Harmful dysfunction and the DSM definition of mental disorder.

Physicians, including psychiatrists, give a lot of thought in their everyday work to answer the question of whether or not a particular patient has a disorder; they rarely give much thought to the broader issue of what constitutes a disorder. Remarkably, and consistent with the harmful dysfunction (HD) analysis, there is a broad consensus in both the general public and the medical and health professions as to what conditions are disorders--even though there is no consensus definition of disorder. The HD analysis is a substantial advance over previous attempts to define disorder in specifying the nature of what is not working in the individual (the dysfunction). The adoption of the HD analysis in DSM-V (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) would probably have little if any effect on the list of categories of mental disorders. Its main value would be in helping make revisions in the diagnostic criteria more valid as true indicators of disorder.     

Disorder as harmful dysfunction: a conceptual critique of DSM-III-R's definition of mental disorder.

The Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R) operationally defines disorder essentially as "statistically unexpectable distress or disability." This definition is an attempt to operationalize 2 basic principles: that a disorder is harmful and that a disorder is a dysfunction (i.e., an inability of some internal mechanism to perform its natural function). However, the definition fails to capture the idea of "dysfunction" and so fails to validly distinguish disorders from nondisorders, leading to invalidities in many of DSM-III-R's specific diagnostic criteria. These problems with validity are traced to DSM-III-R's strategies for increasing reliability.     

The diagnostic and statistical manual's new white coat and circularity of plausible dysfunctions: response to Wakefield, part 1

Wakefield has claimed: (1) logical empiricist models of scientific progress support the view that expansions of the modern DSMs are consistent with such standards of progress; (2) diagnostic label proliferation of the modern DSMs is the same phenomenon as change in physical disease labels of the ICDs; (3) the concepts of disorder and dysfunction should not be separated. I show: (1) Wakefield has misrepresented traditional philosophy of science models of progress to serve his rhetorical aims: (2) Wakefield's claim that DSM label proliferation and ICD change are the same is empirically false; (3) failure to separate the concept of disorder from the concept of dysfunction leads to erroneous reasoning and label proliferation observed in the modem DSMs.     

Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder

Theoretical Medicine and Bioethics - The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental...     

Evolutionary history versus current causal role in the definition of disorder: reply to McNally

The harmful dysfunction (HD) analysis (Wakefield, American Psychologist 47 (1992a) 373) asserts that "disorder" means "harmful dysfunction", where "harm" is a value concept anchored in social values and "dysfunction" is a factual concept referring to failure of a mechanism to perform a natural function. Additionally, the HD analysis claims that a mechanism's natural functions are its naturally selected effects. McNally (Behaviour Research and Therapy (2000) pp. 309-314) argues to the contrary that "dysfunction" is a value concept referring to negative failures of function, that "function" refers to current causal roles and not evolutionarily designed causal roles, and that "disorder" consequently means "harmful failure of a mechanism to perform a valued current causal role." I reply by showing that McNally's proposals lack the HD analysis's power to explain common judgments about function, dysfunction, and disorder. "Dysfunction" cannot be a negative value concept because many dysfunctions are positive or neutral; "function" cannot refer to current causal roles because many current causal roles are not functions and some functions are not current causal roles; and "disorder" cannot refer to harmful failures of current causal roles because that definition allows almost any negative condition whatever to be a disorder and thus fails to explain the distinctions we make between disorder and non-disorder.     

The concept of disorder as a foundation for the DSM's theory-neutral nosology: response to Follette and Houts, Part 2.

Follette and Houts [Follette, W. C., Houts, A. C. (1996). Models of scientific progress and the role of theory in taxonomy development: a case study of the DSM. Journal of Consulting and Clinical Psychology, 64, 1120-1132] argue that 'mental disorder' and 'function' are value concepts that offer no scientific basis for the DSM's theory-neutral nosology or for distinguishing disorders from other behavioral problems. They also claim that the DSM presupposes a biological theory of etiology, thus is not really theory-neutral. They recommend replacing the DSM by theory-laden diagnostic manuals. I argue: (1) DSM criteria do not imply a biological model of disorder, (2) 'mental disorder' and 'function' have scientific content that allows one to distinguish disorder from nondisorder, (3) the evolutionary 'harmful dysfunction' analysis of disorder [Wakefield, J. C. (1992a). The concept of mental disorder: on the boundary between biological facts and social values. American Psychologist, 47, 373-388] coherently demarcates disorder from nondisorder, (4) the proposed behaviorist alternative to the DSM illustrated by the articles in Follette's special section [Follette, W. C. (Ed.) (1996a). Special section on the development of theoretically coherent alternatives to the DSM system. Journal of Consulting and Clinical Psychology, 64, 1117-1201] is incoherent because it does not distinguish disorder from nondisorder.     

The Christian physician in the non-Christian institution: objections of conscience and physician value neutrality.

Christian physicians are in danger of losing the right of conscientious objection in situations they deem immoral. The erosion of this right is bolstered by the doctrine of "physician value neutrality" (PVN) which may be an impetus for the push to require physicians to refer for procedures they find immoral. It is only a small step from referral to compelling performance of these same procedures. If no one particular value is more morally correct than any other (a foundational PVN premise) and a physician ought to be value neutral, than conscientious objection to morally objectionable actions becomes a thing of the past. However, the argument for PVN fails. Therefore, Christian physicians should state their values openly, which would allow patients the ability to choose like-minded physicians. Some possible responses to this erosion of conscientious objection include, disengagement from non-Christian institutions, the formation of distinctly Christian medical institutions and political action. However, for the Christian the initial focus should be on a life of holiness which requires each of us to avoid evil.     

In search of a measure to investigate mental performance among children: Development of the mental speed test

Processing speed is a component of general intelligence and an indicator of learning potential. There is a need for robust measures of mental speed based on contemporary theoretical developments. The current study addressed this need by proposing a mental speed test for children aged 60 to 96 months (5 to 8 years) and examining its psychometric properties. The test included indicators of perceptual speed, memory speed, reasoning speed, and fluency-flexibility speed presented through nonverbal items administered individually using touchscreen tablets. After establishing gender non-bias and concurrent validity with a contemporary intelligence test (i.e., ASIS, r = .59) with 107 children, the next administration included 373 children. Exploratory factor analysis (EFA) with subtest scores revealed a single-factor structure accounting for 45% of the total variance. Additional data from 212 children were used to assess structural validity and gender bias, which showed acceptable goodness of fit, providing evidence of the validity and reliability of the new measure for further use.     

Voluntariness, intention, and the defence of mental disorder: toward a rational approach

This article addresses how mental disorder may be used in common law countries to negate the requirements of voluntariness and intention in serious criminal offences as well as to provide the basis for current versions of the insanity defence. The notion that mental disorder can cause conduct to become completely involuntary or unintentional is questionable, given current thinking in the behavioral sciences. This article argues that different forms of mental disorder should be subsumed within a separate defence of mental disorder. Providing that a range of dispositional options is available, the law in this complex area would be simplified and brought into line with current psychological notions of goal-directed behavior.     

Making it mental: in search for the golden mean of the extended cognition controversy

This paper engages the extended cognition controversy by advancing a theory which fits nicely into an attractive and surprisingly unoccupied conceptual niche situated comfortably between traditional individualism and the radical externalism espoused by the majority of supporters of the extended mind hypothesis. I call this theory moderate active externalism, or MAE. In alliance with other externalist theories of cognition, MAE is committed to the view that certain cognitive processes extend across brain, body, and world—a conclusion which follows from a theory I develop in “Synergic Coordination: an argument for cognitive process externalism.” Yet, in contradistinction with radical externalism, and in agreement with the internalist orthodoxy, MAE defends the view that mental states are situated invariably inside our heads. This is done, inter alia, by developing a novel hypothesis regarding the vehicles of content (in “Extended cognition without externalized mental states”, and by criticizing arguments in support of mental states externalism (in “Reflections and objections”). The result, I believe, is a coherent theoretical alternative worthy of serious consideration.     

Applied ethics in mental health in Cuba: part II--power differentials,dilemmas, resources,and limitations

This article is the second one in a series dealing with mental health ethics in Cuba. It reports on ethical dilemmas, resources and limitations to their resolution, and recommendations for action. The data, obtained through individual interviews and focus groups with 28 professionals, indicate that Cubans experience dilemmas related to (a) the interests of clients, (b) their personal interests, and (c) the interests of the state. These conflicts are related to power differentials among (a) clients and professionals, (b) professionals from different disciplines, and (c) professionals and organizational authorities. Resources to solve ethical dilemmas include government support, ethics committees, and collegial dialogue. Limitations include minimal training in ethics, lack of safe space to discuss professional disagreements, and little tolerance for criticism. Recommendations to address ethical dilemmas include better training, implementation of a code of ethics, and provision of safe space to discuss ethical dilemmas. The findings are discussed in light of the role of power in applied ethics.     

Struggle with ultimate meaning: Nuanced associations with search for meaning,presence of meaning,and mental health

Struggle with ultimate meaning reflects concerns about whether one’s life has a deeper meaning or purpose. We examined whether this construct could be distinguished from presence of meaning in life and search for meaning. In two US samples – a web-based sample (N = 1047) and an undergraduate sample (N = 3978) – confirmatory factor analyses showed that struggle with ultimate meaning loaded on a factor that was distinct from but related to presence (negatively) and search (positively). Moderated regression analyses showed that people with low levels of presence combined with high levels of search for meaning were particularly likely to struggle with ultimate meaning. Additionally, when compared to presence and search, struggle with ultimate meaning related more strongly to depressive symptoms than presence or search. These results suggest that struggle with ultimate meaning represents a distinct component of how people grapple with meaning that has implications for mental health.     

Jews and mental illness: medical metaphors, anti-semitism, and the Jewish response

The idea that Jews were prone to a specific set of illnesses is as old as the Middle Ages. In the nineteenth century the view that the Jew was especially prone to developing mental illnesses became an accepted part of medical discourse. Jewish doctors, too, believed this and had to evolve a means of dealing with their own potential madness.     

On the value of genealogy,materiality, and networks: a response

In response to the challenges posed by Steven Engler, Martha Finch, Mark Gardiner, Laura Harrington, Paul Johnson, and Michael Stausberg, this essay fleshes out key terms in More than Belief (2011), including genealogy, materialism, non-reductionism, and networks, showing their value in researching and theorizing about religion.     

An examination of the assumptions of specialization, mental disorder, and dangerousness in sex offenders

Sex offenders have been singled out for differential treatment by the legal and mental health systems. This article attempts to inform law reform efforts and criminal justice mental health policy by examining the assumptions underlying differential legal and mental health treatment of sex offenders. These assumptions include the theories that sex offenders are mentally disordered and in need of treatment, specialists in sex crimes, and more dangerous than other criminal offenders. Empirical findings demonstrate that sex offenders are not specialists in sex crimes and are not mentally disordered. Examination of past research suggests that sex offenders are not at more risk than other criminal offenders to commit future sex crimes. Implications of research findings for selective prosecution of sex crime cases, mental health policy, sex offender legislation, and predictions of future dangerousness are discussed. Proposals for future research needs and law reform are presented.