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Alternative Models of the Diagnosis of Anxiety Disorders

Harrison Molloy

Melbourne School of Psychological Sciences, University of Melbourne

PSYC30014: The Psychopathology of Everyday Life

Marnie Drake

28 April 2023

Word count: 2194

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Alternative Models of the Diagnosis of Anxiety Disorders

Anxiety is a universal phenomenon that has been experienced and conceptualised in a range

of ways throughout history and across cultures, and it is only relatively recently that it has been

subject to rigorous diagnostic analysis. According to the Diagnostic and Statistical Manual of Mental

Disorders (DSM, 5th ed.), anxiety disorders are characterized by excessive, long-lasting fear (response

to imminent threat) and anxiety (anticipation of threat) that causes behavioural disturbances such as

the avoidance of perceived threats. These include selective mutism, specific phobias, social anxiety

disorder (SAD), panic disorder, agoraphobia and generalised anxiety disorder (GAD), distinguished

based on the types of objects or situations that induce the fear, anxiety, or avoidance. These

disorders are the most prevalent in most western societies and are one of the main causes of

disability (Craske et al., 2017). Specifically, the World Mental Health Survey posits that, in general,

around one in four individuals have had an anxiety diagnosis or will likely have one in the future

(Kessler et al., 2005). Over recent decades, some psychologists have questioned whether the

diagnostic categories defined in the DSM-5 are ‘genuine’ due to a range of factors, including the

vagueness of the criteria and concept creep, a lack of clear biological markers of anxiety, and a

general critique of the categorical approach employed. Given the heightened prevalence and

severity of these disorders, it is particularly important to properly understand the nature of the

concepts being discussed so that clinical practice can be optimised. As such, the question around

whether the DSM’s categorisations of anxiety disorders are ‘genuine’ warrants deep exploration.

This essay will first outline the merits of DSM categorisations of anxiety, before considering some

critiques of this approach that, to some extent, undermine the genuineness of DSM’s

categorisations. In light of these critiques, this essay will argue that the categorical approach to the

diagnosis of anxiety disorders, adopted by the DSM-5, is too limited, and that alternative

dimensional and causal models may be more genuine reflections of the phenomenon of anxiety.

Before undertaking this project, it is important to clarify what it is we mean when we say

that a disorder is “genuine”, as different approaches to psychopathology posit different criteria for
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the attainment of this status. A realist position, sometimes referred to as the diagnostic view, posits

that the grouped variables (symptoms) that constitute a DSM disorder indicate a fixed, underlying

phenomenon that exists independently of human conceptions and activities (Borsboom, 2008).

Essentially, this view gives rise to the current categorical diagnostic approach and assumes we can

be objectively right or wrong about a specific diagnosis in virtue of the fact we can ‘discover’ it, much

like we might discover a new biological species (Kendler, 2016). On the other hand is a

‘constructivist’ position, which claims that mental disorders are social constructs, in that they

conveniently group together key attributes that may be supported statistically, but fundamentally do

not represent any underlying entity, making these conceptualisations somewhat arbitrary

(Borsboom, 2008). This essay will adopt a broadly pragmatic position that aims to occupy a middle-

ground between these two positions, acknowledging that mental disorders are real phenomena in

the world outside of us that we can learn about, while still taking into account the role of culture and

theory in our formulation of categorisations. With this view, the diagnosis of a disorder becomes

more ‘genuine’ in terms of the practical insights it gives us into the aetiology and treatment

strategies for the disorder (Kendler, 2016). Thus, this essay will evaluate the genuineness of DSM

anxiety disorders using these pragmatic criteria of clinical utility as a measure of the validity of an

anxiety diagnosis.

The Prevalence, Reliability, and Validity of an Anxiety Disorder Diagnosis

On the whole, the DSM-5 as the primary diagnostic tool used in clinical practice has been

praised for providing rigorous and reliable diagnostic criteria for psychiatric disorders (Stein et al.,

2010). The importance of this project should not be understated given the significantly high

prevalence of anxiety disorders as has been previously mentioned, particularly given the enduring

and disabling nature of these conditions. Anxiety disorders tend to be chronic, with fluctuating

severity of symptoms and high relapse rates (Beesdo et al., 2009). A rigorous understanding of this

detrimental phenomenon in society is thus imperative, and the DSM-5 has provided an effective

framework for facilitating productive communication between clinicians and researchers. Evidence
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for this can be found in the generally favourable reliability found for most anxiety and mood

disorder categories, established by Brown et al. (2001). Specifically, the improvement in reliability

for GAD between the DSM-III and DSM-IV are encouraging, as we approach a clearer conception of

this disorder beyond its status as a ‘waste-basket’ diagnosis (Brown & Barlow, 2009). Furthermore,

clinical interviews such as the Structured Clinical Interview for DSM-5 have an established reliability

and validity in general (Craske et al., 2017). In terms of our pragmatic criteria for establishing the

validity of these disorders, the significant effects found in post-treatment response rates of 45-55%

to CBT treatment, particularly in combination with pharmacological treatment, demonstrate that

treatment is at least somewhat effective (Loerinc et al., 2015). This speaks to the validity, and by

extension the genuineness, of anxiety disorders under our pragmatic framework. Thus, in general

terms, it is important to recognise the merits of DSM-5 diagnostic criteria in terms of the useful

information it has provided about anxiety disorders as valid mental health conditions with significant

impacts on individuals and society more broadly. To claim outright that DSM anxiety disorders are

not genuine states of mental ill-health in any way is not an empirically tenable position.

However, there are several limitations to these measures of validity and reliability, due to

issues surrounding the high comorbidity of anxiety and other disorders, relatively modest treatment

outcomes, and an absence of clear biomarkers. Evidence for the limitations of the reliability can be

found in the high rates of misdiagnosis studied in Canada, being 86% for panic disorder, 71% for

GAD, and 98% for SAD (Vermani et al., 2011). While Craske et al. (2017) posits that this may be a

result of the underuse of diagnostic criteria in clinical practice, however another reason might be the

high comorbidity between anxiety and mood disorders. For example, 59% of individuals with GAD

would meet the criteria for a Major Depressive Disorder, leading many to question the discriminative

validity of this diagnosis (Zhou et al., 2017). Brown and Barlow (2009) cite the vagueness of the DSM

criteria for GAD as factors undermining the validity of this diagnostic category due to the

considerable measurement error introduced. Indeed, the revised criteria in the DSM-5 have been

notably critiqued for expanding psychiatric diagnosis into areas of everyday distress as a result of
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this vagueness (Wakefield, 2015). Jackson and Haslam (2022) attribute this to a wider trend of

“concept creep” in psychopathology, in which the value of diagnosis is undermined by everyday use

and broadening official definitions. Further, in evaluating the clinical utility of anxiety disorders as a

marker of the ‘genuineness’ of these conditions, we can note that the upper limit on treatment

effectiveness for anxiety is quite low at 50% and relapse is common (Craske et al., 2017). Given that

the social and personal burden of these disorders is so large, the development of more effective

treatments is essential in cementing anxiety disorders as genuine conditions. As such, these factors

undermine the reliability and validity of DSM-5 diagnostic criteria and suggest that alternative

approaches to psychopathology may need to be considered to adequately resolve these issues and

provide a better account of the genuine phenomenon of anxiety.

Contemporary Models of Psychopathology

In order to see how alternative models of psychopathology may help resolve the specific

issues canvassed above, it is necessary to take a step back and offer a broader critique of the

categorical approach of the DSM-5. Increasingly, psychopathology is moving away from realist

assumptions that underlie the categorical diagnostic approach, favouring conceptions that aim to

guide clinical decision making rather than target an underlying condition. This is because the notion

of mental disorders as independent fixed entities is becoming less tenable in light of recent evidence

that it is more ecologically valid to consider them dimensionally. One strong example is the meta-

analysis conducted by Haslam et al. (2020), which found that individual differences in

psychopathology are predominantly dimensional, with findings in support of dimensional models

outnumbering categorical approaches five to one. As such, imposing categorical thresholds on

phenomena that are by nature dimensional can potentially lead to the loss of valuable clinical

information about clinically significant symptoms presentations that falls below the diagnostic

threshold (Widiger & Samuel, 2005). More broadly, a categorical diagnostic approach by its very

nature assumes that a group of symptoms do indeed represent an underlying and discoverable

condition (Borsboom 2008). Given the relative lack of clear biomarkers for anxiety disorders that
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might suggest the reality of this underlying condition (Craske et al., 2017), it does not seem that this

is a viable assumption for psychopathology to accept in its psychometric models. Indeed, the

operationalisation of categorical thresholds for many disorders is often not based on convincing

empirical evidence, further discrediting the idea of mental disorders as entities independent of our

activities (Brown & Barlow, 2009). As such, given these fundamental problems with categorical

approaches to diagnosis as a whole, the need for alternative models with different underlying

assumptions about the nature of psychiatric disorders is clear.

This essay will present two alternative models for psychopathology that have been proposed

in response to the concerns outlined above and will demonstrate how they resolve problems with

the DSM-5 categorical diagnosis of anxiety. The first model presented by Brown and Barlow (2009) is

an example of the most common approach, which is to devise an empirically grounded set of

dimensions that facilitates more reliable and valid diagnosis and treatment plan. In this model, two

higher order dimensions of personality and temperament are proposed, being

neuroticism/behavioural inhibition (N/BI) and behavioural activation/positive affect (BA/P). These

constructs reflect general vulnerability constructs and have been empirically shown in the literature

to be common underlying features of anxiety and depression disorders (Brown, 2007). One key

advantage to this is that it would address the problems with comorbidity and symptom overlap that

obscures the genuineness of DSM anxiety disorders. For example, GAD, which is an excessively

strong expression of N/BI, can now be distinguished from MDD as it also entails low BA/P

(anhedonia). This reintroduces important clinical information about sub-threshold symptoms that

are absent from the DSM-5. The second approach proposed by Cramer and Borsboom (2015) is a

causal-network perspective that addresses the problematic assumption in the categorical approach

that a particular group of symptoms represents an underlying condition. This model employs a

network perspective of psychopathology symptoms which, rather than aiming at a “common cause”

that is the entity of the disorder, posits direct causal relations between symptoms. Rather than

dealing with latent variables (e.g. MDD, GAD) that we have no way to accurately measure, this
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model is able to be more empirically grounded in variables with clear causal relations that are easy

to measure (e.g. insomnia and fatigue). As such, a mental disorder under this framework would look

something like a vicious cycle of symptoms that could be treated directly. This idea is supported by

calls for more mechanism-specific targeted treatments for anxiety, which could offer greater

benefits than current therapies (Craske et al., 2017). It should be noted, however, that no strong

proposals of alternative models of diagnosis have been accepted, despite the several decades of

research that have explored this area (Brown & Barlow, 2009). The models proposed have significant

limitations for application involving the lack of clarity about the constructs in use with disparate

report measures, as well as methodological concerns in practice. Nonetheless, I argue that, in

resolving the problems found in the categorical diagnosis of anxiety disorders, these contemporary

models of psychopathology present a more genuine (useful and informative) account of anxiety

disorders as states of mental ill-health.

Conclusion

In this essay, various approaches to psychopathology were canvassed in order to clarify what

it means for an anxiety disorder to be ‘genuine’. Adopting a pragmatic approach foregrounding

clinical utility, an evaluation of the prevalence, validity, and reliability of DSM-5 anxiety disorder was

offered. From this it was concluded that, although we should not understate the merits of DSM-5

categorisation in grappling with a genuine phenomenon, interrogating the concepts further reveals

issues that undermine the genuineness of this framework. The need for an alternative model was

introduced by canvassing a broader critique of the categorical approach of the DSM-5 as a whole,

and finally, two alternative models were presented which I argue provide more genuine accounts of

anxiety than the DSM diagnostic model. Understanding anxiety disorders in the most accurate and

useful way that we can is of extreme significance given the prevalence and disabling nature of these

conditions. Reframing our approach to psychopathology as pragmatic (rather than realist) can, as

has been demonstrated, offer valuable clinical insights missed by a categorical approach. Given that

exploration of these alternative models is so recent in the literature, future research should be
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dedicated to formalising some of these alternative proposals and testing them thoroughly in clinical

settings.
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