Abstract
The field of mental health continues to struggle with the question of how best to structure its diagnostic systems. This issue is of considerable ethical importance, but the implications for public health approaches to mental health have yet to be explored in any detail. In this article I offer a preliminary treatment, drawing out several core issues while sounding a note of caution. A central strand of the debates over diagnosis has been the contrast between categorical and dimensional models, with renewed attention due to recent publication of the DSM-5, launch of the RDoC, and ongoing work on the ICD-11. This dispute involves an interesting assortment of ethical and empirical considerations, many with direct relevance for public health. It has been proposed, for example, that dimensional diagnosis may be morally preferable because it can help reduce the stigma associated with mental disorder. This is a pressing concern, as preventive strategies are expanded in mental health, often operating under dimensional assumptions that target various risk factors. But this type of proposal relies upon an empirical claim and the scientific status of dimensionality remains unresolved, including its relation to stigma. I suggest, then, that the current state of the evidence does not yet warrant clear adjudication between competing frameworks, and thus any implications for public mental health remain highly provisional. More research is needed to help resolve these issues, including ethical analysis.
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Notes
Though not discussed here, this combination of factors makes it essential for public mental health to engage questions regarding social justice [10].
There are public health initiatives targeting many different psychiatric conditions, including depression, anxiety, and suicidality [18]. The present discussion has a relatively narrow scope, largely restricted to psychosis.
The dimensional measure includes five traits – negative affectivity, detachment, antagonism, disinhibition, and psychoticism – and 25 specific features of abnormal personality, each of which represents the maladaptive end of a continuum [11].
APS is in effect a distilled version of the definition of schizophrenia, requiring the presence of delusions, hallucinations, or disorganized speech but with lower thresholds for severity and frequency [11]. The DSM-5 also includes a psychosis severity scale made up of eight dimensions that are each scored for severity (0–4): hallucinations, delusions, disordered speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania.
The ICD-11’s proposed classification for personality disorder includes the possibility of rating the severity of five personality trait domains: negative affectivity; detachment; disinhibition; dissociation; anankastia [14]. The proposed rating scale for psychosis has six symptom domains: positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, and cognitive symptoms [33]
Other worries, for example, have to do with the soundness of the constructs themselves, especially given their conceptualization as the work of highly networked ‘mechanisms’ [36, 37]. The RDoC’s authors acknowledge that the constructs are likely to be substantially inter-related and will admit of further fractionation [38]; additional interdisciplinary research should help further stabilize the constructs across divergent methodologies [39].
While usage varies by discipline, the following generally holds: a ‘dimension’ is a latent variable that functions along a continuum, identified through factor analysis; a ‘continuum’ is a sequence of quantitative differences running from normal to abnormal, typically defined in behavioral or neural terms; and a ‘spectrum’ is a graded variation in outcome for individuals with similar genetic risk.
To date, no universal preventive strategies have been applied to psychosis. Interesting future possibilities include the targeting of perinatal development and neuroinflammation with nutritional supplements or environmental stressors with school-based interventions [45].
Most patients are referred to first episode psychosis services by other community mental health teams, including crisis teams and child and adolescent services, as well as psychiatric hospitals [47]. Outside of early detection and intervention services, pathways to care for psychosis tend to begin in primary care, hospitals, and the criminal justice system [48].
This is similar to what others have called the ‘mixed blessings model’ [88], with biogenetic models associated with reduced ascriptions of responsibility and blame but increased avoidance and other stigmatized attitudes.
An important issue in the debates over demarcation that is not discussed here concerns the search for biomarkers and related questions about reductionism.
Neither of these reviews examined the distinction between diagnostic approaches, but both had findings with potential relevance. The first found that worries about ‘not being normal’ were an obstacle to help seeking [96]. The second identified a number of themes associated with pathways to care, including a ‘sense of difference’, which was related to feelings of ‘not being normal, something is wrong’ (in at-risk patients) and having a ‘mental illness’ (in first-episode patients) [98].
This kind of claim is typically made in the context of genetic testing [101]. Interestingly enough, a recent small qualitative study asked at-risk patients about their views on genetic risk and found that general fears about diagnosis were reported, as well simultaneous feelings of relief and empowerment from having an explanation; there was also a willingness to share information with friends and family, as well as with employers if there was strong genetic risk [102].
The first analysis identified two higher lever factors, affective and non-affective, and six lower level factors: hallucinations, delusions, negative symptoms, disorganization, mania, and depression [113]. The second identified one ‘general psychosis factor’ alongside five separate symptom-specific factors: positive, negative, disorganization, mania, and depression [114].
These issues are not unrelated to the ongoing debate over whether the identified risk factors are predictive only of psychosis or are transdiagnostic (see target article and commentaries [120]).
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The author would like to thank Peter Zachar and two anonymous reviewers for helpful comments on earlier drafts of this article.
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Cratsley, K. The Ethical and Empirical Status of Dimensional Diagnosis: Implications for Public Mental Health?. Neuroethics 12, 183–199 (2019). https://doi.org/10.1007/s12152-018-9390-7
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DOI: https://doi.org/10.1007/s12152-018-9390-7