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Internalizing disorders: the whole is greater than the sum of the parts

introduced by Feinstein in 1970 asmeaning the simultaneous co-occurrence of two independent, unrelated diseases. The co-occurrence of anxiety and depression does not quality for comorbidity; either they are symptoms of the same condition (like neurotic depression), or they reflect one condition causing another (as inmixed depression,where anxiety is causedby themixed state). The hierarchy proposed by this consortium grows out of the personality literature. It includes concepts that may be relevant to personality, but which are less relevant to mood or psychotic diseases. Dimensionality is relevant in both cases, but perhaps in different ways. For instance, the best clinical research supports the dichotomybetween schizophrenia and manic-depressive illness. Further, the externalizing/internalizing concepts do not capture many of the features of manic-depressive illness, such as the presence of mixed states. The placement of “mania” as part of an “internalizing” disorder is questionable. The distinction betweenbipolar illness and “unipolar” depression is assumed in the hierarchical taxonomy, whereas this distinction has questionable validity based on the best available clinical research. Thus, the proposal of a quantitative hierarchy is welcome, but how it is set up will require more attention to some clinical research that does not appear to have been included in the working taxonomy provided in Krueger et al’s paper. An alternative approach growing out of research on mood and psychotic diseases has been proposed dating back to the 1970s. I have suggested a modernized version of that approach. In this proposal, the hierarchy of psychopathology would involve manic states (bipolar illness) at the top of the pyramid of diagnosis, followed by depressive states (unipolar depression), followed by schizophrenia, then anxiety diagnosis (like obsessive-compulsive disease), then personality “disorders” (such as borderline and antisocial), then attention deficit disorder and narrowly defined diagnoses (such as eating disorders or paraphilias). The general concept is that conditions higher on the hierarchy are polysymptomatic, and cause the symptoms of conditions lower on the hierarchy, and thus the former should be ruled out before the latter are diagnosed. This is standardmedical teaching. Core medical training involves using symptoms to identify diagnoses, and not just converting symptoms into diagnoses, as is the case with DSM-III onwards. Then those diagnoses are organized in a differential diagnosis, where higher order ones are ruled out before lower order ones are made. The opposite approach is taken with the DSM system, which is powerful evidence for an important observation: contrary to what many of the post-modernist and anti-biological critics of DSM claim, the DSM system is not at all representative of the “medical model”. In fact, it is quite anti-medical, as shown in its rejection of the hierarchy concept. In sum, Krueger et al’s effort is very worthwhile, but essentially limited to concepts in the personality literature. If expanded to capture affective andpsychotic conditions, it could begin to put the profession on the road to a better clinical nosology for the future, leaving DSM in the rearviewmirror.