The DOI matches its Crossref record; 45 of the 45 references it cites were found in a registry or an index; 1 of the 10 sources its claims cite were checked for support.
The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria.
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How should DSM criteria relate to the disorders they are designed to assess? To address this question empirically, the author examines how well DSM-5 symptomatic criteria for major depression capture the descriptions of clinical depression in the post-Kraepelin Western psychiatric tradition as described in textbooks published between 1900 and 1960. Eighteen symptoms and signs of depression were described, 10 of which are covered by the DSM criteria for major depression or melancholia. For two symptoms (mood and cognitive content), DSM criteria are considerably narrower than those described in the textbooks. Five symptoms and signs (changes in volition/motivation, slowing of speech, anxiety, other physical symptoms, and depersonalization/derealization) are not present in the DSM criteria. Compared with the DSM criteria, these authors gave greater emphasis to cognitive, physical, and psychomotor changes, and less to neurovegetative symptoms. These results suggest that important features of major depression are not captured by DSM criteria. This is unproblematic as long as DSM criteria are understood to index rather than constitute psychiatric disorders. However, since DSM-III, our field has moved toward a reification of DSM that implicitly assumes that psychiatric disorders are actually just the DSM criteria. That is, we have taken an index of something for the thing itself. For example, good diagnostic criteria should be succinct and require minimal inference, but some critical clinical phenomena are subtle, difficult to assess, and experienced in widely varying ways. This conceptual error has contributed to the impoverishment of psychopathology and has affected our research, clinical work, and teaching in some undesirable ways.
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“Eighteen symptoms and signs of depression were described, 10 of which are covered by the DSM criteria for major depression or melancholia.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Abstract
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“For two symptoms (mood and cognitive content), DSM criteria are considerably narrower than those described in the textbooks.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Abstract
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“Second, the descriptive literature placed greater relative emphasis on the cognitive and attitudinal changes associated with depression than do the DSM criteria, where these features constitute only one criterion, characterized solely by worthlessness and guilt.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Empirical Conclusions
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“However, none of the authors noted increased appetite and weight gain, which are also described in this DSM criterion.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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“Fatigue, exhaustion, and feelings of being tired out, symptoms well captured by DSM criterion A6, were described by only eight authors.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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“Sixth, consistent with recent work (30), these authors gave greater prominence to changes in psychomotor functioning, especially psychomotor retardation, than is our current practice.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Empirical Conclusions
What the sources say
- Not checked — no full text of the sourcecites [30] source
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“Depression-related changes in volition and motivation were described by 15 authors and were typically distinguished both from the more physical feelings of fatigue and the difficulty in decision making.Most commonly, this was described as lack of initiative, loss of will, or inability to work.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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“Of note, only one author described neurovegetative changes in sleep, appetite, or weight as a central symptom of depression.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Prominent Symptoms and Signs
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“Third, second to mood changes, the most frequently noted key symptom of major depression was changes in cognitive Am J Psychiatry 173:8, August 2016 ajp.psychiatryonline.org773 functioning, typically characterized by difficulties in thinking and concentrating.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Empirical Conclusions
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“Mood disturbances in the course of major depression were described by all 19 textbook authors (Table 1).”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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“Second, it does not explain the diminution in psychopathological expertise and interest since the advent of DSM-III (4).”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
What the sources say
- Supportedcites [4] source
The Abstract says that since DSM-III’s publication in 1980, teaching careful clinical evaluation informed by psychopathology has steadily declined. The section ‘To improve communication between clinicians’ adds that classics in psychopathology are largely ignored and research in psychopathology is a dying enterprise. Together, these support the claimed diminution in expertise and interest. (LLM, conf=0.93)
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- Supported
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“Compared with the DSM criteria, these authors gave greater emphasis to cognitive, physical, and psychomotor changes, and less to neurovegetative symptoms.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Abstract
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“Depression-associated depersonalization and derealization were noted in 12 of the textbooks.A number of descriptions were provided, including everything feeling changed or unreal, seeing the world through a mist, and perplexity.No DSM-5 criteria for major depression describe this kind of depressive symptomatology.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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In the paper
“First, Lewis comments on all but two of the symptoms and signs that I developed from the textbook review, so there is a high degree of consilience between these two sources of information (Table 3).”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Lewis's Monograph
What the sources say
- Not checked — no full text of the sourcecites [7] source
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In the paper
“Psychomotor changes were reported by all but one author, 12 of whom described only aspects of psychomotor retardation and six of whom also commented on agitation.These signs are well presented in DSM-5 criterion A5.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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In the paper
“Speech that was slow, hesitant, indistinct, and/ or monosyllabic was described by all but two authors.This symptom is not included in DSM-5.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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In the paper
“Various aspects of anxiety, including panic attacks and obsessive fears, were noted by 14 authors, but anxiety is not included in the DSM criteria for major depression.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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In the paper
“All three of these are well reflected in the DSM criteria for major depression.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Prominent Symptoms and Signs
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In the paper
“Compared with the DSM-5 criteria, Muncie's criteria included symptoms of depersonalization and derealization and gave greater emphasis to physiological symptoms and changes in facial expression and posture.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Criteria for Depression Proposed by Muncie
What the sources say
- Not checked — no full text of the sourcecites [22] Muncie W, 1939 source
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In the paper
“The next most common central symptom, volitional changes, was noted by only 20% of these authors and is not described in DSM-5 criteria.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Prominent Symptoms and Signs
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“Other physical symptoms and signs, noted by 17 authors, was the most difficult symptom category to summarize.Most commonly described were gastrointestinal complaints, but diminished libido, amenorrhea, and headaches were also often noted.Also frequently described were changes in facial expression and posture.These phenomena are not captured by any part of the A criterion in DSM-5 major depression.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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“As seen in Table 4, ten of the 18 symptoms and signs were well described by the DSM A criteria for major depression and one by a criterion for melancholia.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Quantitative Analysis
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In the paper
“Poor appetite and weight loss were described by, respectively, 10 and nine textbook authors, consistent with DSM criterion A3.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Textbooks' Descriptions of Symptoms and Signs
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“Eighth, nearly all authors commented on changes in the speech of depressed patients, most typically describing it as slow, low in volume, with long pauses.This sign is not in DSM-5.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Empirical Conclusions
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In the paper
“Fifth, the textbook authors gave less importance to the neurovegetative features of depression-changes in sleep, appetite, and weight-than the DSM criteria do.No author noted them as key depressive symptoms.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Empirical Conclusions
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“First, the nature of psychiatric practice changed during the 20th century, with outpatient care constituting a larger proportion of our work, especially after 1960.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
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“By the time DSM-III was published in 1980, the majority of depressed patients were being seen in ambulatory settings and were often more mildly ill.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
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“But many of our classical textbook authors believed that derealization was an important clinical feature of major depression.”
- Also stated in: § Illustrations of the Problems Associated With Our Category Mistake · plain
“Yet, senior clinicians of earlier generations thought it was a critical feature of the depressive syndrome that reflected their patients' lived experiences.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
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- Rests on an assumption: The 19 textbooks examined are representative of the Western post-Kraepelinian psychiatric tradition.
- Also stated in: § Illustrations of the Problems Associated With Our Category Mistake · plain
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In the paper
“For the key major depression criteria A1 and A7, DSM-5 lists three and two descriptors, respectively.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
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“Most of our textbook writers considered anxiety to be a prominent and clinically important part of the presentation of major depression.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
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- Rests on an assumption: The 19 textbooks examined are representative of the Western post-Kraepelinian psychiatric tradition.
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In the paper
“Many of the classical textbook writers were seeing severely depressed patients in hospitals.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
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“First, it fails to recognize the degree to which many mental health clinicians have conflated clinical evaluation and assessment of DSM criteria in our clinical work, research, and teaching.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
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In the paper
“But meeting the DSM criteria for major depression is not the same thing as having major depression.The DSM criteria do not constitute clinically significant depression.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Conceptual Issues With Our Current Approach to DSM Criteria
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In the paper
“Increased eating and weight gain were introduced into the Research Diagnostic Criteria (35) for major depression and carried over into all subsequent editions of DSM.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Empirical Conclusions
What the sources say
- Not matchedcites [35] Spitzer RL, 1975
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In the paper
“This conceptual error has contributed to the impoverishment of psychopathology and has affected our research, clinical work, and teaching in some undesirable ways.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Abstract
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“Third and most importantly, the critique does not address the underlying conceptual problems of diagnostic literalism and reification that arise directly from our category mistake of confusing our fallible diagnostic criteria with the categories they are designed to assess.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
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“Second, developers of diagnostic criteria are also appropriately concerned about specificity.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
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In the paper
“Many of us have become diagnostic literalists with respect to DSM, stymied by an excessive respect for own creation.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Consequences of Our Category Mistake
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“That is, criteria need only to identify true cases with sufficient sensitivity and specificity, and not to reflect complete catalogs of important symptoms and signs.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > CONCLUSIONS
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In the paper
“But it is problematic when we focus our teaching, our clinical work, and our research solely around DSM criteria.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > CONCLUSIONS
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“The presence of such validators helps illustrate the difference between indexing and constituting a disorder.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Consequences of Our Category Mistake
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In the paper
“By losing sight of the indexical function of our diagnostic criteria and confounding the criteria with the disorders themselves, we open the door to reification.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Consequences of Our Category Mistake
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“Third, as noted above, the goals of those who develop diagnostic criteria are not the same as those of the textbook writers, with the former being much more concerned with brevity, reliability (and hence low inferential content), and specificity.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
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In the paper
“We can understand why this did not make it into DSM: It is a subtle concept, time-consuming to evaluate, and perhaps of limited reliability.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
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In the paper
“It is possible, although unlikely given modest symptomatic differences seen for depression in major depression as compared with bipolar illness (37), that some of the differences between the symptoms described and those listed in the DSM-5 criteria result from admixture of patients with bipolar illness.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Potential Limitations
What the sources say
- Not checked — no full text of the sourcecites [37] source
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In the paper
“DSM criteria are imperfect approximations created by a very human process that, although scientifically informed, could not be claimed by any knowledgeable individual to be infallible.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Consequences of Our Category Mistake
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In the paper
“As illustrated by our textbook writers, these lists are too short to capture adequately the range of human experience of the mood state of depression and the range of self-derogatory/pessimistic depressive cognitions.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
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In the paper
“Given our pride in our diagnosis and our lack of definitive validators, it is understandable that our field has had undergone a”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Consequences of Our Category Mistake
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“A symptom could be quite clinically important, but if it is shared by many other syndromes, it would likely not make a good diagnostic criterion.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
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“Third, to be practical, diagnostic criteria need to be succinct.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Illustrations of the Problems Associated With Our Category Mistake
Strength:plain· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✗ Load-bearing: fails✗ Based: failsProbably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These criteria have been enshrined in our diagnostic algorithms and structured interviews, and are so often required by journal and grant reviewers that they approach the tokens of an orthodox faith.”
§ The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria > Consequences of Our Category Mistake
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
The paper relies on this without support.
Textbooks are the best place to obtain expert opinion about the important symptoms and signs of depression.
“I focus initially on textbooks as the best place to obtain expert opinion about the important symptoms and signs of depression.”
The paper relies on this without support.
The 19 selected textbooks are representative of the post-Kraepelinian Western psychiatric tradition circa 1900-1960.
“In total, 19 textbooks, published from 1899 to 1956 from five countries (nine from the United States, seven from the United Kingdom, and one each from Germany, France, and Switzerland), met inclusion criteria.”
The paper relies on this without support.
The textbook descriptions and Lewis's cases accurately reflect the phenomenology of depressive illness or major depression.
“I next review the phenomenology of depression described by Aubrey Lewis in what is the most detailed survey of the phenomenology of depression written in the 20th century (7).”
The paper relies on this without support.
Lewis's monograph is the most detailed survey of the phenomenology of depression written in the 20th century.
“I next review the phenomenology of depression described by Aubrey Lewis in what is the most detailed survey of the phenomenology of depression written in the 20th century (7).”
The paper relies on this without support.
The 19 textbooks examined are representative of the Western post-Kraepelinian psychiatric tradition.
“The DSM symptomatic criteria for major depression do a reasonable but incomplete job of assessing the prominent clinical symptoms and signs of depressive illness as described in the Western post-Kraepelinian psychiatric tradition.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Abstract understates the number of symptoms covered by DSM criteria
MinorThe abstract says 10 symptoms or signs are covered by criteria for major depression or melancholia. The quantitative analysis counts 10 well covered by major-depression criteria plus one covered by a melancholia criterion, for a total of 11.
“Eighteen symptoms and signs of depression were described, 10 of which are covered by the DSM criteria for major depression or melancholia.”
“ten of the 18 symptoms and signs were well described by the DSM A criteria for major depression and one by a criterion for melancholia.”
Dana textbook has two publication years
MinorTable 1 dates Dana's textbook to 1907, while its bibliography entry gives 1904.
“| Dana, 1907 (11) | Mental |”
“11. Dana CL: Text-Book of Nervous Diseases and Psychiatry: For the Use of Students and Practitioners of Medicine, 6th rev and enlarged ed. New York, William Wood, 1904”
Conflicting counts of central neurovegetative symptoms
MinorOne section says one author considered a sleep, appetite, or weight change central to depression; a later section says no author considered those changes key symptoms.
“Of note, only one author described neurovegetative changes in sleep, appetite, or weight as a central symptom of depression.”
“No author noted them as key depressive symptoms.”
Citations
Cites
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“in the two earlier sets of diagnostic criteria for depression that influenced the Feighner criteria [33, 34]).”
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“Focusing solely on the symptoms and signs in DSM risks producing an impoverished view of psychopathology (4) and has encouraged the rise of diagnostic literalism (5).”
BackgroundThe Making of DSM-III A Diagnostic Manual’s Conquest of American Psychiatry
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Flagged first, then by citations
Research works printed but not linked: 4
- Burton R, 1893, The Anatomy of Melancholia
- White WA, 1913, Outlines of Psychiatry: Nervous and Mental Disease Monograph Series No 1
- Mayer-Gross W, 1954, Clinical Psychiatry
- Spitzer RL, 1975, Research Diagnostic Criteria for a Selected Group of Functional Disorders
Cited by
Sorted by citations
Major Depression and Its Recurrences: Life Course Matters
Monroe, S. M., & Harkness, K. L. (2022) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-072220-021440 · Cited by 608
Reward Processing in Depression: A Conceptual and Meta-Analytic Review Across fMRI and EEG Studies
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“Cardinal presentations of depression (16), most notably anhedonia, are thought to reflect alterations of the experience of reward (17, 18).”
BackgroundEpidemiology of anxiety disorders: from surveys to nosology and back.
Stein, D. J., Scott, K. M., de Jonge, P., & Kessler, R. C. (2017) · Dialogues in Clinical Neuroscience · doi:10.31887/dcns.2017.19.2/dstein · Cited by 283
The future of rodent models in depression research
Gururajan, A., Reif, A., Cryan, J. F., & Slattery, D. A. (2019) · Nature Reviews Neuroscience · doi:10.1038/s41583-019-0221-6 · Cited by 269
Metadata
- Authors
- Kendler, K. S.
- Affiliations
- Virginia Commonwealth University (US)
- Corresponding author
- Kendler, Kenneth S.
- ORCID
- Kendler, Kenneth S.
- Venue
- American Journal of Psychiatry
- Published
- 2016-08-01
- Volume
- 173
- Issue
- 8
- Pages
- 771-780
- ISSN
- 0002-953X (ISSN-L)
- 1535-7228
- OpenAlex
- W2346168897
- Cited by
- 255
- References
- 42
- Citations by year
- 2026: 25 · 2025: 32 · 2024: 32 · 2023: 20 · 2022: 27 · 2021: 19 · 2020: 24 · 2019: 15 · 2018: 27 · 2017: 27 · 2016: 5
- FWCI
- 153.04
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- American Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Health Sciences › Medicine › Pharmacology (medical) › Treatment of Major Depression
- Social Sciences › Psychology › Clinical Psychology › Psychology and Mental Health
- Keywords
- major depressive disorder, DSM-5 diagnostic criteria, melancholia, history of psychiatry, psychomotor symptoms, neurovegetative symptoms, depersonalization/derealization
- MeSH terms
- Attitude of Health Personnel, Curriculum, Major Depressive Disorder, Diagnosis, Differential, Education, Medical, Humans, Psychopathology, Research, Textbooks as Topic, United States, Diagnostic and Statistical Manual of Mental Disorders
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-11, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-11 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Cited sources are checked with a language model’s help (gpt-6-sol).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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