Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications
Introduction
As a branch of modern medicine, psychiatry has applied models of disease (usually referred to as “disorders”) and pathogenesis to problems of the mind. Categorical diagnoses of disorders are based on structured evaluations of “operational” criteria thought to reflect various aspects of mental problems, such as painful “inner” experiences, reduced cognitive abilities, or maladaptive patterns of behaviours (American Psychiatric Association, 2000). The diagnostic categories are constructed as syndromes with criteria referring to various situations and time frames and ordered in hierarchies to avoid overlaps. Diagnoses are assigned by counting and comparing signs and symptoms to notions of diagnostic “cut offs” or “thresholds” and are understood to entail specific properties, such as aetiology, treatability, and prognosis. This system has drawn on phenomenological work, particularly that of Jaspers, its foremost theorist, who provided a philosophical rationale for focusing on abstract entities considered to be essential across individuals rather than on other aspects, such as subjective experiences, personhood, social relatedness, or culture, that were emphasized by other 20th century strands of thinking.
Categories have also supplied culturally well-defined roles for mental health experts, their patients, and any others confronted with persons who have mental health problems. This, essentially medical, “grand theory” of disease in psychiatry has brought progress indeed. Functional inter-rater diagnostic reliability for mental disorders has been greatly improved, and treatment strategies developed over the last 60 or so years, pharmacologic and psychotherapeutic alike, have reduced suffering and improved the quality of life for countless persons. Epidemiological and longitudinal knowledge about mental health problems is now easily accessible, not least on the internet. Criticism of diagnostic practices has become rare within psychiatry, while external critique tends to be discarded as “unscientific” or even “anti-psychiatric”.
But are we really confident that this medical model does not itself contain fundamental scientific weaknesses, even errors? Widely recognized problems are that large proportions of psychiatric patients meet more than one diagnostic definition, that many have incomplete remission of symptoms and remain severely disadvantaged, and that longitudinal and cross-cultural inconsistencies are common. In this paper, the validity of the current diagnostic categories that have come to structure both psychiatric practice and science will be assessed against the specific criteria developed since first proposed by Robins and Guze (1970). The effects of accepting the medical model as the grand narrative of mental health problems will be exemplified, and new strategies for the definition of such problems will be proposed.
Section snippets
Methods
In psychiatry, validity has mostly been an issue when determining how “validly” a diagnostic instrument may identify a diagnostic category. Comparatively less attention has been focused on the validity of the diagnostic constructs. A few leading psychiatrists have developed criteria for the validity of disorders (Andreasen, 1995, Kendell & Jablensky, 2003, Kendler, 1980, Robins & Guze, 1970). Robins and Guze argued that psychiatric diagnoses should be based on systematic studies instead of “a
Clinical validity (Robins and Guze criteria 1 and 3)
Considering what we now know about the epidemiology of mental health problems, it is obvious that what Andreasen expected in 1995 has not come about. First, no mental disorder (besides mental symptoms induced by medical diseases, such as Huntington's chorea) has yet been statistically distinguished from the normal variation by a “zone of rarity” or shown to constitute a “taxon” among other problem types in the population variance (Cloninger, 1999). Instead, the notions of “broader phenotypes”
Discussion
Despite the obvious lack of empirical support for today's diagnostic models, it is not without a sense of heresy one has to conclude that most, if not all, of the mental disorders known today, i.e. the categories that have structured both the psychiatric praxis and the research into their prevalences, patterns of distributions, “comorbidities”, and aetiologies, simply do not exist as such. The artefactual boundaries between syndromal categories—and between “disorders” and normality—may indeed
Acknowledgements
My co-workers in the Forensic Psychiatric research group in Malmö and Gothenburg and all the colleagues who have attended to my many questions over the last year are gratefully acknowledged for their valuable advice and practical help during the work on this paper, which has been proposed at a number of professional meetings since the first raw sketch presented at the “Sjögren Day” at the University of Lund in December 2005. Several anonymous referees and the editor of this journal are also
References (63)
- et al.
Mental disorder as a cause of crime: The cornerstone of forensic psychiatry
International Journal of Law and Psychiatry
(2009) - et al.
Patterns of remission and symptom decline in conduct disorder: A four-year prospective study of an ADHD sample
Journal of the American Academy of Child and Adolescent Psychiatry
(2001) - et al.
Toward DSM-V: An item response theory analysis of the diagnostic process for DSM-IV alcohol abuse and dependence in adolescents
Journal of the American Academy of Child and Adolescent Psychiatry
(2008) - et al.
Learning disability
Lancet
(2003) - et al.
Childhood-onset disruptive behaviours as the core phenotype definition of aggressive antisociality
International Journal of Law and Psychiatry
(2009) - et al.
Attention-deficit hyperactivity disorder: A category or a continuum? Genetic analysis of a large-scale twin study
Journal of the American Academy of Child and Adolescent Psychiatry
(1997) - et al.
Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: A population-based study
Lancet
(2009) - et al.
Ten-year follow-up of adolescent-onset anorexia nervosa: Personality disorders
Journal of the American Academy of Child and Adolescent Psychiatry
(1999) - et al.
Neural bases for impaired social cognition in schizophrenia and autism spectrum disorders
Schizophrenia Research
(2008) - et al.
Phenotypic and genetic overlap between autistic traits at the extremes of the general population
Journal of the American Academy of Child and Adolescent Psychiatry
(2006)
Bridging the gap between schizophrenia and psychotic mood disorders: Relating neurocognitive deficits to psychopathology
Schizophrenia Research
Diagnostic criteria from DSM-IV-TR
Child neurodevelopmental and behavioural problems are intercorrelated and dimensionally distributed in the general population
The Open Psychiatry Journal
The impact of ADHD and autism spectrum disorders on temperament, character, and personality development
American Journal of Psychiatry
The validation of psychiatric diagnosis: New models and approaches
American Journal of Psychiatry
DSM and the death of phenomenology in America: An example of unintended consequences
Schizophrenia Bulletin
Is Asperger syndrome/high-functioning autism necessarily a disability?
Development and Psychopathology
Does autism occurs more often in families of physicists, engineers, and mathematicians?
Autism
The prevalence of Gilles de la Tourette's syndrome in children and adolescents with autism
Journal of Child Psychology and Psychiatry
Autism, affective and other psychiatric disorders: Patterns of familial aggregation
Psychological Medicine
Postpsychiatry: A new direction for mental health
BMJ
A twin study of genetic relationships between psychotic symptoms
American Journal of Psychiatry
Asperger syndrome and autism: A comparative longitudinal follow-up study more than 5 years after original diagnosis
Journal of Autism and Developmental Disorders
Temperament as a unifying basis for personality and psychopathology
Journal of Abnormal Psychology
A new conceptual paradigm from genetics and psychobiology for the science of mental health
Australian and New Zealand Journal of Psychiatry
Autistic social impairment in the siblings of children with pervasive developmental disorders
American Journal of Psychiatry
Autistic traits in the general population: A twin study
Archives of General Psychiatry
The beginning of the end for the Kraepelinian dichotomy
British Journal of Psychiatry
Mutations in the gene encoding the synaptic scaffolding protein SHANK3 are associated with autism spectrum disorders
Nature Genetics
Infantile autism: A genetic study of 21 twin pairs
Journal of Child Psychology and Psychiatry
Cited by (31)
Pesky gNATs for children experiencing low mood and anxiety – A pragmatic randomised controlled trial of technology-assisted CBT in primary care
2022, Internet InterventionsCitation Excerpt :However, compared to research on both face-to-face and technology-assisted CBT for adults, the weight of evidence for technology-assisted CBT is considerably less for children, particularly in naturalistic settings for those aged 12 and under (Bachmann et al., 2010; Pennant et al., 2015). This may be attributable to several factors, including: transitional challenges from research-to-practice (Fleming et al., 2014; Grimshaw et al., 2012), variable stakeholder uptake of – and attitudes to – new technologies (Du et al., 2013), comparatively smaller overall numbers of randomised controlled trials (RCTs) involving children in real-world settings (Lau et al., 2016), poor understanding of comorbidity (Anckarsäter, 2010), and debates about the impact on traditional therapeutic alliance (Tremain et al., 2020). Additionally, there are concerns regarding the extent to which many interventions are genuinely CBT-based (Stawarz et al., 2018; Wolpert et al., 2019); and poor implementation strategies are reported across settings (Blandford et al., 2018; Mohr et al., 2017).
Growth imperatives: Substantiating a contested concept
2019, Structural Change and Economic DynamicsCitation Excerpt :However, there is no shared definition of ‘social coercion’ or ‘societal coercion’. Both terms appear with a wide range of meanings in the literature, from internalized social norms (role expectations and ‘duties’, decency, bad conscience, e.g., Yllo, 1990), social approval and disapproval (peer pressure, public opinion, e.g., McDermott, 2017) to institutionalized force (laws, military service, compulsory education, referral to psychiatry, e.g., Anckarsäter, 2010). To make social coercion a meaningful analytical term, we derive a more narrow definition (cf. Fig. 3).
Repint of “Reframing autism as a behavioral syndrome and not a specific mental disorder: Implications of genetic and phenotypic heterogeneity”
2018, Neuroscience and Biobehavioral ReviewsCitation Excerpt :In addition, as indicated in Table 2, many CNVs (deletion/duplication) observed in autism are also found in other psychiatric disorders strengthening the need to develop a dimensional and transnosographic approach in ASD research. More generally, children with neurodevelopmental problems, including ASD, are often affected in more than one area of functioning of mental health to the extent that hierarchies of mutually excluding categorical diagnoses have to be considered as conflicting with scientific evidence (Anckarsäter, 2010). It suggests, according to Anckarsäter (2010), that genetic susceptibilities behind mental health problems have to be sought both in relation to specific problem types and to general dysfunction, using multivariate analyses with assessments of different types of mental disorders.
Reframing autism as a behavioral syndrome and not a specific mental disorder: Implications of genetic and phenotypic heterogeneity
2017, Neuroscience and Biobehavioral ReviewsNo more psychiatric labels: Why formal psychiatric diagnostic systems should be abolished
2014, International Journal of Clinical and Health PsychologyCitation Excerpt :The frequency with which patients are given more than one diagnosis raises a concern about the specificity of diagnostic categories. Widespread co-morbidity (making more than one diagnosis in order to encompass patients’ problems) indicates basic deficiencies in our understanding of the natural boundaries of even the most severe conditions we are diagnosing (Anckarsäter, 2010; Middleton, 2008; Van Os, 2003a,b). It is also common to find the ‘dominant’ diagnosis changing in any individual, almost exclusively on a subjective rather than empirical (such as physical test results) basis.
Pathological publishing: A new psychological disorder with legal consequences?
2014, European Journal of Psychology Applied to Legal Context