The lay concept of conduct disorder: do nonprofessionals use syndromal symptoms or internal dysfunction to distinguish disorder from delinquency?

What is a mental disorder? Evaluating the lay concept of Mental Ill Health in the United States

PURPOSE

How "mental disorder" should be defined has been the focus of extensive theoretical and philosophical debate, but how the concept is understood by laypeople has received much less attention. The study aimed to examine the content (distinctive features and inclusiveness) of these concepts, their degree of correspondence to the DSM-5 definition, and whether alternative concept labels ("mental disorder", "mental illness", "mental health problem", "psychological issue") have similar or different meanings.

METHODS

We investigated concepts of mental disorder in a nationally representative sample of 600 U.S. residents. Subsets of participants made judgments about vignettes describing people with 37 DSM-5 disorders and 24 non-DSM phenomena including neurological conditions, character flaws, bad habits, and culture-specific syndromes.

RESULTS

Findings indicated that concepts of mental disorder were primarily based on judgments that a condition is associated with emotional distress and impairment, and that it is rare and aberrant. Disorder judgments were only weakly associated with the DSM-5: many DSM-5 conditions were not judged to be disorders and many non-DSM conditions were so judged. "Mental disorder", "mental illness", and "mental health problem" were effectively identical in meaning, but "psychological issue" was somewhat more inclusive, capturing a broader range of conditions.

CONCLUSION

These findings clarify important issues surrounding how laypeople conceptualize mental disorder. Our findings point to some significant points of disagreement between professional and public understandings of disorder, while also establishing that laypeople's concepts of mental disorder are systematic and structured.

Clients in context: Environment, class, race, and therapists' perceptions of generalized anxiety disorder

Evidence-based practice necessitates the inclusion of client identity and contextual information when conceptualizing diagnosis.

OBJECTIVE

To examine how therapists' perceptions of Generalized Anxiety Disorder is influenced by client environmental contextual and identity factors, like class and race.

METHOD

Therapists (n = 138; 76% women; M_age  = 38.3) were randomly assigned three of six client vignettes and asked to provide diagnostic recommendations, confidence in diagnosis, and perception of client's concerns. Vignettes differed in their description of client class, race, and contextual factors. A linear mixed-model was used to test confidence in diagnosis and generalized linear mixed-models were conducted to predict diagnosis and client concerns.

RESULTS

Therapists altered diagnosis, confidence, and client concerns based on client contextual factors-but not identity factors.

CONCLUSIONS

Therapists consider contextual factors in making clinical decisions, with overall tendency towards diagnosis regardless of if symptoms met the diagnostic criteria of being "excessive" given the environmental context.

Thinking you can catch mental illness: how beliefs about membership attainment and category structure influence interactions with mental health category members

We explored beliefs about mental disorder categories that influence potential interactions with category members. Specifically, we investigated beliefs related to how membership in a mental disorder category is obtained (communicability and causal origin) as well as beliefs related to the underlying reality of disorder categories (essentialism and controllability). In Experiment 1, participants' interaction-willingness decisions were predicted by their beliefs that a mental disorder category was (1) communicable, (2) psychologically caused, (3) environmentally caused, and (4) possessed all-or-none membership. With fictitious mental disorders, people were less willing to interact with people described as having a communicable mental disorder than with those described as possessing any of the other factors of interest, highlighting the independent influence of these contagion beliefs (Experiment 2). We further explored beliefs about the communicability of mental disorders in Experiment 3 by asking participants to generate descriptions of how mental disorders are transferred between people. Our findings suggest the importance of understanding contagion beliefs in discovering why people distance themselves from people diagnosed with mental disorders. More generally, our findings help in understanding how our basic category knowledge is used to guide interactions with category members, illustrating how knowledge is translated into action.

The biostatistical theory versus the harmful dysfunction analysis, part 1: is part-dysfunction a sufficient condition for medical disorder?

Christopher Boorse's biostatistical theory of medical disorder claims that biological part-dysfunction (i.e., failure of an internal mechanism to perform its biological function), a factual criterion, is both necessary and sufficient for disorder. Jerome Wakefield's harmful dysfunction analysis of medical disorder agrees that part-dysfunction is necessary but rejects the sufficiency claim, maintaining that disorder also requires that the part-dysfunction causes harm to the individual, a value criterion. In this paper, I present two considerations against the sufficiency claim. First, I analyze Boorse's central argument for the sufficiency claim, the "pathologist argument," which takes pathologists' intuitions about pathology as determinative of medical disorder and conclude that it begs the question and fails to support the sufficiency claim. Second, I present four counterexamples from the medical literature in which salient part-dysfunctions are considered nondisorders, including healthy disease carriers, HIV-positive status, benign mutations, and situs inversus totalis, thus falsifying the sufficiency claim and supporting the harm criterion.

Perception of depressive symptoms by the Sardinian public: results of a population study

BACKGROUND

With the exception of bereavement, the diagnosis of major depressive disorder in the DSM-IV does not take into account the context in which symptoms occur. Recent criticism has maintained that common sense suggests making a distinction between depression as mental disorder and sorrow as 'normal' reaction to social stress. Results of a study from Vienna support this view. This study sets out to examine whether these results can be replicated in a different cultural setting.

METHODS

In 2012, a population-based survey was conducted by phone in Sardinia (n = 1,200). A fully structured interview was carried out which began with the presentation of a vignette depicting a diagnostically unlabeled case of depression, with or without provision of information about preceding stressful life events.

RESULTS

In general, as compared to the people from Vienna, the Sardinian public was much less prone to define depressive symptoms as expression of mental illness and more reluctant to recommend professional help. However, similar to Vienna, respondents presented with vignettes containing information on loss events were less likely to define depressive symptoms as indication of a psychiatric illness. They were also less willing to recommend professional help and relied more on self-help and support by family members and close friends.

CONCLUSIONS

We were able to replicate the result of the previous study that the public tends to perceive depressive symptoms differently depending on the context in which they occur. This lets us conclude that the divide between the public's view of what depression is and the view of DSM-IV is not limited to a particular culture but seems to represent a more general phenomenon. In consequence, one might rethink the diagnostic criteria for major depressive disorder in order to reconcile both views.

Lessons from the use of vignettes in the study of mental health service disparities

OBJECTIVE

To examine the development, feasibility, and use of a vignette approach as an important tool in health services disparities research.

DATA SOURCE

Interviews with vignette developers and qualitative data from a novel mental health services disparities study that used vignettes in two samples: (1) predominantly low-income parents of children attending mental health specialty care who were Latino or non-Latino White and (2) Latino and non-Latino mental health clinicians who treat children in their practice.

STUDY DESIGN

We conduct a content analysis of qualitative data from patients and providers in the Ethnic Differences Study to explore the feasibility of vignette methodology in health services disparities research, and we identify lessons learned that may guide future vignette development.

PRINCIPAL FINDINGS

Vignettes provide a valuable approach that is acceptable to participants, elicits important insight on participant experience and services, and sheds light on factors that can help optimize study design for exploring health disparities questions.

CONCLUSIONS

Researchers, clinicians, and others should consider a set of factors that help determine when a vignette approach is warranted in research, training, or for other uses, including how best to address identified weaknesses.

DSM-5 proposed diagnostic criteria for sexual paraphilias: tensions between diagnostic validity and forensic utility

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.

Misdiagnosing normality: Psychiatry's failure to address the problem of false positive diagnoses of mental disorder in a changing professional environment

BACKGROUND

In psychiatry's transformation from primarily an asylum-based profession to a community-oriented profession, false positive diagnoses that mistakenly classify normal intense reactions to stress as mental disorders became a major challenge to the validity of psychiatric diagnosis. The shift to symptom-based operationalized diagnostic criteria in DSM-III further exacerbated this difficulty because of the contextually based nature of the distinction between normal distress and mental disorder, which often display similar symptoms. The problem has particular urgency because the DSM's symptom-based criteria are often applied in studies and screening instruments outside of the clinical context and by non-mental-health professionals.

AIMS

To consider, through selected examples, the degree of concern, systematicity and thoroughness - and the degree of success - with which recent revisions of the DSM have attended to the challenge of avoiding false positive diagnoses.

METHOD

Conceptual analysis of selected criteria sets, with a focus on possible counterexamples to the claim that DSM criteria imply disorder.

RESULTS

Psychiatry has so far failed to systematically adjust its diagnostic practices to confront the problem of false positives. Flaws in criteria, which can be recognized immediately by lay people, remain unaddressed or are addressed on a hit-or-miss random basis years after the flaw has been introduced, even though the issue is purely conceptual and is not sensitive to any new research information.

False positives in psychiatric diagnosis: implications for human freedom

Current symptom-based DSM and ICD diagnostic criteria for mental disorders are prone to yielding false positives because they ignore the context of symptoms. This is often seen as a benign flaw because problems of living and emotional suffering, even if not true disorders, may benefit from support and treatment. However, diagnosis of a disorder in our society has many ramifications not only for treatment choice but for broader social reactions to the diagnosed individual. In particular, mental disorders impose a sick role on individuals and place a burden upon them to change; thus, disorders decrease the level of respect and acceptance generally accorded to those with even annoying normal variations in traits and features. Thus, minimizing false positives is important to a pluralistic society. The harmful dysfunction analysis of disorder is used to diagnose the sources of likely false positives, and propose potential remedies to the current weaknesses in the validity of diagnostic criteria.