The transformation of intense normal sadness into depressive disorder occurred in several stages. The development of influential symptom-based research criteria for affective disorders in the Feighner criteria and RDC provided an initial step. Such criteria lacked the contextual assessment that had traditionally protected diagnosis from misclassifying intense sadness as disorder and thus created the potential for false positives. Research on depression was, however, primarily concerned with hospitalized patients and quite severely aficted community members who were clearly disordered. Within this context, the symptom-based criteria worked well to distinguish affective disorders from other serious disorders, and the potential for false positives was not immediately realized. The second step occurred when the DSM-III applied the symptom-based logic to clinical practice in general, including burgeoning outpatient practices and community clinics in which therapists might see all forms of mental distress. Applying decontextualized criteria to this heterogeneous group of outpatients made it more likely that these diagnoses would be applied to those suffering from normal sadness.
However, several factors work to minimiz e the overapplication of the DSM +U0027s criteria to normal sadness in outpatient clinical settings. Patients tend to selfselect, so although many individuals do seek help for normal sadness, more often they seek treatment only after they attribute their symptoms to internal problems and not to stressful situations.1Moreover, clinicians themselves, in spite of enticements by insurance reimbursement to see depressive disorder wherever possible, can still use their commonsense judgments to correct for flaws in the DSM criteria and to recognize when a patient is not disordered but perhaps just in need of reassurance and support to alleviate painful but normal and likely transient feelings.
It is not, then, in the clinical context that the confusion between what is normal and abnormal is most in danger of occurring. Instead, the most radical transformation of ordinary sadness into pathology happened when the DSM +U0027s criteria, developed primarily for treated cases, were lifted out of the