Emerging Trends in The Social and Behavioral Sciences

Normal Negative Emotions and Mental Disorders

Item

Title

Normal Negative Emotions and Mental Disorders

Author

Horwitz, Allan V.

Research Area

Psychopathology

Topic

Mental Illness Diagnosis and Treatment

Abstract

The basic goal of psychiatric diagnosis is to distinguish genuine mental dysfunctions from normal, albeit distressing, emotions. This task is especially difficult because, unlike other medical specialties, psychiatry does not have biological markers that can validate diagnoses of mental disorders. Therefore, diagnostic criteria have an outsized role in psychiatry compared to other medical fields. Until the development of the DSM‐III in 1980, psychiatric diagnoses were general, continuous, and causal. In contrast, the diagnostic system that emerged in the DSM‐III and that has remained basically intact until the present has been specific, categorical, and a causal. This type of classification, however, is prone to mistake contextually appropriate symptoms as indicators of mental disorders. Cutting‐edge research incorporates the context in which symptoms emerge and persist to separate normal, distressing emotions from mental illnesses. It also develops alternatives to the DSM's categorical diagnoses. Other valuable studies try to differentiate conditions that stem from evolutionarily normal genes that no longer fit modern environments rather than from genetic or psychological dysfunctions within individuals. Going forward, research must attempt to use biological, psychological, and social factors to develop definitions that adequately distinguish normal responses to stressful environments, evolutionary mismatches, and mental disorders. It will also try to find biomarkers that can set appropriate boundaries between natural and pathological conditions. Finally, it will consider the best ways to optimize the balance between under‐ and over‐diagnosing mental illnesses.

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Identifier

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extracted text

Normal Negative Emotions
and Mental Disorders
ALLAN V. HORWITZ

Abstract
The basic goal of psychiatric diagnosis is to distinguish genuine mental dysfunctions
from normal, albeit distressing, emotions. This task is especially difficult because,
unlike other medical specialties, psychiatry does not have biological markers that
can validate diagnoses of mental disorders. Therefore, diagnostic criteria have an
outsized role in psychiatry compared to other medical fields. Until the development
of the DSM-III in 1980, psychiatric diagnoses were general, continuous, and causal.
In contrast, the diagnostic system that emerged in the DSM-III and that has remained
basically intact until the present has been specific, categorical, and a causal. This type
of classification, however, is prone to mistake contextually appropriate symptoms
as indicators of mental disorders. Cutting-edge research incorporates the context in
which symptoms emerge and persist to separate normal, distressing emotions from
mental illnesses. It also develops alternatives to the DSM’s categorical diagnoses.
Other valuable studies try to differentiate conditions that stem from evolutionarily
normal genes that no longer fit modern environments rather than from genetic
or psychological dysfunctions within individuals. Going forward, research must
attempt to use biological, psychological, and social factors to develop definitions that
adequately distinguish normal responses to stressful environments, evolutionary
mismatches, and mental disorders. It will also try to find biomarkers that can set
appropriate boundaries between natural and pathological conditions. Finally, it will
consider the best ways to optimize the balance between under- and over-diagnosing
mental illnesses.

The central goal of psychiatric diagnosis is to distinguish mental disorders
from normal, but distressing, conditions. This task is especially difficult
because, unlike other medical specialties, psychiatry does not possess any
biological markers that can validate diagnoses of mental disorders. Unlike,
say, oncologists who use biopsies to validate a diagnosis of cancer, nephrologists who take X-rays to see the presence of a kidney stone, or cardiologists
who employ PET scans to see if a heart has tissue damage, diagnostic criteria
are the only resources that psychiatrists possess to support their judgments.
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Therefore, these criteria have an outsized role in psychiatry compared to
other medical fields.
The lack of any objective measures that could validate psychiatric diagnoses is particularly consequential because many common mental disorders
such as depression and anxiety are symptomatically similar to normal, distressing emotions. While many psychiatrists are increasingly coming to recognize the inadequacies of its existing diagnostic system, the field has yet to
develop a knowledge base that will allow it to overcome this problem. The
most important future breakthroughs will occur when psychiatry comes to
possess markers that can reliably distinguish disordered people from those
who are distressed.
FOUNDATIONAL RESEARCH
Until fairly recently, psychiatrists and other mental health professionals
had little need to separate distressing emotions such as depression and
anxiety from mental disorders. Before the mid-twentieth century, diagnostic
systems focused on classifying seriously mentally ill people who were
housed in inpatient mental institutions. This population usually had severe
and unusual symptoms that distinguished them from others. Once the
mental health system turned from focusing on institutionalized patients
toward treating less ill patients in outpatient settings, diagnostic criteria had
to pay attention to a much broader range of conditions. The initial classification manuals of the American Psychiatric Association, the DSM-I (1952)
and DSM-II (1968) focused on what were then called “psychoneurotic”
conditions.
Nevertheless, clinicians in the post-World War II period did not require a
fine-tuned diagnostic system. For one thing, the dominant psychodynamic
theory at the time stressed the continuity, rather than the separation, of normal and mentally ill populations: most normal people had some degree of
neurosis while most neurotics shared most features with the normal. That is,
mental illness and normality were not distinct categories but different points
on a continuum (Grob, 1991). In addition, because most outpatients at the
time paid for their own treatment, no third party insurers—who would not
pay for treatment unless the patient had some diagnosable disease—were
involved in decision-making. Likewise, commercial interests such as drug
companies were able to advertise their products more for the relief of general stress conditions than as treatments for specific types of mental illnesses.
Thus, no professional, social, or economic pressures existed during the 1950s
and 1960s that pushed psychiatrists to develop a diagnostic system that created distinct lines between normal and abnormal mental conditions.

Normal Negative Emotions and Mental Disorders

3

This situation had dramatically changed by the 1970s (Horwitz, 2002).
The casual approach to diagnosis found in the DSM-I and DSM-II became
a professional liability. For one thing, psychiatry’s medical credentials
were questioned because the field was seen as dealing with general psychosocial problems and not legitimate diseases. There was nothing that
psychiatrists were doing that other mental health professionals such as
clinical psychologists, psychiatric social workers, nurses, and counselors
could not do. For another, the absence of clear diagnostic criteria meant
that psychiatrists could not conduct large, multisite research studies, which
were becoming standard in other areas of medicine, because researchers had
no common measures they could use. In addition, third party private and
public insurance were coming to pay for most mental health therapy: these
organizations would only pay for the treatment of some clearly defined
mental illness. Finally, the Food and Drug Administration began to enforce
its regulations that required drugs only be used to treat distinct illnesses
rather than general problems of living. It was clear that psychiatry needed to
develop new diagnostic criteria that would draw clear lines between what
was mental illness and what was not.
The major source of the diagnostic criteria that eventually appeared in the
DSM-III in 1980, and that in most respects have remained intact until the
present, was the Feighner Criteria (Feighner et al., 1972). A group of psychiatrists at Washington University, a medically minded outpost of empirical
psychiatry that stood in opposition to the dominant psychodynamic thinking of the time, developed these 14 diagnoses. Unlike the DSM-I and DSM-II,
they defined each condition on the basis of clearly defined criteria based on
the specific symptoms patients presented. In addition, diagnoses were categorical not dimensional – one either had or did not have some mental illness.
The Feighner Criteria also seemed ideal for research purposes because their
symptomatic definitions did not seem to involve discretionary judgments so
that they could be easily measured across different sites and diagnosticians.
Moreover, in contrast to the extant DSM manual, observers didn’t have to
inquire about the causes of symptoms, which the designers of the Feighner
Criteria assumed were not known at the time.
Since 1980, psychiatry has used the Feighner model, which relies on the
presence and severity of symptom clusters, as the major way to separate
disordered from natural emotions. For example, Major Depressive Disorder
(MDD) in the DSM-III (which is virtually identical to the definition in the current DSM-5) required either a depressed mood or loss of interest or pleasure
in usual activities. In addition at least four of the following symptoms must
be present nearly every day for a period of at least 2 weeks: (i) poor appetite
or significant change in weight; (ii) insomnia or hypersomnia; (iii) psychomotor agitation or retardation; (iv) decreased sexual drive; (v) fatigue or loss of

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

energy; (vi) feelings of worthlessness, self-reproach, or excessive or inappropriate guilt; (vii) diminished ability to think or concentrate or indecisiveness
and (viii) recurrent thoughts of death or suicidal ideation or suicide attempt
(APA, 1980, p. 213). The only exception was that recently bereaved people
who met the diagnostic criteria would not receive a MDD diagnosis unless
they had at least one especially severe symptom or their symptoms endured
for a 2 month period. Aside from this bereavement exclusion, everyone who
met the five symptom 2 week criteria would be considered to have major
depression.
The other DSM-III diagnostic criteria sets were formulated in similar ways
(Horwitz, 2002). They required that a certain number of symptoms be present
for some defined period of time (which varied according to the disorder).
Some contained additional criteria such as being “unreasonable” or “excessive.” With the exception of post-traumatic stress disorder and acute stress
disorder, which required some traumatic cause, none of the criteria sets specified the reason why the symptoms developed.
Two major reasons accounted for the DSM-III’s reliance on symptoms
alone as indicators of some mental disorder. First, its developers asserted
that the earlier manuals inappropriately specified what the causes of various
conditions were—for example, the loss of some love object or internal conflict led to depression. Therefore, the manual did not specify the causes of the
conditions it classified. Second, they were concerned that the overly general
definitions of the various conditions in the prior manuals led to an almost
complete lack of reliability among clinicians and researchers. Different
diagnosticians could not agree on what constituted some mental disorder:
for example, what some called “schizophrenia,” others diagnosed as “manic
depression.” It was much easier to generate agreement on what condition
someone had if psychiatrists only had to take symptoms in themselves into
account. Judgments of what were “appropriate” or “inappropriate” contexts
were difficult to make and lowered reliability because different clinicians
would have different opinions about whether or not symptoms were normal
responses to distressing contexts.
Therefore, the manual decided to eliminate contextual qualifiers and to
focus on the presence of enough symptoms themselves as indicative of some
disorder. This helped to increase the reliability of diagnosis but led many
diagnoses to have questionable validity. For example, the DSM criteria for
MDD could not separate people who become depressed after losing their
jobs or marriages from those with genuine depressive illnesses. In the case of
depression this problem was especially acute because symptoms need only
be present for a 2 week period, insuring that transient and stress-related
conditions were not separated from long-standing and recurrent ones that
were not linked to the context in which they arose (Horwitz & Wakefield,

Normal Negative Emotions and Mental Disorders

5

2007). The creation of symptom-based, categorical, and mutually exclusive
diagnoses bolstered the prestige of the psychiatric profession in an historical
context when its legitimacy was in question. It also had severe flaws that only
became apparent in future decades.
AREAS OF CUTTING-EDGE WORK
CONTEXT
The fundamental task of psychiatric diagnosis should be to distinguish
genuine mental dysfunctions from normal, albeit distressing, emotions.
This requires situating symptoms within the context in which they arise.
Many people develop symptoms that resemble those specified in psychiatric
diagnostic criteria sets but that are natural results of stressful situations.
For example, people who have suffered the loss of jobs, romantic partners,
or health often develop symptoms that would meet criteria for MDD.
However, if these symptoms dissipate once the individual finds a new job or
romantic partner, or recovers from their illness, nothing was wrong within
such individuals; they responded appropriately to a distressing situation.
Other symptoms such as the inattention, impulsivity, and distractibility
that might signify attention-deficit/hyperactivity disorder are similar to
ordinary behaviors among many adolescent boys. Even severe symptoms
such as the hallucinations found during psychotic episodes can sometimes
mark intense religious experiences among certain groups. Symptoms, in
themselves, are rarely straightforward indicators of mental disorders in the
absence of considerations of the contexts in which they appear.
The best research in this area uses longitudinal studies to examine how
symptoms that arise after some stressful life event unfold over time. If symptoms that result from, say, unemployment, divorce, or the death of an intimate are no longer present at a future period of measurement, it is likely that
they are natural products of a stressful situation as opposed to a mental disorder. They are likely to dissipate when the situation changes or gradually go
away with the passage of time. In contrast, if they persist for extended periods or feature chronic reoccurrences then they are likely to be signs of a mental disorder. Jerome Wakefield and Mark Schmitz (2012, 2013a, 2013b) have
used several large data sets collected at more than one point in time to answer
this question. Their findings show that people who meet the criteria for major
depression after all kinds of losses have similar recurrence rates (3.4%) at
the second period of measurement as people with no history of depression
(1.7%). Both of these groups have far lower recurrence rates than ones whose
depressive symptoms did not arise after some loss (14.6%). Other studies also

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

indicate that bereaved people were no more likely than the nondepressed to
have subsequent depressive episodes 3 years later (Mojtabai, 2011).
These findings indicate that a fundamental weakness of purely symptombased diagnostic criteria is that they cannot separate people who are responding naturally to stressful environments from ones whose symptoms are not
moored to some situational context. Because this type of measure treats both
types of symptoms as indicative of mental disorder, it overstates the number of presumably mentally ill people. Much of the criticism directed at the
recently issued DSM-5 focused on how symptom-based diagnostic criteria
overpathologize many different conditions (e.g., Frances, 2013). Nevertheless, the DSM-5 actually moved toward an even more exclusive focus on
symptoms alone when it removed the bereavement exclusion from the MDD
criteria. This means that even symptoms that arise after the death of an intimate but are not especially severe and persist for as short as a 2-week period
now meet the MDD criteria. Future research should focus on how to identify
the differences between conditions that both arise and persist within stressful
contexts and those that indicate a true mental disorder.
DIMENSIONALIZATION
The psychodynamic conception that dominated views of anxiety before the
DSM-III considered mental disorders to vary along a dimension of lesser to
greater severity. Mental illness formed a continuum with normal, contextually appropriate conditions on the one end and severe conditions on the
other. One of the major motivators of the DSM-III was to establish the kind
of distinct conditions that prevailed in other medical classifications. Yet, the
sharp cutoffs between normal and disordered conditions the diagnostic criteria imposed had little scientific justification. They seemed both arbitrary
and unable to recognize minor forms of disorder (Kendler & Gardner, 1998).
For example, there was no reason for why diagnoses of generalized anxiety
required at least three symptoms or major depression at least five symptoms:
people with fewer symptoms might have milder disorders, not be nondisordered. Moreover, the DSM’s binary logic conflicted with understandings of
the subtler ways in which biological and genetic variance become manifest.
A dimensional system might better fit the underlying nature of most conditions, which have no sharp cutoff point for where the number of symptoms
distinguishes disorder from nondisorder. One of the major goals of the developers of the DSM-5 was to overcome the either/or logic of the manual that
seemed to hinder etiological discoveries.
The DSM-5 Task Force proposed major alterations that would move the
manual from a categorical toward a more dimensional system. Initially, it
suggested a radical revision that would largely replace the distinct criteria

Normal Negative Emotions and Mental Disorders

7

dividing disorders from nondisorders with measures that reflected graded
scales of severity.
The single most important precondition for moving forward to improve
the clinical and scientific utility of DSM-5 will be the incorporation of simple
dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between
DSM-IV and DSM-5 will be the more prominent use of dimensional measures
in DSM-5 (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 649).
Dimensions, the revisers hoped, would overcome the inability of categorical measures to identify people who show some, but not enough, symptoms
to qualify for a diagnosis. Ironically, dimensional assessment invoked a measurement style of an era that preceded the DSM-III.
The developers of the DSM-5, however, recognized that their initial goal
of establishing a dimensional system of measurement was overly ambitious
and, given the existing knowledge base, premature. One major dilemma was
where to place the lower bound for the presence of a disordered condition. If
the line was drawn too high, diagnoses might miss too many genuinely disordered people. Conversely, if it was set too low an enormous number of false
positive conditions might result. This is what had happened during the 1950s
and 1960s when clinicians and epidemiologists commonly assumed that a
small number of symptoms often indicated a milder form of mental disorder,
not the absence of disorder. The major problem of such studies was that they
uncovered immense rates of assumed mental illness. The best-known survey,
the Midtown Manhattan Study, found that just 18.5% of its community sample was symptom free (Srole et al., 1978). Over 80% of the population, therefore, had some degree of “mental illness”: 36% were in the mild category,
22% were in the moderate category, and 23% fell into the marked, severe,
or incapacitated category. The DSM-5 dimensional criteria, which used such
ubiquitous symptoms as feeling “fearful,” “anxious,” “worried,” and so on,
and which must endure for only a brief period of time (7 days), would likely
produce similarly massive rates of mild “disorders.”
The DSM-5 Task Force eventually abandoned its dimensional proposal.
The reason, however, was not because of fears of considering too many
normal people as having some mental illness. Instead, the divergent needs
of researchers and clinicians led to the rejection of the Task Force proposal.
While researchers were most interested in developing diagnoses that would
improve psychiatry’s knowledge base, clinicians had the more practical
concerns that the criteria be easy to apply and guarantee reimbursement for
treatment. Clinicians worried that dimensions would be burdensome to use
in practice, especially if insurance companies mandated their employment.
An APA Assembly rejected the dimensional proposal, in effect, voting

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

to retain the current categorical diagnoses. A proposal that began as a
radical revision of the basic structure of the DSM ended in an appendix as a
suggestion in need of further study (Wholley & Horwitz, 2013).
Ironically, empirically driven researchers had imposed the categorical system of DSM-III on resistant clinicians. By 2012, however, categorical diagnoses had become millstones for researchers but necessities for clinicians,
who must use them to be paid for treatment. Clinicians obtained a measure
of revenge on researchers by rejecting their appeal to institute a possibly
more valid, but less practically useful, diagnostic system. Social considerations mandated that psychiatry continue to employ a classification whose
scientific inadequacies had become blatantly obvious. Psychiatry’s categorical system that had been in place since 1980 was shaken but not replaced.
UNREASONABLENESS
At present, many of the DSM’s major diagnoses use the unreasonable or irrational qualities of symptoms as indications of a mental disorder. For example,
specific and social phobias (the second and third most commonly occurring
mental illnesses in community populations, following only depression) must
be out of proportion to the actual danger or threat posed by specific objects or
situations (APA, 2013, p. 197, 203). The problem is that much human behavior does not seem to be designed to be reasonable and/or rational. Indeed, a
major thrust in current psychological research is to show how automatic and
unconscious emotional responses typically precede conscious judgments and
reasoning about some situation (e.g., Haidt, 2012; Kahneman, 2011).
It is instructive to examine what kinds of things people are afraid of. Those
with simple phobias are afraid of animals (22.2%); heights (20.4); blood (13.9);
flying (13.2); closed spaces (11.9); water (9.4); storms (8.7); being alone (7.3).
The most common forms of social anxiety are public speaking (21.2%); speaking up in a meeting (19.5); and meeting new people (16.8). These figures
indicate that many people fear things and situations that are not, in fact, likely
to harm them and so might seem unreasonable and irrational (Curtis, Magee,
Eaton, Wittchen, & Kessler, 1998; Ruscio et al., 2008).
Yet, the statistically most common anxiety disorders might result from
dangers that were appropriate in the ancient environments when the human
genome formed (Horwitz & Wakefield, 2012). The most pressing dangers
in ancient environments stemmed from carnivores for which humans were
a tasty source of calories; the most ancient human remains from millions of
years ago show that many people were killed by carnivorous saber-toothed
cats and giant cheetahs. Alternatively, falling from a high place posed a
real threat of serious injury or death at a time when no protective measures
existed. Other specific fears of blood, water, closed spaces, and storms

Normal Negative Emotions and Mental Disorders

9

could also be genuine sources or signals of ancestral dangers. Blood, for
example, might suggest the close proximity of enemies. Even air travel,
which obviously didn’t exist when the human genome was being formed,
seems to blend several aspects of biologically shaped fears. It combines fear
of being at extreme heights where falling could mean death with fear of
entering enclosed spaces where escape is impossible. Such fears could have
been useful in ancient periods because they led people to avoid genuinely
dangerous situations. Fears that might not correspond to actual dangers
in present situations seem understandable as reactions that came down to
us as part of our biological inheritance of fears that did make sense in the
prehistoric past.
Likewise, in the distant past, people lived in small bands of one or two hundred people, all of whom were well known to one another. Disapproval or
rejection within such groups could be highly consequential for survival and
incurring the negative evaluations of others carried real risks. A person who
was not part of a collectivity would not have been able to survive if cut adrift
from the group. Fears of ostracism were natural and adaptive when people
depended on tightly connected and long-term ties and where their social
status depended on their position in a group. Unsurprisingly, high anxiety
about social evaluation and potential rejection became a common part of our
nature and remains so even though such anxiety is no longer as contextually suited to modern societies, where individuals often have many alternate
social options if they are rejected or fail an evaluation.
The problems that many specific and social fears entail stems from the fact
that normal genes no longer fit the environment where they must function,
not in any genetic or psychological dysfunction within individuals. An analogy might be the persistence of our craving for highly caloric foods, which
was useful in prehistoric environments where calories were hard to come
by but which now is a source of obesity and disease in environments where
calories are readily available. Such mismatches between what is evolutionarily natural and what is socially reasonable raise fundamental questions about
what is normal and what is not. Future research needs to identify the extent
to many common forms of mental illnesses actually reflect the operation of
natural genetic propensities that might be unreasonable but not disordered.
KEY ISSUES GOING FORWARD
One major issue that future research must address involves how to integrate findings from neurological studies into diagnostic criteria. The principle established in 1980 that the DSM diagnostic criteria sets should not
encompass causal inferences has meant that the manual does not incorporate the biological perspective that otherwise dominates current psychiatric

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

research and treatment. This deficiency is so glaring that the National Institute of Mental Health, the major federal agency concerned with research
about mental illness, is developing an alternative manual to the DSM, the
Research Domain Criteria (Insel, 2009). This manual will attempt to use brain
circuitry and genetic findings as the basis for a new diagnostic system that
might supplement or even replace the DSM. The problem the creators of this
manual will face is how to distinguish disordered genes, molecules, cells,
and so on in the absence of good diagnostic criteria that can separate the
neurological basis of natural negative emotions from dysfunctions.
A second endeavor regards the search for valid, as opposed to merely reliable, criteria to define mental disorders. As noted, unlike other medical disciplines, psychiatry currently lacks any biological markers for the conditions
it studies. A successful demonstration that various brain-related indicators
are associated with different kinds of mental illnesses will not only enhance
the potential to identify, treat, and prevent various conditions but also show
the extent to which current diagnoses mislabel the conditions they strive to
identify.
Another issue going forward will be how to develop appropriate definitions of normal, negative emotions and mental disorders that balance the
risks of false negatives and false positives. To date, psychiatry has emphasized avoiding false negatives—considering people who are actually sick as
if they are well. Many critics claim that this practice has resulted in unnecessary treatment, overmedication, and stigma (e.g., Frances, 2013). However, if
diagnostic criteria are too stringent they can prevent people who might benefit from treatment from getting it. Drawing appropriate lines among normally
distressing symptoms, evolutionarily mismatched emotions, and mental disorders will be a highly challenging endeavor. This task will be especially
difficult because the symptom-based categories of the extant diagnostic manual provide such an inadequate roadmap for guiding future research.
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Normal Negative Emotions and Mental Disorders

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Wakefield, J. C., & Schmitz, M. F. (2013a). When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major
depression diagnostic thresholds. World Psychiatry, 12, 44–52.
Wakefield, J. C., & Schmitz, M. F. (2013b). Can the DSM’s major depression bereavement exclusion be validly extended to other stressors? Evidence from the NCS.
Acta Psychiatrica Scandinavica. http://dx.doi.org. 10.1111acps.12064

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Wholley, O., & Horwitz, A. V. (2013). The paradox of professional success: Grand
ambition, furious resistance, and the derailment of the DSM-5 revision process.
In J. Paris & J. Phillips (Eds.), Making the DSM-5: Concepts and Controversies
(pp. 75–92). New York, NY: Springer.

FURTHER READING
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric
diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York, NY:
William Morrow.
Horwitz, A. V. (2002). Creating mental illness. Chicago, IL: University of Chicago Press.
Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed
normal sadness into depressive disorder. New York, NY: Oxford University Press.
Horwitz, A. V., & Wakefield, J. C. (2012). All we have to fear: Psychiatry’s transformation
of natural anxiety into mental disorder. New York, NY: Oxford University Press.
Paris, J., & Phillips, J. (Eds.) (2013). Making the DSM-5: Concepts and Controversies (pp.
75–92). New York, NY: Springer.
Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between
biological facts and social values. American Psychologist, 47, 373–388.

ALLAN V. HORWITZ SHORT BIOGRAPHY
Allan V. Horwitz is Board of Governors Professor in the Department of
Sociology and Institute for Health, Health Care Policy, and Aging Research
at Rutgers. He has published over 100 articles and chapters about various
aspects of mental health and illness. In addition, he has published seven
books including The Loss of Sadness: How Psychiatry Transformed Normal
Misery into Depressive Disorder (Oxford University Press 2007), All We
Have to Fear: Psychiatry’s Transformation of Natural Anxiety into Mental
Disorder (Oxford University Press 2012), and Anxiety: A Short History
(Johns Hopkins University Press 2013). He is currently Interim Director of
the Institute for Health, Health Care Policy, and Aging Research at Rutgers
University.
RELATED ESSAYS
What Is Neuroticism and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom

Normal Negative Emotions and Mental Disorders

13

Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),
Patrick S. Forscher and Patricia G. Devine
State of the Art in Competition Research (Psychology), Márta Fülöp and
Gábor Orosz
Emerging Evidence of Addiction in Problematic Eating Behavior (Psychology), Ashley Gearhardt et al.
Ambivalence and Inbetweeness (Sociology), Bernhard Giesen
Positive Emotion Disturbance (Psychology), June Gruber and John Purcell
Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison
G. Harvey
Mental Imagery in Psychological Disorders (Psychology), Emily A. Holmes
et al.
Dissociation and Dissociative Identity Disorder (DID) (Psychology), Rafaële
J. C. Huntjens and Martin J. Dorahy
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks
Disorders of Consciousness (Psychology), Martin M. Monti
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takauni Suzuki and Douglas B. Samuel
Taking Personality to the Next Level: What Does It Mean to Know a Person?
(Psychology), Simine Vazire and Robert Wilson
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Crime and the Life Course (Sociology), Mark Warr and Carmen Gutierrez
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.



Normal Negative Emotions
and Mental Disorders
ALLAN V. HORWITZ

Abstract
The basic goal of psychiatric diagnosis is to distinguish genuine mental dysfunctions
from normal, albeit distressing, emotions. This task is especially difficult because,
unlike other medical specialties, psychiatry does not have biological markers that
can validate diagnoses of mental disorders. Therefore, diagnostic criteria have an
outsized role in psychiatry compared to other medical fields. Until the development
of the DSM-III in 1980, psychiatric diagnoses were general, continuous, and causal.
In contrast, the diagnostic system that emerged in the DSM-III and that has remained
basically intact until the present has been specific, categorical, and a causal. This type
of classification, however, is prone to mistake contextually appropriate symptoms
as indicators of mental disorders. Cutting-edge research incorporates the context in
which symptoms emerge and persist to separate normal, distressing emotions from
mental illnesses. It also develops alternatives to the DSM’s categorical diagnoses.
Other valuable studies try to differentiate conditions that stem from evolutionarily
normal genes that no longer fit modern environments rather than from genetic
or psychological dysfunctions within individuals. Going forward, research must
attempt to use biological, psychological, and social factors to develop definitions that
adequately distinguish normal responses to stressful environments, evolutionary
mismatches, and mental disorders. It will also try to find biomarkers that can set
appropriate boundaries between natural and pathological conditions. Finally, it will
consider the best ways to optimize the balance between under- and over-diagnosing
mental illnesses.

The central goal of psychiatric diagnosis is to distinguish mental disorders
from normal, but distressing, conditions. This task is especially difficult
because, unlike other medical specialties, psychiatry does not possess any
biological markers that can validate diagnoses of mental disorders. Unlike,
say, oncologists who use biopsies to validate a diagnosis of cancer, nephrologists who take X-rays to see the presence of a kidney stone, or cardiologists
who employ PET scans to see if a heart has tissue damage, diagnostic criteria
are the only resources that psychiatrists possess to support their judgments.
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Therefore, these criteria have an outsized role in psychiatry compared to
other medical fields.
The lack of any objective measures that could validate psychiatric diagnoses is particularly consequential because many common mental disorders
such as depression and anxiety are symptomatically similar to normal, distressing emotions. While many psychiatrists are increasingly coming to recognize the inadequacies of its existing diagnostic system, the field has yet to
develop a knowledge base that will allow it to overcome this problem. The
most important future breakthroughs will occur when psychiatry comes to
possess markers that can reliably distinguish disordered people from those
who are distressed.
FOUNDATIONAL RESEARCH
Until fairly recently, psychiatrists and other mental health professionals
had little need to separate distressing emotions such as depression and
anxiety from mental disorders. Before the mid-twentieth century, diagnostic
systems focused on classifying seriously mentally ill people who were
housed in inpatient mental institutions. This population usually had severe
and unusual symptoms that distinguished them from others. Once the
mental health system turned from focusing on institutionalized patients
toward treating less ill patients in outpatient settings, diagnostic criteria had
to pay attention to a much broader range of conditions. The initial classification manuals of the American Psychiatric Association, the DSM-I (1952)
and DSM-II (1968) focused on what were then called “psychoneurotic”
conditions.
Nevertheless, clinicians in the post-World War II period did not require a
fine-tuned diagnostic system. For one thing, the dominant psychodynamic
theory at the time stressed the continuity, rather than the separation, of normal and mentally ill populations: most normal people had some degree of
neurosis while most neurotics shared most features with the normal. That is,
mental illness and normality were not distinct categories but different points
on a continuum (Grob, 1991). In addition, because most outpatients at the
time paid for their own treatment, no third party insurers—who would not
pay for treatment unless the patient had some diagnosable disease—were
involved in decision-making. Likewise, commercial interests such as drug
companies were able to advertise their products more for the relief of general stress conditions than as treatments for specific types of mental illnesses.
Thus, no professional, social, or economic pressures existed during the 1950s
and 1960s that pushed psychiatrists to develop a diagnostic system that created distinct lines between normal and abnormal mental conditions.

Normal Negative Emotions and Mental Disorders

3

This situation had dramatically changed by the 1970s (Horwitz, 2002).
The casual approach to diagnosis found in the DSM-I and DSM-II became
a professional liability. For one thing, psychiatry’s medical credentials
were questioned because the field was seen as dealing with general psychosocial problems and not legitimate diseases. There was nothing that
psychiatrists were doing that other mental health professionals such as
clinical psychologists, psychiatric social workers, nurses, and counselors
could not do. For another, the absence of clear diagnostic criteria meant
that psychiatrists could not conduct large, multisite research studies, which
were becoming standard in other areas of medicine, because researchers had
no common measures they could use. In addition, third party private and
public insurance were coming to pay for most mental health therapy: these
organizations would only pay for the treatment of some clearly defined
mental illness. Finally, the Food and Drug Administration began to enforce
its regulations that required drugs only be used to treat distinct illnesses
rather than general problems of living. It was clear that psychiatry needed to
develop new diagnostic criteria that would draw clear lines between what
was mental illness and what was not.
The major source of the diagnostic criteria that eventually appeared in the
DSM-III in 1980, and that in most respects have remained intact until the
present, was the Feighner Criteria (Feighner et al., 1972). A group of psychiatrists at Washington University, a medically minded outpost of empirical
psychiatry that stood in opposition to the dominant psychodynamic thinking of the time, developed these 14 diagnoses. Unlike the DSM-I and DSM-II,
they defined each condition on the basis of clearly defined criteria based on
the specific symptoms patients presented. In addition, diagnoses were categorical not dimensional – one either had or did not have some mental illness.
The Feighner Criteria also seemed ideal for research purposes because their
symptomatic definitions did not seem to involve discretionary judgments so
that they could be easily measured across different sites and diagnosticians.
Moreover, in contrast to the extant DSM manual, observers didn’t have to
inquire about the causes of symptoms, which the designers of the Feighner
Criteria assumed were not known at the time.
Since 1980, psychiatry has used the Feighner model, which relies on the
presence and severity of symptom clusters, as the major way to separate
disordered from natural emotions. For example, Major Depressive Disorder
(MDD) in the DSM-III (which is virtually identical to the definition in the current DSM-5) required either a depressed mood or loss of interest or pleasure
in usual activities. In addition at least four of the following symptoms must
be present nearly every day for a period of at least 2 weeks: (i) poor appetite
or significant change in weight; (ii) insomnia or hypersomnia; (iii) psychomotor agitation or retardation; (iv) decreased sexual drive; (v) fatigue or loss of

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

energy; (vi) feelings of worthlessness, self-reproach, or excessive or inappropriate guilt; (vii) diminished ability to think or concentrate or indecisiveness
and (viii) recurrent thoughts of death or suicidal ideation or suicide attempt
(APA, 1980, p. 213). The only exception was that recently bereaved people
who met the diagnostic criteria would not receive a MDD diagnosis unless
they had at least one especially severe symptom or their symptoms endured
for a 2 month period. Aside from this bereavement exclusion, everyone who
met the five symptom 2 week criteria would be considered to have major
depression.
The other DSM-III diagnostic criteria sets were formulated in similar ways
(Horwitz, 2002). They required that a certain number of symptoms be present
for some defined period of time (which varied according to the disorder).
Some contained additional criteria such as being “unreasonable” or “excessive.” With the exception of post-traumatic stress disorder and acute stress
disorder, which required some traumatic cause, none of the criteria sets specified the reason why the symptoms developed.
Two major reasons accounted for the DSM-III’s reliance on symptoms
alone as indicators of some mental disorder. First, its developers asserted
that the earlier manuals inappropriately specified what the causes of various
conditions were—for example, the loss of some love object or internal conflict led to depression. Therefore, the manual did not specify the causes of the
conditions it classified. Second, they were concerned that the overly general
definitions of the various conditions in the prior manuals led to an almost
complete lack of reliability among clinicians and researchers. Different
diagnosticians could not agree on what constituted some mental disorder:
for example, what some called “schizophrenia,” others diagnosed as “manic
depression.” It was much easier to generate agreement on what condition
someone had if psychiatrists only had to take symptoms in themselves into
account. Judgments of what were “appropriate” or “inappropriate” contexts
were difficult to make and lowered reliability because different clinicians
would have different opinions about whether or not symptoms were normal
responses to distressing contexts.
Therefore, the manual decided to eliminate contextual qualifiers and to
focus on the presence of enough symptoms themselves as indicative of some
disorder. This helped to increase the reliability of diagnosis but led many
diagnoses to have questionable validity. For example, the DSM criteria for
MDD could not separate people who become depressed after losing their
jobs or marriages from those with genuine depressive illnesses. In the case of
depression this problem was especially acute because symptoms need only
be present for a 2 week period, insuring that transient and stress-related
conditions were not separated from long-standing and recurrent ones that
were not linked to the context in which they arose (Horwitz & Wakefield,

Normal Negative Emotions and Mental Disorders

5

2007). The creation of symptom-based, categorical, and mutually exclusive
diagnoses bolstered the prestige of the psychiatric profession in an historical
context when its legitimacy was in question. It also had severe flaws that only
became apparent in future decades.
AREAS OF CUTTING-EDGE WORK
CONTEXT
The fundamental task of psychiatric diagnosis should be to distinguish
genuine mental dysfunctions from normal, albeit distressing, emotions.
This requires situating symptoms within the context in which they arise.
Many people develop symptoms that resemble those specified in psychiatric
diagnostic criteria sets but that are natural results of stressful situations.
For example, people who have suffered the loss of jobs, romantic partners,
or health often develop symptoms that would meet criteria for MDD.
However, if these symptoms dissipate once the individual finds a new job or
romantic partner, or recovers from their illness, nothing was wrong within
such individuals; they responded appropriately to a distressing situation.
Other symptoms such as the inattention, impulsivity, and distractibility
that might signify attention-deficit/hyperactivity disorder are similar to
ordinary behaviors among many adolescent boys. Even severe symptoms
such as the hallucinations found during psychotic episodes can sometimes
mark intense religious experiences among certain groups. Symptoms, in
themselves, are rarely straightforward indicators of mental disorders in the
absence of considerations of the contexts in which they appear.
The best research in this area uses longitudinal studies to examine how
symptoms that arise after some stressful life event unfold over time. If symptoms that result from, say, unemployment, divorce, or the death of an intimate are no longer present at a future period of measurement, it is likely that
they are natural products of a stressful situation as opposed to a mental disorder. They are likely to dissipate when the situation changes or gradually go
away with the passage of time. In contrast, if they persist for extended periods or feature chronic reoccurrences then they are likely to be signs of a mental disorder. Jerome Wakefield and Mark Schmitz (2012, 2013a, 2013b) have
used several large data sets collected at more than one point in time to answer
this question. Their findings show that people who meet the criteria for major
depression after all kinds of losses have similar recurrence rates (3.4%) at
the second period of measurement as people with no history of depression
(1.7%). Both of these groups have far lower recurrence rates than ones whose
depressive symptoms did not arise after some loss (14.6%). Other studies also

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

indicate that bereaved people were no more likely than the nondepressed to
have subsequent depressive episodes 3 years later (Mojtabai, 2011).
These findings indicate that a fundamental weakness of purely symptombased diagnostic criteria is that they cannot separate people who are responding naturally to stressful environments from ones whose symptoms are not
moored to some situational context. Because this type of measure treats both
types of symptoms as indicative of mental disorder, it overstates the number of presumably mentally ill people. Much of the criticism directed at the
recently issued DSM-5 focused on how symptom-based diagnostic criteria
overpathologize many different conditions (e.g., Frances, 2013). Nevertheless, the DSM-5 actually moved toward an even more exclusive focus on
symptoms alone when it removed the bereavement exclusion from the MDD
criteria. This means that even symptoms that arise after the death of an intimate but are not especially severe and persist for as short as a 2-week period
now meet the MDD criteria. Future research should focus on how to identify
the differences between conditions that both arise and persist within stressful
contexts and those that indicate a true mental disorder.
DIMENSIONALIZATION
The psychodynamic conception that dominated views of anxiety before the
DSM-III considered mental disorders to vary along a dimension of lesser to
greater severity. Mental illness formed a continuum with normal, contextually appropriate conditions on the one end and severe conditions on the
other. One of the major motivators of the DSM-III was to establish the kind
of distinct conditions that prevailed in other medical classifications. Yet, the
sharp cutoffs between normal and disordered conditions the diagnostic criteria imposed had little scientific justification. They seemed both arbitrary
and unable to recognize minor forms of disorder (Kendler & Gardner, 1998).
For example, there was no reason for why diagnoses of generalized anxiety
required at least three symptoms or major depression at least five symptoms:
people with fewer symptoms might have milder disorders, not be nondisordered. Moreover, the DSM’s binary logic conflicted with understandings of
the subtler ways in which biological and genetic variance become manifest.
A dimensional system might better fit the underlying nature of most conditions, which have no sharp cutoff point for where the number of symptoms
distinguishes disorder from nondisorder. One of the major goals of the developers of the DSM-5 was to overcome the either/or logic of the manual that
seemed to hinder etiological discoveries.
The DSM-5 Task Force proposed major alterations that would move the
manual from a categorical toward a more dimensional system. Initially, it
suggested a radical revision that would largely replace the distinct criteria

Normal Negative Emotions and Mental Disorders

7

dividing disorders from nondisorders with measures that reflected graded
scales of severity.
The single most important precondition for moving forward to improve
the clinical and scientific utility of DSM-5 will be the incorporation of simple
dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between
DSM-IV and DSM-5 will be the more prominent use of dimensional measures
in DSM-5 (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 649).
Dimensions, the revisers hoped, would overcome the inability of categorical measures to identify people who show some, but not enough, symptoms
to qualify for a diagnosis. Ironically, dimensional assessment invoked a measurement style of an era that preceded the DSM-III.
The developers of the DSM-5, however, recognized that their initial goal
of establishing a dimensional system of measurement was overly ambitious
and, given the existing knowledge base, premature. One major dilemma was
where to place the lower bound for the presence of a disordered condition. If
the line was drawn too high, diagnoses might miss too many genuinely disordered people. Conversely, if it was set too low an enormous number of false
positive conditions might result. This is what had happened during the 1950s
and 1960s when clinicians and epidemiologists commonly assumed that a
small number of symptoms often indicated a milder form of mental disorder,
not the absence of disorder. The major problem of such studies was that they
uncovered immense rates of assumed mental illness. The best-known survey,
the Midtown Manhattan Study, found that just 18.5% of its community sample was symptom free (Srole et al., 1978). Over 80% of the population, therefore, had some degree of “mental illness”: 36% were in the mild category,
22% were in the moderate category, and 23% fell into the marked, severe,
or incapacitated category. The DSM-5 dimensional criteria, which used such
ubiquitous symptoms as feeling “fearful,” “anxious,” “worried,” and so on,
and which must endure for only a brief period of time (7 days), would likely
produce similarly massive rates of mild “disorders.”
The DSM-5 Task Force eventually abandoned its dimensional proposal.
The reason, however, was not because of fears of considering too many
normal people as having some mental illness. Instead, the divergent needs
of researchers and clinicians led to the rejection of the Task Force proposal.
While researchers were most interested in developing diagnoses that would
improve psychiatry’s knowledge base, clinicians had the more practical
concerns that the criteria be easy to apply and guarantee reimbursement for
treatment. Clinicians worried that dimensions would be burdensome to use
in practice, especially if insurance companies mandated their employment.
An APA Assembly rejected the dimensional proposal, in effect, voting

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

to retain the current categorical diagnoses. A proposal that began as a
radical revision of the basic structure of the DSM ended in an appendix as a
suggestion in need of further study (Wholley & Horwitz, 2013).
Ironically, empirically driven researchers had imposed the categorical system of DSM-III on resistant clinicians. By 2012, however, categorical diagnoses had become millstones for researchers but necessities for clinicians,
who must use them to be paid for treatment. Clinicians obtained a measure
of revenge on researchers by rejecting their appeal to institute a possibly
more valid, but less practically useful, diagnostic system. Social considerations mandated that psychiatry continue to employ a classification whose
scientific inadequacies had become blatantly obvious. Psychiatry’s categorical system that had been in place since 1980 was shaken but not replaced.
UNREASONABLENESS
At present, many of the DSM’s major diagnoses use the unreasonable or irrational qualities of symptoms as indications of a mental disorder. For example,
specific and social phobias (the second and third most commonly occurring
mental illnesses in community populations, following only depression) must
be out of proportion to the actual danger or threat posed by specific objects or
situations (APA, 2013, p. 197, 203). The problem is that much human behavior does not seem to be designed to be reasonable and/or rational. Indeed, a
major thrust in current psychological research is to show how automatic and
unconscious emotional responses typically precede conscious judgments and
reasoning about some situation (e.g., Haidt, 2012; Kahneman, 2011).
It is instructive to examine what kinds of things people are afraid of. Those
with simple phobias are afraid of animals (22.2%); heights (20.4); blood (13.9);
flying (13.2); closed spaces (11.9); water (9.4); storms (8.7); being alone (7.3).
The most common forms of social anxiety are public speaking (21.2%); speaking up in a meeting (19.5); and meeting new people (16.8). These figures
indicate that many people fear things and situations that are not, in fact, likely
to harm them and so might seem unreasonable and irrational (Curtis, Magee,
Eaton, Wittchen, & Kessler, 1998; Ruscio et al., 2008).
Yet, the statistically most common anxiety disorders might result from
dangers that were appropriate in the ancient environments when the human
genome formed (Horwitz & Wakefield, 2012). The most pressing dangers
in ancient environments stemmed from carnivores for which humans were
a tasty source of calories; the most ancient human remains from millions of
years ago show that many people were killed by carnivorous saber-toothed
cats and giant cheetahs. Alternatively, falling from a high place posed a
real threat of serious injury or death at a time when no protective measures
existed. Other specific fears of blood, water, closed spaces, and storms

Normal Negative Emotions and Mental Disorders

9

could also be genuine sources or signals of ancestral dangers. Blood, for
example, might suggest the close proximity of enemies. Even air travel,
which obviously didn’t exist when the human genome was being formed,
seems to blend several aspects of biologically shaped fears. It combines fear
of being at extreme heights where falling could mean death with fear of
entering enclosed spaces where escape is impossible. Such fears could have
been useful in ancient periods because they led people to avoid genuinely
dangerous situations. Fears that might not correspond to actual dangers
in present situations seem understandable as reactions that came down to
us as part of our biological inheritance of fears that did make sense in the
prehistoric past.
Likewise, in the distant past, people lived in small bands of one or two hundred people, all of whom were well known to one another. Disapproval or
rejection within such groups could be highly consequential for survival and
incurring the negative evaluations of others carried real risks. A person who
was not part of a collectivity would not have been able to survive if cut adrift
from the group. Fears of ostracism were natural and adaptive when people
depended on tightly connected and long-term ties and where their social
status depended on their position in a group. Unsurprisingly, high anxiety
about social evaluation and potential rejection became a common part of our
nature and remains so even though such anxiety is no longer as contextually suited to modern societies, where individuals often have many alternate
social options if they are rejected or fail an evaluation.
The problems that many specific and social fears entail stems from the fact
that normal genes no longer fit the environment where they must function,
not in any genetic or psychological dysfunction within individuals. An analogy might be the persistence of our craving for highly caloric foods, which
was useful in prehistoric environments where calories were hard to come
by but which now is a source of obesity and disease in environments where
calories are readily available. Such mismatches between what is evolutionarily natural and what is socially reasonable raise fundamental questions about
what is normal and what is not. Future research needs to identify the extent
to many common forms of mental illnesses actually reflect the operation of
natural genetic propensities that might be unreasonable but not disordered.
KEY ISSUES GOING FORWARD
One major issue that future research must address involves how to integrate findings from neurological studies into diagnostic criteria. The principle established in 1980 that the DSM diagnostic criteria sets should not
encompass causal inferences has meant that the manual does not incorporate the biological perspective that otherwise dominates current psychiatric

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

research and treatment. This deficiency is so glaring that the National Institute of Mental Health, the major federal agency concerned with research
about mental illness, is developing an alternative manual to the DSM, the
Research Domain Criteria (Insel, 2009). This manual will attempt to use brain
circuitry and genetic findings as the basis for a new diagnostic system that
might supplement or even replace the DSM. The problem the creators of this
manual will face is how to distinguish disordered genes, molecules, cells,
and so on in the absence of good diagnostic criteria that can separate the
neurological basis of natural negative emotions from dysfunctions.
A second endeavor regards the search for valid, as opposed to merely reliable, criteria to define mental disorders. As noted, unlike other medical disciplines, psychiatry currently lacks any biological markers for the conditions
it studies. A successful demonstration that various brain-related indicators
are associated with different kinds of mental illnesses will not only enhance
the potential to identify, treat, and prevent various conditions but also show
the extent to which current diagnoses mislabel the conditions they strive to
identify.
Another issue going forward will be how to develop appropriate definitions of normal, negative emotions and mental disorders that balance the
risks of false negatives and false positives. To date, psychiatry has emphasized avoiding false negatives—considering people who are actually sick as
if they are well. Many critics claim that this practice has resulted in unnecessary treatment, overmedication, and stigma (e.g., Frances, 2013). However, if
diagnostic criteria are too stringent they can prevent people who might benefit from treatment from getting it. Drawing appropriate lines among normally
distressing symptoms, evolutionarily mismatched emotions, and mental disorders will be a highly challenging endeavor. This task will be especially
difficult because the symptom-based categories of the extant diagnostic manual provide such an inadequate roadmap for guiding future research.
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Normal Negative Emotions and Mental Disorders

11

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Giroux.
Kendler, K. S., & Gardner, C. O. (1998). Boundaries of major depression: An evaluation of DSM-IV criteria. American Journal of Psychiatry, 155, 172–177.
Mojtabai, R. (2011). Bereavement-related depressive episodes: Characteristics, 3-year
course, and implications for DSM-5. Archives of General Psychiatry, 68, 920–928.
Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2009). The conceptual
development of DSM-V. American Journal of Psychiatry, 166, 645–650.
Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., & Kessler, R. C. (2008).
Social fears and social phobia in the USA: Results from the national comorbidity
survey replication. Psychological Medicine, 38, 15–28.
Srole, L., Langner, T. S., Michael, S. T., Kirkpatrick, P., Opler, M. K., & Rennie, T. A. C.
(1978). Mental health in the metropolis: The Midtown Manhattan study (Rev., enlarged
edn.). New York: McGraw Hill (Original work published 1962).
Wakefield, J. C., & Schmitz, M. F. (2012). Recurrence of depression after bereavementrelated depression: Evidence for the validity of DSM-IV bereavement exclusion
from the epidemiologic catchment area study. The Journal of Nervous and Mental
Disease, 200, 480–485.
Wakefield, J. C., & Schmitz, M. F. (2013a). When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major
depression diagnostic thresholds. World Psychiatry, 12, 44–52.
Wakefield, J. C., & Schmitz, M. F. (2013b). Can the DSM’s major depression bereavement exclusion be validly extended to other stressors? Evidence from the NCS.
Acta Psychiatrica Scandinavica. http://dx.doi.org. 10.1111acps.12064

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Wholley, O., & Horwitz, A. V. (2013). The paradox of professional success: Grand
ambition, furious resistance, and the derailment of the DSM-5 revision process.
In J. Paris & J. Phillips (Eds.), Making the DSM-5: Concepts and Controversies
(pp. 75–92). New York, NY: Springer.

FURTHER READING
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric
diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York, NY:
William Morrow.
Horwitz, A. V. (2002). Creating mental illness. Chicago, IL: University of Chicago Press.
Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed
normal sadness into depressive disorder. New York, NY: Oxford University Press.
Horwitz, A. V., & Wakefield, J. C. (2012). All we have to fear: Psychiatry’s transformation
of natural anxiety into mental disorder. New York, NY: Oxford University Press.
Paris, J., & Phillips, J. (Eds.) (2013). Making the DSM-5: Concepts and Controversies (pp.
75–92). New York, NY: Springer.
Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between
biological facts and social values. American Psychologist, 47, 373–388.

ALLAN V. HORWITZ SHORT BIOGRAPHY
Allan V. Horwitz is Board of Governors Professor in the Department of
Sociology and Institute for Health, Health Care Policy, and Aging Research
at Rutgers. He has published over 100 articles and chapters about various
aspects of mental health and illness. In addition, he has published seven
books including The Loss of Sadness: How Psychiatry Transformed Normal
Misery into Depressive Disorder (Oxford University Press 2007), All We
Have to Fear: Psychiatry’s Transformation of Natural Anxiety into Mental
Disorder (Oxford University Press 2012), and Anxiety: A Short History
(Johns Hopkins University Press 2013). He is currently Interim Director of
the Institute for Health, Health Care Policy, and Aging Research at Rutgers
University.
RELATED ESSAYS
What Is Neuroticism and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom

Normal Negative Emotions and Mental Disorders

13

Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),
Patrick S. Forscher and Patricia G. Devine
State of the Art in Competition Research (Psychology), Márta Fülöp and
Gábor Orosz
Emerging Evidence of Addiction in Problematic Eating Behavior (Psychology), Ashley Gearhardt et al.
Ambivalence and Inbetweeness (Sociology), Bernhard Giesen
Positive Emotion Disturbance (Psychology), June Gruber and John Purcell
Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison
G. Harvey
Mental Imagery in Psychological Disorders (Psychology), Emily A. Holmes
et al.
Dissociation and Dissociative Identity Disorder (DID) (Psychology), Rafaële
J. C. Huntjens and Martin J. Dorahy
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks
Disorders of Consciousness (Psychology), Martin M. Monti
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takauni Suzuki and Douglas B. Samuel
Taking Personality to the Next Level: What Does It Mean to Know a Person?
(Psychology), Simine Vazire and Robert Wilson
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Crime and the Life Course (Sociology), Mark Warr and Carmen Gutierrez
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.


Normal Negative Emotions
and Mental Disorders
ALLAN V. HORWITZ

Abstract
The basic goal of psychiatric diagnosis is to distinguish genuine mental dysfunctions
from normal, albeit distressing, emotions. This task is especially difficult because,
unlike other medical specialties, psychiatry does not have biological markers that
can validate diagnoses of mental disorders. Therefore, diagnostic criteria have an
outsized role in psychiatry compared to other medical fields. Until the development
of the DSM-III in 1980, psychiatric diagnoses were general, continuous, and causal.
In contrast, the diagnostic system that emerged in the DSM-III and that has remained
basically intact until the present has been specific, categorical, and a causal. This type
of classification, however, is prone to mistake contextually appropriate symptoms
as indicators of mental disorders. Cutting-edge research incorporates the context in
which symptoms emerge and persist to separate normal, distressing emotions from
mental illnesses. It also develops alternatives to the DSM’s categorical diagnoses.
Other valuable studies try to differentiate conditions that stem from evolutionarily
normal genes that no longer fit modern environments rather than from genetic
or psychological dysfunctions within individuals. Going forward, research must
attempt to use biological, psychological, and social factors to develop definitions that
adequately distinguish normal responses to stressful environments, evolutionary
mismatches, and mental disorders. It will also try to find biomarkers that can set
appropriate boundaries between natural and pathological conditions. Finally, it will
consider the best ways to optimize the balance between under- and over-diagnosing
mental illnesses.

The central goal of psychiatric diagnosis is to distinguish mental disorders
from normal, but distressing, conditions. This task is especially difficult
because, unlike other medical specialties, psychiatry does not possess any
biological markers that can validate diagnoses of mental disorders. Unlike,
say, oncologists who use biopsies to validate a diagnosis of cancer, nephrologists who take X-rays to see the presence of a kidney stone, or cardiologists
who employ PET scans to see if a heart has tissue damage, diagnostic criteria
are the only resources that psychiatrists possess to support their judgments.
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Therefore, these criteria have an outsized role in psychiatry compared to
other medical fields.
The lack of any objective measures that could validate psychiatric diagnoses is particularly consequential because many common mental disorders
such as depression and anxiety are symptomatically similar to normal, distressing emotions. While many psychiatrists are increasingly coming to recognize the inadequacies of its existing diagnostic system, the field has yet to
develop a knowledge base that will allow it to overcome this problem. The
most important future breakthroughs will occur when psychiatry comes to
possess markers that can reliably distinguish disordered people from those
who are distressed.
FOUNDATIONAL RESEARCH
Until fairly recently, psychiatrists and other mental health professionals
had little need to separate distressing emotions such as depression and
anxiety from mental disorders. Before the mid-twentieth century, diagnostic
systems focused on classifying seriously mentally ill people who were
housed in inpatient mental institutions. This population usually had severe
and unusual symptoms that distinguished them from others. Once the
mental health system turned from focusing on institutionalized patients
toward treating less ill patients in outpatient settings, diagnostic criteria had
to pay attention to a much broader range of conditions. The initial classification manuals of the American Psychiatric Association, the DSM-I (1952)
and DSM-II (1968) focused on what were then called “psychoneurotic”
conditions.
Nevertheless, clinicians in the post-World War II period did not require a
fine-tuned diagnostic system. For one thing, the dominant psychodynamic
theory at the time stressed the continuity, rather than the separation, of normal and mentally ill populations: most normal people had some degree of
neurosis while most neurotics shared most features with the normal. That is,
mental illness and normality were not distinct categories but different points
on a continuum (Grob, 1991). In addition, because most outpatients at the
time paid for their own treatment, no third party insurers—who would not
pay for treatment unless the patient had some diagnosable disease—were
involved in decision-making. Likewise, commercial interests such as drug
companies were able to advertise their products more for the relief of general stress conditions than as treatments for specific types of mental illnesses.
Thus, no professional, social, or economic pressures existed during the 1950s
and 1960s that pushed psychiatrists to develop a diagnostic system that created distinct lines between normal and abnormal mental conditions.

Normal Negative Emotions and Mental Disorders

3

This situation had dramatically changed by the 1970s (Horwitz, 2002).
The casual approach to diagnosis found in the DSM-I and DSM-II became
a professional liability. For one thing, psychiatry’s medical credentials
were questioned because the field was seen as dealing with general psychosocial problems and not legitimate diseases. There was nothing that
psychiatrists were doing that other mental health professionals such as
clinical psychologists, psychiatric social workers, nurses, and counselors
could not do. For another, the absence of clear diagnostic criteria meant
that psychiatrists could not conduct large, multisite research studies, which
were becoming standard in other areas of medicine, because researchers had
no common measures they could use. In addition, third party private and
public insurance were coming to pay for most mental health therapy: these
organizations would only pay for the treatment of some clearly defined
mental illness. Finally, the Food and Drug Administration began to enforce
its regulations that required drugs only be used to treat distinct illnesses
rather than general problems of living. It was clear that psychiatry needed to
develop new diagnostic criteria that would draw clear lines between what
was mental illness and what was not.
The major source of the diagnostic criteria that eventually appeared in the
DSM-III in 1980, and that in most respects have remained intact until the
present, was the Feighner Criteria (Feighner et al., 1972). A group of psychiatrists at Washington University, a medically minded outpost of empirical
psychiatry that stood in opposition to the dominant psychodynamic thinking of the time, developed these 14 diagnoses. Unlike the DSM-I and DSM-II,
they defined each condition on the basis of clearly defined criteria based on
the specific symptoms patients presented. In addition, diagnoses were categorical not dimensional – one either had or did not have some mental illness.
The Feighner Criteria also seemed ideal for research purposes because their
symptomatic definitions did not seem to involve discretionary judgments so
that they could be easily measured across different sites and diagnosticians.
Moreover, in contrast to the extant DSM manual, observers didn’t have to
inquire about the causes of symptoms, which the designers of the Feighner
Criteria assumed were not known at the time.
Since 1980, psychiatry has used the Feighner model, which relies on the
presence and severity of symptom clusters, as the major way to separate
disordered from natural emotions. For example, Major Depressive Disorder
(MDD) in the DSM-III (which is virtually identical to the definition in the current DSM-5) required either a depressed mood or loss of interest or pleasure
in usual activities. In addition at least four of the following symptoms must
be present nearly every day for a period of at least 2 weeks: (i) poor appetite
or significant change in weight; (ii) insomnia or hypersomnia; (iii) psychomotor agitation or retardation; (iv) decreased sexual drive; (v) fatigue or loss of

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

energy; (vi) feelings of worthlessness, self-reproach, or excessive or inappropriate guilt; (vii) diminished ability to think or concentrate or indecisiveness
and (viii) recurrent thoughts of death or suicidal ideation or suicide attempt
(APA, 1980, p. 213). The only exception was that recently bereaved people
who met the diagnostic criteria would not receive a MDD diagnosis unless
they had at least one especially severe symptom or their symptoms endured
for a 2 month period. Aside from this bereavement exclusion, everyone who
met the five symptom 2 week criteria would be considered to have major
depression.
The other DSM-III diagnostic criteria sets were formulated in similar ways
(Horwitz, 2002). They required that a certain number of symptoms be present
for some defined period of time (which varied according to the disorder).
Some contained additional criteria such as being “unreasonable” or “excessive.” With the exception of post-traumatic stress disorder and acute stress
disorder, which required some traumatic cause, none of the criteria sets specified the reason why the symptoms developed.
Two major reasons accounted for the DSM-III’s reliance on symptoms
alone as indicators of some mental disorder. First, its developers asserted
that the earlier manuals inappropriately specified what the causes of various
conditions were—for example, the loss of some love object or internal conflict led to depression. Therefore, the manual did not specify the causes of the
conditions it classified. Second, they were concerned that the overly general
definitions of the various conditions in the prior manuals led to an almost
complete lack of reliability among clinicians and researchers. Different
diagnosticians could not agree on what constituted some mental disorder:
for example, what some called “schizophrenia,” others diagnosed as “manic
depression.” It was much easier to generate agreement on what condition
someone had if psychiatrists only had to take symptoms in themselves into
account. Judgments of what were “appropriate” or “inappropriate” contexts
were difficult to make and lowered reliability because different clinicians
would have different opinions about whether or not symptoms were normal
responses to distressing contexts.
Therefore, the manual decided to eliminate contextual qualifiers and to
focus on the presence of enough symptoms themselves as indicative of some
disorder. This helped to increase the reliability of diagnosis but led many
diagnoses to have questionable validity. For example, the DSM criteria for
MDD could not separate people who become depressed after losing their
jobs or marriages from those with genuine depressive illnesses. In the case of
depression this problem was especially acute because symptoms need only
be present for a 2 week period, insuring that transient and stress-related
conditions were not separated from long-standing and recurrent ones that
were not linked to the context in which they arose (Horwitz & Wakefield,

Normal Negative Emotions and Mental Disorders

5

2007). The creation of symptom-based, categorical, and mutually exclusive
diagnoses bolstered the prestige of the psychiatric profession in an historical
context when its legitimacy was in question. It also had severe flaws that only
became apparent in future decades.
AREAS OF CUTTING-EDGE WORK
CONTEXT
The fundamental task of psychiatric diagnosis should be to distinguish
genuine mental dysfunctions from normal, albeit distressing, emotions.
This requires situating symptoms within the context in which they arise.
Many people develop symptoms that resemble those specified in psychiatric
diagnostic criteria sets but that are natural results of stressful situations.
For example, people who have suffered the loss of jobs, romantic partners,
or health often develop symptoms that would meet criteria for MDD.
However, if these symptoms dissipate once the individual finds a new job or
romantic partner, or recovers from their illness, nothing was wrong within
such individuals; they responded appropriately to a distressing situation.
Other symptoms such as the inattention, impulsivity, and distractibility
that might signify attention-deficit/hyperactivity disorder are similar to
ordinary behaviors among many adolescent boys. Even severe symptoms
such as the hallucinations found during psychotic episodes can sometimes
mark intense religious experiences among certain groups. Symptoms, in
themselves, are rarely straightforward indicators of mental disorders in the
absence of considerations of the contexts in which they appear.
The best research in this area uses longitudinal studies to examine how
symptoms that arise after some stressful life event unfold over time. If symptoms that result from, say, unemployment, divorce, or the death of an intimate are no longer present at a future period of measurement, it is likely that
they are natural products of a stressful situation as opposed to a mental disorder. They are likely to dissipate when the situation changes or gradually go
away with the passage of time. In contrast, if they persist for extended periods or feature chronic reoccurrences then they are likely to be signs of a mental disorder. Jerome Wakefield and Mark Schmitz (2012, 2013a, 2013b) have
used several large data sets collected at more than one point in time to answer
this question. Their findings show that people who meet the criteria for major
depression after all kinds of losses have similar recurrence rates (3.4%) at
the second period of measurement as people with no history of depression
(1.7%). Both of these groups have far lower recurrence rates than ones whose
depressive symptoms did not arise after some loss (14.6%). Other studies also

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

indicate that bereaved people were no more likely than the nondepressed to
have subsequent depressive episodes 3 years later (Mojtabai, 2011).
These findings indicate that a fundamental weakness of purely symptombased diagnostic criteria is that they cannot separate people who are responding naturally to stressful environments from ones whose symptoms are not
moored to some situational context. Because this type of measure treats both
types of symptoms as indicative of mental disorder, it overstates the number of presumably mentally ill people. Much of the criticism directed at the
recently issued DSM-5 focused on how symptom-based diagnostic criteria
overpathologize many different conditions (e.g., Frances, 2013). Nevertheless, the DSM-5 actually moved toward an even more exclusive focus on
symptoms alone when it removed the bereavement exclusion from the MDD
criteria. This means that even symptoms that arise after the death of an intimate but are not especially severe and persist for as short as a 2-week period
now meet the MDD criteria. Future research should focus on how to identify
the differences between conditions that both arise and persist within stressful
contexts and those that indicate a true mental disorder.
DIMENSIONALIZATION
The psychodynamic conception that dominated views of anxiety before the
DSM-III considered mental disorders to vary along a dimension of lesser to
greater severity. Mental illness formed a continuum with normal, contextually appropriate conditions on the one end and severe conditions on the
other. One of the major motivators of the DSM-III was to establish the kind
of distinct conditions that prevailed in other medical classifications. Yet, the
sharp cutoffs between normal and disordered conditions the diagnostic criteria imposed had little scientific justification. They seemed both arbitrary
and unable to recognize minor forms of disorder (Kendler & Gardner, 1998).
For example, there was no reason for why diagnoses of generalized anxiety
required at least three symptoms or major depression at least five symptoms:
people with fewer symptoms might have milder disorders, not be nondisordered. Moreover, the DSM’s binary logic conflicted with understandings of
the subtler ways in which biological and genetic variance become manifest.
A dimensional system might better fit the underlying nature of most conditions, which have no sharp cutoff point for where the number of symptoms
distinguishes disorder from nondisorder. One of the major goals of the developers of the DSM-5 was to overcome the either/or logic of the manual that
seemed to hinder etiological discoveries.
The DSM-5 Task Force proposed major alterations that would move the
manual from a categorical toward a more dimensional system. Initially, it
suggested a radical revision that would largely replace the distinct criteria

Normal Negative Emotions and Mental Disorders

7

dividing disorders from nondisorders with measures that reflected graded
scales of severity.
The single most important precondition for moving forward to improve
the clinical and scientific utility of DSM-5 will be the incorporation of simple
dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between
DSM-IV and DSM-5 will be the more prominent use of dimensional measures
in DSM-5 (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 649).
Dimensions, the revisers hoped, would overcome the inability of categorical measures to identify people who show some, but not enough, symptoms
to qualify for a diagnosis. Ironically, dimensional assessment invoked a measurement style of an era that preceded the DSM-III.
The developers of the DSM-5, however, recognized that their initial goal
of establishing a dimensional system of measurement was overly ambitious
and, given the existing knowledge base, premature. One major dilemma was
where to place the lower bound for the presence of a disordered condition. If
the line was drawn too high, diagnoses might miss too many genuinely disordered people. Conversely, if it was set too low an enormous number of false
positive conditions might result. This is what had happened during the 1950s
and 1960s when clinicians and epidemiologists commonly assumed that a
small number of symptoms often indicated a milder form of mental disorder,
not the absence of disorder. The major problem of such studies was that they
uncovered immense rates of assumed mental illness. The best-known survey,
the Midtown Manhattan Study, found that just 18.5% of its community sample was symptom free (Srole et al., 1978). Over 80% of the population, therefore, had some degree of “mental illness”: 36% were in the mild category,
22% were in the moderate category, and 23% fell into the marked, severe,
or incapacitated category. The DSM-5 dimensional criteria, which used such
ubiquitous symptoms as feeling “fearful,” “anxious,” “worried,” and so on,
and which must endure for only a brief period of time (7 days), would likely
produce similarly massive rates of mild “disorders.”
The DSM-5 Task Force eventually abandoned its dimensional proposal.
The reason, however, was not because of fears of considering too many
normal people as having some mental illness. Instead, the divergent needs
of researchers and clinicians led to the rejection of the Task Force proposal.
While researchers were most interested in developing diagnoses that would
improve psychiatry’s knowledge base, clinicians had the more practical
concerns that the criteria be easy to apply and guarantee reimbursement for
treatment. Clinicians worried that dimensions would be burdensome to use
in practice, especially if insurance companies mandated their employment.
An APA Assembly rejected the dimensional proposal, in effect, voting

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

to retain the current categorical diagnoses. A proposal that began as a
radical revision of the basic structure of the DSM ended in an appendix as a
suggestion in need of further study (Wholley & Horwitz, 2013).
Ironically, empirically driven researchers had imposed the categorical system of DSM-III on resistant clinicians. By 2012, however, categorical diagnoses had become millstones for researchers but necessities for clinicians,
who must use them to be paid for treatment. Clinicians obtained a measure
of revenge on researchers by rejecting their appeal to institute a possibly
more valid, but less practically useful, diagnostic system. Social considerations mandated that psychiatry continue to employ a classification whose
scientific inadequacies had become blatantly obvious. Psychiatry’s categorical system that had been in place since 1980 was shaken but not replaced.
UNREASONABLENESS
At present, many of the DSM’s major diagnoses use the unreasonable or irrational qualities of symptoms as indications of a mental disorder. For example,
specific and social phobias (the second and third most commonly occurring
mental illnesses in community populations, following only depression) must
be out of proportion to the actual danger or threat posed by specific objects or
situations (APA, 2013, p. 197, 203). The problem is that much human behavior does not seem to be designed to be reasonable and/or rational. Indeed, a
major thrust in current psychological research is to show how automatic and
unconscious emotional responses typically precede conscious judgments and
reasoning about some situation (e.g., Haidt, 2012; Kahneman, 2011).
It is instructive to examine what kinds of things people are afraid of. Those
with simple phobias are afraid of animals (22.2%); heights (20.4); blood (13.9);
flying (13.2); closed spaces (11.9); water (9.4); storms (8.7); being alone (7.3).
The most common forms of social anxiety are public speaking (21.2%); speaking up in a meeting (19.5); and meeting new people (16.8). These figures
indicate that many people fear things and situations that are not, in fact, likely
to harm them and so might seem unreasonable and irrational (Curtis, Magee,
Eaton, Wittchen, & Kessler, 1998; Ruscio et al., 2008).
Yet, the statistically most common anxiety disorders might result from
dangers that were appropriate in the ancient environments when the human
genome formed (Horwitz & Wakefield, 2012). The most pressing dangers
in ancient environments stemmed from carnivores for which humans were
a tasty source of calories; the most ancient human remains from millions of
years ago show that many people were killed by carnivorous saber-toothed
cats and giant cheetahs. Alternatively, falling from a high place posed a
real threat of serious injury or death at a time when no protective measures
existed. Other specific fears of blood, water, closed spaces, and storms

Normal Negative Emotions and Mental Disorders

9

could also be genuine sources or signals of ancestral dangers. Blood, for
example, might suggest the close proximity of enemies. Even air travel,
which obviously didn’t exist when the human genome was being formed,
seems to blend several aspects of biologically shaped fears. It combines fear
of being at extreme heights where falling could mean death with fear of
entering enclosed spaces where escape is impossible. Such fears could have
been useful in ancient periods because they led people to avoid genuinely
dangerous situations. Fears that might not correspond to actual dangers
in present situations seem understandable as reactions that came down to
us as part of our biological inheritance of fears that did make sense in the
prehistoric past.
Likewise, in the distant past, people lived in small bands of one or two hundred people, all of whom were well known to one another. Disapproval or
rejection within such groups could be highly consequential for survival and
incurring the negative evaluations of others carried real risks. A person who
was not part of a collectivity would not have been able to survive if cut adrift
from the group. Fears of ostracism were natural and adaptive when people
depended on tightly connected and long-term ties and where their social
status depended on their position in a group. Unsurprisingly, high anxiety
about social evaluation and potential rejection became a common part of our
nature and remains so even though such anxiety is no longer as contextually suited to modern societies, where individuals often have many alternate
social options if they are rejected or fail an evaluation.
The problems that many specific and social fears entail stems from the fact
that normal genes no longer fit the environment where they must function,
not in any genetic or psychological dysfunction within individuals. An analogy might be the persistence of our craving for highly caloric foods, which
was useful in prehistoric environments where calories were hard to come
by but which now is a source of obesity and disease in environments where
calories are readily available. Such mismatches between what is evolutionarily natural and what is socially reasonable raise fundamental questions about
what is normal and what is not. Future research needs to identify the extent
to many common forms of mental illnesses actually reflect the operation of
natural genetic propensities that might be unreasonable but not disordered.
KEY ISSUES GOING FORWARD
One major issue that future research must address involves how to integrate findings from neurological studies into diagnostic criteria. The principle established in 1980 that the DSM diagnostic criteria sets should not
encompass causal inferences has meant that the manual does not incorporate the biological perspective that otherwise dominates current psychiatric

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

research and treatment. This deficiency is so glaring that the National Institute of Mental Health, the major federal agency concerned with research
about mental illness, is developing an alternative manual to the DSM, the
Research Domain Criteria (Insel, 2009). This manual will attempt to use brain
circuitry and genetic findings as the basis for a new diagnostic system that
might supplement or even replace the DSM. The problem the creators of this
manual will face is how to distinguish disordered genes, molecules, cells,
and so on in the absence of good diagnostic criteria that can separate the
neurological basis of natural negative emotions from dysfunctions.
A second endeavor regards the search for valid, as opposed to merely reliable, criteria to define mental disorders. As noted, unlike other medical disciplines, psychiatry currently lacks any biological markers for the conditions
it studies. A successful demonstration that various brain-related indicators
are associated with different kinds of mental illnesses will not only enhance
the potential to identify, treat, and prevent various conditions but also show
the extent to which current diagnoses mislabel the conditions they strive to
identify.
Another issue going forward will be how to develop appropriate definitions of normal, negative emotions and mental disorders that balance the
risks of false negatives and false positives. To date, psychiatry has emphasized avoiding false negatives—considering people who are actually sick as
if they are well. Many critics claim that this practice has resulted in unnecessary treatment, overmedication, and stigma (e.g., Frances, 2013). However, if
diagnostic criteria are too stringent they can prevent people who might benefit from treatment from getting it. Drawing appropriate lines among normally
distressing symptoms, evolutionarily mismatched emotions, and mental disorders will be a highly challenging endeavor. This task will be especially
difficult because the symptom-based categories of the extant diagnostic manual provide such an inadequate roadmap for guiding future research.
REFERENCES
American Psychiatric Association (1952). Diagnostic and statistical manual of mental
disorders. Washington, DC: Author.
American Psychiatric Association (1968). Diagnostic and statistical manual of mental
disorders (2nd ed.). Washington, DC: Author.
American Psychiatric Association (1980). Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Curtis, G. C., Magee, W. J., Eaton, W. W., Wittchen, H.-U., & Kessler, R. C. (1998).
Specific fears and phobias: Epidemiology and classification. British Journal of Psychiatry, 173, 212–217.

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Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G., & Munoz, R.
(1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57–63.
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric
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Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed
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Horwitz, A. V., & Wakefield, J. C. (2012). All we have to fear: Psychiatry’s transformation
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Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2009). The conceptual
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(1978). Mental health in the metropolis: The Midtown Manhattan study (Rev., enlarged
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Wakefield, J. C., & Schmitz, M. F. (2012). Recurrence of depression after bereavementrelated depression: Evidence for the validity of DSM-IV bereavement exclusion
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Disease, 200, 480–485.
Wakefield, J. C., & Schmitz, M. F. (2013a). When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major
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Wakefield, J. C., & Schmitz, M. F. (2013b). Can the DSM’s major depression bereavement exclusion be validly extended to other stressors? Evidence from the NCS.
Acta Psychiatrica Scandinavica. http://dx.doi.org. 10.1111acps.12064

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Wholley, O., & Horwitz, A. V. (2013). The paradox of professional success: Grand
ambition, furious resistance, and the derailment of the DSM-5 revision process.
In J. Paris & J. Phillips (Eds.), Making the DSM-5: Concepts and Controversies
(pp. 75–92). New York, NY: Springer.

FURTHER READING
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric
diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York, NY:
William Morrow.
Horwitz, A. V. (2002). Creating mental illness. Chicago, IL: University of Chicago Press.
Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed
normal sadness into depressive disorder. New York, NY: Oxford University Press.
Horwitz, A. V., & Wakefield, J. C. (2012). All we have to fear: Psychiatry’s transformation
of natural anxiety into mental disorder. New York, NY: Oxford University Press.
Paris, J., & Phillips, J. (Eds.) (2013). Making the DSM-5: Concepts and Controversies (pp.
75–92). New York, NY: Springer.
Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between
biological facts and social values. American Psychologist, 47, 373–388.

ALLAN V. HORWITZ SHORT BIOGRAPHY
Allan V. Horwitz is Board of Governors Professor in the Department of
Sociology and Institute for Health, Health Care Policy, and Aging Research
at Rutgers. He has published over 100 articles and chapters about various
aspects of mental health and illness. In addition, he has published seven
books including The Loss of Sadness: How Psychiatry Transformed Normal
Misery into Depressive Disorder (Oxford University Press 2007), All We
Have to Fear: Psychiatry’s Transformation of Natural Anxiety into Mental
Disorder (Oxford University Press 2012), and Anxiety: A Short History
(Johns Hopkins University Press 2013). He is currently Interim Director of
the Institute for Health, Health Care Policy, and Aging Research at Rutgers
University.
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