When . . . you see someone pale with worry . . . this man is disordered in his desires and aversions.
Let’s say a patient comes to you with a recent history of a single florid panic attack, in the context of giving a speech before an audience of 2000 colleagues. I don’t mean a case of the “jitters”—I mean a 10-minute episode of palpitations, shaking, sweating, choking, dizziness, derealization, and the belief that he is dying. Since you are remarkably empathic, and have had some public speaking anxiety yourself, you think, “I can understand how someone could have an attack like that, under those circumstances.
Let’s hold off on suggesting any formal diagnoses (a panic attack is not a formal DSM diagnosis—only a “building block” for one). Was this episode normal and non-disordered anxiety, because it is understandable to you? What about a patient with the identical set of symptoms, in the context of, say, hanging by his fingers over the edge of a cliff? If you can understand the occurrence of a panic attack in this context, was it therefore normal? These may sound like very theoretical questions, but they go to the heart of what we think of as normal or disordered, in both psychiatry and general medicine. How we answer these questions also has important implications for what we mean by the term “false positive” in psychiatry, and what categories we create for DSM-5.
At the last annual meeting of the APA—where I had just spoken on the experiential differences between grief and major depression—a very well-respected senior researcher in the audience rose to comment, evidently quite perturbed. He expressed great surprise at my claim that an explanatory context shouldn’t determine our clinical assessment of disorder or abnormality. My critic gave the example of someone who has a full-blown panic attack while hanging by his fingers, over a steep cliff. Surely, he insisted, context is critically important in such a case. After all, the context explains the person’s panic attack, and thus renders the attack non-pathological.
This is a perfectly plausible position, and probably represents the prevailing opinion among the general public. Indeed, many clinicians may be inclined to say, “Hey, I’d have a panic attack, too, if I were hanging by my fingers, over a cliff!” So calling such a panic attack normal is just common sense. Maybe so—but as Einstein once reminded us, “Common sense is the collection of prejudices acquired by age eighteen.” Science is the systematic testing of “common sense” assumptions against the range of alternative theories.
In my view, the hypothetical panic attack on the precipice is inherently pathological and disordered. And this “disorderness”—that state in which healthy and adaptive organismic function is disrupted—is not mitigated by any explanatory context. Furthermore, I want to suggest that “explanatory context” is usually a misleading guidepost, in so far as the determination of disorderness is concerned. It leads us to erroneous conclusions in other areas of psychiatry, besides panic attacks, such as whether to regard bereavement-related major depressive syndromes as instances of normal sadness or of bona fide MDD.1
And so, I want to suggest that the general concept of disorderness in psychiatry ought to be—with very few exceptions—non-contextual. But before my psychodynamically oriented colleagues recoil in horror, I hasten to add that context is critically important in working psychotherapeutically with patients. After all, psychotherapeutically speaking, there is a world of difference between a severely depressed patient who has just lost a loved one and an equally depressed patient who is being investigated for bank fraud—although, in my view, both are in a disordered state and deserve professional treatment.
1. Zisook S, Corruble E, Duan N, et al. The bereavement exclusion and DSM-5 [published correction appears in Depress Anxiety. 2012;29:665]. Depress Anxiety. 2012;29:425-443.
2. Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. New York: Oxford University Press; 2007.
3. Kendler KS. Review of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=1595220. Accessed January 4, 2013.
4. Kendler KS. American Psychiatric Association, 2010. http://www.dsm5.org/about/Documents/grief%20exclusion_Kendler.pdf. Accessed November 23, 2012.
5. Wakefield JC. Misdiagnosing normality: psychiatry’s failure to address the problem of false positive diagnoses of mental disorder in a changing professional environment. J Ment Health. 2010;19:337-351.
6. Lilienfeld SO, Marino L. Essentialism revisited: evolutionary theory and the concept of mental disorder. J Abnorm Psychol. 1999;108:400-411.
7. Lilienfeld SO. Book review of: Horwitz AV, Wakefield JC. The Loss of Sadness. Soc Serv Rev. 2009;83:473-477.
8. Selye H. Forty years of stress research: principal remaining problems and misconceptions. CMAJ. 1976;115:53-56.
9. Soh KC, Lee C. Panic attack and its correlation with acute coronary syndrome—more than just a diagnosis of exclusion. Ann Acad Med Singapore. 2010;39:197-202.
10. Craske MG, Kircanski K, Epstein A, et al; DSM V Anxiety; OC Spectrum; Posttraumatic and Dissociative Disorder Work Group. Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V. Depress Anxiety. 2010;27:93-112.