I greatly enjoyed Dr Ron Pies’ editorial “What Should Count as a Mental Disorder in DSM-V?”1 in which he encouraged framers of DSM-V to critically examine the boundaries of mental illness and to more carefully distinguish between diseases, disorders, and syndromes. As I have noted elsewhere, current plans to integrate a “spectrum” approach into DSM-V require a careful consideration of these issues that must be defensible to critics of diagnostic expansion within psychiatry.2
Echoing DSM-IV’s requirement of “distress and impairment” for most of its disorders, Dr Pies begins with “suffering and incapacity” as core fibers to craft a model of mental disease. He then proposes that progressive discoveries about pathophysiology elevate a syndrome in step-wise fashion toward a disease entity. While this model seems logical enough, I would like to review several challenges that arise from any model that is based on a foundation of “dis-ease.”
The first is the Szaszian issue of society’s role in defining (or creating) suffering and impairment in the context of behavioral disorders. Dr Pies specifically emphasizes the importance of phenomenology—the subjective experience of distress—and also requires that suffering be inherent to the disorder rather than imposed by society (eg, as punishment for deviance). But thinking Socratically, what about conditions in which subjective dis-ease is absent? And what of conditions in which incapacity is defined only by impaired social functioning? Isn’t it sometimes true that a patient with schizophrenia with no insight and no complaints about his or her homelessness, unemployment, and “symptoms” is hospitalized involuntarily because of society’s paternalistic, if not punitive, view of impairment? If that example seems to have obvious holes, what of the thorny history of DSM and homosexuality—if presently excluded based on lack of intrinsic suffering,3 should that same status now be extended to paraphilias (for example, pedophilia)?4
Dr Pies notes that value judgments are unavoidable in diagnosis and notions of disorder and argues that this does not detract from “facts.” In his model, the “facts” seem to be manifest symptoms or known pathophysiologies. Does this mean that any condition with a known physiology that is associated with value-laden suffering or incapacity qualifies as a disease entity? Should human variations that result in less than ideal social functioning and that are almost assuredly rooted in “biomolecular etiology” (eg, ugliness, shortness, baldness, shyness, diminutive sex organs) be categorized as disorders or diseases?5 Part of this dilemma can be sidestepped by arguing that “pathological” suffering should be defined by some threshold of severity, such that therapeutic and cosmetic interventions can be disentangled. But anyone who has ever used a visual analog scale to measure a patient’s self-reported pain can appreciate the difficulties arising from such subjectivity.
Finally, it would appear that disease models that start with “dis-ease” are based on the assumption that “normal” existence does not or should not involve “prolonged suffering or incapacity.” In contrast, Freud wrote of the “common unhappiness” inherent to the human condition—a view now mirrored by proponents of acceptance and commitment therapy,6 Horwitz and Wakefield’s critique of depression,7 or those lamenting “disease mongering.”5,8 Here the underlying issue is causation: is prolonged suffering and incapacity caused by intrinsic pathophysiology, or is subjective dis-ease a “normal” response to extrinsic circumstances (eg, poverty, war, oppression, a less than ideal childhood development)? Such etiological distinctions were deliberately abandoned in DSM-III but seem to be vitally important to the task of defining disease.
These issues are hardly novel and on the contrary have confronted each wave of DSM architects. One can only hope the changes occurring in DSM-V will represent a step forward in accounting for these challenges.
Joseph M. Pierre, MD
Associate Director of Residency Education
UCLA Semel Institute for Neuroscience
West Los Angeles VA Medical Center
Co-Chief, Schizophrenia Treatment Unit
West Los Angeles VA Medical Center
Associate Clinical Professor
Department of Psychiatry & Biobehavioral Sciences
David Geffen School of Medicine at UCLA
1. Pies R. What should count as a mental disorder in DSM-V? Psychiatric Times. 2009;26(4):17-24. http:// www.psychiatrictimes.com/display/article/ 10168/1402032. Accessed August 5, 2009.
2. Pierre J. Deconstructing schizophrenia for DSM-V: challenges for clinical and research agendas. Clin Schizophr Related Psychoses. 2008;2:166-174.
3. Spitzer RL. The diagnostic status of homosexuality in DSM-III: a reformulation of the issues. Am J Psychiatry. 1981;138:210-215.
4. Silverstein C. The implications of removing homosexuality from the DSM as a mental disorder. Arch Sex Behav. 2009;38:161-163.
5. Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ. 2002;324:886-891.
6. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press; 1999.
7. Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. Oxford, UK: Oxford University Press; 2007.
8. Smith R. In search of “non-disease.” BMJ. 2002; 324:883-885.
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