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Hunter J, Jackson SH, Van Norman GA. Ethics of Preanesthesia Mandatory Laboratory Testing. Anesthesiol Clin 2024; 42:473-490. [PMID: 39054021 DOI: 10.1016/j.anclin.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Some practices require mandatory preoperative laboratory testing for select patients presenting for anesthesia and surgery. Such mandatory preanesthesia laboratory testing has significant ethical implications related to informed consent and patient autonomy. Assumptions that a patient provides "presumed consent" by merely presenting for a test are flawed because such consents are often not informed and do not acknowledge patient autonomy. By placing a condition on access to a medical treatment, mandatory preanesthesia testing may not be ethically justifiable. Not all laboratory tests are "ethically equal"; several raise specific questions regarding informed consent, related to their potential to cause significant harm.
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Affiliation(s)
- James Hunter
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen H Jackson
- Department of Anesthesiology, Good Samaritan Hospital, San Jose, CA, USA
| | - Gail A Van Norman
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
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Jackson S, Hunter J, Van Norman GA. Ethical Principles Do Not Support Mandatory Preanesthesia Pregnancy Screening Tests: A Narrative Review. Anesth Analg 2024; 138:980-991. [PMID: 37801601 DOI: 10.1213/ane.0000000000006669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Respect for patient autonomy is a pillar of medical ethics, manifested predominantly through informed consent. Mandatory (routine) nonconsented preoperative urine pregnancy testing does not adequately respect patient autonomy, is potentially coercive, and has the potential to cause harm medically, psychologically, socially, and financially. Inaccuracies in pregnancy testing can result in false-positive and false-negative results, especially in early pregnancy. There is substantial scientific evidence that anesthesia is not harmful to the fetus, raising the question of whether pregnancy testing provides substantial benefit to the patient. Not performing a preanesthesia pregnancy test has not been associated with significant medicolegal consequences. We review the ethical implications of mandatory preanesthesia pregnancy testing in light of these facts.
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Affiliation(s)
- Stephen Jackson
- Department of Anesthesiology, Good Samaritan Hospital, San Jose, California
| | - James Hunter
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gail A Van Norman
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Balcombe L, De Leo D. Psychological Screening and Tracking of Athletes and Digital Mental Health Solutions in a Hybrid Model of Care: Mini Review. JMIR Form Res 2020; 4:e22755. [PMID: 33271497 PMCID: PMC7746225 DOI: 10.2196/22755] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is a persistent need for mental ill-health prevention and intervention among at-risk and vulnerable subpopulations. Major disruptions to life, such as the COVID-19 pandemic, present an opportunity for a better understanding of the experience of stressors and vulnerability. Faster and better ways of psychological screening and tracking are more generally required in response to the increased demand upon mental health care services. The argument that mental and physical health should be considered together as part of a biopsychosocial approach is garnering acceptance in elite athlete literature. However, the sporting population are unique in that there is an existing stigma of mental health, an underrecognition of mental ill-health, and engagement difficulties that have hindered research, prevention, and intervention efforts. OBJECTIVE The aims of this paper are to summarize and evaluate the literature on athletes' increased vulnerability to mental ill-health and digital mental health solutions as a complement to prevention and intervention, and to show relationships between athlete mental health problems and resilience as well as digital mental health screening and tracking, and faster and better treatment algorithms. METHODS This mini review shapes literature in the fields of athlete mental health and digital mental health by summarizing and evaluating journal and review articles drawn from PubMed Central and the Directory of Open Access Journals. RESULTS Consensus statements and systematic reviews indicated that elite athletes have comparable rates of mental ill-health prevalence to the general population. However, peculiar subgroups require disentangling. Innovative expansion of data collection and analytics is required to respond to engagement issues and advance research and treatment programs in the process. Digital platforms, machine learning, deep learning, and artificial intelligence are useful for mental health screening and tracking in various subpopulations. It is necessary to determine appropriate conditions for algorithms for use in recommendations. Partnered with real-time automation and machine learning models, valid and reliable behavior sensing, digital mental health screening, and tracking tools have the potential to drive a consolidated, measurable, and balanced risk assessment and management strategy for the prevention and intervention of the sequelae of mental ill-health. CONCLUSIONS Athletes are an at-risk subpopulation for mental health problems. However, a subgroup of high-level athletes displayed a resilience that helped them to positively adjust after a period of overwhelming stress. Further consideration of stress and adjustments in brief screening tools is recommended to validate this finding. There is an unrealized potential for broadening the scope of mental health, especially symptom and disorder interpretation. Digital platforms for psychological screening and tracking have been widely used among general populations, but there is yet to be an eminent athlete version. Sports in combination with mental health education should address the barriers to help-seeking by increasing awareness, from mental ill-health to positive functioning. A hybrid model of care is recommended, combining traditional face-to-face approaches along with innovative and evaluated digital technologies, that may be used in prevention and early intervention strategies.
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Affiliation(s)
- Luke Balcombe
- School of Health and Sport Science, University of the Sunshine Coast, Sunshine Coast, Australia.,Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia
| | - Diego De Leo
- Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia
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Obaid FP, Albagli RDLF. A critical analysis of debates on grief and depressive disorder in the age of the Diagnostic and Statistical Manual of Mental Disorders. Salud Colect 2019; 15:e2319. [PMID: 32022133 DOI: 10.18294/sc.2019.2319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/19/2019] [Accepted: 09/27/2019] [Indexed: 11/24/2022] Open
Abstract
Since the incorporation of the major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, and until its update in the DSM-IV-TR, the DSM classification system considered it necessary to include the criterion of "bereavement exclusion", with the aim of differentiating normal sadness linked to a loss, from a mental disorder, such as the major depressive disorder. In its latest version (DSM-5), this exception was removed, giving rise to a controversy that continues to this day. The debate has set those who are in favor of maintaining this exclusion and extending it to other stressors against those who have intended to eradicate it. Our hypothesis is that these positions account for two qualitatively diverse clinical and epistemological matrices, linked to major transformations in health sciences and in psychiatry. We show that this debate involved a profound renewal of the meaning of psychiatric practice, a change in the function of diagnosis and in the way of conceiving the etiology of mental disorders, as well as a reformulation of the patient's suffering status for the medical act.
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Affiliation(s)
- Francisco Pizarro Obaid
- Psicólogo. Doctor en Sexualidad, Procreación y Perinatalidad. Profesor asociado, director de postgrado, Facultad de Psicología, Universidad Diego Portales, Santiago, Chile.
| | - Rodrigo De La Fabián Albagli
- Psicólogo. Doctor en Psicopatología Fundamental. Profesor asociado, Facultad de Psicología, Universidad Diego Portales, Santiago, Chile.
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Fabián RDL, Pizarro F, Ruperthuz M. [The energy metaphor for the human body and its effect on the rise of neurasthenia, neurosis and depression]. HISTORIA, CIENCIAS, SAUDE--MANGUINHOS 2019; 26:879-897. [PMID: 31531581 DOI: 10.1590/s0104-59702019000300009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/05/2018] [Indexed: 06/10/2023]
Abstract
This article aims to provide a historical critique of the rise of three diagnostic categories: neurasthenia (late nineteenth century), neurosis (first half of the twentieth century) and depression (mid-twentieth century to the present). The hypothesis is that their broad dissemination can be explained through their link to the energy metaphor for the human body. From the mid-nineteenth century on, the concept of energy spread through western culture, encouraging certain fictions about what we are - the ontological dimension - and what we could be - the ethical dimension. The article shows that these pathologies have codified and made intelligible a set of life trajectories that did not obey the imperatives of those onto-ethical fictions.
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Affiliation(s)
| | - Francisco Pizarro
- Profesor y director de Postgrado, Facultad de Psicología/ Universidad Diego Portales. Santiago - Chile.
| | - Mariano Ruperthuz
- Profesor y director de Magíster en Psicologia, Facultad de Psicología/Universidad Diego Portales. Santiago - Chile.
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Wakefield JC. Diagnostic Issues and Controversies in DSM-5: Return of the False Positives Problem. Annu Rev Clin Psychol 2016; 12:105-32. [PMID: 26772207 DOI: 10.1146/annurev-clinpsy-032814-112800] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was the most controversial in the manual's history. This review selectively surveys some of the most important changes in DSM-5, including structural/organizational changes, modifications of diagnostic criteria, and newly introduced categories. It analyzes why these changes led to such heated controversies, which included objections to the revision's process, its goals, and the content of altered criteria and new categories. The central focus is on disputes concerning the false positives problem of setting a valid boundary between disorder and normal variation. Finally, this review highlights key problems and issues that currently remain unresolved and need to be addressed in the future, including systematically identifying false positive weaknesses in criteria, distinguishing risk from disorder, including context in diagnostic criteria, clarifying how to handle fuzzy boundaries, and improving the guidelines for "other specified" diagnosis.
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Affiliation(s)
- Jerome C Wakefield
- NYU Silver School of Social Work, New York University, New York, NY 10003.,Department of Psychiatry, NYU School of Medicine, New York University, New York, NY 10016;
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Affiliation(s)
- A. Lasalvia
- Address for correspondence: Dr A. Lasalvia, Department of Psychiatry, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico “G.B. Rossi”, Piazzale L.A. Scuro, 37134 – Verona, Italy. ()
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Wakefield JC, Schmitz MF. The harmful dysfunction model of alcohol use disorder: revised criteria to improve the validity of diagnosis and prevalence estimates. Addiction 2015; 110:931-42. [PMID: 25622535 DOI: 10.1111/add.12859] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 10/31/2014] [Accepted: 01/14/2015] [Indexed: 11/30/2022]
Abstract
AIMS To formulate harmful dysfunction (HD) diagnostic criteria for alcohol use disorder (AUD) and test whether they increase validity relative to standard DSM criteria, as evidenced by lowered prevalence, increased validator levels including service use, severity and family history and enhanced specificity. DESIGN DSM-IV AUD, DSM-IV dependence, DSM-5 AUD and HD AUD definitions were compared on eight validity related tests using nationally representative community data. SETTING United States. PARTICIPANTS National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) respondents, aged 18-54 years (wave 1, n = 29 673; wave 2, n = 24 244). MEASURES NESARC DSM-IV and DSM-5 criteria were taken from published studies. Whereas DSM-5 diagnosis requires any two AUD symptoms, HD criteria were constructed from NESARC items to require symptoms of both impaired-control dysfunction [withdrawal, drink to prevent/stop withdrawal, cannot stop/reduce drinking, or craving (wave 2 only)] and harm (sacrificed important activities, problems caring for home/family, job/school problems, health problems, psychological problems or problems with family/friends). Validators included service use, severity and family history, among others. Specificity was tested using a teen transient drinker criterion group. FINDINGS Compared with DSM-5 AUD (DSM-IV results were similar), HD criteria yielded lower prevalence (95% confidence intervals): HD life-time 6.7% (6.2, 7.2%), 1-year 2.3% (2.0, 2.5%); and DSM-5 life-time 38.2% (36.5, 39.9%), 1-year 12.4% (11.7, 13.1%). HD AUD was higher than DSM-5 on pathology validators, including: life-time alcohol-related service use: HD 41.0% (38.1, 43.9%), DSM-5 11.5% (10.7, 12.3%); severity (number of life-time alcohol symptoms): HD 20.8 (20.4, 21.2), DSM-5 10.6 (10.4, 10.8); and family history of alcohol problems: HD 50.1% (47.3, 52.9), DSM-5 32.8% (31.6, 34.0). HD criteria eliminated 83% of a DSM-5 teen transient drinker false-positives criterion group. CONCLUSIONS Prevalence estimates of alcohol use disorder are lowered and diagnostic validity improved when using 'harmful dysfunction' diagnostic criteria compared with standard DSM criteria, partly by reducing misdiagnosis of teenage transient drinkers.
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Affiliation(s)
- Jerome C Wakefield
- School of Social Work and Department of Psychiatry, New York University, New York, NY,, USA
| | - Mark F Schmitz
- School of Social Work, Temple University, Philadelphia, PA,, USA
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Abstract
The revision effort leading to the publication of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was flawed in process, goals and outcome. The revision process suffered from lack of an adequate public record of the rationale for changes, thus shortchanging future scholarship. The goals, such as dimensionalising diagnosis, incorporating biomarkers and separating impairment from diagnosis, were ill-considered and mostly abandoned. However, DSM-5's greatest problem, and the target of the most vigorous and sustained criticism, was its failure to take seriously the false positives problem. By expanding diagnosis beyond plausible boundaries in ways inconsistent with DSM-5's own definition of disorder, DSM-5 threatened the validity of psychiatric research, including especially psychiatric epidemiology. I present four examples: increasing the symptom options while decreasing the diagnostic threshold for substance use disorder, elimination of the bereavement exclusion from major depression, allowing verbal arguments as evidence of intermittent explosive disorder and expanding attention-deficit/hyperactivity disorder to adults before addressing its manifest false positives problems.
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Wakefield JC, Schmitz MF. How Many People have Alcohol Use Disorders? Using the Harmful Dysfunction Analysis to Reconcile Prevalence Estimates in Two Community Surveys. Front Psychiatry 2014; 5:10. [PMID: 24550847 PMCID: PMC3910138 DOI: 10.3389/fpsyt.2014.00010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 01/17/2014] [Indexed: 11/22/2022] Open
Abstract
Community prevalence rates of alcohol use disorders (AUDs) provided by epidemiological studies using DSM-based diagnostic criteria pose several challenges: the rates appear implausibly high to many epidemiologists; they do not converge across similar studies; and, due to low service utilization by those diagnosed as disordered, they yield estimates of unmet need for services so high that credibility for planning purposes is jeopardized. For example, two early community studies using DSM diagnostic criteria, the Epidemiologic Catchment Area Study (ECA) and the National Comorbidity Survey (NCS), yielded lifetime AUD prevalence rates of 14 and 24%, respectively, with NCS unmet need for services 19% of the entire population. Attempts to address these challenges by adding clinical significance requirements to diagnostic criteria have proven unsuccessful. Hypothesizing that these challenges are due to high rates of false-positive diagnoses of problem drinking as AUDs, we test an alternative approach. We use the harmful dysfunction (HD) analysis of the concept of mental disorder as a guide to construct more valid criteria within the framework of the standard out-of-control model of AUD. The proposed HD criteria require harm and dysfunction, where harm can be any negative social, personal, or physical outcome, and dysfunction requires either withdrawal symptoms or inability to stop drinking. Using HD criteria, ECA and NCS lifetime prevalences converge to much-reduced rates of 6 and 6.8%, respectively. Due to higher service utilization rates, NCS lifetime unmet need is reduced to 3.4%. Service use and duration comparisons suggest that HD criteria possess increased diagnostic validity. Moreover, HD criteria eliminate 90% of transient teenage drinking from disorder status. The HD version of the out-of-control model thus potentially resolves the three classic prevalence challenges while offering a more rigorous approach to distinguishing AUDs from problematic drinking.
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Affiliation(s)
- Jerome C. Wakefield
- Silver School of Social Work and Department of Psychiatry, School of Medicine, New York University, New York, NY, USA
| | - Mark F. Schmitz
- School of Social Work, Temple University, Philadelphia, PA, USA
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Ludvigsson M, Milberg A, Marcusson J, Wressle E. Normal Aging or Depression? A Qualitative Study on the Differences Between Subsyndromal Depression and Depression in Very Old People. THE GERONTOLOGIST 2014; 55:760-9. [PMID: 24398652 DOI: 10.1093/geront/gnt162] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 11/12/2013] [Indexed: 11/13/2022] Open
Abstract
PURPOSE OF THE STUDY The aim of this study was to make a qualitative comparison of experiences of being in very old people with subsyndromal depression (SSD), in relation to the experiences of very old people with syndromal depression or nondepression. Through investigation and deeper understanding of the interface between depressive disease and normal aging, clinicians might give more accurate prevention or treatment to those very old persons who need such help. DESIGN AND METHODS Semistructured qualitative interviews were conducted for 27 individuals of 87-88 years of age, who were categorized in the 3 strata of nondepressive, SSD, and syndromal depression. Transcripts were analyzed using qualitative content analysis within each stratum and later with a comparison between the strata. RESULTS The content analysis resulted in 4 themes in people with SSD, as defined by a self-report depression screening instrument, giving a comprehensive picture of SSD in very old people, and also showed qualitative differences between the SSD, syndromal depression, and nondepressive groups. A main finding was that SSD differs qualitatively from syndromal depression but not clearly from nondepression. IMPLICATIONS The results might indicate that SSD in very old people is not related to pathology but to normal aging, even though the condition correlates with negative health parameters. Overlooking certain psychosocial aspects of living in the very old may pose a risk of both underdiagnosis and overdiagnosis in the spectrum of depressive disorders.
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Affiliation(s)
- Mikael Ludvigsson
- Division of Geriatric Medicine, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Department of Geriatrics, County Council of Östergötland, Sweden.
| | - Anna Milberg
- Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, LAH/Unit of Palliative Care, County Council of Östergötland, and Palliative Education and Research Centre in the County of Östergötland, Sweden
| | - Jan Marcusson
- Division of Geriatric Medicine, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Department of Geriatrics, County Council of Östergötland, Sweden
| | - Ewa Wressle
- Division of Geriatric Medicine, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Department of Geriatrics, County Council of Östergötland, Sweden
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Stein DJ. What is a mental disorder? A perspective from cognitive-affective science. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:656-62. [PMID: 24331284 DOI: 10.1177/070674371305801202] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Defining disease and disorder remains a key conceptual question in philosophy of medicine and psychiatry, and is currently a very practical matter for psychiatric nosology, given the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the upcoming International Classification of Diseases, 11th Revision. There have been advances in the cognitive-affective science of human categorization, and it is timely to consider implications for our understanding of the category of psychiatric disorder. The category of mental disorder has graded boundaries, and conditions within this category can be conceptualized using MEDICAL or MORAL metaphors. One key set of constructs used in MEDICAL metaphors relates to the notion of dysfunction, and it may, in turn, be useful to conceptualize such dysfunction in evolutionary terms. For typical disorders, it is relatively easy to agree that dysfunction is present. However, for atypical disorders, there may be considerable debate about the presence and extent of dysfunction. Rational arguments can be brought to bear to help decide whether particular entities should be included in our nosologies, and, if so, what their boundaries should be. However, it is appropriate that there should be ongoing debate on diagnostic validity, clinical utility, and other relevant facts and values, for cases that are difficult to decide. The perspective here can be illustrated using many nosological debates within the anxiety disorders and the obsessive-compulsive and related disorders, including the question of delineating normal from abnormal anxiety, of deciding whether anxiety is psychiatric or medical, and the debate about the optimal meta-structure for anxiety disorders.
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Affiliation(s)
- Dan J Stein
- Professor and Chair, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Parker M. Defending the indefensible? Psychiatry, assisted suicide and human freedom. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:485-497. [PMID: 23845163 DOI: 10.1016/j.ijlp.2013.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The siege guns of the forces for change to euthanasia and assisted suicide laws have been pounding for decades, but the longstanding proscription on these practices has held out in all but a few jurisdictions. A few psychiatrists have enlisted with the challengers, but many remain on the battlements, defending the impermissibility of active assistance in dying. Given the long history of the separation of church and state and the significant secularisation of society; the recognition by the law of both acts and omissions as legal causes; lenient sentences for mercy killers; critiques of the "psychiatriatisation" of different aspects of life; and the consistency of public opinion, this recalcitrant stand bespeaks undercurrents and positions that are often by rationalised or camouflaged, and which call for exploration. In this paper, I examine connections between psychiatry and conceptualisations of harm, suffering and natural death; medicalisation, psychiatrisation and medical paternalism; decision-making capacity, rationality and diagnosis; recent legal developments; social pluralism; and religious intuitionism. I conclude that psychiatrists and the psychiatry profession, concerned as they are with enlarging the province of human freedom, should begin a more transparent rapprochement with those they would repel.
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Affiliation(s)
- Malcolm Parker
- Mayne Medical School, 288 Herston Road, Herston, Queensland 4006, Australia; School of Medicine, University of Queensland, Australia.
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Wakefield JC. DSM-5 proposed diagnostic criteria for sexual paraphilias: tensions between diagnostic validity and forensic utility. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2011; 34:195-209. [PMID: 21531463 DOI: 10.1016/j.ijlp.2011.04.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In order to prevent sexual crimes, "sexual predator" laws now allow indefinite preventive civil commitment of criminals who have completed their prison sentences but are judged to have a paraphilic mental disorder that makes them likely to commit another crime. Such proceedings can bypass the usual protections of criminal law as long as the basis for incarceration is the attribution of a mental disorder. Thus, the difficult conceptual distinction between deviant sexual desires that are mental disorders versus those that are normal variations in sexual preference (even if they are eccentric, repugnant, or illegal if acted upon) has attained critical forensic significance. Yet, the concept of paraphilic disorders - called "perversions" in earlier times - is inherently fuzzy and controversial and thus open to conceptual abuse for social control purposes. Consequently, the criteria used in diagnosing paraphilic disorders deserve careful scrutiny. The DSM-5 sexual disorders work group is proposing substantial revisions to the paraphilia diagnostic criteria in the DSM-5 nosology. It is claimed that the new criteria provide a reconceptualization that clarifies the distinction between normal variation and paraphilic disorder in a way relevant to forensic settings. In this article, after considering the logic of the concept of a paraphilic disorder, I examine each of the proposed changes to the DSM-5 paraphilia criteria and assess their conceptual validity. I argue that the DSM-5 proposals, while containing a kernel of an advance in distinguishing paraphilias from paraphilic disorders, nonetheless would yield criteria for paraphilic disorders that are conceptually invalid in ways open to serious forensic abuse.
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