Two is Not Necessarily Better Than One: An Alternative Perspective on Comorbidity and “Behavioral” Health Diagnoses

Constructing a diagnostic manual for the mental health professions is not a straightforward task. Unlike medical disorders, mental health conditions do not come with biological markers. There is no culture that can be taken, no blood test, no specific bacteria or virus that can be found. In short, while well-trained practitioners most often agree, the diagnosis of mental health disorders is somewhat subjective.

If we rely on the DSM 5 (Diagnostic and Statistical Manual of Mental Disorders), the manual most widely used by the mental health professions, we find that diagnosis is to be made on the basis of observable behaviors. The manual lists the groups of behaviors typically found in each diagnostic category, and if someone presents with a certain number of the behaviors listed, that person meets the criteria for having that disorder.

For example, the behaviors most often seen in children with Oppositional Defiant Disorder (ODD) are: often loses temper; often touchy or easily annoyed; often angry and resentful; often argues with authority figures; often actively refuses to comply with requests from authority figures or with rules; often deliberately annoys others; often blames others for his or her mistakes or misbehavior; the child has been spiteful or vindictive at least twice within the past six months. The manual states that if a child has manifested four or more of these behaviors for six months or more, that child meets the criteria for the diagnosis of Oppositional Defiant Disorder.

You may have noted a couple of things with this. For one, some of these behaviors can appear with other diagnostic categories (e.g., Attention Deficit Disorder, Bi-Polar Disorder, Adjustment Disorders). It’s also not clear by what science the bar is set at four or more of these behaviors. What happens if the child only manifests three of these behaviors? Is there something different between a child that manifests four and the child who manifests all 10 of the listed criteria? It should be considered that this diagnostic category and perhaps all diagnostic categories in the DSM are dimensional and that it is not only Autism Spectrum Disorder that warrants conceptualization as a “spectrum” diagnosis.

Diagnostic categories in the current version of the DSM are instead considered to be binary; either you meet the criteria set and you have it, or you don’t meet criteria and you don’t have it. The DSM 5 authors have recognized this and are in the process of further developing “severity” measures that will refine the diagnostic process. They have also acknowledged that diagnostic categories are dimensional in nature and that levels of mental functioning should be an integral part of the process. Another diagnostic manual, the Psychodynamic Diagnostic Manual-2, incorporated these principles in 2017.

Another problem acknowledged by the DSM 5 authors is that of comorbidity (the presence of more than one disorder in the same person). In addition to treating diagnostic categories as binary, DSM also treats them as if they were homogeneous, when in fact they are heterogeneous in nature. Viewing diagnoses as binary and homogeneous (i.e., everyone with a given diagnosis is the same as everyone else with that diagnosis) may improve research reliability and be useful in organizing how we group and label various constellations of behaviors, but they do not always make good sense in the real or clinical world. It is why when we talk among friends we might describe a person as being a little OCD and really anxious, or really OCD and a bit depressed, etc.

We intuitively (mental health professionals as well as lay people) recognize that everyone we know who is depressed will have behaviors that overlap with other people who suffer in the same way. However, those people may be very different in the degree of their depression, and they can manifest many different behaviors and personality traits. They are a heterogeneous group, though they share similar symptoms. If we were to add people who meet the criteria for personality disorders to the mix, the problem becomes even more apparent.

I’ve recently seen a child diagnosed with Autism Spectrum Disorder and Attention Deficit Disorder (ADD). We might also recognize that it’s nearly impossible to meet DSM criteria for Autism Spectrum Disorder and not have significant neuropsychological issues that present in ways that meet criteria for ADD, or don’t produce symptoms of anxiety or depression in response to those challenges. Likewise, I’ve recently seen an adult patient who was diagnosed with Paranoid Personality Disorder and co-morbid Social Anxiety Disorder. Most often, referring to these as separate diagnoses makes no more sense than classifying a sore throat, cough, headache, and running nose as four co-morbid diagnoses. Typically, a single antibiotic will suffice in alleviating all of those symptoms because they relate to the same disorder.

There is another point to make here; all of the above symptoms are labeled as such because the term symptom implies that they are reflective of something under the surface that is causing what is wrong. In other words, they have meaning, an underlying cause or causes. Physical symptoms can sometimes be treated easily, such as taking two Tylenol, and your headache goes away.

In this case, the underlying cause is not serious, unless the headache keeps reoccurring. With the cold symptoms mentioned above, the body may fight them off on its own. Alternatively, the symptoms might persist, and if they did, a physician would be interested in finding out the cause. Coughing and sneezing are not just behaviors.

For various reasons, the mental health profession has been renamed as the behavioral health profession. Perhaps this is nothing more than an attempt to destigmatize psychiatric problems, but there are other ramifications. For example, if a person is having difficulty paying attention, is distractible, restless, forgetful, etc., that person may have Attention Deficit Disorder. But they might instead, or additionally, be depressed, anxious, reacting to domestic violence at home, or be neglected, abused, at risk of losing their job or grieving. The point is that, just as with physical health, the same group of symptoms can be reflective of different underlying causes.

As with physical health, treating the symptoms without investigating the causes can have unfortunate consequences. Viewing psychiatric symptoms as behaviors can be destigmatizing and make things easier to measure, and may also contribute to a fuller understanding of what those symptoms may be reflecting.

While recognizing the complex nature of mental health diagnosis, it is suggested here that given the current construction of the mental health profession’s primary diagnostic manual, things can prove confusing or misleading for the lay public and even some practitioners. Hopefully, in looking at diagnosis from an alternative perspective, this essay has clarified some of the issues that have made some diagnoses difficult to understand.

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About the Author: Dr. Larry Rosenberg is a licensed clinical psychologist. For many years, he was the Clinical Director of The Child Guidance Clinic of Stamford, where he supervised many clinicians and interns. He is also the Past President of Section II, Division 39 of the American Psychological Association. In addition to maintaining a private practice, Dr. Rosenberg serves as Adjunct Faculty at the Postgraduate Program, Derner School of Psychology at Adelphi University. Dr. Rosenberg is a member of the Resources to Recover Advisory Board.

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