Christian Perring, a philosopher, reviews Advancing DSM: Dilemmas in Psychiatric Diagnosis. Edited by Katherine A. Phillips, Michael B. First, and Harold Alan Pincus.:
Those interested in the philosophy of psychiatry will find much food for thought in the chapter by Wakefield and First, “Clarifying the Distinction Between Disorder and Nondisorder.” They explain that it is important to distinguish between mental disorders and other conditions including normal intense emotional reactions, social deviance, personal unhappiness, lack of fit between an individual and a specific social role or relationship or environment, and socially disapproved or negatively evaluated behavior in general.
This is especially motivated by concerns within the psychiatric profession and the general public that mental disorders are being overdiagnosed, and ordinary human problems are being medicalized. They call this the false-positives problem, and they spell out the wide range of clinical, research and social concerns that it raises. They examine the strengths and weaknesses of the current DSM-IV-TR definition, which have been discussed at length elsewhere.
Unsurprisingly, the authors are inclined to adopt Wakefield’s well-known “harmful dysfunction” account of mental disorder. It is disappointing that they scarcely mention the existence of a considerable body of literature that finds serious flaws in this account, although they do address some general sorts of concerns that have been raised. They suggest however, that the false-positives problem stems not so much from the defects of the current definition but rather a failure to abide by that definition in the DSM criteria sets. They examine a number of different cases to illustrate their claim here. For example, DSM-IV-TR would count someone who had just lost their job and had experienced 2 weeks of depressed mood, diminished pleasure in usual activities, insomnia, fatigue, and a diminished ability to concentrate on work tasks as having major depression. Wakefield and first argue that such symptoms are a normal reaction to such a loss, and do not give reason to believe that there is a psychological dysfunction. They argue that the criteria for adjustment disorder, substance abuse, acute stress disorder, conduct disorder and separation anxiety are also overinclusive, counting as mental disorders conditions that do not involve internal dysfunctions of individuals.
Wakefield and First also point out that the attempt to reduce false positives through requiring that symptoms be “clinically significant” is unhelpful because it is circular — the whole point of a definition of mental disorder is to explain the meaning of what should count as clinical significance, and so it cannot simply appeal to such a notion in its definition. They suggest that definitions of mental disorder should attempt to focus on the essence of the dysfunction that is the cause of the mental disorder.
Furthermore, they emphasize that there is a dysfunction when a person’s symptoms do not match the context. As they explain, “A dysfunction exists when a person’s internal mechanisms are not able to function in the range of environments to which they were designed to respond. Thus, one can construct a test for dysfunction by specifying an environment in which the function is designed to manifest itself; if the function is not manifested in that environment, there is likely a dysfunction” (p. 51).
Wakefield and First’s call to bring the DSM criteria for mental disorders in line with the DSM definition of mental disorder is certainly to be welcomed. It is likely that their emphasis on clarifying the distinction between normal reactions and internal dysfunctions could lead to improved formulations of psychiatric criteria in many cases. However, their reliance on a concept of dysfunctional mechanisms within a person, often supported by reference to functions of internal mechanisms as set out by evolutionary psychology, is problematic. As many critics have pointed out, evolutionary psychology is in no position to give us a clear picture of what counts as normal function, and it is debatable whether it ever will be. Furthermore, even if we did could use evolutionary psychology for this purpose, there are reasons whether it is appropriate to use the standards of evolutionary fitness for survival in conditions that existed long before the creation of any human civilizations of the last our thousand years for our standards of normality in the twenty-first century. (This point applies as much to standards of physical health as is does to mental health.)
Many will worry that the desire for DSM to clothe itself in the garb of scientific respectability will result in smuggling in a host of ideological and normative assumptions under the guise of scientific objectivity. A strong case can be made that rather than basing criteria for mental disorder on dubious science or pseudoscience, we be better served by encouraging an open public discussion of the normative bases of our psychiatric categories and with the aim of reaching broad agreement.
