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Psychological Medicine (2010), 40, 1787–1788.

f Cambridge University Press 2010


The search for dysfunctions
A commentary on ‘ What is a mental/psychiatric disorder ? From DSM-IV to DSM-V ’ by Stein et al. (2010)

B. Verhoeff1,2 and G. Glas3,4*

Department of Psychiatry, GGZinGeest/Jeugdriagg, Amsterdam, The Netherlands
Department of Psychology, University of Groningen, The Netherlands
Leiden University Medical Centre, Leiden, The Netherlands
Dimence, Institute of Mental Health Zwolle, The Netherlands

Received 6 March 2010 ; Accepted 11 March 2010 ; First published online 12 April 2010
Key words : Context, DSM-5, dysfunctions, mental disorder, values.

The editorial by Stein et al. (2010) proposes several
changes to the DSM-IV definition of mental disorder.
We would like to give a brief comment on their proposal.
Stein et al. rightly emphasize that context is a key
issue in determining whether disorder is present. The
inclusion of common stressors and losses in criterion
C implies clinicians to evaluate and judge whether
responses are expectable or not, in order to dissuade
them from pathologizing normal problems of life. We
welcome the expansion of this criterion and the sensitivity for context it presupposes. We wonder, however, whether the inclusion of criterion D (presence of
‘ underlying psychobiological dysfunction ’) does add
anything substantial and is not vulnerable to similar
criticisms as have been levelled against the use of
this term in the DSM-IV. One main point of criticism
has been the circular definition of dysfunction in
the Introduction of DSM-IV. Dysfunctions are defined
in terms of the clinical syndromes of which they are
supposed to be the underlying determinants (Fulford,
Stein et al. are aware of the different approaches to
the concept of dysfunction (statistical, evolutionary,
in terms of clinical consequences or of brain abnormalities) and – wisely – do not make a choice. By
doing so, however, their proposal runs the risk of
reinforcing the lack of clarity of the DSM-IV definition
of disorder and of suggesting more than can be
accounted for on scientific grounds.
We think it helpful to make a distinction between
‘ real ’ underlying dysfunctions (brain abnormalities,

* Address for correspondence : G. Glas, Professor of Philosophical
Aspects of Psychiatry, Leiden University Medical Centre, Leiden,
The Netherlands.
(Email :

basic psychological disturbances ; in short, dysfunction 2) and dysfunctions at the clinical level (affective
instability, thought disorder, inability to maintain
stable relationships, and so on ; dysfunction 1) (Glas,
1994). For the majority of psychiatric disorders we lack
a ‘ scientific ’ concept of dysfunction (dysfunction 2)
(Murphy, 2006). However, to view dysfunction 1 as
criterion for disorder would just circularly redefine
criterion A and B (syndrome, leading to distress or
disability) as dysfunction (criterion D). Therefore, our
criticism of Stein et al.’s proposal is twofold : (1) they
insufficiently distinguish type 1 dysfunctions (clinical)
from type 2 dysfunctions (scientific) ; and (2) the type 2
dysfunctions they suggest as criterion are at best assumptions at the present moment. It would be wise to
skip criterion D from the list of ‘ features ’ and add it to
the list of ‘ other considerations ’. Otherwise, the Stein
et al. proposal would lead to the same conceptual
confusion as the current DSM-IV use of the term dysfunction.
At the clinical level expectable and culturally sanctioned responses (criterion C) as well as psychological
distress and disability (criterion B) are inextricably
bound to a context in which social norms and values
co-determine whether disorder is present (Sadler,
2005). Two other criteria require that there exists
a behavioural or psychological syndrome in the
individual (criterion A) that ‘ reflects an underlying
psychobiological dysfunction ’ (criterion D). How are
psychobiological dysfunctions (type 2) related to the
clinical level of psychological distress and disability
(type 1 dysfunctions) ? The authors state that distress
and disability are consequences of a syndrome and
that dysfunction underlies the syndrome. The authors
point out that dysfunction cannot be understood in
purely naturalistic terms. We could add that even in
the definition of blood levels of sodium, potassium or

Psychology 7. provided that the distinction between the two types of dysfunctions is maintained. Psychiatry. 77–94. neo-naturalism. References Fulford KWM (2000). We agree with this position. American Psychologist 47. The concept of mental disorder. doi :10. Psychiatry in the Scientific Image. .1788 B. Kendler KS (2010). Verhoeff and G. Philosophy. Psychological Medicine. The MIT Press : Cambridge. Wakefield. Phillips KA. but would like to emphasize two additional points. France. MA. Sadler JZ. determinants) fruitless. 3 : 3. Published online : 20 January 2010. 1992). On the contrary. Bulletin of the European Society for Philosophy of Medicine and Health Care. Teleology without tears : naturalism. On the boundary between biological facts and social values. The DSM-V would do a great job if it would provide for the conceptual and procedural framework for the inclusion of such norms. Glas pharmacological agents we implicitly refer to a lifeworld in which certain states of affairs are negatively valued and others not. Proceedings of the First World Congress Medicine and Philosophy in Paris. What is a mental/psychiatric disorder ? From DSM-IV to DSM-V. Bolton D. Stein DJ. Glas G (1994). It would also bring psychiatry closer to the social sciences and to socio-critical approaches of the interaction between psychiatry and society. Fulford KWM. First. we think that the effort to find such dysfunctions is critical for the development of psychiatry. Special Issue.1017/ S0033291709992261. ISSN 0928-7493 (CD-Rom). Oxford University Press : Oxford. Murphy D (2006). Sadler JZ (2005). 373–388. we should be more explicit about the way in which we apply sociocultural norms in the distinction between normality and pathology. if there is no value-free definition of dysfunction (contra . the fact that we will probably never be able to formulate a purely objective concept of dysfunction does not make the search for such ‘ underlying ’ dysfunctions (mechanisms . Values and Psychiatric Diagnosis. Wakefield JC (1992). Recognition of values does not preclude conceptual distinction and refinement ! Declaration of Interest None. vol. Second. and evaluationism in the analysis of function statements in biology (and a bet on the twentyfirst century).