The threshold problem of impairment criteria in psychiatric diagnosis

Abstract

Dear Editor, Psychiatric diagnoses are made based on careful ascertainment of cluster of signs and symptoms. However, just having symptoms and signs is not sufficient, these need to create problems to the person (or others around him/her) and manifest as distress or functional impairment. For example, a person may have third-person-discussing-type auditory hallucinations for over a month, but he or she may be able to attend to most social occasions and conduct the occupation as an agriculturist diligently. Similarly, individuals may present with symptoms of cannabis use disorder, but not manifest impairment of substance use disorder.[1] We argue that there is considerable heterogeneity in the conceptualization, practical ascertainment, and interpretation of functional impairment. This results in, at least to some degree, nebulousness of determining the threshold of psychiatric disorders.[2] Determining a threshold has implications in adjudicating the prevalence of psychiatric disorder, whether a psychiatric disorder is in remission, and whether a person needs treatment. We envisage three main reasons contributing to the threshold of psychiatric diagnosis. The first is the individual context of the person being interviewed for a diagnosis. A pilot experiencing sleep difficulties due to anxiety and missing a day of flight would be considered to have a diagnosis, whereas a college student missing a class in a month might not be considered passing the diagnosis threshold. The second is the social and cultural context of the person being evaluated. A person from rural parts of Punjab in India being extremely jocular and interrupting the therapist occasionally may be passed off as nonimpairing. A similar presentation of an individual from rural Tamil Nadu may be considered manifesting impairment associated with an affective illness. The third factor is the experience and expectations of the therapist. The therapist decides whether a person crosses the threshold or not. This may have something to do with how they appraise the information and what clinico-therapeutic experiences they may have had in the past. Since there is heterogeneity in determining the threshold of psychiatric diagnoses, there are a few suggestions to address the issue. One is acceptance of the subjectivity of the process of determining the threshold of diagnosis. One could determine kappa values of interrater reliability of impairment criteria. Interrater reliability of diagnoses and functional impairment assessment has been found to be acceptable, though not completely concordant.[3] The second approach could be greater recognition of contextual aspect in determining diagnosis and addition of an explanatory note on how social, educational, economic, political, legal, and other factors might have influenced determining threshold in a particular case. The third approach could be to put a-priori note during diagnostic evaluation process, when the diagnosis is being made and about in what circumstances or degree of functional impairment would the mental health professional not consider a psychiatric diagnosis or the diagnosis to be deemed to be in remission. To conclude, we do proffer that subjectivity exists in determining the lower threshold of impairment of psychiatric disorders, and being cognizant of this may help in rationally labeling an individual as having psychiatric disorder. Financial support and sponsorship The authors disclosed no funding related to this article. Conflicts of interest The authors disclosed no conflicts of interest related to this article.