Psychological problems, biomedical models, and stigma: A commentary on Lahey et al. (2022)

In a provocative article, Lahey et al. (2022) advocate that, on the basis of substantial research evidence plus the potential to reduce stigma, the field should eliminate psychiatric diagnostic categories in favor of a dimensionalized approach to what should be termed “psychological problems” (as opposed to labels of mental disorders or psychopathology). More boldly, their argument includes a case for eschewing any underlying medical model of such psychological problems. In this commentary I begin by lauding their key arguments with respect to quantitative and dimensional perspectives. I then proceed to question the view that medical models are inherently stigmatizing, so long as integrative (rather than reductionistic) perspectives are at the forefront. Indeed, even in medicine there is no single medical model (think, for example, of infectious diseases vs. chronic health conditions linked with heritable risk compounded by toxic exposures). That is, a purely behavioral and psychological account is not only overly simplistic but also potentially stigmatizing. Indeed, unintended consequences may emerge from calling all that is typically subsumed undermental disturbance as problems in living or psychological issues. I highlight the existing evidence on consequences of eschewing biomedical conceptions of risk and etiology with respect to both public attitudes and self‐perceptions of those experiencing serious life impairments related to psychological and behavioral functioning.


mental illness, psychological problems, stigma
In a provocative article, Lahey et al. (2022) advocate that, on the basis of substantial research evidence plus the potential to reduce stigma, the field should eliminate psychiatric diagnostic categories in favor of a dimensionalized approach to what should be termed "psychological problems" (as opposed to labels of mental disorders or psychopathology). More boldly, their argument includes a case for eschewing any underlying medical model of such psychological problems.
In this commentary I begin by lauding their key arguments with respect to quantitative and dimensional perspectives. I then proceed to question the view that medical models are inherently stigmatizing, so long as integrative (rather than reductionistic) perspectives are at the forefront. Indeed, even in medicine there is no single medical model (think, for example, of infectious diseases vs. chronic health conditions linked with heritable risk compounded by toxic exposures).
That is, a purely behavioral and psychological account is not only overly simplistic but also potentially stigmatizing. Indeed, unintended consequences may emerge from calling all that is typically subsumed under mental disturbance as problems in living or psychological issues.
I highlight the existing evidence on consequences of eschewing biomedical conceptions of risk and etiology with respect to both public attitudes and self-perceptions of those experiencing serious life impairments related to psychological and behavioral functioning.

KUDOS
Bravo to the authors for an articulate and convincing review of the clear superiority of dimensional accounts regarding the underlying problems (or in a medical view, symptoms) of psychological disturbance. Space limitations preclude a substantive summary, but I highlight the authoritative sources cited by Lahey et al. (2022), which emphasize the non-appearance of true categories/taxa in systematic literature reviews-along with the polygenic (i.e., multiple genes of small effect) nature of the genetic underpinnings of most neurodevelopmental and mental conditions. Data from the authors' own labs are also highly persuasive, including findings related to the greater reliability and validity of quantitative versus categorical perspectives. Even more, taxonic conceptions (e.g., major depressive disorder; post-traumatic stress disorder; attention deficit hyperactivity disorder) directly imply that all individuals receiving such diagnoses are fundamentally similar, which is simply untrue on a number of grounds. Heterogeneity rules.
So, a reader might be asking, why not drop any and all categorical taxonomies and adopt a fully dimensionalized perspective, especially one that avoids any disease-oriented accounts?

CAVEATS
On the basis of voluminous evidence, it's apparent that categorical diagnoses are arbitrary, relatively unreliable, and insufficiently valid.
However, in medicine (e.g., high blood pressure/hypertension), in ascertainment of psychosocial risk (e.g., poverty levels; adverse childhood experiences [ACEs]), or in clinical psychology and psychiatry (e.g., number of relevant problems or symptoms), binary designations are often needed as to who surpasses a given cutoff. Such thresholds are increasingly determined through available data-for example, plotting systolic and diastolic blood pressure readings against eventual stroke risk; plotting poverty levels or ACE scores This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. against impairments in later life; or plotting numbers of attention deficit hyperactivity disorder (ADHD) symptoms against risk for school failure or peer rejection. Note that a host of social and cultural factors may be related to (a) differential cut scores for differing subgroups and (b) the make-up of the eventual criterion scores linked to impairment. For a recent, extremely lucid article on the promise and perils of precision mental health, see Szatmari and Susser (2022).
Healthcare systems are based on yes/no, diseased/healthy conceptions of illness. In the article's last section, while still advocating for a dimensionalized view, Lahey et al. (2022) explicitly address the categorical question of "who needs treatment" as a driving force for the status quo, stating that challenges of changing the health care system to a fully dimensional approach would be "enormous." Even more, they assert that anyone asking for help with psychological problems should receive reimbursable intervention, perhaps saving societal money in the long run given the pernicious consequences of serious psychological issues.
I believe that the term "enormous" here may be an understatement. Even more, who's to say, absent thresholds, whether more educated and affluent individuals and parents might not demand services for relatively mild psychological issues, while lessenfranchised members of the population, with far greater needs, would in the process be denied needed care?
Crucially, I believe that the target article's insistence on terming the issues at hand as "psychological problems"-eschewing any kind of underlying medical model with the goal of reducing stigma-may be misguided in key respects. As someone deeply concerned with the reduction of stigma and discrimination, the enhancement of access to services, and the promotion of humanization (Hinshaw, 2017;Martinez & Hinshaw, 2016), I provide some additional thoughts. What's needed is a fully integrated and integrative perspective, not a psychological problems versus mental illness dichotomization.
Coronary artery disease (CAD)-which involves the building of plaques inside crucial arteries supplying blood to the heart-is a key trigger for myocardial infarctions (heart attacks). The heritability of CAD is almost exactly 0.5, meaning that individual differences in CAD risk are explained about half by genetic differences and half by environmental/contextual differences across people. But do we perceive those with CAD as less than human, fundamentally flawed?
Typically not. Because, however, the brain (with its intricate connections to the rest of the body) is the "seat" of personality and emotion, views of a fundamental lack of humanity still cling to atypical behavior, views that are potentially exacerbated by an exclusive lens on flawed genes.
At the root here is essentialism: the belief that a person with a psychological, mental, or physical illness is qualitatively and essentially distinct from other humans (Haslam & Kvaale, 2015).

CONCLUSION
If our ultimate goal is to help individuals, families, and cultures thrive, to drive our economies, and to promote a more harmonious world, we must address psychological distress and pain with the realization that humans lie on multiple spectra of core dimensions of functioning and well-being. Most forms of psychological disturbance/mental dysfunction are common, waxing and waning over months and years, with recovery a true possibility. Research continues to reveal, especially for the most severe and impairing forms of such conditions, clear biomedical underpinnings that always operate and transact with family, social, and cultural systems. The aims of recognition (and, when needed, use of the most evidencebased thresholds), provision of evidence-based treatment, promotion of strengths despite areas of impairment, and insistence on humanization will be not be well served by an "either/or" in terms of biological risk versus psychological functioning and cultural contexts. Rather, to promote humanization, inclusion, and belonging, our perspectives must be "both/and."

CONFLICT OF INTEREST
The author has declared that he has no competing or potential conflicts of interest.

DATA AVAILABILITY STATEMENT
No data analyzed in this narrative Commentary.