum duration of approximately 6 months D. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) Important notice regarding HHDD Homosexual behavior or desire is not a disorder per se. HHDD specifically refers to an absence of heterosexual functioning that is not due to an overall absence of sexual desire, which is the result of a dysfunction in the evolutionarily designed mechanisms that motivate procreation. It is important to remember that the diagnosis of HHDD is not equivalent to a need for treatment. Treatment decisions should be informed by the patients level of distress, disability, the severity of their symptoms, and many other factors. The presence of HHDD within this classification should not be seen as a representation of any moral or legal stance regarding the desirability of homosexuality. Alternatively, HHDD could be one of the disorders that may not be diagnosable without satisfying clinical significance criterion, although as I noted those considerations could simply be moved to treatment, as Lehman et al. (2002) argue. There are certainly groups that have been pushing for this kind of change for quite some time.

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Although it is unclear exactly whether same-sex sexuality represents a breakdown in evolutionarily designed mechanisms (Spitzer, 1999), it is very reasonable to infer that exclusive same-sex desire is a dysfunction in Wakefields sense. Because of the epistemological problem, most judgments of dysfunction are reasonable inferences (e.g., Spitzer, 1997). The existing evolutionary hypotheses regarding same-sex sexuality are generally not borne out by the evidence, implausible, largely untested, or do not apply to exclusive same-sex sexuality (Bobrow & Bailey, 2001; Kirkpatrick, 2000; Rahman & Hull, 2005; Rahman & Wilson, 2003). Even factors that may represent an evolutionarily adaptive mechanism, such as the fraternal birth order effect, would only exclude a certain percentage of people. Although the etiology of same-sex sexuality is the result of many different factors, genetic factors play a large role. The most plausible evolutionary explanation for exclusive same-sex sexuality is that it represents extreme variation in some trait that is typically adaptive in certain dosages (see Rahman & Wilson, 2003 for a review of the hypotheses and further discussion of this argument). Wakefield has argued that, for example, sickle-cell anemia is a dysfunction, even though in certain genetic dosages it provides an adaptive protective effect against malaria (1999a). Although the overall mechanism is adaptive on average, when it causes other maladaptive side effects in certain individuals, those individuals possess a dysfunction. Admittedly, the proposed definition does not specifically use Wakefields definition of dysfunction, but that does not actually preclude the inclusion of this diagnosis conceptually. In practice, the inclusion of a disorder like HHDD is highly unlikely due to the large political backlash that would result. In that case, the decision not

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to include HHDD in the DSM would clearly be a value judgment concerning what should be included within the category of mental functioning. That is, the continued removal of HHDD would only be due to a covert value judgment, subject entirely to transient political whims, rather than the relatively clear, firm stance that the DDC has represented in the past. Because of psychiatrys incredibly limited understanding of etiology, the proposed definition provides almost no guidance regarding whether any given disorder should be included in or excluded from the DSM. HHDD is not the only problem the removal of the DDC raises. Gender Identity Disorder has widely been criticized by the transgender community for stigmatizing trans identities (Drescher, 2010). The diagnostic category proposed for DSM-5 lessens the DSMs stigmatization of transgender people by renaming the disorder Gender Dysphoria and emphasizing the experience of incongruence between ones experienced/expressed gender and assigned gender. The experience of incongruence is what generally causes transgender individuals distress or impairment, not their gender identity itself, and the DSM-5 criteria reflect this. Removing the DDC from the definition of mental disorder eliminates the conceptual basis for this change. From the etiological point of view that the definition of mental disorder is based in, the dysfunction would presumably be the gender identity, not the feelings of incongruence, because the gender identity likely causes the feeling of incongruence. Although I am not certain whether there is empirical evidence directly to support that claim, it is certainly an inference some have made, including Robert Spitzer at a roundtable in 2003: Kids, we all know, kids develop a sense of identity, of gender identity, and again its not taught it just happens. So I would argue that that is why sexual arousal its

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part of the human condition and as I said, I think theres good reason why for evolution that makes a lot of sense. I would argue that by itself, the failure of gender identity that is the child who is uncomfortable in their sex that is a dysfunction. It seems to me that is a dysfunction. Now how severe it has to be, how much you treat it, exactly what behaviors in any given culture (Spitzer, 2003) During that discussion Spitzer explicitly discusses the evolutionary view of dysfunction, and that is the meaning of the word he is using here. It is worth noting that this issue transcends the CSC, which does still exist within the criteria proposed for Gender Dysphoria, despite attempts to remove it presumably as a result of the pressures from the Disability and Impairment Assessment Study Group. This is an example of how the DDC affects the diagnostic criteria as a whole and how its effects manifest beyond the application of the CSC. Hypoactive Sexual Desire Disorder and Sexual Interest/Arousal Disorder represent another potential problematic consequence of the removal of the DDC. There have been repeated calls for the removal of the CSC from the sexual dysfunctions (Althof, 2001; Spitzer & Wakefield, 1999). However, the proposed shift from HSDD to SIAD is in part a response to the large percentage of women surveyed who did not experience distress or disability despite being labeled as having clinically low levels of sexual desire (Brotto, 2010). SIAD attempts to reframe the diagnosis in light of emerging research regarding the normative patterns of womens sexuality as being less drive-based and more context-based. However, because SIAD will not be tested in field trials, it is not clear whether prevalence rates will decrease as a result of this change. The CSC is an important stopgap in order to prevent the wholesale pathologization of womens sexuality in light of the historical pattern of researching predominantly male sexuality and then generalizing those findings to women (Basson, 2008).

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The CSC also can provide a first line of defense in preventing the pathologization of minority groups that researchers and clinicians may not have been aware of. For example, the CSC has put a cap on the stigmatization of the growing community of people who identify as asexual. Asexuals do not experience sexual attraction to anyone and, according to one prevalence study, may represent around one percent of the population (Bogaert, 2004; Brotto, Knudson, Inskip, Rhodes, & Erskine, 2010). Without the CSC, asexuals would be diagnosed with HSDD (lifelong subtype), despite the fact that they report no distress about their lack of desire and that they do not suffer overall impairment as a result (Bogaert, 2006). The DDC plays an important role in curtailing stigma in many different ways. As a standard of harm that does not suffer from the severe epistemological issues that dysfunction does, the DDC provides a basic guide for what diagnostic categories should be included in the DSM. It also helps separate empirical claims from value judgments by limiting the extent to which etiological research on dysfunctions can act as a vehicle for covert value judgments. The DDC prevents conditions that may be biologically disadvantageous, statistically non-normative, or evolutionarily maladaptive (depending on how one chooses to interpret the proposed definition) and yet do not actually directly cause any suffering or other problems from necessarily being considered disorders. Furthermore, the DDC provides a conceptual basis for crafting the diagnostic criteria to minimize the stigmatizing affect on oppressed groups that may still need medical treatment. In situations where the disorder is not well operationalized by the criteria, the DDC can be used to curtail false positives that would be unnecessarily stigmatizing.

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Finally, the DDC gives the diagnoses some amount of flexibility in the face of changing social trends, such as the appearance of a new (a)sexual identity. Many of those under the protection of the CSC are members of oppressed or marginalized groups: gay men and lesbians, transgender people, and women. Members of oppressed groups are those most vulnerable to the stigmatizing effects of diagnosis. While there are many different ways that stigma manifests within mental health diagnosis and treatment, the DSM itself as a document represents a potent symbolic force within the culture of the United States. The removal of homosexuality from the DSM, for example, was an important victory for the burgeoning gay rights movement, and although there are still many religious and legal institutional forces upholding homophobic oppression, psychiatry and psychology as institutions have been ahead in their support of the struggle for gay rights for quite some time. Because overarching societal norms can influence the scientific understanding of dysfunction, oppressed groups at especially at risk for being harmed by the concept of dysfunction. Standards of harm are necessary to prevent that from happening. The stigmatizing effect that the DSM can have does not rest wholly on its influence on treatment or even diagnosis: the mere existence and description of a diagnostic category can have a stigmatizing effect on an overarching cultural level. That is why attempting to move the considerations represented by the CSC over to the determination of treatment is not an adequate solution for the problem of stigma. The very inclusion of a condition within the DSM, even if it were undiagnosable, would still have a stigmatizing effect, and the diagnosis of a disorder can have a stigmatizing effect even if the individual is allowed to decline treatment. This is demonstrated by the

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example of same-sex sexuality. It would be nonsensical to include a disorder like HHDD in the DSM and yet claim that it should not be taken as a sign that being gay is a disorder, and it would be nonsensical to diagnose someone with a disorder for being gay but reassure them by telling them that they will have some say in what the treatment will look like. These scenarios are as absurd as the scenario mentioned in the White Paper, of a person with the flu only being considered to have a disorder if they decide to stay in bed and rest. Conclusion As Wakefield noted, standards of harm are influenced by cultural values. It makes sense, then, for the classification of mental disorders created and used primarily within the United States to prioritize individual freedom within its standard of harm. Similarly, it is reasonable for an international classification to use a different standard of harm. As I have demonstrated, the distress and disability criterion represents a standard of harm that is more strongly weighted toward protecting individual freedom, but that does not make it the right standard of harm. It is simply one that is appropriate for the DSMs cultural context. If the distress and disability criterion undermines the view of the DSM as a collection of empirically proven categories, that simply makes it all the more necessary. Many of the problems that DSM-5 has run into are a result of the weight of the DSMs societal influence crushing itself. Because it has such widespread impact and the diagnostic categories have become reified, it is much more difficult to make significant changes to the DSM as a result. As I have reviewed, the disproportionate influence of the DSM-5 on research funding has impeded the progress of etiological research, the very

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research that is necessary to improve the DSM. Removing the DDC only serves to further reify the existing diagnoses as a set of objectively valid categories rather than a collection of refined hypotheses and clinically useful distinctions. The DSM needs more reminders of its provisional status, not fewer, and the DDC provides one of those reminders. A more refined way to determine treatment need is certainly a laudable goal, but removing impairment from the DSM is not necessary to achieve it. It is possible to integrate concerns regarding treatment need into diagnosis, to develop a more refined clinical significance criterion. All information regarding functional impairment could be moved to a separate section of each one of the diagnostic criteria, enabling the type of research desired by those in support of removing the DDC without incurring the stigmatizing consequences of doing so. The proposed definition does not even remove impairment from the DSM. It simply aids future attempts to remove impairment by undermining the conceptual validity of the CSC throughout the entire DSM. If the DDC is to be removed, then at least do so after the CSC has been removed. The inclusion of an explicit value-based standard of harm does not actually make the DSM less scientific. As Wakefields harmful dysfunction analysis demonstrates, values are a part of diagnosis. Obfuscating the relative influence of empirical findings and value judgments impedes research and clinical practice. It is important to know when the lack of understanding is being filled in by values. The benefits of removing the DDC are not worth the costs. Each of the claimed benefits supporting research into etiology, treatment need, and risk factors, harmonizing the DSM and ICD, increasing the apparent legitimacy of the DSM represent at best very marginal benefits. The research goals are either not actually significantly aided by

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removing the DDC or could be done without removing the DDC at all. Eliminating conceptually needless differences between the DSM and the ICD is certainly a worthwhile goal, but the DDC plays a unique conceptual role within the DSM. The DDCs most important function is the one it was invented for: combating stigmatization, especially of groups that could otherwise be labeled sick, wrong, or crazy due to systemic oppression. The concept of dysfunction is fundamentally limited in its ability to play that role. Suggested Changes to the Proposed Definition of Mental Disorder One option is to reinstate the distress and disability criterion as conceptually necessary: A Mental Disorder is a health condition characterized by significant dysfunction in an individuals cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. That dysfunction must be associated with distress or impairment in one or more important areas of performance. Even if it is not reinstated, I would advise removing Sentence 2 from the proposed definition it is out of place because it does not actually help define what a mental disorder is, and it has so many qualifications that it is effectively meaningless. Another option would be to make the DDC conceptually required for the inclusion of a condition in the DSM, but not conceptually necessary for every diagnosis. A Mental Disorder is a health condition characterized by significant dysfunction in an individuals cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. That condition must be generally associated with distress or impairment in one or more important areas of performance, though the presence of distress or impairment is not necessarily required for every actual diagnosis. This would still cause some problems, because it is not clear when distress or impairment are necessary (and the CSC does play an important role in some diagnoses), but it would

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prevent some of the potential problems caused by removing the distress and disability criterion. Wakefield has called for a case-by-case review of each diagnostic category to set a different standard of harm for each. While some dysfunctions might be considered sufficient for the diagnosis of a disorder, other dysfunctions may need a higher standard of harm. That would still require some overarching value framework for determining which disorders receive a higher standard of harm. A definition of mental disorder could then appear as such: A Mental Disorder is a health condition characterized by significant dysfunction in an individuals cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. In cases where diagnosis would be particularly stigmatizing in proportion to the need for treatment, that dysfunction must cause subjective distress or impairment in or more important areas of performance. There are many different ways to phrase or frame this type of requirement. The overall goal here is to define which disorders fall under the proposed definitions category of Some disorders that possess the CSC. Regardless, the kind of process Wakefield describes, determining for each disorder whether the symptoms themselves represent a sufficient standard of harm, is a process that should be done openly and with a clear set of value commitments, and in the mean time the best course of action would be to maintain the inclusion of the DDC. Whatever definition is ultimately chosen for DSM-5, the original purpose of the distress and disability criterion, protecting the stigmatization of oppressed groups, must be kept in mind.

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