Disability and diagnosis: should role impairment be eliminated from DSM/ICD diagnostic criteria?

摘要: Ustun and Kennedy propose that “no functioning or disability should appear as part of the threshold diagnosis” any disorder. They note disentangling disability/impairment from disorder would bring DSM into greater conformity with ICD. However, real issue is conceptual: can criteria – understood, in clinical significance criteria, impairment social role (not to be confused psychological dysfunction appearing symptoms) entirely disentangled diagnostic at this point psychiatry’s history? In a related vein, Robert Spitzer I 1, 4 have argued “clinical significance” using generally are not very useful for distinguishing non-disordered problems living, because often entail impairment. Recent studies tend support redundancy broad DSM-like both epidemiologic contexts 5, 7. Despite ICD’s explicit goal avoid family, occupational other they vary cross-culturally, enters many ICD sets. For example, conduct requires “major violations age-appropriate expectations”; reading must “significantly interfere academic achievement activities daily living require skills”; neurasthenia involves “decrease performance coping efficiency tasks”. fail explain why still contain so references disability. offer no systematic argument fully disentangled. The absurdity itself sufficient indicator readily apparent; how pathological then distinguished normal inability? 8. Consider sleep (one-third life spent paralyzed hallucinating), pregnancy, fatigue after exertion, human limitations; variation traits like intelligence, shyness, height disadvantage some; differences knowledge, skill, talent yield variations ability perform roles. It but it caused makes pathological. Given absurdity, logic regarding potential use diagnosis more troubling than one might suspect goes well beyond specific criteria. The DSM’s introductory section on criterion explains: “This helps establish those situations which symptomatic presentation by (particularly its milder forms) inherently may encountered individuals whom ‘mental disorder’ inappropriate”. Thus, allowed change status condition non-disorder Moreover, explains situation diagnosed under “not otherwise specified” category when “the con-forms symptom pattern has been included DSM-IV classification causes clinically significant distress impairment”. Such patterns include subthreshold conditions fewer usually required symptoms. In sum, implicitly allows problematic few symptoms disorders based simply impairment, contrary own definition requiring internal dysfunction. A corrective sort suggested plainly needed. But fact does imply mean whatever diagnosis. According mental my “harmful analysis” (HDA) concept 8, 9, an (meaning failure biologically designed function) harm (as socially evaluated). HDA proposes two dimensions: harm. Consequently, legitimately considerations reasons. First, constitute harm. Generally, direct will harmful enough, there instances only type cited This points basic fallacy: assume equivalent underlying even medical unless benign angiomas genuine dysfunctions, yet All such biological flaws due lack sometimes needed determine whether thus distinguish non-disorder. Second, independent way versus problem One capacity shaped, function implies phobia occurs interacting family members, functions parenting sexual interaction compromised. This simultaneously Another failure, though dysfunction, infer invention, nonexistent preliterate societies. Nor inability read illiteracy considered But learn despite opportunity we Because unknown effects, cite key diagnosis. In reasons Kennedy’s general thrust attempt degree possible separate consider adequately multifaceted conceptual relations between disability, illuminated, maintained, analysis’s two-dimensional account terms conclude proposal totally disengage unrealistic stage development science. validity category-by-category analysis preferable their blanket approach.