Osocial Anxiety Disorder. Obsessive-compulsive disorder. Major depressive disorder. Borderline personality disorder. Post-traumatic stress disorder. Generalized anxiety disorder. There are many labels that describe mental health problems. You may have experienced some of these difficulties yourself or know someone who has. You or someone you know may even experience several of these difficulties at the same time.
Take "Jane" as an example. Jane was a shy and anxious child, and now, as a young adult, she lives with a combination of social anxiety (fear of negative evaluation), generalized anxiety (constant and uncontrollable worry), and depression (low mood and loss of pleasure). Many probably think of Jane's problems as individual disorders, but what if they are not individual difficulties but manifestations of a general and underlying mental health problem that waxes and wanes over time?
When I started my clinical psychology training, psychological difficulties were presented as separate categories of disorders, probably because that was the best way to organize information about mental health. However, once I started working with people in therapy, it quickly became very clear that this system was not appropriate—most of the people I worked with would meet the criteria for multiple official diagnoses. I was wondering how I was going to integrate information from multiple treatment guidelines in a way that would effectively deal with the many challenges many of my clients had.
Despite the need for guidelines to support decisions about who "has the disorder and who needs treatment", the categorical diagnostic system no longer serves its purpose. There is a mismatch between research and public policy, on the one hand, which are often based on a categorical system, and, on the other hand, what it really means to live with mental health problems and work in everyday clinical practice. . It is inappropriate or wrong to place the experiences of many people in convenient diagnostic categories. Clinicians and people with a lifetime of mental illness have known this for decades, but it is only recently that researchers have begun to take notice.
This is why the emerging “transdiagnostic approach” to mental health is potentially so important. He defines mental health along a continuum; according to this view, we all share the psychological processes such as irrational beliefs, anxiety, and bad moods that underlie so-called "disorders," but we exhibit them to varying degrees. This helps explain the apparent overlap between traditional disorders and better understand the wide range of mental health experiences, from the more common day-to-day stresses and anxieties that almost everyone understands, to anxiety, mood, psychotic disorders, or eating difficulties that interfere with one's ability to function in daily life. The transdiagnostic approach promises to shed light on the common factors underlying poor mental health in order to improve classification, research into biopsychosocial processes, and development of treatments. If the current formal diagnostic system is not up to the mark, you may be wondering why it has been around for so long. What are the benefits and challenges associated with maintaining this system? To be fair, it's not all that bad. This helps us figure out who has the "disorder" and who needs treatment, as well as how to group volunteers for clinical trials and other types of research.
The categorical approach emerged in the late 19th century when mental health professionals—at that time mostly psychiatrists and neurologists—wanted to find a way to describe the difficulties their patients faced. The approach they took reflected other classification systems that emerged in that era in biology and medicine, in which sets of symptoms were grouped together and their beginning and end, course, and outcome observed as a way to formalize diagnostic categories.
The compendium der Psychiatrie (1883) by the German psychiatrist Emil Kraepelin attempted to describe mental illness and was particularly influential. In particular, in the sixth edition, published in 1899, he distinguished between manic-depressive psychosis and dementia praecox, laying the foundation for how we now distinguish between affective syndromes (such as bipolar disorder) and non-affective syndromes (such as schizophrenia). But it is significant that Kraepelin himself was not satisfied that these descriptions cover what he observed in his patients, claiming that they fix
the general presence of a mental syndrome, but that the boundaries of this syndrome are not clearly defined.
More than a century later, we are still trying to resolve these issues. Over the decades, two guidelines that embody the categorical approach to mental health, the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classification of Diseases, have been repeatedly revised. ICD) published by the World Health Organization (WHO). The DSM, now in its fifth edition (DSM-5), and the ICD, now in its 11th edition (ICD-11), cover a huge number of possible diagnoses - there are 541 diagnostic categories in DSM-5!
Diagnostic manuals have created an "epistemic prison".
These manuals have retained their authority in recognizing and classifying mental health problems with a large set of labels for describing individual experiences of psychological symptoms. However, there are also many published critiques of these systems as practitioners and researchers balance working in medical settings somewhat related by these categories and creating a new way of working that does not adhere strictly to diagnostic labels.
For example, Stephen Hyman, a neuroscientist at Harvard University and former director of the U.S. National Institute of Mental Health (NIMH), has suggested that diagnostic manuals have created an "epistemic prison," a self-replicating system between classification systems and clinical research. He was referring to the fact that while individual disorders do not reflect the clinical reality of mental health problems, they continue to shape research agendas and policy decisions, which in turn determine funding for research based on the categorical diagnostic system. For example, in the UK, treatment guidelines for depression published by the National Institute for Health and Excellence (NICE) are based on specific depression data and in turn guide depression policy and practice, although there are also calls for funding that fall back. from research on specific disorders.
"What good is it that they have names," said Gnat, "if they won't answer them?"
"It's useless from them," said Alice. “But I suppose it's useful to those who call them. If not, why do things even have names?
As Lewis Carroll suggests in Through the Looking-Glass (1871), names are only useful to the extent that they serve a purpose for those who use them. Diagnostic systems have been and remain useful in certain situations, but the reality is that in many cases they are inadequate. One of the main functions of the categorical diagnostic system is to provide guidance to clinicians, researchers, health systems, and policy makers regarding the signs and symptoms of mental health problems, and to define thresholds for the level of distress and impairment that differentiate "normal" from "abnormal".
If diagnostic categories are useful descriptors, they will facilitate communication and understanding in clinical settings and research. It is true that for many people the right label for their mental health problems can be incredibly important and help them find the right professional and peer support. For example, someone who has experienced a traumatic event, such as a car accident, may take comfort in the fact that flashbacks, nightmares, and feelings of anxiety or dread are an understandable and treatable reaction called "post-traumatic stress disorder." But while diagnostic labels can be valid for a person if they correctly describe their problems, receiving a diagnosis that does not accurately reflect the problems a person is facing, or potentially misidentifies their cause, is frustrating and stigmatizing.
Stigma can be especially problematic in disorders previously considered "incurable" by psychiatrists. For example, a number of "personality disorders", including borderline personality disorder and paranoid personality disorder, describe persistent states and patterns of emotions and behaviors that were long thought to be exclusively related to a person's personality, but are now better understood as reactions to difficult life experiences and/or early trauma.
There are three more main problems for the existing categorical diagnostic system. First, "comorbidity" or the presence of two or more diagnoses at the same time. It is estimated that 57-81% of people diagnosed with one so-called "general mental health problem" also have a separate separate diagnosis of another problem at the same time. Some suggest that this comorbidity is actually a misnomer
a term that arose as a result of the diagnostic system, and not referring to multiple comorbidities.
Secondly, heterogeneity - differences in the manifestation of symptoms of "the same disorder". One study, for example, suggests that there are up to 10,377 unique ways to qualify for a diagnosis of major depressive disorder. Third, variability is that the manifestations of mental health problems vary throughout life, but it is likely that people experience manifestations of similar underlying problems rather than completely different disorders.
Diagnostic tags are designed to help people access appropriate services
All of these problems suggest that it is very difficult to group symptoms in a meaningful way. However, it would be useful to inform about treatment if we could better recognize and treat the underlying pathologies. Imagine how difficult it would be to recognize and treat the flu if it were classified as "cough", "fever" and "runny nose"? Similarly, in relation to mental health, we could think of "general distress" as some combination of "low mood", "anxiety", "sleep problems", "appetite changes", "irritability", and "difficulty concentrating" (to name a few) that have an overarching commonality not adequately covered by the criteria for depression or generalized anxiety alone.
So why might a transdiagnostic approach be an important and suitable alternative to the current system, and what are some of the recent and ongoing developments in this exciting area of research? Many of the "recent" advances in transdiagnostic thinking about mental health issues are not new, but their implementation in policy and practice has been slow. One of the pioneers of this approach was the clinical psychologist David Barlow, who, along with colleagues at Boston University, helpfully summarized how things evolved from general psychotherapeutic approaches before the 1950s to the subsequent proliferation of specific psychological treatments for individual disorders thereafter. decades. In 2004, he and colleagues presented an explicit argument for "unified" treatments for emotional disorders based on transdiagnostic theory and treatment principles, citing some of the same evidence for common causes and processes that I presented in this essay, as well as on the practical problems associated with multiple individual treatment approaches.
There are many proponents of the no-diagnosis approach today, which uses a "clinical formulation" to integrate psychological theory with a mapping of individual experience to help understand it. For example, a doctor's understanding of the processes that maintain anxiety and low mood, such as useless thinking patterns and withdrawal from situations, can help a person see patterns in their own difficulties. Understanding the relationship between life experiences and mental health challenges can seem daunting, but the idea that many of the symptoms of mental health problems are intelligent responses to stress is not new, and psychologists have championed it for many years.
At the service and policy level, diagnostic labels are designed to help people access appropriate services that have the expertise and resources to help with their specific problems. They also help with decisions about where to allocate funding for research and treatment, including access to health insurance in the US and thresholds required to access specialist public health services in the UK and Australia. For example, the NICE guidelines inform evidence-based practice in the UK, and while there is some recognition of the overlap of conditions and the heterogeneity of people's experiences, most treatment recommendations are still presented in a disorder-specific format, as if they were separate conditions.
And although the categorical diagnostic system may no longer serve its purpose, relatively little progress has been made in its improvement. The main problem is to find a viable alternative. Should we improve the current categorical system to better reflect clusters of mental health experiences readily encountered in clinical practice by promoting clinics and programs that better account for overlapping symptoms such as "emotional distress" rather than separate clinics for "mood"? anxiety and personality disorder? And if we develop trauma services that integrate alcohol and substance abuse treatment programs instead of treating them as separate issues? Should we aim for a hybrid system that bridges the gap between categories
Orial diagnostic systems and dimensional transdiagnostic systems? Or should we completely abolish boundaries and move to a purely spatial approach where any mental health problem can be managed with varying program intensities depending on the severity of the problems and their impact on functioning? I don't have answers to these questions, but large groups of mental health researchers and data scientists are working on some potential solutions. with varying program intensities depending on the severity of the problems and their impact on functioning? I don't have answers to these questions, but large groups of mental health researchers and data scientists are working on some potential solutions. with varying program intensities depending on the severity of the problems and their impact on functioning? I don't have answers to these questions, but large groups of mental health researchers and data scientists are working on some potential solutions.
One such approach is the Hierarchical Taxonomy of Psychopathology (HiTOP). It is a proposed model by an international consortium of more than 70 classification researchers, quantitative data scientists, psychologists and psychiatrists who aim to map relationships between a wide range of mental health problems. They aim to address the limitations associated with categorical diagnostic systems for theory, empirical research, and clinical practice by examining the building blocks of individual mental health and patterns in data to extract more general syndromes and higher order factors. A key strength of the HiTOP approach is that it allows mental health problems to be described according to specific signs/symptoms, symptom components, syndromes (which map to categorical diagnoses), and other higher order factors that consider the common elements of syndromes. .
For example, a person may experience low mood, anxiety, fatigue, insomnia, and symptoms of physical panic, which may be related to major depressive disorder, generalized anxiety disorder, and panic disorder syndromes; more broadly, under the sub-factors of distress and fear; and, collectively, under the "internalization" of spectra. This can be compared to physical health metabolic syndrome, which is a descriptor for the combination of diabetes, high blood pressure, and obesity. Descriptions at these different levels can help explain the various manifestations of symptoms and comorbidities, providing guidance for individualized symptom networks as a unified framework for clinical formulation. There is strong evidence to support this approach based on epidemiological studies with massive samples showing how often different mental health symptoms occur simultaneously, including a recent study that demonstrated clustering of symptoms among so-called "internalizing disorders" (such as anxiety and depression). ) and "general psychopathological factor". Questions are currently being raised about how these data-driven approaches can help guide clinical decision making based on the intervention threshold and the type of intervention that would be appropriate.
Clinical decisions about therapy goals can be made on the basis of processes that maintain a person's difficulty or distress, and can be studied outside the diagnostic framework. In fact, research looking at common factors across diagnostic boundaries suggests that very few biological or cognitive processes are unique to individual diagnoses. One such research structure that has received significant support is NIMH's Research Domain Criteria initiative, which aims to move away from categorical systems and instead stimulate research and provide evidence for transdiagnostic biopsychosocial processes relevant to mental health.
It is important to study the processes at these different levels of analysis in order to obtain comprehensive information about the causes and supporting factors of poor mental health. We already have some reasonable evidence that, according to genetic psychiatrist Jordan Smaller and colleagues, "our genes don't seem to read the DSM" (i.e. the same genes are involved in multiple disorders), further supports the need move on to a transdiagnostic conceptualization of mental health. Exciting and large-scale studies are currently underway to further explore the genetic links to anxiety and depression.
In a similar but more specific scheme, a group of British clinical psychologists led
e with Allison Harvey in 2004 summarized several cognitive-behavioral processes that are characteristic of various manifestations of mental health problems. The processes they identified, such as selective attention to negative stimuli, negative biases in the interpretation of ambiguous information, avoidance of situations, and safe behavior to reduce negative feelings, were present in various problems such as depression, anxiety, and stress-related disorders, and are relevant at least for the four "traditional categorical disorders", paving the way for research and clinical practice targeting these factors.
Today, there are also evidence-based interventions such as thought-focused cognitive behavioral therapy or memory flexibility training that target other processes that underlie multiple “disorders,” including repetitive negative thinking, fear avoidance, and excessive general memory, and these are just some of them. They target the cognitive mechanisms that support mental health problems, rather than more distant causative factors or direct reduction in symptoms.
In identifying relevant transdiagnostic processes, the focus is on function: that is, whether the process is "adaptive" or "normal" with respect to psychological functioning, and whether we have the ability to intervene. Imagine investigating the factors that caused the plane crash. Gravity is definitely related to an airplane falling out of the sky, and probably related to engine failure as well. However, in terms of preventing accidents in the future, it's best for us to focus our efforts on improving the engine of the aircraft, and not on counteracting gravity! Similarly, while we cannot easily change someone's early life experience or temperament, we are likely to get some support in changing processes that are not helpful in the present, such as repetitive negative thinking styles, memory distortions, and avoidance behavior.
There is an ongoing debate about how to accurately define functionality in terms of process or content. If we look again at Jane's example, we see that she may have been bullied a lot in her youth, and understandably focuses on other people's behavior and reactions to protect herself. However, despite her current context as a bully-free working adult, her focus is still shifted towards social menace, which contributes to her experience of social anxiety disorder and depression. Jane's attention processes are probably in perfect working order, so in this context it would be more fruitful to focus on her adaptive or non-adaptive beliefs—the content rather than the function of mental processes.
Of course, none of this research or development in transdiagnostic approaches is meaningful without the goal of ultimately improving how we understand, evaluate, and treat or manage mental health problems. As I mentioned at the beginning, many of the interventions were based on the expertise of clinicians working with people with mental health problems. Interestingly, eminent clinical psychologists such as Barlow emphasized that many of the early psychological interventions were not tied to specific diagnoses, and that it was only in the last few decades, with the proliferation of research bunkers and the publication of specific treatment guidelines, that disorder-specific approaches , dominated.
Optimization of the structure of therapy is aimed at the effective treatment of a group of difficulties
Unfortunately, even our best psychological interventions currently achieve a recovery rate in only 50-80 percent of people who experience general mental health problems, and people with multiple diagnoses feel much worse. Interventions targeting specific disorders are limited in scope and effectiveness, especially in cases of comorbidity, heterogeneity and variability. If we look at Jane's treatment options (social anxiety, generalized anxiety, and depression), she could be offered three different evidence-based, physician-led, or self-directed treatments, but that doesn't seem like an efficient use of resources. , not to mention the large expenditure of time, finances and emotions.
We can do better. Transdiagnostic treatment approaches are gaining popularity and attempt to provide evidence and formalize how experienced mental health clinicians synthesize components from treatment guidelines and formulate difficulties in order to tailor treatment to specific individuals. Universal transdiagnostic therapies such as the Unified Protocol for Emotional Disorders and transdiagnostic group cognition
Behavioral Therapies for Anxiety Disorders target a number of factors common to all common mental health problems. Alternatively, modular approaches such as MATCH (Modular Approach to Therapy for Children with Anxiety, Depression, Trauma or Behavioral Problems) and Healthy Mindset can be used to offer options for selecting appropriate evidence-based treatment components to personalize the structure of the treatment course. While the content of the treatment has always been adapted, the optimization of the therapy structure aims to effectively treat a group of difficulties. There are many challenges in developing and disseminating these approaches, the most relevant of which are ways to determine the most efficient way to make treatment decisions that maintain treatment accuracy, as well as appropriately tailor assessment and intervention.
The goal of the transdiagnostic approach is to develop appropriate theories that explain mental health problems in a clear and adequate way that will guide classification, research, and treatment. The development of many psychological interventions—cognitive behavioral therapy, acceptance and commitment therapy, dialectical behavior therapy, and psychoanalysis—came out of clinical discovery. In addition, many of these approaches have proven effective in a range of disorders, as have psychoactive drugs such as selective serotonin reuptake inhibitors and benzodiazepines. Bridging the translation gap will be important for the development of the field as a whole. As psychological science works to develop transdiagnostic approaches to better classify and understand mental health problems, we must acknowledge the bidirectional relationship between science and practice.
Let's go back to Jane for the last time and the treatment options that may be available to her. There are many different ways her symptoms interact, and it would be important to determine what is most important to her. For example, it may be that her anxiety in social situations is the most debilitating, so perhaps we would like to target that first by exploring the thoughts, feelings, and behaviors that come up in social situations, and then designing some behavioral experiments to test accuracy. her beliefs and expectations. Reflecting on these observations—the discovery that many of her worst fears are not coming true—could help develop more useful and accurate beliefs.
For people like Jane who have multiple difficulties, it is also helpful to encourage the generalization of psychological skills applied to one problem to other problems, such as testing catastrophic predictions with generalized anxiety or re-engaging in daily activities, hobbies, or social events in daily life. life. behavioral activation in depressed mood. The idea is that by addressing relevant cognitive and behavioral processes in one area, it will have indirect benefits for other areas of her life and functioning. Cognitive behavioral therapy lends itself well to this approach because the underlying methods and principles are transdiagnostic, amenable to application to comorbid and heterogeneous difficulties, but this guidance is often missing from standard treatment guidelines.
Thus, the transdiagnostic approach looks promising. But this is not a panacea. There are a number of challenges ahead of any paradigm shift, not to mention one that aims to redefine the mental health space and dramatically improve how we manage and treat mental health issues. In advocating for changes in mental health science, policy and practice, we could focus on a softer approach that aims to build bridges between diagnostic and transdiagnostic approaches that may be more acceptable in the short term. Alternatively, a harsher and more radical paradigm shift that completely abandons traditional diagnoses and promotes a "true" transdiagnostic or adiagnostic alternative may better capture the complexities involved in describing mental health. Currently in the UK, NICE guidelines focus on individual disorders. Instead of abandoning them entirely, an integrated approach that recognizes the usefulness of treating a particular disorder while also including transdiagnostic ideas may be the path of least resistance. This will create a workable and viable alternative as the field develops.
Finally, transdiagnostic research and practice is not immune to the risk that treatment guidelines will become so widely disseminated that it will become even more difficult for therapists and consumers to make decisions. Coord needed
dedicated efforts to ensure the effectiveness of treatment development and proper dialogue with scientists, clinicians and service users. In particular, our studies should be designed to identify the potential “added value” of transdiagnostic treatment, as well as broadly evaluate not only self-reported symptoms, but also quality of life, general processes, important individual outcomes, and cost-effectiveness.
Overall, we need to better reflect the personal and clinical realities of common mental health issues, ultimately improving the understanding and treatment options available to people who experience mental health challenges. Transdiagnostic approaches potentially offer a promising path forward, but there is a long way ahead of us and we can only move forward with a coordinated group of travelers.