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Received: 31 July 2022
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Accepted: 15 September 2022
DOI: 10.1002/jcv2.12108
RESEARCH REVIEW
Seven reasons why binary diagnostic categories should be
replaced with empirically sounder and less stigmatizing
dimensions
Benjamin B. Lahey
1
|Henning Tiemeier
2
|Robert F. Krueger
3
1
Department of Public Health Sciences (MC
2000), University of Chicago, Chicago, Illinois,
USA
2
Harvard T. H. Chan School of Public Health
and Erasmus University Medical Center
Rotterdam, Boston, Massachusetts, USA
3
University of Minnesota, Twin Cities,
Minneapolis, Minnesota, USA
Correspondence
Benjamin B. Lahey, Department of Public
Health Sciences (MC 2000), University of
Chicago, Chicago, IL 606037, USA.
Email: blahey@uchicago.edu
Abstract
Background: An ongoing positive revolution advocates a new approach to the in-
dividual differences in human emotions, cognitions, and behavior that cause distress
and impair functioning. This revolution endorses the long‐proposed, but still unre-
alized rejection of the medical model, which attributes psychological problems to a
sick brain or mind. In addition, it advocates replacing the binary diagnoses used in
ICD and DSM, which assume a clear discontinuity between “normal” and “abnormal”
functioning, with continuous dimensions of psychological problems.
Method: Selective literature review.
Results and Discussion: Seven strong reasons are provided for adopting a dimen-
sional approach.
KEYWORDS
dimensional approach, stigma, taxonomy
Many psychologists and psychiatrists (Kotov et al., 2022;
Lahey, 2021) believe that a tipping point has been reached in an
ongoing revolution that advocates a new understanding of the indi-
vidual differences in human emotions, cognitions, and behavior that
cause distress and impair functioning across the life span. This rev-
olution involves two key changes: First, it endorses the long‐
proposed, but incompletely enacted, abandonment of the medical
model, which attributes psychological problems to a sick brain or
mind (Bandura, 1969). We use the term, psychological problems, in this
paper with the same denotative meaning as psychopathology, but we
explicitly reject terms like psychopathology, mental disorder, and
mental illness because their connotative meanings cause stigma by
implying that the person is no longer whole, but has a has sick mind
(Lahey, 2021). We do not mean that psychological problems are the
purview of only psychology rather than other disciplines. Further-
more, we certainly do not support a Cartesian mind‐body dichotomy
that implies that advances in neuroscience and genetics do not help
us understand psychological problems (Lahey, 2021). Individual
differences in behavior are always accompanied by individual
differences in brain and related systems, but it is unnecessarily stig-
matizing to view such differences as illness.
Second, this revolution advocates replacing the binary diagnoses
used in ICD and DSM
1
with continuous dimensions of psychological
problems. Diagnoses assume that there is a clear discontinuity in which
a person is either “abnormal” (i.e., meets criteria for a diagnosis) or is
“normal” (i.e., does not meet criteria for a diagnosis). There are no
shades of gray in ICD and DSM diagnoses, even though there are
nothing but shades of gray in reality. In sharp contrast, the assertion
of dimensionality avers that there is continuous variation in the
frequency and severity of problems—and the distress and functional
impairment associated with them—across the full range of each
dimension and that there is no natural or meaningful binary threshold
between “having” or “not having” a psychological problem.
Child and adolescent psychologists and psychiatrists have used
dimensional measures for many years (Achenbach et al., 1989;
Quay, 1986). Thus, many in the field are already comfortable with
dimensional assessments of psychological problems. Even if moving
from categorical to dimensional assessments of psychological
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© 2022 The Authors. JCPP Advances published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.
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https://doi.org/10.1002/jcv2.12108
problems feels like a major paradigm shift to some, however, it is a
necessary revolution that will be well‐worth the effort.
SEVEN REASONS FOR ADOPTING A DIMENSIONAL
APPROACH
The most compelling reasons for shifting from categories to
dimensions of psychological problems are:
Psychological problems are empirically dimensional
The categorical versus dimensional status of psychological problems
has been the focus of numerous investigations using sophisticated
statistical modeling to compare the fit of categorical and dimensional
models to data. This literature overwhelmingly supports dimensional
models of psychological problems. Haslam and colleagues presented
the results of an extraordinary meta‐analysis of 183 articles using
taxometric methods (methods designed to identify a category, should
a category exist in data), and found consistent support for dimen-
sional structures (Haslam et al., 2020). Latent variable modeling
approaches to this issue also reach the same conclusions (Krueger
et al., 2018). Psychological problems are empirically dimensional, and
adoption of categorical approaches runs counter to an extensive
literature supporting dimensional approaches via direct comparison
with categorical approaches.
In addition, findings from genomic‐wide association studies have
firmly established that all psychological problems studied to date are
polygenic (Smoller et al., 2019), which means that they are influenced
by the net presence or absence of large numbers of genetic poly-
morphisms, which each account for a very small amount of genetic
variance in the phenotype. This is important because R. A. Fisher
demonstrated mathematically that under plausible assumptions even
modest polygenicity results in a normally distributed continuum of
genetic risk (Fisher, 1918). This implies that every person has a value
somewhere—from very low to very high—on every continuum of
genetic liability for every kind of psychological problem. When
manifestations of such genetic liability transact with the environ-
ment, the result is some level of manifest problems on the continuous
phenotypic dimensions (Plomin et al., 2009).
Dimensions are more reliable than binary categories
The assessment of psychological problems requires measuring human
behavior. To best serve people seeking help, therefore, we must use
the most reliable measures. Reliable measures are ones that appraise
people similarly each time they are assessed within a short time
frame by the same or a different assessor. Reliability of measurement
is not an abstruse issue; rather, it affects everyday efforts to help
persons whose behavior is causing them misery and harming their
lives.
Both categorical and dimensional approaches to measurement
must deal with an inherent lack of perfect consistency in what people
say about their own psychological problems or those of their
children, but they do so in different ways. Consider an evaluation of
the test‐retest reliability of parent reports of the DSM‐IV symptoms
of depression in 288 children in a larger study of psychological
problems in the general population (Lahey et al., 2004). Parents rated
the nine symptoms of depression on a scale of 0–3 on two occasions,
7–14 days apart. The left‐hand side of Figure 1shows the association
between the sum of these 4‐point ratings on the two occasions.
Children rated lower/higher on depression at time 1 tended to be
rated lower/higher at time 2, indicating imperfect, but substantial
consistency in the ratings (intraclass correlation; ICC =0.83). When
the ratings were rescored as binary “symptoms” as in DSM‐IV
(ratings of 2 or 3 =symptom), the ICC dropped to 0.74. Further-
more, when the symptoms were used to calculate a dichotomous
“diagnosis” of major depression according to DSM‐IV criteria,
Cohen's kappa was 0.44. This kappa reflected high consistency in not
meeting criteria for major depression at the two time points (98.8%),
but only 34.6% of children who met criteria for depression the first
assessment still met criteria 7–14 days later. The magnitudes of ICC
and kappa are not directly comparable, but the kappa for the cate-
gorical diagnosis was just above the conventional threshold for “fair”
agreement of 0.40 (Koch et al., 1977), whereas an ICC of 0.83 is well
above the conventional threshold for “excellent” reliability of 0.75
(Fleiss, 1986).
In the DSM5 field trials, 40% of the DSM5 diagnoses examined in
adults did not reach the conventional cut‐off for acceptable agreement
between clinicians (Regier et al., 2013). Of great concern, the kappas
for reliability of the common problems of major depressive disorder
and generalized anxiety disorder were in the “unacceptable” range. In
the earlier DSM‐IV field trials for children and adolescents, the reli-
ability of externalizing diagnoses was in the barely acceptable range
for parent reports of symptoms in their 9–17 year old children, but
were unacceptable for youth reports of their own symptoms
(Schwab‐Stone et al., 1996).
Fortunately, we can and should do better in assessing and
conceptualizing psychological problems. Measuring psychological
problems as continua is inherently more reliable than placing persons
into binary categories.
1
When using categorical measurement, a
change to a single diagnostic criterion could change the diagnosis
Key points
�Taxometric and other methods indicate that psycholog-
ical problems are empirically dimensional.
�The measurement of psychological problems in dimen-
sional terms is far more reliable and valid than categor-
ical classification of problems.
�Categorical diagnoses ignore the unique needs of the
individual.
�Categorical diagnoses encourage the reification of psy-
chological problems and promote viewing them as un-
changing rather than dynamic.
�Categorical diagnoses promote stigmatizing views of
persons with problems as being fundamentally different
from others.
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from ‘mentally ill’ to ‘normal.’ When measuring psychological prob-
lems dimensionally, the same amount of change does not radically
change the appraisal of the person's problems.
Dimensions are more valid predictors of adverse
outcomes than categorical diagnoses
The greater validity of dimensional measurement is partly the result
of its greater reliability, but also because continuous dimensions
capture variations above and below the “diagnostic threshold” that
are related to distress and impairment. Consider how diagnostic
thresholds are chosen for ICD and DSM mental categories. Often this
is done based solely on tradition and expert opinion, but even when
data is used to choose thresholds, the process is not what most of us
assume. For example, the symptoms and thresholds for DSM‐IV
disruptive behavior disorders were selected using data from the
DSM‐IV field trials (Lahey, Applegate, Barkley, et al., 1994; Lahey,
Applegate, McBurnett, et al., 1994). Plots of numbers of symptoms
against continuous measures of impairment were used to select
thresholds. It is not widely appreciated that those plots almost al-
ways showed linear associations although this was stated in the
reports at the time (Lahey, Applegate, Barkley, et al., 1994).
Consider the plot of the number of parent‐reported DSM‐IV
symptoms of oppositional defiant disorder (ODD) against a mea-
sure of global distress and impairment in Figure 2, which is based on
the Georgia Health and Behavior Study (GHBS) of a general popu-
lation sample (Lahey et al., 2004). The plot shows the same linear
association seen in the field trials. How can one select a meaningful
diagnostic threshold based on such data? In the case of DSM‐IV
ODD, an arbitrary threshold was imposed on the continuous mea-
sure of impairment to help select an arbitrary diagnostic threshold
for the dimension of ODD problems (Lahey, Applegate, Barkley,
et al., 1994). This was not done as an exercise in smoke and mirrors,
but in a well‐meaning effort to consider empirical data when making
an inherently arbitrary decision. Nonetheless, the first‐author's (BBL)
participation in this effort was a signal event in his rejection of
dichotomous diagnostic categories (Lahey, 2021).
Beyond the arbitrary nature of diagnostic thresholds, Figure 2
has important practical implications. Many children just below the
diagnostic threshold for ODD and longitudinal studies of children,
adolescents, and adults have reported that persons whose problems
fall just below the diagnostic criteria for a diagnosis (“subthreshold”)
are often substantially distressed and impaired and are at increased
risk for meeting full diagnostic threshold for the disorder in the
future (Angst et al., 1997; Balazs et al., 2013; Balazs & Ker-
eszteny, 2014; Fergusson et al., 2005; van Os, 2014). Thus, a
dimensional approach is more inclusive and facilitates the selection
of graded interventions appropriate to the severity of the individual's
problems (Lahey, 2021).
Binary diagnoses are Procrustean beds that ignore the
needs of the individual
Diagnostic categories are Procrustean beds that distort or ignore
many of the specific and unique characteristic of each individual by
implying that everyone who meets criteria for a diagnosis is essen-
tially alike. This term comes to us from the Greek myth of the robber
baron, Procrustes. Procrustes lived near a well‐travelled road to an
important religious site. He offered lodging to wealthy travelers, but
while they slept in his iron bed, he made each traveler fit the bed
exactly by stretching some parts of their bodies and cutting off
protruding parts with a sword. Diagnostic categories can act like
Procrustean beds by encouraging professionals to make the problems
of each individual person fit the diagnostic category by stretching
some facts and ignoring others.
People very often experience psychological problems from more
than one diagnostic category at the same time (Caspi & Moffitt, 2018;
Lahey, 2021; Lahey et al., 2017). Focusing on a differential diagnosis
distracts attention from the individual's unique combination of
problems from across dimensions, each of which may be a legitimate
FIGURE 1 Illustration of the test‐retest reliability of parent ratings on a 0–3 scale of the sum of the 9 DSM‐IV symptoms of major
depressive episode in 288 6–17 year old children and adolescents on two occasions 7–14 days apart in the population‐based Georgia Health
and Behavior Study (left), and expressed at the sum of binary “symptoms” (right) (Lahey et al., 2004)
SEVEN REASONS WHY BINARY DIAGNOSTIC CATEGORIES SHOULD BE REPLACED
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target for intervention. This occurs because of a fundamental fact
ignored by ICD and DSM: Every dimension of psychological problems
is positively correlated with every other dimension. The problems
that define each dimension of psychological problems do not come
from separate silos as implied by categorical diagnostic systems.
Owing to the ubiquitous positive correlations among problems,
people do not exhibit the ‘symptoms’ of a single ‘mental disorder;’
they experience an admixture of psychological problems.
Almost no child exhibits, for example, six inattention problems
and no other problems. Rather they typically also exhibit multiple
other correlated psychological problems, often from more than one
other dimension. Such admixtures of problems are expected in the
dimensional approach. In contrast, in a categorical approach, admix-
tures of psychological problems are viewed as violations of the sharp
boundaries that should divide supposedly distinct diagnostic cate-
gories. This encourages Procrustean distortions of the individual's
problems to fit the binary diagnoses. This is a primary shortcoming of
the diagnostic approach and a sufficient reason by itself for leaving it
behind. Nature is complex and children and adolescents with
psychological problems do not conveniently present with problems
that match neatly one and only one diagnostic category description.
In nature, psychological problems are dimensional, correlated, and
admixed.
Diagnostic categories encourage us to reify
psychological problems
Binary categories of anything, including problematic behaviors,
emotions, and cognitions, encourage us to reify the category as a set
of things (Hyman, 2010). Psychological problems are not things; they
are individual differences in emotions, motivations, actions, percep-
tions, and thinking that cause distress and impairment that are
properly described by modifiers—adjectives and adverbs that refer to
variations in our behavior. Dimensions promote thinking in terms of
quantitative modifiers (e.g., slightly, moderately, or extremely anxious
when speaking in public).
Categorical diagnoses foster a static understanding of
psychological problems
Diagnoses incorrectly imply that the individual has a relatively con-
dition that is unlikely to change. Instead, longitudinal studies reveal
that people of all ages frequently change from one categorical diag-
nosis to another over time (Lahey et al., 2014; Shevlin et al., 2017).
The assumptions underlying systems of correlated dimensions are
not inconsistent with change over time.
Dimensional approaches promote less stigmatizing
views of psychological problems
Nearly all cultures stigmatize people whose behavior causes them
distress and interferes with their lives. Such stigma magnifies the
challenge of having psychological problems immensely (Hin-
shaw, 2006,2017). Stigma hurts us in three major ways. First, if we
are embarrassed that we feel depressed, for example, that embar-
rassment can make us even more depressed. Second, stigmatizing
psychological problems can make it more difficult for parents to seek
help for their children when they might would benefit from it. The
same is true for parents who often have psychological problems that
interfere with helping their troubled children (Chronis et al., 2003;
Chronis‐Tuscano et al., 2013). Third, the stigma felt by other people
about our psychological problems can lead them to treat us as less
than fully human, avoid being with us, and create barriers to
employment and housing that make our lives far worse. Indeed,
stigmatized and uninformed views of psychological problems often
FIGURE 2 Plot of the number of “symptoms” of parent‐rated oppositional defiant disorder against means levels of parent‐rated global
impairment and distress in the population‐based Georgia Health and Behavior Study (Lahey et al., 2004)
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lead to unnecessary incarceration and deadly confrontations with
police.
There are two separable ways in which the use of diagnostic
categories in ICD and DSM promotes stigma. First, even if diagnostic
categories were not currently tied to the medical model, the mere
use of binary categories promotes stigma by suggesting that the in-
dividual has a problem that is qualitatively different from problems of
other persons. In contrast, dimensional portrayals of psychological
problems reveal the quantitative variation in dimensions of problems
from very low to high in the population. It should be easier to reduce
the stigmatization of problems that are simply viewed as extreme on
a natural continuum enough to warrant intervention than for prob-
lems that are viewed as fundamentally different in kind.
Second, the fact that binary categories are tied to the medical
model in ICD and DSM makes the problem of stigma much worse.
The view that psychological problems are the result of biological
problems dates back at least 2400 years to Hippocrates, who
believed that psychological problems were manifestations of imbal-
ances in the fluids of the body. For centuries, this model competed
with views that psychological problems were caused by gods, de-
mons, or moral turpitude, but Hippocratic thinking became the
dominant view in the Western world in the 1800s in the guise of the
medical model of psychological problems. This happened because of
the truly astonishing discovery by Richard Krafft‐Ebing and others
that the bacteria that causes syphilis often infects the brain resulting
in the debilitating syndrome of psychosis and dementia known as
general paresis. When the successful treatment of syphilis with
penicillin was perfected a hundred years later during World War II,
the previously high number of persons with incidence cases of gen-
eral paresis fell to nearly zero in Western countries. It was an elec-
trifying scientific triumph! Understandably, this advance in alleviating
human suffering led to the optimistic belief that every kind of psy-
chological problem would eventually be found to be caused by germs
affecting the brain. This fostered the belief that psychological prob-
lems are actually medical problems and that medical doctors are the
professionals who should treat psychological problems.
There is, of course, every reason to provide medical treatments
to persons with treatable infections that cause psychological prob-
lems. Very few other infections that cause psychological problems
subsequently have been discovered, however. This fact should have
led to a delimited medical model of psychological problems, but it did
not. Very unfortunately, the medical model took on a much broader
metaphorical meaning when few additional links between germs and
psychological problems were discovered. The logic of the modern
medical model was extended to metaphorical “diseases of the
mind”—syndromes of mental ‘symptoms’ without known biological
illnesses (Klerman, 1977).
Most psychologists and psychiatrists active today were trained
to believe that they can discern the difference between ‘normal’ and
‘abnormal’ minds, and thereby ‘diagnose mental illnesses.’ Our view is
that this is an entirely fictional and baseless notion that is toxic to
people. Telling people that psychological problems are the result of
terrifying illnesses of the mind promotes the worst forms of stigma.
Over 50 years ago, psychologist Albert Bandura (1969) prag-
matically defined psychological problems without reference to bio-
logical illness simply as “…behavior that is harmful to the individual or
departs widely from accepted social and ethical norms…” (p. 10).
Psychiatrist Thomas Szasz similarly advocated replacing medical
model terms such as mental illness with the less judgmental phrase,
problems in living (Szasz, 1960,1974). Szasz has been widely misun-
derstood as denying the existence psychological problems. He
explicitly did not do so, but he denied the meaningfulness of the
concept of mental illnesses based on an analogy to medical illness.
Nonetheless, we stigmatize psychological problems partly
through the words we use, often with the best of intentions. Most of
us refer to psychological problems with medical model terms such as
mental illnesses, mental disorders, psychopathology, or mental health
problems. We often use these medical model terms in caring ways to
imply that the psychological problem is not the person's fault, but is
the result of their mental illness. These are profoundly stigmatizing
terms, however. They say that your psychological problems are the
result of your illness, disorder, and pathology—that you have psycho-
logical problems because your mind is sick! How can that not worsen
stigma?
“ORDINARINESS” OF PSYCHOLOGICAL PROBLEMS
To fully fight stigma, we need to recognize that psychological prob-
lems are ordinary. This emphatically does not mean that they are
unimportant and can be ignored. Psychological problems often make
people miserable and interfere significantly with their lives, some-
times in ways that are nothing short of tragic. Nonetheless, psycho-
logical problems are ordinary in two very important ways: First,
psychological problems are not the product of diseased minds or
brains, they arise through the same normal biological and psychological
processes as any other aspect of behavior (Lahey, 2021). That does not
mean that there are not some forms of problem behavior that are
distinctly different from typical behavior, such as hallucination and
delusions. It is simply to assert that even extreme forms of psycho-
logical problems arise from the same processes as all behavior
(Lahey, 2021). Second, recent studies have revealed that psycholog-
ical problems are so much more common in the population than we
realized that they cannot be considered to be anything but ordinary
(Moffitt et al., 2010).
When we recognize that the great majority of us will experience
problems like fear, anxiety, sadness, or cravings for deadly sub-
stances at some time in our lives, it will be harder to stigmatize
psychological problems. Psychological problems are not rarefied
things experienced by a few people with diseased minds; they are
quite ordinary things experienced by nearly all of us. Several large
longitudinal studies of the general population in several countries
have been conducted in which the same individuals were persons
were asked about their psychological problems multiple times from
early adolescence through middle adulthood. These studies (Schaefer
et al., 2017) tell us that an eye‐popping 80% of people in the general
population met DSM diagnostic criteria for at least one mental dis-
order at least once during the decades they were studied. The level of
diminished functioning was not great in all cases, but psychological
problems are always a burden. Note, too, that these studies only
reported the prevalence of meeting full DSM diagnostic criteria for a
mental disorder. Far more people reported psychological problems
that were just below the ‘official’ DSM threshold for a diagnosis.
Therefore, even the remarkable finding that most of us will meet full
SEVEN REASONS WHY BINARY DIAGNOSTIC CATEGORIES SHOULD BE REPLACED
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DSM criteria for a mental disorder at some point in our lives un-
derstates the ordinariness of psychological problems.
IMPLICATIONS OF A DIMENSIONAL APPROACH
FOR SERVICES
If psychological problems are viewed in dimensional terms, where on
the continuum is intervention useful and appropriate? How would
mental health and school systems decide who is eligible for scarce
professional services? There are no natural thresholds between
adaptive behavior and psychological problems. Rather, all evidence to
date indicates that as problems gradually increase across continua, so
do distress and functional impairment (Lahey, 2021; Lahey, Apple-
gate, Barkley, et al., 1994; Lahey, Applegate, McBurnett, et al., 1994;
Lahey et al., 2008).
It has been argued that categorical thinking is justified given the
need in medical practice to make treatment decisions that are
inherently dichotomous. Indeed, administrative and reimbursement
requirements impede the movement towards a continuum approach.
To address this issue, some have advocated developing a triage and
service delivery based on severity, functional difficulties, and prog-
nosis to direct limited resources to those most in need of treatment
(McLennan, 2016). Diagnoses arguably provide false comfort in
making dichotomous treatment decisions partly because this
approach overestimates the accuracy of the link between diagnosis
and treatment.
If we do not use diagnostic thresholds, how do we make the
inherently binary decision to treat or not treat (Widiger, 2019)? One
pragmatic answer is that persons with problems or the adult care-
givers of minor children could legitimately decide, in consultation
with teachers and professions that individual's thoughts, feelings, and
actions are distressing or interfering enough to seek help at any point
on the continuum. Specifically, at any point on the continuum where
the distress and impaired functioning that the individual currently
experiences—and may experience in the future if help is not provided
—is judged to outweigh the usually small risks inherent in receiving
help, then help is justified. No one has to decide that the individual
has a mental illness to receive help.
This approach is subjective to be sure. Psychological problems
and distress and functional impairment can be reliably measured
across the life span, but decisions on the points on these continua
where the expected benefits outweigh the likely costs cannot
currently be based on sound normative data. Although that is true,
the alternative is keep the current system, which is based on binary
diagnoses measured with unacceptable reliability and validity.
It is easy to imagine a system that provides help to all those who
would benefit from it without requiring them to have a diagnosis of a
mental illness. This might be politically difficult to achieve, but it
would be just and it would not be impractical. Adopting such a non‐
stigmatizing dimensional would require a revamping of policies and
funding strategies for treatment, however, and it would require
controlled trials to evaluate the clinical utility of approaches to
providing services based on dimensional assessments versus the
current categorical approaches. A defensible dimensional approach
to decision making would require standardized continuous mea-
surement of psychological problems and functional deficiencies. This
could improve cost‐effectiveness of treatment allocation and would
almost certainly reduce structural inequalities. Currently, those most
need of services often have the greatest barriers to obtaining them
(Kazdin, 2019; Velasco et al., 2020).
The obstacles to such changes would likely be enormous. In
countries like the United States, insurance for services of psycho-
logical problems is provided by health insurance companies, who
almost certainly would deny payment for services for psychological
problems if they are no longer considered to be “health” problems.
Services from a national health service may be similarly affected.
Schools should be a position to change to a dimensional approach
more easily, but the legislation that authorizes services for children
with psychological problems would need to be considered carefully
and potentially revised.
Would it be affordable for people and families to be allowed to
decide freely for themselves when they need professional help?
Services for psychological problems cost money. Currently, psychol-
ogists, special educators, psychiatrists, and other physicians are the
gatekeepers to such services. Only persons given a reimbursable
DSM or ICD diagnosis of a mental disorder can receive services for
psychological problems without paying directly for it themselves in
nearly every country. Whether you live in the United States where
private and government health insurance plans pay for psychological
services—if you are lucky enough to have good health insurance—or
live in one of the many countries in which taxpayer‐supported
services for psychological problems are provided essentially for
free, you cannot receive those services without a qualifying diagnosis
in virtually every case. Your diagnosis is your only ticket to services,
unless you are willing to pay for them yourselves. Government sys-
tems and insurance companies likely believe that this is necessary
control the costs of services.
Nonetheless, societies could decide to provide services for psy-
chological problems to all who seek them for one of three reasons.
First, it may not actually increase the number of people who receive
services very much. As hard as we fight stigma, many families and
individuals are still reluctant to seek services because of stigma and
other barriers. Indeed, the number of people seeking professional
services may not increase very much if they are free to do so without
a diagnosis, particularly in the beginning. Thus, the increase in cost
may not be great; we will not know unless we try.
Second, some societies may decide that providing services to all
who feel that they need them would actually save the society money.
Psychological problems are extremely costly to society in terms of
reduced economic productivity and increased physical health prob-
lems. There is every reason to believe that increased expenditures
for evidence‐based, cost‐effective methods of preventing and
reducing psychological problems would be more than repaid by re-
ductions in the large economic costs of psychological problems to
society (Cuijpers et al., 2021; Kazdin, 2019; Moffitt, 2019).
Third, even if it resulted in increased costs, it would not be un-
reasonable for a society to decide that spending tax money on
reducing psychological problems in everyone who felt the need for it
would be one of the most justifiable ways in which public monies
could be spent. It may make sense from the perspective of health
insurance companies and government health systems only to reim-
burse services that treat “medical conditions,” but this economic‐
based practice forces psychiatrists, educators, psychologists, and
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ET AL.
other helping professionals to address psychological problems in
medical terms. This leads all of us to think about psychological
problems in genuinely harmful ways, usually without realizing that we
are doing so.
AUTHOR CONTRIBUTIONS
Benjamin B. Lahey: Conceptualization, Formal analysis, Writing –
original draft, Writing – review & editing. Henning Tiemeier:
Conceptualization, Writing – original draft, Writing – review &
editing. Robert F. Krueger: Conceptualization, Writing – original
draft, Writing – review & editing.
CONFLICTS OF INTEREST
Benjamin B. Lahey and Henning Tiemeier both serve on the JCPP
Advances Editorial Advisory Board. Robert F. Krueger declares that
they have no competing or potential conflicts of interest.
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article.
ETHICAL CONSIDERATIONS
No new human participant data were created or analyzed in this
study.
ORCID
Benjamin B. Lahey
https://orcid.org/0000-0002-0385-9676
Henning Tiemeier https://orcid.org/0000-0002-4395-1397
ENDNOTE
1
The various editions of the International Classification of Diseases
published by the World Health Organization and the Diagnostic and
Statistical Manual of Mental Disorders published by the American
Psychiatric Association.
REFERENCES
Achenbach, T. M., Conners, C. K., Quay, H. C., Verhulst, F. C., & Howell,
C. T. (1989). Replication of empirically derived syndromes as a basis
for taxonomy of child and adolescent psychopathology. Journal of
Abnormal Child Psychology,17(3), 299–323. https://doi.org/10.1007/
bf00917401
Angst, J., Merikangas, K. R., & Preisig, M. (1997). Subthreshold syndromes
of depression and anxiety in the community. Journal of Clinical Psy-
chiatry,58, 6–10.
Balazs, J., & Kereszteny, A. (2014). Subthreshold attention deficit hyper-
activity in children and adolescents: A systematic review. European
Child & Adolescent Psychiatry,23(6), 393–408. https://doi.org/10.
1007/s00787‐013‐0514‐7
Balazs, J., Miklosi, M., Kereszteny, A., Hoven, C. W., Carli, V., Wasserman,
C., Apter, A., Bobes, J., Brunner, R., Cosman, D., Cotter, P., Haring, C.,
Iosue, M., Kaess, M., Kahn, J. P., Keeley, H., Marusic, D., Postuvan, V.,
Resch, F., & Wasserman, D. (2013). Adolescent subthreshold‐
depression and anxiety: Psychopathology, functional impairment
and increased suicide risk. Journal of Child Psychology and Psychiatry,
54(6), 670–677. https://doi.org/10.1111/jcpp.12016
Bandura, A. (1969). Principles of behavior modification. Holt, Rinehart &
Winston.
Caspi, A., & Moffitt, T. E. (2018). All for one and one for all: Mental dis-
orders in one dimension. American Journal of Psychiatry,175(9),
831–844. Epub ahead of print. https://doi.org/10.1176/appi.ajp.
2018.17121383
Chronis, A. M., Lahey, B. B., Pelham, W. E., Kipp, H. L., Baumann, B. L., &
Lee, S. S. (2003). Psychopathology and substance abuse in parents
of young children with attention‐deficit/hyperactivity disorder.
Journal of the American Academy of Child & Adolescent Psychiatry,
42(12), 1424–1432. https://doi.org/10.1097/01.chi.0000093321.
86599.d6
Chronis‐Tuscano, A., Clarke, T. L., O'Brien, K. A., Raggi, V. L., Diaz, Y.,
Mintz, A. D., Rooney, M. E., Knight, L. A., Seymour, K. E., Thomas,
S. R., Seeley, J., Kosty, D., & Lewinsohn, P. (2013). Development and
preliminary evaluation of an integrated treatment targeting
parenting and depressive symptoms in mothers of children with
attention‐deficit/hyperactivity disorder. Journal of Consulting and
Clinical Psychology,81(5), 918–925. https://doi.org/10.1037/a003
2112
Cuijpers, P., Pineda, B. S., Ng, M. Y., Weisz, J. R., Munoz, R. F., Gentili, C.,
Quero, S., & Karyotaki, E. (2021). A meta‐analytic review: Psycho-
logical treatment of subthreshold depression in children and ado-
lescents. Journal of the American Academy of Child & Adolescent
Psychiatry,60(9), 1072–1084. https://doi.org/10.1016/j.jaac.2020.
11.024
Fergusson, D. M., Horwood, L. J., Ridder, E. M., & Beautrais, A. L. (2005).
Subthreshold depression in adolescence and mental health out-
comes in adulthood. Archives of General Psychiatry,62(1), 66–72.
https://doi.org/10.1001/archpsyc.62.1.66
Fisher, R. A. (1918). The correlation between relatives on the supposition
of Mendelian inheritance. Transactions of the Royal Society of Edin-
burgh,52(52), 399–433. https://doi.org/10.1017/s008045680001
2163
Fleiss, J. (1986). The design and analysis of clinical experiments. Wiley.
Haslam, N., McGrath, M. J., Viechtbauer, W., & Kuppens, P. (2020).
Dimensions over categories: A meta‐analysis of taxometric research.
Psychological Medicine,50(9), 1418–1432. https://doi.org/10.1017/
s003329172000183x
Hinshaw, S. P. (2006). The mark of shame: Stigma of mental illness and an
agenda for change. Oxford University Press.
Hinshaw, S. P. (2017). Another kind of madness: A journey through the stigma
and hope of mental illness. St. Martin's Press.
Hyman, S. E. (2010). The diagnosis of mental disorders: The problem of
reification. Annual Review of Clinical Psychology,6(1), 155–179.
https://doi.org/10.1146/annurev.clinpsy.3.022806.091532
Kazdin, A. E. (2019). Annual Research Review: Expanding mental health
services through novel models of intervention delivery. Journal of
Child Psychology and Psychiatry,60(4), 455–472. https://doi.org/10.
1111/jcpp.12937
Klerman, G. L. (1977). Mental illness, medical model, and psychiatry.
Journal of Medicine and Philosophy,2(3), 220–243. https://doi.org/10.
1093/jmp/2.3.220
Koch, G. G., Landis, J. R., Freeman, J. L., Freeman, D. H., & Lehnen, R. G.
(1977). General methodology for analysis of experiments with
repeated measurement of categorical data. Biometrics,33(1),
133–158. https://doi.org/10.2307/2529309
Kotov, R., Cicero, D. C., Conway, C. C., DeYoung, C. G., Dombrovski, A.,
Eaton, N. R., First, M. B., Forbes, M. K., Hyman, S. E., Jonas, K. G.,
Krueger, R. F., Latzman, R. D., Li, J. J., Nelson, B. D., Regier, D. A.,
Rodriguez‐Seijas, C., Ruggero, C. J., Simms, L. J., Skodol, A. E., &
Wright, A. G. C. (2022). The hierarchical taxonomy of psychopa-
thology (HiTOP) in psychiatric practice and research. Psychological
Medicine,52(9), 1666–1678. https://doi.org/10.1017/S0033291722
001301
Krueger, R. F., Kotov, R., Watson, D., Forbes, M. K., Eaton, N. R., Ruggero,
C. J., Simms, L. J., Widiger, T. A., Achenbach, T. M., Bach, B., Bagby,
R. M., Bornovalova, M. A., Carpenter, W. T., Chmielewski, M., Cicero,
D. C., Clark, L. A., Conway, C., DeClercq, B., DeYoung, C. G., …,
Zimmermann, J. (2018). Progress in achieving quantitative classifi-
cation of psychopathology. World Psychiatry,17(3), 282–293. https://
doi.org/10.1002/wps.20566
Lahey, B. B. (2021). Dimensions of psychological problems: Replacing diag-
nostic categories with a more science‐based and less stigmatizing alter-
native. Oxford University Press.
Lahey, B. B., Applegate, B., Barkley, R. A., Garfinkel, B., McBurnett, K.,
Kerdyk, L., Greenhill, L., Hynd, G. W., Frick, P. J., Newcorn, J.,
Biederman, J., Ollendick, T., Hart, E. L., Perez, D., Waldman, I., &
SEVEN REASONS WHY BINARY DIAGNOSTIC CATEGORIES SHOULD BE REPLACED
-
7 of 8
Shaffer, D. (1994a). DSM‐IV field trials for oppositional defiant dis-
order and conduct disorder in children and adolescents. American
Journal of Psychiatry,151, 1163–1171.
Lahey, B. B., Applegate, B., McBurnett, K., Biederman, J., Greenhill, L.,
Hynd, G. W., Barkley, R. A., Newcorn J., Jensen, P., Richters, J.,
Garfinkel B., Kerdyk, L., Frick, P. J., Ollendick, T., Perez, D., Hart, E. L.,
Waidman, I., & Shaffer, D. (1994b). DSM‐IV field trials for attention‐
deficit/hyperactivity disorder in children and adolescents. American
Journal of Psychiatry,151, 1673–1685.
Lahey, B. B., Applegate, B., Waldman, I. D., Loft, J. D., Hankin, B. L., & Rick,
J. (2004). The structure of child and adolescent psychopathology:
Generating new hypotheses. Journal of Abnormal Psychology,113(3),
358–385. https://doi.org/10.1037/0021‐843x.113.3.358
Lahey, B. B., Krueger, R. F., Rathouz, P. J., Waldman, I. D., & Zald, D. H.
(2017). A hierarchical causal taxonomy of psychopathology across
the life span. Psychological Bulletin,143(2), 142–186. https://doi.org/
10.1037/bul0000069
Lahey, B. B., Rathouz, P. J., Applegate, B., Van Hulle, C., Garriock, H. A.,
Urbano, R. C., Chapman, D. A., & Waldman, I. D. (2008). Testing
structural models of DSM‐IV symptoms of common forms of child
and adolescent psychopathology. Journal of Abnormal Child
Psychology,36(2), 187–206. https://doi.org/10.1007/s10802‐007‐
9169‐5
Lahey, B. B., Zald, D. H., Hakes, J. K., Krueger, R. F., & Rathouz, P. J. (2014).
Patterns of heterotypic continuity associated with the cross‐
sectional correlational structure of prevalent mental disorders in
adults. JAMA Psychiatry,71(9), 989–996. https://doi.org/10.1001/
jamapsychiatry.2014.359
McLennan, J. D. (2016). Understanding attention deficit hyperactivity
disorder as a continuum. Canadian Family Physician,62, 979–982.
Moffitt, T. E., Caspi, A. (2019). Psychiatry’s opportunity to prevent the
rising burden of age‐related disease, Jama Psychiatry,76(5),
461‐462. https://doi.org/10.1001/jamapsychiatry.2019.0037
Moffitt, T. E., Caspi, A., Taylor, A., Kokaua, J., Milne, B. J., Polanczyk, G., &
Poulton, R. (2010). How common are common mental disorders?
Evidence that lifetime prevalence rates are doubled by prospective
versus retrospective ascertainment. Psychological Medicine,40(6),
899–909. https://doi.org/10.1017/s0033291709991036
Plomin, R., Haworth, C. M. A., & Davis, O. S. P. (2009). Common disorders
are quantitative traits. Nature Reviews Genetics,10(12), 872–878.
https://doi.org/10.1038/nrg2670
Quay, H. C. (1986). Classification. In H. C. Quay & J. S. Werry (Eds.),
Psychopathological disorders of childhood (3rd ed., pp. 1–42). Wiley.
Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J.,
Kuhl, E. A., & Kupfer, D. J. (2013). DSM‐5 field trials in the United
States and Canada, Part II: Test‐retest reliability of selected
categorical diagnoses. American Journal of Psychiatry,170(1), 59–70.
https://doi.org/10.1176/appi.ajp.2012.12070999
Schaefer, J. D., Caspi, A., Belsky, D. W., Harrington, H., Houts, R., Hor-
wood, L. J., Hussong, A., Ramrakha, S., Poulton, R., & Moffitt, T. E.
(2017). Enduring mental health: Prevalence and prediction. Journal of
Abnormal Psychology,126(2), 212–224. https://doi.org/10.1037/abn
0000232
Schwab‐Stone, M. E., Shaffer, D., Dulcan, M. K., Jensen, P. S., Fisher, P., Bird,
H. R., Goodman, S. H., Lahey, B. B., Lichtman, J. H., Canino, G., Rubio‐
Stipec, M., & Rae, D. S. (1996). Criterion validity of the NIMH diag-
nostic interview schedule for children version 2.3 (DISC‐2.3). Journal
of the American Academy of Child & Adolescent Psychiatry,35(7),
878–888. https://doi.org/10.1097/00004583‐199607000‐00013
Shevlin, M., McElroy, E., & Murphy, J. (2017). Homotypic and heterotypic
psychopathological continuity: A child cohort study. Social Psychiatry
and Psychiatric Epidemiology,52(9), 1135–1145. https://doi.org/10.
1007/s00127‐017‐1396‐7
Smoller, J. W., Andreassen, O. A., Edenberg, H. J., Faraone, S. V., Glatt, S. J.,
& Kendler, K. S. (2019). Psychiatric genetics and the structure of
psychopathology. Molecular Psychiatry,24(3), 409–420. https://doi.
org/10.1038/s41380‐017‐0010‐4
Szasz, T. S. (1960). The myth of mental illness. American Psychologist,15(2),
113–118. https://doi.org/10.1037/h0046535
Szasz, T. S. (1974). Myth of mental illness: Foundations of a theory of personal
conduct. Harper.
van Os, J. (2014). Attenduated psychosis syndrome =Common mental
disorder with subthreshold psychosis. Schizophrenia Research,153,
S23. https://doi.org/10.1016/s0920‐9964(14)70074‐x
Velasco, A. A., Cruz, I. S. S., Billings, J., Jimenez, M., & Rowe, S. (2020).
What are the barriers, facilitators and interventions targeting help‐
seeking behaviours for common mental health problems in adoles-
cents? A systematic review. BMC Psychiatry,20(1), 293. https://doi.
org/10.1186/s12888‐020‐02659‐0
Widiger, T. A. (2019). Considering the research: Commentary on the
"trait‐type dialectic": Construct validity, clinical utility, and the
diagnostic process. Personality Disorders: Theory Research and Treat-
ment,10(3), 215‐219. https://doi.org/10.1037/per0000322
How to cite this article: Lahey, B. B., Tiemeier, H., & Krueger,
R. F. (2022). Seven reasons why binary diagnostic categories
should be replaced with empirically sounder and less
stigmatizing dimensions. JCPP Advances,2(4), e12108. https://
doi.org/10.1002/jcv2.12108
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