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DSM-IV-TR Invalidities:
1. Major Depressive Disorder
a. Exclusion for uncomplicated bereavement (up to 2 months of symptoms after the
loss of a loved one is considered normal) but no exclusions for equally normal
reactions to other major losses, such as terminal medical diagnosis in oneself or a
loved one, separation from one’s spouse, the end of an intense love affair, or loss
of one’s job and retirement fund.
i. Reactions to such losses may satisfy DSM diagnostic criteria but are not
necessarily disorders. If one experiences just 2 weeks of depressed mood,
diminished pleasure in usual activities, insomnia, fatigue, and a
diminished ability to concentrate on work tasks, one’s reaction to the loss
satisfies DSM-IV-TR criteria for major depressive disorder, even though
such a reaction need not imply pathology any more than it does in
bereavement.
ii. The essential requirement that there be a dysfunction in a depressive
disorder – perhaps one in which loss-response mechanisms are not
responding proportionately to loss as designed – is not adequately
captured by the DSM-IV-TR criteria set.
b. The “disorder-nondisorder” distinction for depression should not be confused
with the traditional “reactive-endogenous” distinction.
i. Endogenous depressions that fulfill the symptom criteria for a major
depressive episode are disorders, and some reactive depressions represent
proportionate, designed responses to environmental events that do not
involve any internal dysfunction and are not disorders.
ii. Some reactions to loss can be of such disproportionate intensity or
duration that they imply the probability of a breakdown in the designed,
adaptive functioning of loss-response mechanisms.
iii. Many reactive depressions that meet DSM-IV criteria are disorders in
which the triggering event interacts with inner processes and dispositions
to produce a dysfunction.
iv. Just as there can be disorder reactions to loss of a loved one, so also there
can be disorder reactions to other losses.
v. Among reactive depressions to a variety of losses, some are disorders and
some are not, and the problem is that DSM-IV-TR criteria do not
adequately distinguish the disorder reactions from the nondisorder
reactions.
2. Adjustment Disorder
a. Defined in terms of a reaction to an identifiable stressor that either causes marked
distress that is in excess of what would be expected from exposure to the stressor
or significantly impairs academic, occupational, or social functioning.
i. The “greater than expected” criterion allows a disorder diagnosis to be
made with regard to the top third of the normal distribution of reactivity to
stress and so does not adequately deal with normal variation.
ii. It does not take into account the contextual factors that may provide good
reasons for one person to react more intensely than others.
iii. The “role impairment” criterion classifies as evidence of a disorder even
normal reaction to adversity that temporarily impairs functioning (for
example, one does not want to socialize or one does not feel up to going to
work). Temporarily retreating from normal role functioning is often
exactly how normal coping or adjustment responses work.
iv. The criteria contain an exclusion for bereavement but not for other equally
normal reactions to misfortunes other than death of a loved one.
v. The essence of an adjustment disorder is that something has gone wrong
with normal coping mechanisms, which are presumably designed to return
the individual to homeostasis after some stress or change in life
circumstances. This essential element of a dysfunction in coping
mechanisms is not captured by the DSM-IV-TR criteria set.
3. Substance Abuse
a. For a DSM-IV-TR diagnosis of substance abuse, one of four criteria must be met:
i. Poor role performance at work or at home because of substance use
ii. Recurrent substance-related legal difficulties
iii. Substance use in hazardous circumstances, such as driving under the
influence of alcohol
iv. Continued use despite having persistent social or interpersonal problems
due to substance use, such as arguments with family members about the
consequences of intoxication.
b. These criteria are not valid indicators of disorder and are inconsistent with the
DSM-IV-TR definition of mental disorder, which asserts that “symptoms” must
not be due to conflict with society.
c. Arrests for illegal activity and use of drugs despite disapproval of family members
are exactly the kinds of social conflicts that are insufficient for diagnosis of a
disorder according to the DSM-IV-TR definition.
i. According to DSM-IV-TR, continuing to use alcohol or drugs despite
arguments with one’s spouse about alcohol or drug use is sufficient by
itself for a diagnosis of substance abuse. Therefore, if you drink or smoke
marijuana, your spouse can give you a mental disorder simply by arguing
with you about it and can cure you by becoming more tolerant of your
being intoxicated.
ii. Being arrested more than once for disorderly conduct is also sufficient for
diagnosis, therefore, one’s diagnostic status depends on the diligence of
the local police force.
d. As for the “hazardous use” criterion, it is clear that very large numbers of people
drive under the influence of alcohol for all kinds of foolish reasons, and a person
need not have a mental disorder to do so.
4. Acute Stress Disorder
a. The category implies that normal-range stress responses are pathological.
i. If a terrible event (threat of death, injury, or rape) causes fear,
helplessness, or horror and one has stress-response symptoms for at least 2
days, one is considered to have a disorder.
ii. The criteria indicate that the more extreme dissociative symptoms need be
present only while one is experiencing the event – they need not continue
after the event itself.
iii. After the event, one need only be distressed by reminders of the event or
keep processing thoughts about the event, try to avoid those reminders,
and remain anxious and continue to have impaired functioning for two
days.
iv. DSM-IV-TR criteria do not adequately distinguish these genuine disorders
from intense, normal stress reactions.
5. Conduct Disorder
a. Diagnostic criteria allow the diagnosis to be made in adolescents responding with
antisocial behavior to peer pressure, to the dangers of a deprived or threatening
environment or to abuses at home.
i. If a girl who is trying to avoid escalating sexual abuse by her stepfather
lies to her parents about her whereabouts and often stays out late at night
despite their prohibitions, and then, tired during the day, often skips
school, with the result that her academic functioning becomes impaired, a
diagnosis of conduct disorder can be made.
ii. Rebellious children or adolescents, or children or adolescents who fall in
with the wrong crowd who skip school and repetitively shoplift and
vandalize, also meet the criteria for this diagnosis.
b. A paragraph in the “Specific Culture, Age, and Gender Features” section states
that “consistent with the DSM-IV definition of mental disorder, the Conduct
Disorder diagnosis should be applied only when the behavior in question is
symptomatic of an underlying dysfunction within the individual and not simply a
reaction to the immediate social context and that “it may be helpful for the
clinician to consider the social and economic context in which the undesirable
behaviors have occurred.
6. Separation Anxiety
a. Diagnosed in children on the basis of symptoms that last at least 4 weeks and
indicate age-appropriate, excessive anxiety concerning separation from those to
whom the individual is attached.
b. The symptoms are the sorts of things children experience when they have a
normal, intense separation anxiety response
c. The criteria do not provide the user of DSM-IV-TR with any guidance on how to
distinguish between a true disorder, in which separation responses are triggered
inappropriately, and normal responses to unusual perceived threats to the child’s
primary bond due to a caregiver’s unreliability or other serious disruptions.
d. Psychiatrically healthy children whose attachments are threatened in reality could
thus be treated as though they had attachment responses indicative of a disorder,
rather than having their real attachment needs addressed.
DSM-IV suggests, for most diagnoses, that the condition must cause “clinically significant
distress or impairment in social, occupational, or other important areas of functioning.” The goal
of the clinical significance criterion is to set an impairment or distress threshold for diagnosis so
that false positives are eliminated in cases in which there is minimal harm to the individual.
Requiring “clinically significant” distress or role impairment as a criterion for distinguishing
disorder from nondisorder is circular because “clinically significant” in this context can only
mean that the impairment is significant enough to imply the existence of a disorder. The phrase
offers no real guidance in deciding whether the level of impairment is or is not sufficient to
imply disorder. This criteria does not deal with situations in which there may be harm but no
dysfunction.