This article initiates a good discussion of how psychiatric syndromes should be understood within a specific context. I want to clarify some aspects of this discussion using the example of major depressive disorder (MDD), since MDD is also brought up in the article.

THREAD (1/n) https://twitter.com/WIRED/status/1303338662831304705

There are two aspects to a diagnosis of MDD. The first aspect is major depression as an "operational concept" and the second aspect is major depression as a "disorder".

(2/n)

Major depression as operational concept: it refers to depressive symptoms of a certain severity & duration. This operationalization is largely independent of causes & contexts, & says nothing about the symptoms being "understandable", "normal" or "proportional".

(3/n)

Major depression as a "disorder": this characterization imbues the operational concept, which is otherwise neutral, with additional assumptions. What these additional assumptions are is highly contested & a big reason why this debate is so difficult to resolve.

(4/n)

Some of the different ways of understanding the assumptions:
i) deflationary position: "disorder" is playing no role here at all & MDD is nothing more than an operational concept.
ii) clinical significance: the distress/impairment is such that it leads to help-seeking

(5/n)

iii) therapeutic: the condition would benefit from clinical assessment & treatment
iv) judgments of "abnormality": this is an abnormal reaction to circumstances
v) judgments of "dysfunction": some internal mechanism is no longer functioning as it ought to

(6/n)

So it's important to be clear, as much as possible, what the assumptions are that we impose on the operational concept. Furthermore, it's important to remember that these are merely assumptions. The *validity* of these assumption is yet to be demonstrated.

(7/n)

For example, the presence of *dysfunction* in major depression may be assumed by some, but that does not prove or demonstrate that all those who meet criteria for major depression do indeed suffer from said dysfunction.

(8/n)

Challenging the validity of a particular assumption, such as the dysfunction assumption, does not (strictly speaking) challenge any scientific utility offered by the operational definition component of major depression. These are different things.

(9/n)

When ppl say "if someone meets MDD criteria, then they have MDD, period", often they are conflating the operational concept with the assumptions of "disorder". MDD as an operational concept is indifferent to causes & context, but that is not necessarily so with "disorder".(10/10)