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Aliquando Non Nocere: The Exclusion of Values from the Definition of Mental Disorder Proposed for DSM-5

Aliquando Non Nocere: The Exclusion of Values from the Definition of Mental Disorder Proposed for DSM-5

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This is a commentary on the definition of mental disorder proposed for DSM-5.
This is a commentary on the definition of mental disorder proposed for DSM-5.

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Published by: Rowan Hildebrand-Chupp on Jun 16, 2012
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 Aliquando Non Nocere
: The Exclusion of Valuesfrom the Definition of Mental Disorder Proposedfor DSM-5
Rowan Hildebrand-Chupphildebrr@reed.edu
Table of Contents/Summary
Introduction (pg. 3)
The proposed definition changes the distress and disability criterion, whichhas been the core of the DSM definition of mental disorder for over 30 years.
Conceptual Analysis of the Proposed Definition (pg. 5)
The proposed definition precludes the distress and disability criterion from playing any conceptual role, instead making the presence of dysfunction theonly conceptually necessary requirement.
Applying Harmful Dysfunction to the Proposed Definition (pg. 9)
The harmful dysfunction analysis suggests that the proposed definition
excludes the harm component from playing any independent conceptual rolealtogether.
The Conceptual Rationale for the Removal of Disability (pg. 11)
The arguments in favor of removing the distress and disability criterion
ultimately rely on the conceptual distinction between “symptoms” and“consequences” of symptom. This distinction may guide research, but it is not
empirically research.
The Conceptual Purpose of the Harm Component (pg. 19)
Mental disorder is a hybrid theoretical-practical concept, and the harmcomponent addresses the practical side: treatment, research, stigma, etc.
The View on Practical Concerns behind the Removal of Disability (pg. 21)
Those arguing for the removal of the distress and disability criterion havedenigrated concerns over treatment and stigma as “unscientific,” but the
distinction between “symptoms” and “consequences” is itself a pragmatic one,meant to prioritize research and deemphasize treatment within the DSM.
Evaluating the Proposed Definition’s Impact on Etiological Research (pg. 25)
The removal of the distress and disability criterion is meant to enable a biological reductionist etiological paradigm, but that research either cannot bereconciled with the DSM criteria, requires more extensive changes to theDSM, or represents a fundamentally flawed paradigm.
Evaluating the Proposed Definition’s Impact on Treatment (pg. 28)
The removal of the distress and disability criterion is design to reduce the
 pressure on the DSM criteria to accurately represent treatment need, but theDSM is better served integrating those concerns into the criteria, just as will
 be done with the etiological research on dysfunction.
The Origin and Structure of the Distress and Disability Criterion (pg. 34)
The distress and disability criterion was originally created to fight the stigma
and provide a conceptual basis for the removal of homosexuality by allowingindividuals who do not suffer generalized impairment some amount of inputin nosological decisions.
Dysfunction and the Proposed Definition’s Standard of Harm (pg. 38)
Because our understanding of dysfunction is greatly limited, by definingdysfunction as the standard of harm the proposed definition will inevitablylead to a dangerous, covert entanglement of empirical findings and value judgments.
The Proposed Definition’s Inability to Prevent Stigmatization (pg. 41)
The removal of the distress and disability criterion removes any conceptual
rationale for the prevention of stigma. The proposed definition could be usedto justify the reclassification of exclusive same-sex sexuality as a disorder, thelabeling of all transgender people with a disorder, and the wholesale
 pathologization of women’s sexuality.
Conclusion (pg. 48)
It makes sense for the classification of mental disorder created and used in theUnited States to prioritize individual freedom more strongly than aninternational classification might, and overall the benefits of removing thedistress and disability criterion are ultimately not worth the potentialconsequences.
Suggested Changes to the Proposed Definition of Mental Disorder (pg. 50)
I discuss several potential alternatives to the proposed definition that would
address the problem of stigma in various ways
The definition of mental disorder currently proposed for DSM-5 would be themost dramatic change to the definition in over 30 years. The revision ends therequirement of distress or disability, which has been at the center of the DSM’s definitionof mental disorder since the definition’s inception. This move represents a stark divergence from the definitions that were previously proposed during the DSM-5 process.Its arrival at such a late stage of the DSM-5 process, too, gives reason for intensescrutiny. Unfortunately, despite the definition’s important role as conceptual foundationfor the DSM, the rationale for the proposed definition has not been thoroughly analyzedin the literature and potentially major issues have been ignored.The distress and disability criterion (DDC) is described in the first part of theDSM-IV definition of mental disorder:Each of the mental disorders is conceptualized as a clinically significantsyndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or 
more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom… (DSM-IV-TR)These requirements were condensed and added to the diagnostic criteria of manydisorders in DSM-IV in the form of the “clinical significance criterion” (CSC)
, whichrequires (sometimes with slight alterations) that the condition “…causes clinicallysignificant distress or impairment in social, occupational, or other important areas of functioning” (DSM-IV-TR). The terms “disability,” “impairment,” and “functionalimpairment” are all used interchangeably to refer to the level of overall functioning in
Usage note: Because the term “clinical significance criterion” (CSC) is widely used torefer specifically to the criterion that is included within the diagnostic criteria, I defer tothat usage in those situations. However, in all other cases I use the term “distress and

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