According to DSM-IV, all diagnoses should be applied only if the symptoms are the result of an underlying dysfunction within the individual and not a reaction to the immediate social context or a problematic environment. This inclusion represents a genuine attempt of DSM-IV to include contextual factors into the definition of disorders. Nevertheless, and as stated elsewhere [17], the DSM-IV has not formally incorporated social or cultural factors as exclusionary criteria of disorders, nor are explicit definitions of underlying dysfunctions provided for each disorder. As a result, it is difficult and sometimes impossible to distinguish between behaviors caused by negative environments that do not involve internal dysfunction and those that originate from negative environments but do involve internal dysfunction [80]. Some have questioned whether this distinction is appropriate and even possible (see [54]). However, it is clear that most clinicians and research using epidemiologic surveys are not able to distinguish between symptoms that cause an internal dysfunction from those that are merely reflections of a negative environment [11]. Moreover, research has demonstrated that negative environments can be influenced by a
