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“I think the DSM gives you one sense of depression,” Sidney Zisook, MD, told attendees of the 2021 Annual 

 World CME Conference. “But I think it's very, very one dimensional. A better way of really understanding what it is to be depressed and the diagnosis is getting firsthand accounts from those who have dealt with depression.”

Zisook, director of the University of California, San Diego (UCSD) Residency Training Program, Distinguished Professor of Psychiatry at UCSD, and last year’s Educator of the Year awardee, shared insights from several famous folks about their experiences with depression. Of depression, David Foster Wallace said:

It is a level of psychic pain wholly incompatible with human life as we know it. It is a sense of radical and thoroughgoing evil not just as a feature but as the essence of conscious existence. It is a sense of poisoning that pervades the self at the self’s most elementary levels. It is a nausea of the cells and soul.

This quote, and others like it, show a sense of hopelessness, even suicidality, more than other aspects of depression, including those recognized by the DSM 5, he noted.

To better understand the current state of diagnosis, Zisook took attendees back in time to discuss the various iterations of depression in the DSM, from being classified as psychoneurotic disorder in DSM I in 1952 through the psychoanalytic approaches through the specifiers in DSM IV. Changes continued into DSM 5, where we now have a variety of disorders: major depressive disorder, disruptive mood dysregulation disorder, persistent depressive disorders, substance- and medication-induced depressive disorder, premenstrual dysphoric disorder, depressive disorder due to another medical condition, and other specified (or unspecified) depressive disorder.

To help illustrate the problems associated with the current system, Zisook shared 2 case examples. Ms A is a 30 year old married woman complaining of stress. Upon further exploration, you learn she has been tearful and increasingly sad since her mother received a diagnosis of cancer. She has little motivation, is overeating and gaining weight, and sleeps about 12 hours a day. She has never felt like this before.

On the other hand, Mr B is a 60 year old man who is brought to you by the police after found wandering on the Coronado Bridge. He is unshaven, slovenly, and demonstrates psychomotor retardation. He shows no interest in answering questions, but an informant tells you he has not been eating or drinking for weeks. He has expressed feeling miserable and worthless. He had a similar episode 30 years prior; he achieved full recovery after responding to electroconvulsive therapy.

“What do they have in common?” Zisook asked rhetorically. “Definitely nothing except the diagnosis of major depressive disorder—without any overlap in functioning.”

In reviewing DSM 5 criteria, he posed a few questions for the authors of DSM 6 to consider. For instance, why must symptoms last 2 weeks? “This never made much sense to me,” he said. “Somebody is undergoing a horrible situation—they lost their job, they've lost their family, they've lost their money—they've never been depressed before, and the depression is relatively mild, moderate. You don't want to label them with a major depressive disorder in 2 weeks. Give me more time to see what happens. Let them take care of some of the situations.”

“On the other hand,” Zisook added, “if they had a history of severe major depressive disorder, and for the last 2 days they're despondent, hopeless, feeling worthless, feeling suicidal, you have got to wait another 12 days to make the diagnosis.”

To better understand the diagnosis, again Zisook looked to patients. He discussed studies conducted by Mark Zimmerman, MD, and colleagues looking at what was needed for patients with depression to consider themselves in remission.

 The top 3 features were: positive mental health, such as optimism and self-confidence; a return to one’s usual, normal self; and a return to a usual level of functioning. Interestingly, one-quarter of respondents who were mildly symptomatic and, per HAM-D scores, not in remission considered themselves remitters. As such, they reported better quality of life, less functional impairment due to depression, higher positive mental health scores, and better coping ability.

I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.

So, how does Zisook define and diagnosis depression? “There are screening instruments, which is fine for looking at depression,” he told attendees. “But I think there's nothing to substitute for clinical inquiry. And I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.”

He also reminded attendees that differential diagnosis is very important, adding “Always look for bipolar disorder or general medical conditions.” Bereavement and burnout also need special attention, he explained, since those are often misdiagnosed and/or confused with depression. A careful examination of the criteria and symptoms will help to distinguish the disorders.

Zisook concluded by saying, “I think our diagnostic concepts are a work in progress in terms of helping us communicate with each other, helping us take into account what patients are saying about what it feels like to be depressed, and helping us to prescribe very personalized medications.”

1. Zimmerman M, McGlinchey JB, Posternak MA, et al. 

How should remission from depression be defined? The depressed patient's perspective

2. Zimmerman M, Martinez J, Attiullah N, et al. 

Why do some depressed outpatients who are not in remission according to the hamilton depression rating scale nonetheless consider themselves to be in remission?

Sidney Zisook, MD, shares insights into defining depression diagnosis.

Defining and Diagnosing Depression: Clinical and Patient-Oriented Perspectives

So, you think you have a pretty good handle on DSM-5—what the lay press loves to call, quite misleadingly, “Psychiatry’s Bible”? OK, maybe you know most of the criteria for the major categories of serious mental illness. No doubt, you are aware of serious problems with some aspects of DSM-5 (the 

, including the limited reliability and validity of many of its disorder categories.

 But how well do you understand the “deep structure” of DSM-5 as a diagnostic tool?

Just to get your adrenaline flowing, try taking this 2-minute quiz:

A. DSM-5 permits the clinician to make a mental disorder diagnosis simply by checking off the symptoms listed in a disorder’s diagnostic criteria.

B. To make a DSM-5 mental disorder diagnosis, the clinician need not assess the social, psychological and biological factors that may have contributed to the patient’s condition.

C. DSM-5 is an embodiment and expression of the “biomedical” model in psychiatry.

D. DSM-5 posits that mental disorders are discrete entities sharply distinguished both from “normality” and from each other.

Critics of psychiatric diagnosis often caricaturize the DSM process as the “Chinese Menu” approach. Thus, a professor of history and philosophy—in an article titled, “Forget talking, just fill a script: how modern psychiatry lost its mind”—

In clinical practice, DSM-III led to a “Chinese menu” approach to psychiatric diagnosis: a specific mental illness can be diagnosed if a sufficient number of boxes can be ticked. This is only of limited value in clinical practice.

Indeed, merely checking off boxes of symptoms (and signs) 

but that is not at all what DSM-5 calls for.

 As my colleague, Dr Mark Ruffalo, and I 

, the DSM-5 makes it crystal clear: Simply checking off symptoms 

cannot and does not constitute a psychiatric diagnosis—

The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological and biological factors that may have contributed to developing a given mental disorder. 

Hence, it is not sufficient to simply check off the symptoms of the diagnostic criteria to make a mental disorder diagnosis 

, the case formulation “. . . is a core clinical skill that links assessment information and treatment planning. It is a hypothesis about the mechanisms that cause and maintain the problem. It answers the question, ‘Why is this person, having this type of problem, now?’”

In principle, the case formulation—and by extension, the final DSM diagnosis—requires medical knowledge, or at least access to medical consultation, in order to assess the “biological factors” that may have contributed to the patient’s problem. Finally, we should note that, in addition to meeting sign/symptom criteria for a mental disorder, virtually all the major 

 require evidence of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” You cannot snag a DSM diagnosis merely by collecting a group of signs and symptoms. There must also be adverse consequences in the person’s life.

The DSM-5 Is “Biomedical”? Not So Much

It is clear from the aforementioned description of the case formulation that the DSM-5 explicitly uses a “biopsychosocial” approach to diagnosis. In addition, DSM-5 has extensive coverage of cultural issues, as they impinge on differential diagnosis. Excellent examples of the “case conceptualization” using a bio-psychosocial-cultural approach may be found in the text by Sperry and Sperry.

Nonetheless, some commentators—mainly critics of psychiatric nosology—have asserted that DSM-5 represents the “biomedical” model. For example, 1 paper 

Diagnostic and Statistical Manual of Mental Disorders

 . . . offers a biomedical framing of people’s experiences of distress and impairment, and despite decades of criticism, it remains the dominant approach.

These authors go on to argue that, “. . . a biomedical construction of ‘mental illness’ all too frequently fails to protect individuals from delegitimation and stigma.” That is a provocative claim worth examining but is beyond the scope of this essay. What is striking about the paper by these 2 psychologists is that the term “biomedical” is never fully defined. The authors do 

 the biomedical model is oriented “around the problems of the body . . . such as genetics or neurochemistry.”

If we take that rough formulation as a guide, it can be readily seen that—with a few exceptions—there is very little in DSM-5 that invokes “genetics” or “neurochemistry.” True, DSM-5’s discussion of 

 does reference abnormalities on chromosome 4; and other neurocognitive disorders, such as Lewy body disease, are linked to genetic abnormalities. But such references to specific genetic abnormalities are by far the exception, particularly for the more classically “psychiatric” disorders, such as schizophrenia and bipolar disorders. (We do find, under the rubric of “Risk and Prognostic Factors,” the statement that “Schizophrenia and bipolar disorder likely share a genetic origin . . .”

As far as I know, discussion of “neurochemistry” as a 

 in any of the common psychiatric disorders is entirely lacking in DSM-5. (So much for “chemical imbalances”). With only a few exceptions, DSM-5 avoids commitments regarding etiology. Indeed, the 

, “a diagnosis does not carry any necessary implications regarding the etiology or causes of the individual’s mental disorder. . .”

 One can see this as a serious deficiency in the DSM-5—but one cannot claim the 

endorses anything resembling neurochemical etiologies or “chemical imbalances” for the major mental disorders.

 that the DSM-5 “offers a biomedical framing of people’s experiences of distress and impairment.”

 Deacon, in a detailed review and critique, argues that “The biomedical model posits that mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities.”

 I do not contest that description, but nothing in Deacon’s analysis shows that DSM-5 is essentially “biomedical” in the sense he explicates.

Fuzzy Boundaries, Overlapping Symptoms, and Dimensions of Pathology

Another common claim is that DSM-5 is a strictly “categorical” framework that conceptualizes mental illness as a collection of discrete, diagnostically separable entities. As one paper puts it, “. . . the DSM-5 is a categorical system. Thus, individual disorders are regarded as discrete units—“you either have it, or you don't.”

 A related claim is that DSM-5 posits a clear and distinct separation between mental abnormality and “normal” mental or psychological states. 

In truth, neither claim is supported in the DSM-5 (

). On the contrary, the Introduction to the 

The results of numerous studies of comorbidity and disease transmission . . . make strong arguments for what many astute clinicians have long observed: the boundaries between many disorder “categories” are more fluid over the life course than DSM-IV recognized, and many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders. These findings mean that DSM . . . should accommodate ways to introduce dimensional approaches to mental disorders, including dimensions that cut across categories . . . Although some mental disorders may have well-defined boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors, and possibly shared neural substates . . . 

In short, we have come to recognize that the boundaries between disorders are more porous than originally believed.

Furthermore, the DSM-5 does not argue for a hard and fast boundary between “normal” and “abnormal” states and conditions. On the contrary, it states:

The boundaries between normality and pathology vary across cultures for specific types of behaviors…Hence, the level at which an experience becomes problematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians.

All this is not to say that psychiatric illnesses are merely “

” labels that have no corresponding physical or pathological referents in “the real world”—a thorny topic for another time.

 DSM-5 merely affirms what all good clinicians know: There are many 

 in the realm of psychopathology, often influenced by culture; and it is very doubtful that we can “carve Nature at its joints.”

 that democracy is the very worst form of government, except for all the others that have been tried.

 It is tempting to suggest, tongue slightly in cheek, that DSM-5 is by far the worst diagnostic framework psychiatry could have chosen—except for all the rest. To be sure, many different approaches to psychiatric diagnosis have been 

Personally, I favor a prototype-based diagnostic approach for every-day clinical work; and a parallel set of “research diagnostic criteria” for investigative purposes (

). “Prototype” diagnosis refers to the use of idealized models or archetypes of disease, rather than either “categorical” or “dimensional” methods of classification. 

 discuss and debate various diagnostic models in a wide-ranging colloquium.

It seems very clear that diagnosis is, and will always remain, a necessary part of clinical care, both in general medicine and psychiatry. When a patient presents with the complaint, “I hear threatening voices in my head,” we simply must

—a word whose etymology means, “knowing the difference between.” For example, we must know the difference between “threatening voices” stemming from combat-related trauma, on the one hand, versus schizophrenia or anti-NMDA receptor encephalitis

 on the other. Otherwise, our treatment is likely to be misguided.

No, whatever the lay press claims, DSM-5 is not “The Bible of psychiatry.’ It is not a sacred, eternal, and inviolable text, or even a very sophisticated diagnostic tool. John Talbott, MD, professor emeritus of psychiatry and former president of the 

, “If you let the specifics of the DSM tie you down, it prevents you from practicing the art of medicine. So, I would hope people would not be bound by it, but be flexible and use their clinical judgment instead.”

I agree. But before we use the DSM-5’s text to line our bird cages—as a renowned British psychiatrist I once met described the utility of the DSM-III—we should at least understand what DSM-5 does, and does not, represent.

 is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

 Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

1. jmm1000. Dr Pepper "So Misunderstood" feat Carol Kane - 1973-1974. YouTube. June 30, 2017. Accessed March 17, 2021. 

https://www.youtube.com/watch?v=WA_NnXyDDLk

2. Regier DA, Narrow WE, Clarke DE, et al. DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. 

3. Pols H: Forget talking, just fill a script: how modern psychiatry lost its mind. 

 October 21, 2012. Accessed March 17, 2021. 

https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569

4. Ruffalo ML. Pies RW. Psychiatric Diagnosis 2.0: The Myth of the Symptom Checklist. 

 June 14, 2020. Accessed March 17, 2021. 

https://www.psychologytoday.com/us/blog/freud-fluoxetine/202006/psychiatric-diagnosis-20-the-myth-the-symptom-checklist

. Washington, DC; American Psychiatric Publishing, Inc: 2013.

6. Gintner GG. Using DSM-5 in Case Formulation. Louisiana Counseling Association presentation. Accessed March 17, 2021. 

http://www.lacounseling.org/images/lca/Conference/DSM-5%20LCA%20Case%20Formulation%20Rev.pdf

Mastering this Competency with Ease and Confidence.

9. Deacon BJ. The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research. 

10. van Heugten-van der Kloet D, van Heugten T. The classification of psychiatric disorders according to DSM-5 deserves an internationally standardized psychological test battery on symptom level. 

What kinds of things are psychiatric disorders?

12. Gabor, GT. ‘Carving nature at its joint’: The Platonic method of division in Plato, Aristotle, and their Neoplatonic commentators. 

. AAI3466699. 2011. Accessed March 17, 2021. https://research.library.fordham.edu/dissertations/AAI3466699

13. Churchill W. The Worst Form of Government. International Churchill Society. November 11, 1947. Accessed March 17, 2021. 

https://winstonchurchill.org/resources/quotes/the-worst-form-of-government/

14. Phillips J, Frances A, Cerullo MA, et al. The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis. 

. 2012;7:9. Accessed March 17, 2021. https://peh-med.biomedcentral.com/articles/10.1186/1747-5341-7-9

15. Kayser MS, Dalmau J. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. 

16. Vlessides M. The Past, Present, and Future of the DSM. 

. December 15, 2020. Accessed March 17, 2021. 

https://www.medscape.com/viewarticle/942694#vp_1

A DSM-5 diagnosis requires a biopsychosocial case formulation—not just a symptom checklist.

Poor DSM-5—So Misunderstood!

John J. Miller, MD, talks through the changes and developments of DSM. 

DSM 1 was published in 1952, and sadly the terms were less than kind; but it was based on the information available at the time. DSM 2, published in 1968, consisted of mostly psychodynamics and therapy, when psychopharmacology was very young.  DSM 3 published in 1980, introduced PTSD – only 40 yrs ago. 1994 saw the publication of DSM 4, and DSM 5 in 2013. 

is Medical Director, Brain Health, Exeter, NH; Editor in Chief,

Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

How did DSM begin and how did the most recent DSM get to its current state? 

A Tale of the DSMs

Dr Aftab is a geriatric psychiatry fellow at University of California San Diego (UCSD) in La Jolla, CA, and a former psychiatry resident at Case Western Reserve University/University Hospitals Cleveland Medical Center in Cleveland. He is also a member of the 

 Advisory Board. He can be reached at awaisaftab@gmail.com.

This is the third and final part of a three-part series on a pertinent philosophical question in the era of diagnostic inflation: What conceptual means are available to prevent deviant and undesirable behavioral conditions from being diagnosed as mental disorders as a result of social bias and stigma? The series is based on an essay (“Social Misuse of Disorder Designation: Exploring Dysfunction and Harm-Based Conceptual Defenses”) that was awarded the 2018 Karl Jaspers Award by the Association for the Advancement of Philosophy and Psychiatry. Dr Aftab has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry, and this series constitutes one effort to bring this discussion to a wider audience. 

, I argued that a dysfunction-based defense strategy does not adequately protect against arbitrary disorder designations. In Part 3 of this series, I will explore the notion of a harm-based defense.

At a minimum, a mental disorder is considered an undesirable and unwanted condition either for the individual or the society. However, that is clearly very relativistic and does little to protect against social misuse of disorder designation. 

 in a broad fashion, barely distinguishable from negative social evaluation. For instance, Wakefield writes: "As traditional value accounts suggest, a condition is a mental disorder only if it is harmful according to social values and thus at least potentially warrants medical attention. . . . ‘Harm’ is construed broadly here to include all negative conditions."

We can, however, restrict undesirability to certain kinds of harm to come up with a criterion that offers more protection. Consider the following degrees of undesirability:

1. Unwanted/undesired/negatively evaluated by the individual only;
	2. Unwanted/undesired/negatively evaluated by the society;
	3. Associated with harm (distress/disability/harm to others) (DSM);
	4. Associated with intrinsic harm (distress or disability which is a direct result of a specific biological or psychological process).

The only way to reliably exclude ego-dystonic homosexuality from the realm of mental disorders is to require intrinsic harm to be a necessary criterion for a mental disorder definition. Homosexuality can be (and was) negatively evaluated by individuals as well as society, and it can be (and was) perceived to be harmful according to social values; ego-dystonic homosexuality is also associated with distress.

 reason for limiting harm in the definition of mental disorder to intrinsic harm. It is an artificial maneuver that is difficult to justify on conceptual analysis aside from saying that it offers protection against social prejudice. This point has been well-articulated by 

In any case, it would be an artificial polarisation to attempt to understand distress or harm as separable from cultural values, and it is not obviously desirable for healthcare to be informed by a narrow view of harm. This would run counter to ideals of holistic healthcare and attempts understand people in context. If correct, Wakefield rightly extends ‘harm’ to cultural standards. But if so, then socially undesirable conditions are not excluded from the definition of disorder by distress or harm criteria.

I agree with Bingham and Banner that such a move would conceptually be an artificial polarization. There is, however, a strong ethical argument to be made requiring 

 as a necessary criterion for mental disorder designation in the practice of psychiatry. We have an ethical obligation to prevent social misuse of disorder designation, and we need a conceptualization of mental disorder that would exclude “states that are wrongly pathologised due to prejudice and social exclusion, including those we might not have identified as such yet.”

Distress refers to some sort of psychological suffering. Although the DSM makes no further classifications, the following distinctions can be made regarding types of distress:

 is distress that is the direct result of a specific biological or psychological process.

 is not the direct result of a specific biological or psychological process. It can originate from conflict with society (ie, individual would not experience distress if society were to accept the condition as normal-exogenous distress) or it can originate from within the individual due to internalized moral and social values (ie, internalized distress) but not as a direct result of biological or psychological processes.

The distinction between intrinsic distress and extrinsic distress in the case of a particular condition can be facilitated by means of a thought experiment. If social norms were to change such that the condition in question is no longer considered disordered, does the distress disappear? Even if society were to accept generalized anxiety as a normal variant, the persistent anxiety remains distressing for the individual experiencing it. In the past, homosexual individuals were distressed by the sexual orientation due to the antagonism with social norms and sought conversion therapy for that reason. However, with change of social norms, homosexual individuals are (by and large) no longer distressed.

As utilized in the harm criterion, “functional impairment” (or “functional disability”) refers to the negative consequences in social or occupational functioning or other important activities of life. For instance, heart failure is impairing as it restricts physical activity; agoraphobia can be impairing if one becomes unable to leave the house. 

 is a product of the interaction between a deficit and the environment, and the presence of impairment and the degree of impairment may depend on the environmental context. For instance, attention deficits and hyperactivity in a child may be quite impairing in a highly structured modern classroom but may have had little to no impairment in pre-modern societies.

One important consideration is whether functional impairment is direct product of the biological processes in question or is a result of society’s stigmatization. For instance, red hair by itself leads to no functional impairment, but individuals with red hair may not be able to find employment because of social stigma.

Paraphilias can cause impairment in sexual life in the absence of appropriate stimulus. However, it is unclear if this is an impairment just because society considers the behaviors pathological. Voyeurism or sadomasochism can be highly impairing if one is unable to find consensual sexual partners with whom to engage. Similarly, the more stigmatized these conditions are in a society, the more difficult it will be to find consensual partners. If impairment disappears simply by society’s acceptance of that behavior as a non-pathological normal variant, it is likely a result of society’s discrimination and I will term it 

, which is a direct result of a specific biological or psychological process).

It is fairly obvious that distress occurs in cases of socially deviant behavior and conflicts between individual and society. The requirement for distress alone does not protect social deviance from being pathologized. Distress or impairment that results from social deviance and conflict is extrinsic. It is different from intrinsic distress and intrinsic impairment, which are a direct result of the biological or psychological processes in question. A harm criterion that restricts disorder designation only to cases of intrinsic distress and intrinsic functional impairment can, therefore, protect against disorder designations of extrinsic distress and extrinsic impairment. (

 have made a similar argument, namely that "psychiatry’s ability to distinguish deviance from disorder rests on the ability to define, identify, and exclude socially constituted forms of distress. These should lie outside the purview of candidacy for mental disorder."

Based on the above discussion of harm, I posit the notion of ethical validity of disorder designation. Ethical validity arises from considerations of intrinsic harm as well as considerations of harm caused by disorder designation. Harm caused by disorder designation includes all the ways in which disorder designation prevents individuals from flourishing in a manner that those without a disorder designation can flourish. This includes imposition of sick role, social discrimination and stigmatization, production of self-guilt and self-doubt in the individuals, unnecessary-possibly coercive-treatment, and barriers to progressive social change. Disorder designation lacks ethical validity in the case of conditions without intrinsic harm.

It is easy to see why it is ethically wrong to classify homosexuality or red hair as a disorder. Both conditions lack intrinsic distress and intrinsic impairment. In both cases, there is harm caused by disorder designation. A person whose sexual orientation is considered a disorder and a person whose red hair is considered a disorder cannot flourish in the same manner as a person whose differences are seen as normal variants.

The biggest practical challenge in implementing harm validity as a tool to limit disorder designation is that it may not always be possible to make the distinction between intrinsic distress and internalized distress, as both may be present simultaneously. In the case of ego-dystonic homosexuality, it is clear in hindsight that the distress was internalized. However, consider the distress associated with paraphilic disorders-how much of it is intrinsic and how much of it is extrinsic? It may also vary depending on the specific paraphilia. The degree of intrinsic distress may be different in pedophilic disorder compared to fetishistic disorder. It may very well be the case that all of distress with paraphilias is extrinsic, but it is difficult to determine conclusively. Another example would be hypoactive sexual desire disorder. How much of distress associated with low sexual desire is a direct result of the low sexual desire, and how much of it is due to our contemporary social norms that place a high emphasis on the need for an active sexual life?

I suggest that even when these distinctions are not easily sorted, an emphasis on determining the presence of intrinsic harm would serve to stimulate social and psychiatric discourse on the nature of associated distress, particularly if it allows individuals with the conditions to talk about their subjective experience of distress. Perhaps, over time, stimulation of such discourse will lead to greater diagnostic clarification.

In this three-part essay I have dealt with the thorny question of what conceptual defenses are available to restrict the ability of a society to arbitrarily designate negatively valued behavioral states as mental disorders. Ego-dystonic homosexuality presents a way to stress test candidate defense strategies; ego-dystonic homosexuality is ideal for this purpose since there is widespread consensus in contemporary psychiatry regarding its non-pathological status. Plus, any definition of mental disorder that simply requires the presence of distress in the individual without an analysis of the nature of distress will fail to exclude ego-dystonic homosexuality and other similar conditions where distress is generated because of social conflict. Notions of dysfunction, including objectivist notions by Boorse and Wakefield, offer limited defense, since the presence of dysfunction is already inferential in the vast majority of behavioral disorders and, even in cases like homosexuality, the question of whether dysfunction is present has proven remarkably elusive. Evaluative criteria of harm provide similarly weak defenses, either because they are highly relativistic or because they are unable to exclude distress resulting from social conflict. Instead, the only way to reliably exclude ego-dystonic homosexuality from the realm of mental disorders is to require intrinsic harm to be a necessary criterion for a mental disorder definition. There is no a priori reason for this requirement based on conceptual analysis of mental disorder, but there is a strong ethical argument in support. There are practical challenges in distinguishing between intrinsic distress and internalized distress but requiring intrinsic harm as a criterion would serve to stimulate social and psychiatric discourse on the nature of associated distress and lead to greater diagnostic clarification.

The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis

 The definition of mental disorder: evolving but dysfunctional?

Can psychiatry distinguish social deviance from mental disorder?

At a minimum, a mental disorder is considered an undesirable and unwanted condition either for the individual or the society. However, that is clearly very relativistic and does little to protect against social misuse of disorder designation.

Social Misuse of Disorder Designation, Part III: Harm and Ethical Validity

This is Part 2 of a three-part series on a pertinent philosophical question in the era of diagnostic inflation: What conceptual means are available to prevent deviant and undesirable behavioral conditions from being diagnosed as mental disorders as a result of social bias and stigma? This series is based on an essay (“Social Misuse of Disorder Designation: Exploring Dysfunction and Harm-Based Conceptual Defenses”) that was awarded the 2018 Karl Jaspers Award by the Association for the Advancement of Philosophy and Psychiatry. Dr Aftab has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry, and this series constitutes one effort to bring this discussion to a wider audience. 

, we noted that DSM recognizes the need to prevent arbitrary disorder designation of negatively valued conditions and does so by adopting a dysfunction-based defense. However, I argue that a dysfunction-based defense against misuse of disorder designation has serious conceptual deficiencies, is vulnerable to social biases, and offers very little protection in practice. Let us take a closer look at some of these problems with dysfunction.

Given the important role dysfunction plays here, one would imagine that the DSM (and psychiatry, more broadly) would have a valid, unambiguous definition of dysfunction that would clearly determine which deviancies and conflicts are disorders and which are not, even in situations of controversy. Sadly, that is not the case. DSM never formally defines this crucial term. It is not surprising, then, that the authors of the DSM 5 white paper on nomenclature felt that the mental disorder definition “is not cast in a way that allows it to be used as a criterion for deciding what is and is not a mental disorder, and it has never been used for that purpose.”

This lack of official definition is compounded by the fact that the presence of dysfunction can only be inferred or hypothesized in vast majority of the cases due to the current state of neuroscientific knowledge. Again, the authors of the DSM 5 white paper on nomenclature noted: “The problem is that too little is known about the cerebral mechanisms underlying basic psychological functions, such as perception, abstract reasoning, and memory, for it to be possible in most cases to do more than 

infer the probable presence of a biological dysfunction

Biological causation is not equivalent to dysfunction

 when the condition has already been designed as a disorder on the behavioral level. However, mere determination of causal pathway is not enough, as even normal phenomena have causal pathways. For instance, in our example red hair being labeled as a disorder, we know red hair is produced by recessive genes and from a specific ratio of pheomelanin and eumelanin, but etiology by itself does not tell us that red hair results from a dysfunction. What is needed is a discriminative account of what sort of causal mechanisms or what sorts of etiologies constitute dysfunction.

, made a similar argument in the discussion on homosexuality

Often in discussions of this kind a hope is expressed that some biological ‘abnormality,’ such as an endocrine or genetic disturbance, will be discovered and will resolve the issue once and for all. It is hard to see how this would answer the question any more than would knowledge of the biological cause or antecedents of left-handedness (surely there must be one) indicate whether that condition should be regarded as a normal variant or pathology.

Derek Bolton, PhD, explains this reasoning in the context of functional neuroimaging

By all means it is the case that if we are assuming that a specific psychological condition is a disorder then we may say in a derivative sense that the brain activity involved in producing it is disordered, but the inferential logic runs this way round, not the other: we do not see from the functional neuroimages that the brain activity (or the areas involved in the brain activity) are disordered, and then infer that the associated psychological functioning is a disorder.

Objectivist definitions of dysfunction do not solve the problem

Dysfunction can be defined at the level of the phenomenon or in terms of underlying causal mechanisms. When 

 is defined at the level of the phenomenon, a typical strategy is to show a disadvantageous deviation from the norm, ie, the phenomenon is statistically atypical in a harmful way. Dysfunction at the level of the phenomenon requires a quantitative or qualitative comparison with a reference class. This line of reasoning has been developed in its most elaborate form by Christopher Boorse, PhD, in his 

 Boorse’s account is not merely statistical but biostatistical: disease can be said to be present when organs dysfunction to an extent that they statistically deviate from some biological norm.

One of the major problems with this approach lies in defining an appropriate reference class, and usually the question of dysfunction depends on the selection of appropriate reference class. Boorse stated that there are three reference classes based on age, sex, and race. However, this leaves out sexual orientation, potentially making homosexuality statistically atypical. The question then becomes whether sexual orientation should be a reference class or not. Boorse maintained that it should not be and, following his reasoning, had to admit that homosexuality was a disorder (and worked his way around it by saying that it was a disorder but not an “illness”).

Since the judgement that homosexuality is a disease precedes the judgement that the BST is a correct account of health, it is circular to insist, as Boorse does, that the BST can tell us whether homosexuality is a disease. The BST does not give a real answer, let alone a non-evaluative answer, to such a question. Instead it presupposes the answer it gives.

It is obvious that there is no objective way of determining the appropriate reference class. Should the reference class of posttraumatic symptoms be all individuals of same age, sex, and race, or all individuals of same age, sex, and race who have been exposed to trauma? If the former is true, symptoms of acute stress are statistically atypical, but they are statistically typical if the latter is true.

Defining in terms of underlying causal mechanisms requires a notion of design from which the causal mechanisms deviate. The most precise definition of this approach comes from Wakefield’s 

, which states that dysfunction is “a failure of some internal mechanism to perform a function for which it was biologically designed (i.e., naturally selected).”

 Biological and psychological systems are designed by evolution to perform a function within a certain range. Dysfunction is the failure to live up to that design.

The biggest problem is that the biological mechanisms underlying much of psychological functioning are known with only limited detail, and the presence of dysfunction cannot be established definitively. In practice, this leads to the use of surface phenomena as dysfunction indicators, the presence of which infers the existence of dysfunction. 

 have reviewed strategies employed by the DSM diagnostic criteria to infer the presence of dysfunction. Strategies include the following [emphasis added]

[R]equiring a minimum duration and persistence; requiring that the frequency or intensity of a symptom exceed that seen in 

 of symptoms, given the context; requiring pervasiveness of symptom expression across contexts; adding specific exclusions for 

contextual scenarios in which symptoms are best understood as normal reactions

; combining symptoms to increase cumulative pathosuggestiveness; and requiring enough symptoms from an overall syndrome to meet a minimum threshold of pathosuggestiveness.

The use of dysfunction indicators utilizes comparisons with a so-called normal control group, and the use of this normative comparisons makes it highly susceptible to social biases, depending on the societal notions of 

. If a society considers heterosexuality to be the norm, then these strategies would offer little to no protection against pathologizing of homosexuality. This is similar to the problem of reference class that BST faces. Additionally, the inference of dysfunction in the presence of dysfunction indicators is just that-an inference. It is tentative, and its validity remains to be demonstrated.

There are many ways for things to go wrong in biological systems. 

 outline four ways things can go wrong from a biological perspective

1. Mechanism failure
	2. Abnormal environment
	3. Normal but inhospitable environment
	4. Heuristic failure

 points out in his commentary on the Mathewson and Griffiths paper, only the first of these ways of going wrong-mechanism failure-can be considered 

 Other ways of going wrong do not come under the category of dysfunction. This is when we are just considering traditional biological systems; once we add psychological and social phenomena into the mix, there are additional ways for things to go wrong. In something as complicated as behavioral disturbances, it can be behaviorally clear that something has gone wrong, yet it may not be entirely clear whether it reflects a mechanism failure or failure of some other sort. All the dysfunction indicators that First and Wakefield describe simply reinforce that something has gone wrong, but do not necessarily distinguish between mechanism failure and other failures that would not qualify as dysfunctions.

The practice of psychiatry makes little use of dysfunction

Perhaps one of the most telling practices is the use of 

 disorders. Even when symptom presentations do not satisfy DSM thresholds of dysfunction indicators, the accepted practice is to label them as 

 and prescribe treatment for them as such. For instance, if a person presents to a psychiatrist with depressive symptoms that do not meet criteria for major depression, the presentation is usually labelled as “other specified depressive disorder” if the patient finds them distressing. DSM clearly sanctions the disorder designation when there is insufficient evidence of dysfunction, even by its own indirect inferential standards.

Consider someone who presents with overwhelming anxiety after being given the diagnosis of a terminal cancer. Does the anxiety represent a failure of an internal mechanism to perform a natural function? If we were to ask the practicing psychiatrist, we would find that they are hardly concerned with this abstract question of failure of natural design. What the psychiatrists will assess is the degree of distress and impairment. If the degree of distress and impairment is judged to warrant treatment, the psychiatrist will call it a 

 ( “other specified anxiety disorder” or something else).

A dysfunction-based defense against misuse of disorder designation has serious conceptual deficiencies, is vulnerable to social biases, and offers very little protection in practice.

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