Martha is a 20-year-old student at a prestigious liberal arts college. She has struggled with restrictive type anorexia nervosa (AN) for many years. Martha receives a letter awarding her a full scholarship to a top humanities graduate program. At the same time, she finds out she has gotten an A2 on a biology exam. All she can think about is that not getting an A will somehow lead to the graduate school withdrawing the offer. Her professors congratulate her on the scholarship and tell her the exam grade is not important, but she is unable to accept their reassurance. To punish herself, Martha eats only a bowl of cereal for 2 days.
Most clinicians will classify this case as an eating disorder in DSM categories. The maelstrom of intellectual activity—much of it debated in the pages and Web site of Psychiatric Times—has included proposals for reclassification of several disorders.1,2 This essay does not proffer a change in the classification of specific conditions but will sketch a new meta-concept of evaluative disorders that encompasses a number of prevalent and serious psychiatric diagnoses.
Popular discussions of values and valuation have been reduced to “value judgments” that are too often eu- phemisms for conservative political opinions or fundamentalist religious views. The Encyclopedia of Philosophy returns to the origins of the terms in economic theory and moral philosophy:
“Value” (in the singular) is sometimes used as an abstract noun, (a) in a narrower sense to cover only that to which such terms as “good,” “desirable,” or “worthwhile” are properly applied, and (b) in a wider sense to cover, in addition, all kinds of rightness, obligation, virtue, beauty, truth and holiness. This term can be limited to what might be the plus side of the zero line; then what is on the minus side (bad, wrong and so forth) is called disvalue. “Value” is also like “temperature” to cover the whole range of a scale—plus, minus, or indifferent; what is on the plus side is called positive value and what is on the minus side, negative value.3
Evaluative disorders are distortions or diminishments of a fundamental human capacity for valuing and evaluating that meet the general DSM criterion of causing, “significant distress or impairment in social, occupational, or other important areas of functioning.” Individuals with intact evaluative systems possess the complex ability to appraise priorities that have utility and importance within their personal biographies and social contexts. Critical readers will correctly point out that the entire idea of evaluative disorders represents an implicit value judgment about which activities and aims should be deemed worthwhile. Evaluative disorders share with other forms of psychiatric classification this broad assumption that those endeavors and experiences, which foster human flourishing, objectively lead to better functioning and less distress in modern Western culture.
Emerging neurobiological research suggests that persons with AN may well have an evaluative disorder. Individuals with AN have a pathological need to disvalue positive input and to overvalue negative stimuli. As the opening scenario shows, individuals with AN also have an evaluative scale set so narrowly that experiences which would in a more balanced assessment be seen as pluses are actually judged to be minuses. Similarly, indifferent events and actions, such as sleeping 30 minutes late on a Sunday morning, are evaluated as “bad or wrong.” Research has identified the disturbances in reward systems as being in part due to alterations in serotonin and dopamine metabolism that adversely affect the hedonic recognition of individuals with AN. I am suggesting that this biochemical abnormality may also contribute to the evaluative pathology found in AN. Such disordered valuation also offers a framework to better understand the logic, not just of the dyshedonia of AN but also of the ascetic temperament, harm avoidance, inability to live in the present, and rigid decision making clinically associated with restrictive type AN.4
We may define therapy as a search for value.
As the vignette poignantly illustrates, persons with AN are unable to find satisfaction in Maslow’s higher order attainments of self-worth and self-actualization. Wagner and colleagues5 used functional MRI to show that individuals with AN have dysfunctions in the reward and motivation systems, specifically the anterior ventral striatum and caudate. Using a monetary reward task, inves-tigators showed that women with restricting type AN were unable to distinguish between positive and negative feedback, indicating a disturbed capacity to realize the emotional salience of stimuli. Women with active AN, as opposed to those who had recovered, attempted to reduce anxiety by adopting an approach to rewarding stimuli based on consequences and planning (strategic) rather than the seeking of pleasure (hedonic). AN is the prototypical evaluative disorder. Substance use disorders and even some forms of depression can also be conceptualized within this model.
Consider this case.
Joseph is a 54-year-old highly successful physician who has severe alcohol dependence. During the past few months, a deep venous thrombosis developed that was thought to be a complication of his heavy drinking. Joseph also left his private practice to work for the state government because he could not handle the long hours and patient demands.
One night his wife and adult children conducted an intervention in which they asked Joseph if drinking mattered more to him than his family. He replied that he wouldn’t stop drinking and when one of his sons pressed him, he said, “Drinking is what matters most to me.”
Understood from the perspective of reward theory, Joseph’s response indicates that the hedonic amplitude of drinking is more intense than the satisfaction he gains from being with his loving family and is consistent with a severe addictive disorder. Referring back to the philosophical definition of valuation, Joseph is saying that the consumption of alcohol has become the most worthwhile activity in his life. Employing the broader definition, Joseph has evaluated continued drinking as a plus that outweighs the minuses of hurting his family and not fulfilling his obligations as a father and husband. Note that this conceptualization is also consonant with the DSM criteria for substance dependence: “Important social, occupational, or recreational activities are given up or reduced because of substance use.”6
The work of Volkow7 and others has demonstrated that salience may be as powerful a force in the maintenance of addiction as is pleasure in its initiation. The dictionary defines salient as, “1. Projecting or jutting beyond a line or surface; protruding. 2. Strikingly conspicuous; prominent.”8 Salience as a theory of addiction describes a complex dopamine-mediated evaluation of the prominence or significance of various stimulators of human motivation and behavior. In a review of the neurobiology of addiction, Goldstein and Volkow9 employ the language of valuation to describe salience: “These results imply that addiction connotes cortically regulated cognitive and emotional processes, which result in the overvaluing of drug reinforcers, the undervaluing of alternative reinforcers and deficits in inhibitory control for drug response.”
These new scientific findings suggest that an intact and whole capacity for evaluation is at least as fundamental to a good human life as right thinking and sound emotions. These considerations argue that the classification of psychiatric conditions as evaluative disorders as an alternative to established categorizations appears to have at least face validity deserving of closer examination.
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2. Brown RJ, Cardeña E, Nijenhuis E, et al. Should conversion disorder be reclassified as a dissociative disorder in DSM V? Psychosomatics. 2007;48:369-378.
3. Frankena W. Value and valuation. In: Edwards P, ed. The Encyclopedia of Philosophy. Vol 7-8. New York: Macmillan; 1967:229-232.
4. Kaye WH, Fudge JL, Paulus M. New insights into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci. 2009;10:573-584.
5. Wagner A, Aizenstein H, Venkatraman VK, et al. Altered reward processing in women recovered from anorexia nervosa. Am J Psychiatry. 2007;164:1842-1849.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. 4th ed. Washington, DC: American Psychiatric Press; 2000.
7. Volkow ND, Fowler JS, Wang GJ, et al. Imaging dopamine’s role in drug abuse and addiction. Neuropharmacology. 2009;56(suppl 1):3-8.
8. The American Heritage Dictionary of the English Language. 4th ed. Boston: Houghton Mifflin; 2006.
9. Goldstein RZ, Volkow ND. Drug addiction and its underlying neurobiological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry. 2002;159:1642-1652.