Jerome C. Wakefield

Adaptations, Exaptations, and Spandrels

Adaptation and natural selection are central concepts in the emerging science of evolutionary psychology. Natural selection is the only known causal process capable of producing complex functional organic mechanisms. These adaptations, along with their incidental by-products and a residue of noise, comprise all forms of life. Recently, S. J. Gould (1991) proposed that exaptations and spandrels may be more important than adaptations for evolutionary psychology. These refer to features that did not originally arise for their current use but rather were co-opted for new purposes. He suggested that many important phenomena--such as art, language, commerce, and war--although evolutionary in origin, are incidental spandrels of the large human brain. The authors outline the conceptual and evidentiary standards that apply to adaptations, exaptations, and spandrels and discuss the relative utility of these concepts for psychological science.

Limits of operationalization: a critique of spitzer and Endicott's (1978) proposed operational criteria for mental disorder

Spitzer and Endicott (1978) proposed an operational definition of mental disorder that is a more rigorous version of the brief definitions that appeared in the 3rd and revised 3rd editions of the Diagnostic and Statistical Manual of Mental Disorders. The heart of their proposal is a translation of the concept of dysfunction into operational terms. I argue that their definition fails to capture the concept of dysfunction and is subject to many counterexamples. I use my harmful dysfunction account of disorder (Wakefield, 1992a, 1992b), which interprets dysfunction in evolutionary terms, to explain both the appeal and the problems of Spitzer and Endicotts definition and to provide support for the harmful dysfunction view. I conclude that the failure of Spitzer and Endicotts sophisticated attempt at operationalization indicates that nonoperational definitions that use functional concepts must play a role in formulating valid diagnostic criteria.

When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds

High community prevalence estimates of DSM‐defined major depressive disorder (MDD) have led to proposals to raise MDDs diagnostic threshold to more validly distinguish pathology from normal‐range distress. However, such proposals lack empirical validation. We used MDD recurrence rates in the longitudinal 2‐wave Epidemiologic Catchment Area Study to test the predictive validity of three proposals to narrow MDD diagnosis: a) excluding “uncomplicated” episodes (i.e., episodes that last no longer than 2 months and do not include suicidal ideation, psychotic ideation, psychomotor retardation, or feelings of worthlessness); b) excluding mild episodes (i.e., episodes with only five to six symptoms); and c) excluding nonmelancholic episodes. For each proposal, we used lifetime MDD diagnoses at wave 1 to distinguish the group proposed for exclusion, other MDD, and those with no MDD history. We then compared these groups’ 1‐year MDD rates at wave 2. A proposal was considered strongly supported if at wave 2 the excluded groups MDD rate was not only significantly lower than the rate for other MDD but also not significantly greater than the no‐MDD‐history group. Results indicated that all three excluded groups had significantly lower recurrence rates than other MDD (uncomplicated vs. complicated, 3.4% vs. 14.6%; mild vs. severe, 9.6% vs. 20.7%; nonmelancholic vs. melancholic, 10.6% vs. 19.2%, respectively). However, only uncomplicated MDDs recurrence rate was also not significantly greater than the MDD occurrence rate for the no‐MDD‐history group (3.4% vs. 1.7%, respectively). This low recurrence rate resulted from an interaction between uncomplicated duration and symptom criteria. Multiple‐episode uncomplicated MDD did not entail significantly elevated recurrence over single‐episode cases (3.7% vs. 3.0%, respectively). Uncomplicated MDDs general‐distress symptoms, transient duration, and lack of elevated recurrence suggest it may generally represent nonpathologic intense sadness that should be addressed in treatment guidelines and considered for exclusion from MDD diagnosis to increase the validity of the MDD/normal sadness boundary.

Does the DSM-IV Clinical Significance Criterion for Major Depression Reduce False Positives? Evidence From the National Comorbidity Survey Replication

OBJECTIVE To reduce false positive diagnoses, DSM-IV added a clinical significance criterion to many diagnostic criteria sets requiring that symptoms cause significant distress or impairment. The DSM-V Task Force is considering whether clinical significance should remain a diagnostic threshold or become a separate dimension, as it is in ICD. Yet, the criterions effectiveness in validly reducing the prevalence of specific disorders remains unclear. Critics have argued that for some categories, notably major depression, the criterion is redundant with symptoms, which are inherently distressing or impairing. The authors empirically evaluated the criterions effect on the prevalence of major depression in the community. This report also considers more broadly the relationship of symptoms to impairment in diagnosis. METHOD Subjects were respondents, aged 18 to 54 years, who participated in the National Comorbidity Survey Replication (N=6,707). The effect of the clinical significance criterions distress and impairment components on major depression was assessed in this sample. Distress questions were administered to all respondents reporting persistent sadness (> or = 2 weeks) or the equivalent. Questions pertaining to role impairment were asked of all respondents satisfying major depression symptom-duration criteria. RESULTS Of 2,071 individuals reporting persistent sadness or the equivalent, 97.2% (N=2,016) satisfied criteria for distress. Of 1,542 individuals satisfying depression symptom-duration criteria, 96.2% (N=1,487) satisfied criteria for impairment. CONCLUSIONS These findings support the redundancy thesis. Distress is virtually redundant with symptoms of persistent sadness, even in the absence of major depression, and impairment is almost always entailed by major depression-level symptoms. Thus, the clinical significance criterion does not substantially reduce the prevalence of major depression in the community. The DSM-V Task Force should consider eliminating the criterion and explore alternative ways to identify false positives in the diagnosis of depression. The criterions status for other disorders should be evaluated on a disorder-by-disorder basis because the diagnostic relationship between symptoms and impairment varies across categories.

Does Social Work Need the Eco-Systems Perspective? Part 2. Does the Perspective Save Social Work from Incoherence?

This is the second part of a two-part article in which I analyze the arguments for the eco-systems perspective. In Part 1, published in the March 1996 issue of this journal, I examined four arguments for the clinical usefulness of the perspective and found them to be invalid. Here, I consider three arguments for the conceptual usefulness of the perspective: (1) it is needed to make social work a coherent profession; (2) it is needed to adequately identify the unique domain of social work; and, (3) it is merely a way of looking at things and not a theory or model, so it can be used without empirical support. A close examination of these arguments demonstrates that they, too, are invalid and that the claimed conceptual usefulness of the perspective is an illusion. The conceptual benefits can be achieved only by further clarification of the purpose of social work and by directing practice interventions at that purpose. There is no need to add a generic theory or perspective to the professions purpose and practice methods.

Recurrence of depression after bereavement-related depression: evidence for the validity of DSM-IV bereavement exclusion from the Epidemiologic Catchment Area Study.

Abstract The DSM-IV diagnostic criteria for major depressive disorder exclude bereavement-related depressive episodes that are brief and lack certain severe symptoms and are thus better explained as normal grief responses. However, the DSM-5 Task Force proposes to eliminate this exclusion because of a lack of evidence that such episodes differ relevantly from standard major depression. Using the two-wave longitudinal Epidemiologic Catchment Area Study, we compared 1-yr depression recurrence rates at wave 2 of four groups at wave 1 baseline: (1) those with no history of depressive disorder (n = 18,239), (2) those who had only lifetime excludable bereavement-related depression (n = 25), (3) those with brief-episode (⩽2 months duration) lifetime standard depressive disorder (n = 446), and (4) those with nonbrief lifetime standard depressive disorder (n = 581). The recurrence rate in the excludable-depression group (3.7%) was not significantly different from the no-history group (1.7%) but was significantly and substantially lower than in the brief and nonbrief standard depression groups (14.4% and 16.2%, respectively). These findings confirm findings reported by Mojtabai (Arch Gen Psychiatry 68:920–928, 2011) using a different data set and time frame and thus substantially strengthen the support for the validity of bereavement exclusion and for its preservation in the DSM-5.

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

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

Background: In psychiatrys 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 DSMs 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.

Wittgenstein's nightmare: why the RDoC grid needs a conceptual dimension.

RDoC attempts to finesse an existential dilemma facing psychiatry: psychiatry is most persuasively a medical field if mental disorders are understood as brain disorders, but brain disorders seem to fall under neurology. The RDoC attempts to resolve this dilemma by distinguishing brain circuit malfunctions as the distinctive domain of psychiatry: “the RDoC framework conceptualizes mental illness as brain disorders; in contrast to neurological disorders with identifiable lesions, mental disorders can be addressed as disorders of brain circuits” (1). RDoC further locates brain circuit function within a grid of analytical and developmental levels and dimensions that together are supposed to replace DSM/ICD categories with more valid diagnoses.

Did Narrowing the Major Depression Bereavement Exclusion From DSM-III-R to DSM-IV Increase Validity?: Evidence From the National Comorbidity Survey

The DSMs major-depression “bereavement exclusion” eliminates bereavement-related depressive episodes (BRDs) from diagnosis unless they are “complicated” by prolonged duration or certain severe symptoms. The exclusion was substantially narrowed in DSM-IV to decrease false-negative diagnoses, but the impact of this change remains unknown. We divided BRDs in the National Comorbidity Survey into uncomplicated versus complicated categories using broader DSM-III-R and narrower DSM-IV exclusion criteria. Using 6 pathology validators (symptom number, melancholic depression, suicide attempt, interference with life, medication for depression, and hospitalization for depression), we compared the validity of the 2 exclusion criteria sets using 2 tests: (1) which criteria set yielded less pathological uncomplicated cases or more pathological complicated cases; (2) which yielded the largest separation between uncomplicated and complicated pathology levels. Results of both tests indicated that the narrower DSM-IV criteria substantially decreased the exclusions validity. These results suggest caution regarding the current proposal to eliminate the bereavement exclusion in DSM-5.