Hero

Videos

Slideshows

Articles

Podcasts

Poll

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).

All these conceptual difficulties surrounding 

 does not protect against social misuse of disorder designation. In current practice of psychiatry, 

 is driven by distress and impairment with little essential role played by dysfunction. The existence of dysfunction is inferred on the basis of normative judgments, which are not only unable to differentiate dysfunction from other ways of going wrong but are also heavily influenced by social views of normality. The weakness of dysfunction to protect against social misuse of disorder designation is also clear from the history of nosology. The declassifications of homosexuality, ego-syntonic cases of some paraphilias, and ego-syntonic cases of transgender identity in recent times were all justified on the basis of lack of harm and not on the basis of dysfunction.

Since a dysfunction-based defense does not adequately protect against arbitrary disorder designations, we will explore what a harm-based defense might look like in 

1. Rounsaville BJ, AlarcÃ³n RD, Andrews G, et al. Basic nomenclature issues for DSM-V. In: 

. Arlington, VA, US: American Psychiatric Association; 2002:1-29.

The diagnostic status of homosexuality in DSM-III: a reformulation of the issues

What is Mental Disorder?: An Essay in Philosophy, Science, and Values

. Oxford, United Kingdom: Oxford University Press; 2008.

Diagnostic criteria as dysfunction indicators: bridging the chasm between the definition of mental disorder and diagnostic criteria for specific disorders

Biological criteria of disease: four ways of going wrong

Progress in defining disease: improved approaches and increased impact

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.

Social Misuse of Disorder Designation, Part II: The Dysfunction Defense

Dr Aftab is a geriatric psychiatry fellow at University of California San Diego 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 

This is Part 1 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. 

Consider a hypothetical society that severely marginalizes individuals with red hair and considers red hair to be a genetic disorder with a recessive pattern of inheritance. The “pathology” is determined to be an imbalance between the levels of the red pigment pheomelanin and dark pigment eumelanin in the hair filaments. Red-haired individuals-and parents of red-haired children-in this society go to extreme lengths to dye their hair black. In fact, this society has spent extensive resources to develop complex dyeing procedures, performed only by specially trained medical professionals, that work best for red hair and last longer than regular dyes.

Variants of this thought experiment are sometimes utilized in the gene-environment debates

; for gene-environment theorists, the thought experiment provides a scenario in which a socially sanctioned phenotype leads to reduced biological fitness solely because of that sanction. However, I utilize this scenario to explore a different question. The disorder designation in this case is entirely arbitrary on part of the society. There is nothing inherently pathological about red hair. The designation is arbitrary in this case because any hair color, if stigmatized, could have been regarded as a disorder. Disorder designation is one of the ways in which this stigma is expressed, although possibly a relatively humane way, since disorder designation recognizes that the condition can potentially be fixed with a treatment (in this case, hair dyeing), and treatment may lead to alleviation of the social exclusion.

We do not have to come up with thought experiments to confront situations like these. There are already instances of such in the history of psychiatry, with homosexuality being the prime example. While we now recognize homosexuality as a normal sexual variant similar to heterosexuality, homosexuality was severely stigmatized in Western societies in the past. Over time, the religious and moral sin of sodomy was transformed into the medical notion of 

. Homosexuality was believed by many in the 18th and 19th century to be a congenital disease. In fact, many physicians considered all non-procreative sexual behaviors, masturbation included, as psychopathological. The pathological view of homosexuality further evolved with psychoanalysts, who theorized various sorts of psychopathology within the analytical framework.

In 1973, after prolonged controversy, the American Psychiatric Association declassified homosexuality as a disorder. Yet the APA continued to consider ego-dystonic homosexuality a disorder until 1987.

 Ego-dystonic homosexuality is the case where homosexual feelings, fantasies, or behavior generate distress in the individual because they are at odds with the individual’s desired heterosexual orientation. When the APA voted to exclude homosexuality from the DSM, it created the new category of ego-dystonic homosexuality. This category met the DSM-III definition of mental disorder by virtue of the individual experiencing distress and because of the practical reason that these individuals were seeking treatment and were being treated by psychiatrists.

We can draw the pessimistic conclusion from the history of erroneous disorder designations that a society will utilize whatever tools are available to stigmatize a negatively valued condition, including the tool of disorder designation. In retrospect, the pathologization of homosexuality was as much driven by stigma as is the pathologization of red hair in our thought experiment, and the distress experienced by ego-dystonic homosexuals was a result of internalization of social values. I begin with the red hair thought experiment to illustrate that the issue of the validity of disorder designations relates to “disorder” as a medical concept and is not restricted to the psychiatric subset, even though I will focus my attention on the latter.

With this background, these are the central questions that will occupy us in this series: In the domain of mental health, what conceptual means are available to us to restrict the ability of a society to arbitrarily designate negatively valued behavioral states as mental disorders? Can we define 

 in a manner that would prevent social misuse of disorder designation?

 is related to, but different from, the issue of involuntary treatment. Our response to the question of coercive treatment has been based on discussions of ethical boundaries of personal autonomy, and Western societies have developed elaborate laws to determine under what circumstances it is acceptable for us to override someone’s refusal of treatment. Preventing abuse of treatment, however, does not prevent abuse of disorder designation. Preventing involuntary treatment of homosexuality does not by itself prevent homosexuality from being labelled as a disorder.

The Ego-dystonic homosexuality litmus test for mental disorder definition

 have suggested a litmus test for any definition of mental disorder: “If a candidate definition of mental disorder is put forward, it should be able to exclude homosexuality.”

 I propose to take this test one step further and make it more stringent by stating that any candidate definition of mental disorder should be able to exclude ego-dystonic homosexuality. This is because 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.

Most people in contemporary psychiatry would say that it is wrong to call homosexuality a disorder. This can be understood in two ways. The first sense is factual: By calling homosexuality a disorder, we are making an error regarding a matter of fact. The second sense is ethical: It is morally wrong to call homosexuality a disorder. To say that we are making an objective, scientific error is to say that this disorder designation lacks 

. To say that it is unethical to label homosexuality as a disorder is to say that it lacks 

. The two ways are complementary and not mutually exclusive, but one may be better suited that the other in the defense against social misuse of disorder designation. 

An extended body of literature analyzing the notion of disorder in medicine suggests that disorder designation utilizes two kinds of judgments.

 These notions can be descriptive (ie, describing the current state of affairs) as well as prescriptive (ie, how we should define disorders). From a descriptive stand point, I will simplify these judgements as follows:

1. Some process is “abnormal” or “not functioning right” within the individual;
	and
2. It is undesirable, unwanted, disadvantageous or harmful in some way.

The first criterion is usually referred to as 

. The second criterion is often captured by the term 

 in discussions, but I am using the broader term 

 is that the condition is unwanted in some sense, and it provides individuals in a society with a reason for treatment. Psychiatric manuals often refer to specific instances of undesirability, generally the presence of distress or impairment for the individual (and implicitly, harm posed to others).

A philosophically satisfactory definition of 

has shown that there are multiple considerations competing for priority in the definition of mental disorder, these desiderata (such as coherence, precision, simplicity conditions, reliability, and compatibility with ordinary language use) lead to differing definitions, and no single definition can satisfy all desiderata simultaneously.

 Although the DSM offers an official definition for the psychiatric community, it does little to abate the controversy, as it leaves key conceptual terms undefined. The DSM definition generally follows the framework of 

 previously discussed by utilizing the concepts of dysfunction and specific kinds of harm; mental disorders are clinical syndromes associated with distress and impairment, and there is an inference that the clinical syndrome is due to an underlying dysfunction.

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.

All editions of DSM from III to 5 explicitly state, with some variation of words, that deviance or conflict between individual and the society is not mental disorder per se; deviance or conflict elevates to the level of a mental disorder if it is a product of a dysfunction in the individual. This is the statement in DSM-5: “Socially deviant behavior (eg, political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual.”

DSM recognizes the need to prevent arbitrary disorder designation of negatively valued conditions and does so by adopting a dysfunction-based defense. However, 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. In 

 of this series, we will take a closer look at some of these problems with dysfunction.

The author acknowledges Jeanne Lackamp and Susan Stagno at Case Western Reserve University/University Hospitals Cleveland Medical Center, both of whom reviewed early drafts of this manuscript and offered valuable feedback.

Out of DSM: depathologizing homosexuality

The definition of mental disorder: evolving but dysfunctional?

. 2014;40:537-542. doi:10.1136/medethics-2013-101661

On defining “mental disorder”: purposes and conditions of adequacy

8. APA. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

Part 1 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?

Social Misuse of Disorder Designation, Part I: Conceptual Defenses

The approach that has been used for revising the 

 since its inception has been to overhaul the diagnostic classification in its entirety at fixed intervals. While revising the entire DSM in this way has some advantages, such as ensuring the uniformity and stability of the diagnostic definitions during the interval in which the manual is in effect, a significant disadvantage is that it prevents the incorporation of new scientific knowledge into DSM as it emerges.

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way toward the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances. Thus, rather than waiting until the next wholesale revision to implement a clinically useful change (such as incorporating a clinically validated biomarker into the definition of a disorder), such a change could be put into effect as soon as it has been determined that it is diagnostically advantageous to do so. Moreover, implementing a continuous data-driven approach has the added advantage of discouraging changes that are not well supported by empirical evidence.

It is expected that most submissions will originate from interested persons who are external to the APA committee overseeing the DSM revision process (eg, psychiatric researchers, individual clinicians). This is in marked contrast to the way prior DSM revisions were done, during which proposals were drafted by DSM workgroup members who were also responsible for providing supportive literature reviews and data re-analyses.

) was set up by the APA at the beginning of this year to field proposals for changes to DSM-5. Proposals must be accompanied by supportive information including the reasons for the change and, depending on the nature of the proposal, data documenting improvements in validity across a range of validators, evidence of reliability and clinical utility, and a consideration of potential deleterious consequences associated with the proposed change.

This new continuous revision process is being overseen by a Steering Committee (analogous to the DSM Task Force). Five standing Review Committees, with about 6 members each, will work with the Steering Committee to consider the evidence in support of the proposed change. Proposals submitted to the DSM web portal will first be reviewed by the Steering Committee, which will refer the proposal to the appropriate review committee if it appears that the evidence for the proposal is substantially likely to meet the criteria for approval.

The Review Committee will undertake whatever additional investigation might be needed, such as consultation with relevant experts. It will then forward the reviewed proposal back to the Steering Committee to decide whether the proposal is suitable to be posted for public comment.

If the Steering Committee determines that the proposal has met the criteria for approval, it will submit the proposal and a summary of the public comments for review by the Board of Trustees of the APA. Once approved, changes will be publicized by the APA and digital versions of the manual will be updated to reflect the change.

The DSM-5 web portal has identified 3 types of proposals that require substantial empirical support, each with explicit criteria regarding the type of evidence that is expected to be submitted. In general, proposals should include a thorough review of the relevant literature and the results of any secondary data analyses conducted by those making the proposal.

 proposals involve changes to an existing diagnostic criteria set that purport to markedly improve the validity, reliability, or clinical utility of a criteria set, or to substantially reduce identified deleterious consequences

 proposals involve the addition of a new diagnostic category, subtype, or specifier

 proposals entail deleting an existing category or subtype or specifier

Proposals involving corrections and clarifications of existing criteria that do not require empirical support (type 4 proposals) are being considered on an expedited basis by a subcommittee of the Steering Committee. Included here are instances of lack of clarity or ambiguity in the meaning of the wording of criteria or text; inconsistencies or contradictions within the text or criteria (eg, diagnostic criteria that conflict with corresponding descriptions in the text); and errors of omission or inadvertent inclusion.

The first set of proposed changes to DSM-5 since the web portal was opened for submissions are now being posted for public comment on the DSM-5 web site, with comments being accepted from November 22, 2017 until December 22, 2017.

The first proposal concerns the ICD-10-CM diagnostic codes that apply to situations in which in a patient taking a medication, which is capable of causing physiological dependence, that is being taken as prescribed (ie, not abused), a withdrawal syndrome in the context of stopping the medication develops. The ICD-10-CM codes currently listed in DSM-5 for the categories of Opioid Withdrawal, Sedative, Hypnotic, or Anxiolytic Withdrawal, Cannabis Withdrawal, and Stimulant Withdrawal apply only to cases of withdrawal that develop in the context of a diagnosis of a substance use disorder. This proposal involves a change to the coding notes for these conditions so that they include the ICD-10-CM codes, which apply to cases of withdrawal that occur in the absence of a substance use disorder.

The second proposed change involves the definitions of Other/Unspecified Depressive Disorder and Other/Unspecified Anxiety Disorder, categories respectively reserved for cases in which the patient presents with depressive (or anxiety) symptoms that do not meet diagnostic criteria for any of the specific depressive disorders (or anxiety disorders). Since DSM-III, patients who present with mood or anxiety symptoms that do not meet criteria for one of the specified DSM disorders receive a diagnosis of either an Adjustment Disorder (if there is an identified causative psychosocial stressor) or the appropriate depressive or anxiety residual category (eg, Atypical Depression in DSM-III, Depressive Disorder NOS in DSM-III-R and DSM-IV, and Other/Unspecified Depressive Disorder in DSM-5). To make Adjustment Disorder take precedence over the residual categories, the definition of the residual category must indicate that the residual category NOT be diagnosed if the criteria are met for an Adjustment Disorder. This exclusion for Adjustment Disorder, inadvertently omitted from DSM-5, has been added.

 The third proposal applies to situations in which a patient’s response to exposure to a traumatic stressor does not meet criteria for PTSD. According to DSM-5, if the duration of the symptomatic response lasted 6 months or less, the diagnosis should be Adjustment Disorder. If the symptoms persist for more than 6 months, however, the Adjustment Disorder diagnosis no longer applies, since the 6-month limit on duration has been exceeded. Such cases should be diagnosed instead as Other Trauma- and Stressor-related Disorder. To clarify that this is the correct diagnosis for such scenarios, the following example has been added to the definition of Other Specified Trauma- and Stressor-related Disorder: “Persistent response to trauma with PTSD-like symptoms (ie, symptoms occurring in response to a traumatic event that fall short of the diagnostic threshold for PTSD and that persist for longer than 6 months).”

 The fourth proposal corrects an error in the hallucinations dimension that is a component of the Clinician-Rated Dimensions of Psychotic Symptom Severity scale included in DSM-5 Section III (“Emerging Measures and Models”). The anchor points for the hallucination severity dimension incorrectly focus exclusively on the impact of voices on the patient, when it should instead include all types of hallucinations.

 The final proposal corrects an unintended discrepancy between the wording of the stressor criterion (criterion A) in Posttraumatic Stress Disorder and Acute Stress Disorder. Criterion A in PTSD requires “exposure to actual or threatened death, serious injury, or sexual violence,” whereas criterion A in Acute Stress Disorder includes “exposure to actual or threatened death, serious injury, or 

” (italics added). The correct wording for both versions of criterion A is “exposure to . . . sexual violence.”

This article was originally posted on 11/16/17 and has since been updated.

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way towards the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances.

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

Although psychogenic non-epileptic seizures (PNES) are events that appear to be similar to seizures, they are not caused by abnormal electrical brain activity. Instead, they are thought to have an underlying psychological cause.

PNES is classified as a subtype of conversion disorder under the category, somatic symptom and related disorders in DSM-5. When coding for PNES as a conversion disorder using ICD-10, the diagnosis must include the specifier “with attacks or seizures” (ICD-10 code F44.5) to differentiate it from other conversion symptoms (eg, dysarthria, sensory loss), which are coded separately. Alternate names frequently used for PNES are non-epileptic attack disorder, functional seizures, stress seizures, psychogenic seizures, and pseudoseizures. The last has largely fallen out of favor because of the pejorative nature of the term “pseudo,” which may imply that the symptoms are not real and therefore undermine the impact of the disorder on a patient’s life. It is not uncommon to see both PNES and epileptic seizures in the same patient.

PNES has a long history in the medical literature, where it has been described by several aliases, the most common being hysteria. Equally as varied were the many hypotheses for the causes of hysteria. Because of its observed frequency in females, hysteria was conceptualized as the result of a “wandering uterus” that had been displaced in the body and subsequently inhabited other organs and appendages, applying pressure and leading to the manifestation of physical symptoms. This theory eventually lost prominence as symptoms of hysteria were increasingly reported in males.

Update on Psychogenic Nonepileptic Seizures

In the 19th century, the phenomenon became a passion of French neurologist Jean Charcot, who identified it primarily as a neurological disorder with psychological underpinnings that could, in some cases, be treated by hypnosis. Sigmund Freud, after studying under Charcot, theorized the symptoms as a conversion of repressed libidinal impulses into physical form, which brought about its current title of conversion disorder. Alternatively, Pierre Janet suggested hysteria was more of a dissociative phenomenon that occurred at times of stress with the purpose of allowing an individual to re-experience a traumatic event while separating the memory from conscious awareness.

Clues to a possible diagnosis of PNES can be discovered by eliciting a seizure history including onset, typical semiology of the seizure, and treatment. Patients with PNES are likely to have seizures more frequently with more hospital visits than patients with epilepsy. They may often carry a diagnosis of refractory epilepsy, and it is not uncommon for patients to have current or past prescriptions of antiepileptic drugs. Antiepileptic drugs, however, are not effective in treating PNES and may either worsen the symptoms or cause only a transient partial response.

Psychiatric comorbidity is quite common in patients with PNES. The most frequently co-occurring disorders are PTSD, anxiety disorder, personality disorder, and depression (

). Patients with comorbid psychiatric disorders may also have more severe dysfunction and higher levels of stress. Identifying a comorbid psychiatric condition can result in more specific treatments that target those symptoms as well as better outcomes for patients.

In addition to performing a psychiatric review of systems, inquire about any history of medically unexplained symptoms (hand tingling, paralysis, etc) and screen for possible somatoform disorders. Patients with PNES may frequently report pain as other somatic symptoms. Prescriptions for pain medication were found to have a positive predictive value of 76.9% in patients with PNES compared with patients with epilepsy.

Attempts to identify typical psychological features of PNES have been largely unsuccessful. 

, coined by Freud in his observation of patients with conversion disorder, has been thought to be a classic characteristic; however, a systematic review of the literature found this feature was observed in only a minority of those with conversion disorder and not at a significantly higher rate than in controls.

 Alexithymia was thought to be more common in this patient population but has been found to occur at similar rates in patients with PNES and in patients with epilepsy or other medical disorders.

 Patients with PNES can be divided based on problems with emotional regulation: one group has a tendency toward emotional dysregulation, and the other is emotionally over-regulated.

The precipitating psychological stressor criterion to confirm a diagnosis of PNES was removed from the criteria for conversion disorder in DSM-5. Rates of precipitation trauma are between 44% and 100% in patients with PNES; however, most patients do not report a trigger or stressor during the initial psychiatric assessment. That is not to say traumatic factors will not be discovered once the patient engages in treatment. Lifetime physical and sexual abuse in particular are reported at rates of 23% to 77% and childhood sexual or physical abuse at 32.4% to 88%.

 Outside of abuse, bereavement and being in or witnessing an accident are other possible antecedent factors. Early-onset (adolescence) PNES has been associated with bullying; late-onset PNES has been associated with health-related trauma.

When assessing triggers, keep in mind that one-third of epilepsy patients also report childhood physical or sexual abuse. Moreover, stress can trigger epileptic seizures.

The gold standard for diagnosing PNES is continuous video electroencephalography, or vEEG. This should be done only after carefully eliciting a description of the typical seizure presentation, also known as semiology, from the patient or a family member. Only a video recording that captures an episode resembling the reported semiology with no concomitant epileptiform activity seen on EEG (vEEG) can be used to make a definitive diagnosis. If multiple seizure types are reported, then each type of seizure should be visualized on vEEG because of the possible co-occurrence of PNES with epileptic seizures.

vEEG usually requires inpatient admission to an epilepsy monitoring unit, which is not found at all hospitals. Such admissions are also costly and may have long wait times. However, a routine EEG that lasts 20 to 30 minutes has a 1% chance of capturing even an epileptic seizure and is an insufficient substitute. Ambulatory EEG has also not been shown to be a reliable diagnostic test for PNES. The Nonepileptic Seizures Task Force for the International League Against Epilepsy published a staged diagnostic approach to PNES.

 Some of their recommendations are reviewed here; however, we encourage readers to refer to the article for a more comprehensive review.

When vEEG is not available, a seasoned clinician could possibly diagnose PNES by observing specific semiology alone. Bedside tools based on data from several studies have been created to aid in visual diagnosis of PNES episodes (

). However, the studied semiologic differences are specifically between convulsive-type PNES and generalized tonic-clonic (GTC) seizures. PNES as well as epileptic seizures have various presentations (eg, absence seizures, frontal seizures) that significantly reduce the ability to diagnose PNES by observation alone and can lead to misdiagnosis. In such cases, a push for vEEG referral by the consulting psychiatrist is warranted.

In regards to observed semiologic differences, convulsion-type attacks in PNES tend to be asymmetrical and asynchronous, have a more fluctuating inconsistent course, and may respond to bystander intervention. Preserved awareness during events, especially with bilateral limb movements, should raise suspicion for PNES. Pelvic thrusting has been observed more frequently in PNES; however, it can occur in GTC seizures as well. Side-to-side head and body movement along with eye and mouth closure have been more readily associated with PNES than with GTC seizures. Urinary incontinence and tongue biting have not been shown to be useful in differentiating PNES from GTC seizures. The latter rarely last more than 2 minutes.

Post-ictally, patients with PNES are more likely to regain awareness quickly, recall the seizure event, and not have symptoms of fatigue or headache. PNES episodes are also more typically followed by rapid shallow breathing that quickly subsides, whereas GTC seizures are frequently followed by prolonged harsh, loud, deep breathing.

Non-epileptic status, a prolonged episode of seizure-like symptoms that lasts more than 30 minutes, was reported by one-third of patients in one study.

 However, unlike status epilepticus, non-epileptic status does not pose an imminent risk of brain injury.

Along with semiology, there are a handful of soft signs that may heighten suspicion of PNES. One is the teddy bear sign, in which an adult patient keeps a stuffed animal in the hospital bed. The specificity of this soft sign was rated highly by a retrospective chart review.

 However, a prospective study that looked at the presence of a stuffed animal at the time of admission in 264 patients found that of the 34 patients who presented with a stuffed animal, 56% had a diagnosis of epilepsy and 39% had a diagnosis of PNES, which gives the sign poor predictive value.

Another soft sign for PNES is the number of allergies a patient reports. Independent of other risk factors, patients who reported more than 12 allergies had a 6-fold higher likelihood of a PNES diagnosis.

As mentioned above, one of the conditions in the differential diagnosis of PNES is epilepsy. 

 summarizes various sites of seizure origin and likely semiology. (For a more complete description of epileptic semiology, see the article by Noachtar and Peters.

Another condition in the differential may be periodic limb movements of sleep, which are highly correlated with restless legs syndrome. They occur only during sleep with very repetitive, stereotyped limb movements; are more likely to involve the lower extremities; and can be bilateral.

Up to 13% of patients who are referred to an epilepsy clinic may have neurocardiogenic syncope, a syndrome that can mimic epileptic seizures. There are multiple precipitating factors, one of which is emotional stress. On rare occasions, patients can have seizure-like activities during syncopal episodes. Patients would likely lose consciousness first and fall before uncontrolled muscle movements.

It is important to recognize when seizure-like symptoms are being volitionally produced for the purpose of maintaining a sick role or for secondary gain. Unfortunately, vEEG may not be able to separate conversion disorder from factitious disorder. However, a study that looked at the possibility of physical symptoms in PNES serving as an unconscious motivation to acquire “the sick role” found that there were no differences between patients with PNES and controls in attitudes toward illness or the desire to be sick.

While the desire to maintain a sick role in factitious disorder may be unconscious, the act of deception itself is conscious and purposely perpetrated. Clinical scenarios that may heighten suspicion of factitious disorder are those where the symptoms seem to occur or increase in severity when requests for unnecessary interventions are declined by the treatment team. Another example is a sudden increase in seizure frequency when a patient is informed that discharge from the hospital is imminent.

The prognosis of the disorder, like its etiology, is varied. With no intervention, slightly more than one-third of 260 patients with PNES were seizure-free at 1-year follow-up.

 Psychological factors that predict poor prognosis include dissociative tendencies, somatization, negativism, and depression. Keep in mind, however, that seizure frequency may not always correlate with quality of life, and patients who are seizure-free with untreated comorbid psychiatric disorders may be as impaired as those who continue to experience seizures.

The authors shed light on a disorder that is difficult to diagnose and manage, and offer insights on how to develop an appropriate treatment plan.

DSM

A Tale of the DSMs

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

Social Misuse of Disorder Designation, Part II: The Dysfunction Defense

Social Misuse of Disorder Designation, Part I: Conceptual Defenses

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

Psychogenic Non-Epileptic Seizures: Clinical Issues for Psychiatrists

6 Challenges in Assessing ADHD in Adult Patients

A More Nuanced View of Hypomania

DSM-5 and Paraphilias: What Psychiatrists Need to Know

Psychotic Disorders in DSM-5: Clinical Implications of Revisions From DSM-IV