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Lecture 1, literature
Coghill, Edmund, Categories versus dimensions in the classification and conceptualisation of
Sonuga- Barke child and adolescent mental disorders – implications of recent empirical
study
Key question - Whether mental disorders should be classified and conceptualised in
categorical or dimensional terms
In this article - 1) describe the nature of the category/ dimension debate and its
influence on current models of classification
- 2) understand the practical, political and philosophical origins of the
current category based system and its implications for clinical
practice and scientific enquiry
- 3) distinguish these philosophical and practical issues from the
empirical question about the existence of categories of disorder as
discrete causal entities
- 4) review the empirical data directly addressing these empirical
questions
- Explore the implications of these data for approaches to
classification and diagnosis in the light of the upcoming DSM-5 and
ICD-11 systems
Lecture definitions
Categorical - Regard mental disorders as qualitatively different from variation
across the normal range of expression in the population, and as
having their own pattern of rather distinct causes
- Disorders differ from normality in both degree and kind
Dimensional - Regard mental disorder as an extreme expression of normal
variation in the population and emphasise continuity in underlying
causes
- Disorder and normality differ only in degree but not in kind
Section 1: Current - First attempts to introduce more formal and universal diagnostic
category-based criteria, guided by attempts to promote clear communication,
approaches and reliability, validity and consistency of application across clinicians
dimensional who often held very different views of the causes of disorder
alternatives to - There was an era of classification
classification of - There was an attempt to shift away from a psychodynamic approach
child and to mental health and illness with vague boundaries towards a more
adolescent mental scientific approach which shared a common frame of reference with
disorders mainstream medicine category based approach
- The introduction of this category-based approach with its clear and
A.Braam, Tilburg University
, explicit criteria for making a diagnosis meant that identifying the
presence of a disorder changed, at least in theory, from something
of an art-form linked to the nuanced interpretations of symptom
meaning, to a more technical task involving the application of
algorithms based on ‘data’ from systematic observation
There are political, economic, sociological and psychological reasons why
these systems have come to hold such a strong position in the field
1. Practical clinical reality
- It is a clinician’s job to make difficult practical decisions about
whether an individual should or should not receive specialist health
interventions and which interventions they should receive
- By definition these are categorical decisions
2. Politics and economics
- it is important for both the advocates of the diagnosis and treatment
of child and adolescent mental health problems and those who
campaign against their existence to be able to point to the label and
diagnostic criteria – even where the ultimate aim is to dismantle
these same criteria
- it is easier to justify the need for clinical care if one can associate this
need with a discrete diagnostic entity
- no diagnostic label can form a barrier to funding treatment
3. Psychology
- Humans are natural categorisers
Issues associated - Comorbidity is common in childhood mental disorder and the
with heterogeneity relationships between disorders is complex and appears to work
and comorbidity against the concept of disorders as discrete entities with clear
boundaries
- The problem here is that if one seeks to reduce comorbidity by
reducing categories, one is faced with increasing levels of
heterogeneity and vice versa
Heterogeneity - Not everybody with a disorder has the same pattern of symptoms or
even defining features
- These criticisms have been accompanied by calls to abandon current
category-based approaches
Theoretically - Symptoms that share the same cause should be seen as indicating
driven position (as the same disorder
in medicine) Problems with this approach
1. It was proven that causal factors do not map on a one to one basis
with other indicators of disorder-integrity such as treatment
response or prognosis (one cause can lead to different prognoses)
2. Failure to find different estimates of heritability at either extreme of
the continuum clearly supports a dimensional rather than a
categorical model of ADHD
Different - These propose either:
dimensional 1. The replacement of specific categorical disorders with
approaches equivalent dimensional concepts
2. The wholesale replacement of the current categorical structure
with an common set of empirically derived dimensions
representing the major aspects of behaviour and cognition that
can lead to impairment and distress
3. A mixed approach whereby both dimensions and categories are
A.Braam, Tilburg University
, used alongside each other
2 broad-based 1. Externalising
dimensions of 2. Internalising
disorder
Scales - There are symptoms that do not readily map onto particular
diagnostic categories
- Scales can therefore be used more flexible than categorical systems
The 3rd approach: 1st way: both approaches are used together within the same class of
using a behaviour
combination of - Allows identification of those who are subthreshold for diagnosis
categorical and and gives a clear picture of an individual’s standing on each
dimensional dimension
systems Problems
- one could ask what relevance the diagnostic category has if it can be
trumped by the dimensional data
- It is also the case that if such an approach was adopted into clinical
practice, there would be many difficult choices to make for those
cases that were at the borders either dimensionally and/or
categorically
2nd way different classes of problem are described differently
- E.g. antisocial behaviour requires a categorical approach, whereas
those with ADHD require a dimensional approach
Problems
- Using the categorical approach is familiar, but when do clinicians use
the dimensional approach?
Section 2: The Important distinctions between different levels of analysis and different
category/dimensio usages:
n debate: 1. Practical level Clinician must be categorisers to some degree
important 2. The practical need to categorise must be distinguished from a
distinctions second level whereby the distinctions drawn between those in need
between practical of treatment are considered to reflect a discrete causal entity
necessity, meta- - Essentialists : argue that mental disorders reflect objective
theoretical underlying causal realities that are independent of human values
convictions and - Nominalists : argue that psychiatric disorders reflect deviations from
empirical reality socially constructed prescriptions for behaviour and that there are
no objective means of demarcating normality from abnormality
3. Relationship between categorical approaches and diagnosis
according to DSM 5 need to be understood
4. we need to distinguish these practical (I need to distinguish X from Y
so X get the right treatment) and meta-theoretical levels (the
conviction that X differs in both degree and kind from Y) from the
empirical question – ‘Is X a member of a discrete category that is not
only quantitatively but also qualitatively different from the category
which Y inhabits?
5. The category/ dimensions debate is of as fundamental importance
for clinical scientists too as it is for clinicians (determines how they
do they job)
6. we need to understand how categories operate at the intercept
between the clinic and the laboratory
Section 3: - there have been several important developments in data analysis
Statistical that have started to impact on our ability to describe more
A.Braam, Tilburg University
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