Are “More” Categories Appropriate for Diagnostics?: Some Preliminary Concerns
Is “more” better? This question first sparked my interest as I watch a television commercial promoting a mobile phone service. The advertisement asked children “what is better having more or less”. In a series of non-sensible rambling, the child argued because people want more, more is better. Given this series of statements that both beg the question and appeal to the masses, the advertisement concluded that more is better. Of course, the advertisement represents a ploy to convince consumers to buy their products by appealing to the illogical cultural paradigm of overabundance or excess.
However, this commercial raises yet another interesting question concerning the issue of “more” accompanied with the value of better. In this case, I am intentionally asserting abstractions concerning valuation of the way people perceive the world around them. Every night, millions of television viewers tune it to watch international royalty, celebrities, high power executives, and debutants flaunt their lavish lifestyle for hundreds of cameras fighting to get only a mere glimpse. The valuation is therefore established as a myriad of assumptions that one is “better off”. Sapolksy (2005), among other researchers, have demonstrated that social hierarchy perpetuates this system of normative valuation that exacerbates the stress response given the lack of affiliation to the higher echelons of society. In other words, like the animal kingdom, common beliefs not only produce the desire to gain the above status but also contribute to physiological and psychological deficiencies in the onlooker (Lynch, Kaplan, and Shema, 1997). For this Dx Summit post, I will explore the concept “more” by considering the substantial increase in diagnostic categories over the course of the DSM development. It is my hope that I can introduce an issue of over-categorization. If this is true, what are its potential pitfalls in mental health?
Is More Better?
Why discuss the valuation “more” for this forum of the Dx Summit? “More” involves one primary question. Does “more” signify improvement/progress in the diagnostic process or does it merely suggest further uncertainty? Considering the value of “more” in reference to diagnostics, I raise questions of utility and functionality.
On the one hand, utility provides the diagnostic process with a general sense of usefulness to popular and civil society. This aspect of diagnostics, especially concerning DSM-5 development, embarked on an extensive journey of exploration and thought. According to the DSM-5, consulting and contributing personnel included mental health clinicians, neuroscientists, psychologists, patients, family, lawyers, advocacy groups, consumer groups, and a host of other individuals (APA, 2013). The primary goal involves attainment of a general consensus that will minimize stigma while producing an all-inclusive text. However, like any text, schema, or paradigm one must ask the age-old postmodern question of power and whose interest does it serve.
However, external to the postmodern question, we are still confronted with the problem of “more” as in the general sense of utility that reveals itself as useful to the masses. It is no secret that comorbidity was a primary problem of axial systems. As a solution to the problem, the DSM Task Force included comorbidity into the clinical considerations. As such, the clinician ought to consider additional diagnoses to include in case conceptualization. The nature of “more” therefore introduces another dimension to the issue of diagnostics vis-à-vis additional labeling. Interestingly enough, we can simplify comorbidity as being the solution to its own problem. Does additional labeling benefit the masses? In this case, I am not so sure. I will contend, however, that additional labeling does not promote well-being; rather, it promotes excessive lists of symptoms not directed towards the problem.
On the other hand, diagnostic functionality provides assurance that a feelings are not exclusive to the person. Far too often clients gain a sense of relief given that others can and are experiencing the same feeling. The sense of relief can bring someone to the point of tears with the knowledge that he or she is not alone. I cannot help but to wonder what are the psychological ramifications of such labeling. Quite often, clients talk of diagnoses as something external to themselves and biologically motivated. While we do not want to get into the habit of blaming the client for his or her affliction, clinicians would agree that coping with psychological trauma, dysfunction, and destabilization is half the battle. Certainly, it is not solely biological.
When is something too much? The nature of the question itself suggests both the culture of excess and a functional reliability directed towards continual consensus concerning disciplinary nomenclature. In reference to the latter, the proposition rests on the notion that such inclusiveness enables the DSM composers to produce a manuscript that attempt to take all perspectives into account. I will not argue this point at this juncture. The former, however, refers to a commonly held notion that we need to value that which is great, abundant, and excessive. Following this consideration, the DSM has now topped the charts at 347 distinct diagnoses. Several disorders, such as Mood disorders were grouped in DSM-IV are now separated into their own distinctive categories, some conjoined to develop spectral models, and some new categories. What purpose do the additional categories serve? At this point, it is unclear.
Does “more” diagnoses equate to a better? To answer this question we must consider the nature of diagnostics within the context of reaction to stressors. A client’s reaction to various forms of stress, in many ways, represents the way he or she perceives the world. Sapolsky (1994) identified four major manifestations of stress: Lack of control, Lack of predictability, Loss or lack of frustration outlets, or the perceiver interprets the event as getting worse rather than improving. In context, these four manifestations provide us with some interesting information within the client’s central concern. For example, some authors identified the lack of predictability or lack of control in anxiety, personality, and affective disorders. In addition, there has also been significant evidence to identify frustration outlets to the role of suicidal thoughts, mood disorder, and social isolation (Sapolsky 2004 and Lee, Ogle, and Sapolsky, 2002). Given that stressors and their reactions provide some useful information, “more” diagnoses seem to complicate matters rather than help the client. While on the surface, it would seem that the psychological manifestations support the separation into more categories, at least sufficiently. However, recent biological understanding of the Hypothalamic-Pituitary-Adrenal (HPA) axis demonstrates the relationship between and variety of pathological states (Van den Berg, Van Calster, Smits, Van Huffel, and Lagae, 2008; Young, 2004; Sapolsky, 1999). As such, the question of “more” categories seems to present some real problem.
The primary concern presented here involves the nature of “more” as it relates to the DSM. The question being: Is “more” better? I presented this question given that development of DSM ushered in an era of increased labeling. However, one would have to wonder if the increase of diagnostic categories in conjunction with comorbidity further complicates an issue rather than provide clarity. The current edition of the DSM-5 attempts to account for biological, psychosocial, developmental, neurocognitive, and other aspects of pathology. However, if we consider the nature of pathology concerning varying manifestations, I cannot help but to question the necessity of adding “more” categories. I would have to wonder if we fully understand the nature pathology or are we merely making the waters muddy? Given the conflicts in cognitive, psychosocial, and biological research, “more” diagnoses seem problematic and questionable.
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