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From Categories to Continua?

We often consider mental health as a yes-or-no situation. You are either basking in the full light of well-being or you are trapped in the shadows of depression. You either see, hear, or taste things that aren’t really there (hallucinations), or you, well, just don’t. But is it really that simple? Can we neatly package mental health into distinct boxes with their own labels? And allocate each and every one of us to either one or none of these boxes…?

A visual model created by Isabella Molnar

Hello everyone! My name is Isabella Molnar, and I am a Master’s Student at King’s College London., and am currently doing an internship at Inspire the Mind. In this article, I want to talk about the shift from the categorical to the continuous view of mental health due to its enormous relevance in research, approach, and treatment. So, I am hoping to give you some insights into how mental health has been and most likely will be viewed in the future as well as encourage you to think about your ideas on this topic.

The categorical approach has dominated the field of clinical psychology and psychiatry for decades, classifying mental health conditions into discrete categories, each with its own set of symptoms and diagnostic criteria. Yet, a growing body of literature has challenged this approach, emphasising the notion of a continuum approach, which assumes mental health lies on a continuum rather than being an either-or construct.

The reason that the categorical view has dominated the field for so long is because it helps professionals identify those who need treatment (patients) and those who don’t (non-patients). Based on this approach, guidelines have been developed which state what criteria an individual has to meet in order to be diagnosed with a certain mental health condition. Without this categorical tool, it might be more difficult for professionals to exclude and/or include certain conditions in their diagnosis process.

Besides being helpful for professionals, it has been suggested by research that some individuals might find it helpful to be able to "label" their experiences. It can be considered a relief, reassurance, and, importantly, a validation of their feelings and problems that goes beyond stress and adversity. A psychiatric diagnosis is not only helpful for some individuals, but also crucial in many legal, financial, and educational contexts (e.g., when seeking out disability support). Having a shared language can facilitate mutual understanding and communication in many of these contexts.

You ‘have’ it, or you don’t. What’s so wrong with that?

Disadvantages of the Categorical View

The problem with the categorical view, widely criticised by academics, is that you can’t just neatly package mental health into distinct boxes with distinct labels. Mental health and illness are far too complex and multifactorial to be differentiated into a patient vs. non-patient model. Besides, even within the patient population, symptoms and experiences vary. Two individuals can receive the same diagnosis without sharing a single symptom.

The categorical view has also been criticised by academics due to the high overlap across conditions (comorbidity). Patients often meet criteria for more than one condition, and there is even evidence to suggest that conditions even overlap genetically (for example, between panic disorder and major depressive disorder).

Additionally, the patient vs. non-patient model can create stigmatisation. Individuals receiving a psychiatric diagnosis might experience negative connotations, myths, and misconceptions associated with the condition. Also, similar symptoms have been reported in non-clinical populations. 6-15% of the general population experience hallucinations — does this mean it should be considered a symptom of a conditions we have to uncover? Or does that mean we are all just on different positions on the continuum? In some cultures, hallucinations are also perceived as something positive, so maybe there should be a continuum for cultural beliefs and views?

Lastly, individual symptoms are likely to change over time. Consider someone who is experiencing depressive symptoms, but then goes home for a week or so, and feels much better. Would we then say this person is not depressed anymore? Even though these diagnostics do consider time, I think it presents an issue. Individuals might think they aren’t struggling enough to seek help, or that you only need treatment, if you have been struggling for a long time. Therefore, the cut off points are not representative of the full spectrum of experiences.

So, what can we do instead?

The Continuum View

There has been a lot of research investigating the potential shift from the categorical view to the continuum view. According to this notion, mental health conditions lie on a continuum. So, rather than either being a patient or not, experiences range from non-clinical, healthy functioning to problematic and severe mental illnesses causing distress. The position on the scale can shift as situations improve or deteriorate due to several factors (e.g., age, prognosis/progression of symptoms, treatment, formulation).

What’s so good about it?

The continuum view might lead to a reduction of stigmatisation, as we can appreciate that we all lie somewhere on the scale. It diminishes the idea of you are either mentally "ill" or you are "well" — which might be helpful for many people. It also might help normalising the discussion around mental health by emphasising the idea that no matter where on a continuum you find yourself and to what degree you are struggling: We all have mental health, therefore, we can all be part of the conversation!

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