You Don’t Need a Diagnosis to Have a Problem

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I'm pleased to have my colleague, Dr. Alisha Pollastri, join me as a guest co-author for this particular blog.

We are often asked how challenging behaviors relate to mental health disorders. Historically, psychiatry has understood mental health problems through the lens of categorical diagnoses listed in the always controversial Diagnostic and Statistical Manual of Mental Disorder, which is in its 5th edition (the DSM-5). One of the reasons that the DSM is controversial is that categorical diagnoses imply that a person who has depression is different from a person who has anxiety, etc. However, the last decade’s advancements in genetic and brain imaging technologies have told a very different story. Genetic research has found that there is a significant cross-heritability of psychiatric disorders. Suppose someone in your family has one mental health disorder. In that case, you are indeed more likely to have that disorder than another randomly selected person, but also more likely to have another psychiatric disorder, even one from an entirely different diagnostic category.

Meanwhile, brain imaging research finds significant overlap between the parts of the brain that are affected in people diagnosed with disorders that were previously thought to be separate. As a result, the National Institute of Mental Health (NIMH) now emphasizes a framework for understanding and studying the common elements that contribute to all mental health disorders. These common elements underlie all the different mental health disorders in the same way that flour, sugar, and eggs can make cookies on one day and cake on another, depending on how they are mixed and with what. The “ingredients” of all of these mental health disorders include components of our cognitive, social, regulatory, and sensorimotor systems. These components represent the skills we need to navigate the complicated environments in which we live. These systems mix in a certain way with our environment to produce our psychology, including mental and behavioral health.

These advances in genetic and brain imaging research help us understand that challenging behaviors are simply the downstream effect of neurocognitive skill deficits, which underlie many mental disorders cutting across diagnostic categories, including mood disorders, anxiety disorders, disruptive behaviors disorders like ADHD, autism spectrum disorders, and psychosis, to name several.

“So what?” you might ask. Well, focusing on these skills instead of the diagnostic categories they reflect has important ramifications for early identification, prevention, and treatment:

1. Challenging behavior is the canary in the coal mine, informing us of early trouble in neurocognitive development before the typical age of onset for many psychiatric disorders.
2. Building neurocognitive skills associated with managing our behavior can prevent brain-based disorders (i.e., mental health disorders) or lessen their impact.

What we have learned from recent genetic and brain imaging research also helps explain why categorical diagnoses leave a lot to be desired for so many children and adolescents (and adults) with challenging behavior. Most kids don’t fit neatly into a particular diagnostic box but rather meet the criteria for a literal alphabet soup of diagnoses which is more overwhelming than helpful. And then some kids don’t seem to meet any criteria for any specific diagnosis but clearly experience plenty of problems managing their behavior. We like to say that you don’t need a diagnosis to have a problem; you just need a problem to have a problem!

For all of these reasons, we advocate for a focus less on categorical diagnosis and more on the underlying skills that someone struggles with that lead to challenges in living which, if unaddressed, can result in a mental health diagnosis (Wang et al, 2019). Focusing on skills also helps remind us of the good news that skills can be built through practice.