Dimensional or categorical: different

classifications and measures of

anxietyand depression -
Medicographia

Dan J. STEIN, MD, PhD

Dept of Psychiatry
University of Cape Town
Cape Town – SOUTH AFRICA

Dimensional or categorical: different

classifications and measures of anxiety and
depression

by D. J . Stein, South Africa

Psychiatric syndromes and symptoms are complex

phenomena that can potentially be conceptualized and
assessed both categorically and dimensionally. Both the
Diagnostic and Statistical Manual of Mental Disorders (DSM)
and the International Classification of Disease (ICD) systems
rely extensively on a categorical approach, but also note the
dimensional nature of syndromes and symptoms. Here, some
of the relevant conceptual issues for anxiety and mood
disorders are reviewed, and exemplars from the DSM and ICD
revision process are used to illustrate these issues.
Categorical diagnoses and specifiers are often useful,
although they also have key limitations that should be
recognized. Dimensional ratings allow more fine-grained
conceptualization and assessment of symptom profiles and
etiological factors; this may have some benefits, but also
some costs. Categorical and dimensional approaches should
be seen as complementary, andmay usefully be employed in
tandem.

Medicographia. 2012;34:270-275 (see French abstract on page 275)

Psychiatric syndromes and symptoms are complex

phenomena that can be conceptualized and assessed both
categorically and dimensionally. The category of major
depressive disorder, for example, is often used in clinical
settings. In clinical settings, however, the profile and severity
of symptoms in major depression varies a great deal. Such
variation is even more apparent in community settings.1
Similarly, the diagnosis of anxiety disorders such as social
anxiety disorder (SAD) is commonly made in clinical settings.
But, again, the profile and severity of anxiety symptoms,
including social phobia symptoms, ranges broadly in both
clinical and community settings.2 Both the Diagnostic and
Statistical Manual of Mental Disorders (DSM) and the
International Classification of Disease (ICD) systems rely
extensively on a categorical approach, but also note the
dimensional nature of syndromes and symptoms. Thus in
both systems, the main focus is on describing a range of
categorical clinical entities. At the same time, both systems
make use of a range of specifiers, such as “mild,” “moderate,”
and “severe,” which introduce a dimensional aspect. DSM-IV
explicitly notes that categories are fuzzy, and that it is difficult
to draw clear boundaries between disorders and normality,
and between different disorders.3 What are the advantages
and disadvantages of categorical versus dimensional
approaches to psychiatric syndromes and symptoms? Are
these complementary or competing approaches? Here, some
of the relevant conceptual issues for anxiety and mood
disorders are reviewed, and exemplars from the DSM and ICD
revision process are used to illustrate these issues.
Categorical approaches

A categorical approach to psychiatric disorders is frequently

adopted in clinical practice, because the presence or absence
of a particular condition crucially informs treatment
decisions. Although symptoms are often measured
dimensionally, categorical cut points are then used tomake a
determination about treatment. The utility of categories is not
limited to the clinic; psychiatric epidemiologists may, for
example, find it useful to record details about a history of
lifetime major depression, and intervention researchers may
find it useful to determine categorical treatment response,
even if statistical methods demonstrate that depressive
symptoms fall on a continuum (ie, there is no underlying
taxon).4

A categorical approach to conceptualizing and assessing

psychiatric disorders has several major limitations that
deserve recognition.A first problemis encouraging whatmay
be termed “essentialism.”5,6 Major depression is not a “natural
kind” in the same way that say gold or silver is.7,8 First, two
individuals with major depression may have quite different
symptom profiles and symptom severity. Second, two
individuals with major depression may have quite different
factors contributing to the pathogenesis of symptoms; these
may differ both in type and extent (eg, one patient may have
several minor genetic variants contributing to an episode; a
second patient may have one major genetic variant that is
responsible).

Nevertheless, the provision of categories such as “major

depression,” defined in terms of operationalized criteria,
means that such entities may be reified, and viewed as natural
kinds. This may have significant negative consequences in
clinical and research contexts. First, clinicians may focus their
clinical assessment primarily on the operational criteria
provided in the nosological systems rather than on many
other kinds of symptoms and contexts which may also be
clinically relevant. Second, clinicians may not only fail to
appreciate the complexity of symptomatology, but they may
also overlook the complexity of contributing factors, focusing
for example, only on particular genetic and environmental risk
factors at the expense of others.

The use of a categorical approach may lead, then, to a

systematic under appreciation of the importance of variations
in overt symptoms and in underlying mechanisms from
individual to individual. One patient may have typical
symptoms of a mild degree in one kind of situation, while
another patient may have atypical symptoms of a moderate
degree caused by a quite different range of factors. The type
and extent of depressive and anxiety symptoms may differ
across gender, developmental stage, and culture; such
differences may be downplayed or ignored by using a single
category, such as “generalized anxiety disorder,” to describe
anxiety symptoms in each of these cases. Such dimensional
variation may occur even in disorders where discontinuity in
symptom measures indicates an underlying latent taxon (eg,
schizotypy).4

Another important problem with the categorical approach is

that when the DSM system is employed, many individuals are
found to have more than one disorder. Such extensive
comorbidity seems artifactual.9 Individuals with
bothmajordepression and generalized anxiety may arguably,
for example, be more accurately conceptualized as having a
mixed anxiety depressive disorder.10 Diagnosing individuals
with two comorbid disorders would seem to suggest that
each involves different etiological mechanisms and requires
different treatments, when a more parsimonious approach
may be more accurate. (The entity of subthreshold mixed
anxiety disorder remains, however, controversial.)11 A final
problem with a categorical approach is particularly important
in research settings; analyses of dimensional measures offer
greater statistical power.

Dimensional approaches

Given these kinds of difficulties raised by the categorical

approach, many clinicians and researchers advocate the use
of a dimensional approach to conceptualizing and assessing
psychiatric syndromes and symptoms. Given that nature
cannot easily be carved at her joints,12 one argument is that
an understanding of the psychobiology of psychiatric disorder
requires an acceptance of the dimensional nature of
symptoms.10 Dimensions can conceivably be used to record
not only symptomprofiles, but also etiological contributors,8
including the full range of relevant types and extents. Indeed,
there have been ongoing efforts to include a dimensional
approach in DSM-5.13-15 Such dimensions may include
continuous assessment of core symptoms, dimensional
assessments that cut across different disorders, and
spectrum constructs.16

At the same time, it should be noted that there are also

potential problems with a dimensional approach. First,
dimensional analysis is only useful when the association of
predictors with dimensional scores is in fact constant
throughout the relevant dimensional severity range.4 Second,
the use of dimensions does not necessarily avoid
essentialism and reification; instead of there being reification
of a single entity, there is potentially reification of particular
symptoms or causal dimensions. Third, while artifactual
comorbidity may be diminished, there is potentially the
problemof how to easily articulate complex patterns of overt
symptoms and underlying mechanisms. Thus, for example,
the use of just 3 dimensions requires 8 categories based on
high and low cut-off scores to articulate constructs situated
at the high and low ends of these dimensions. This creates
difficulties for both clinicians and researchers, and raises
issues of user acceptability.17

Table I. Differences between compulsive hoarding and

obsessive-compulsive disorder.
Abbreviations: CBT, cognitive behavioral therapy; DSM-IV-TR, Diagnostic
and Statistical Manual of Mental Disorders-IV-text revision; OCD,
obsessive-compulsive disorder; OCPD, obsessive-compulsive
personality disorder; PD, personality disorder; SRI, serotonin reuptake
inhibitor.
Modified from reference 29: Mataix-Cols. Depress Anxiety.
2010;27:556-572. © 2010, Wiley-Liss, Inc.

Indeed, dimensional approaches are often translated back

into categorical approaches via the use of cut points. Thus, in
clinical settings, patients with scores above a particular cut
point on a symptom severity rating scale may be viewed as
having the relevant disorder, while those with scores below
this cut point may be viewed as not having the condition.
Fortunately, the research literature has provided a growing
body of information on the relationship between coarse-
grained, but user-friendly categorical measures, and more
fine-grained, dimensional measures. Thus, for example, in the
World Mental Health Surveys, tandem use of categorical and
dimensional measures allowed validation of cut points for
assessing constructs such as psychological distress.18-20
Similarly, in treatment studies, the tandem use of categorical
and dimensional measures allows a rigorous evaluation of
optimal cut points for determining treatment response.21

Exemplars

Is SAD a psychiatric disorder? Certainly, if one considers a

patient with severe SAD symptoms and consequent
symptoms of major depression, with associated marked
distress and impairment, it seems clear that such an
individual deserves to be diagnosed with a psychiatric
disorder and to receive appropriate intervention. What about a
patient who suffers from a single kind of performance anxiety,
such as speaking in public, but who manages to avoid such
situations, and who otherwise lives his or her life without
distress or impairment? How about patients who are
somewhat introverted and shy, but who find themselves in
work situations that demand a high level of social interaction,
where those who are more outgoing are rewarded with higher
pay packages?22

From a categorical perspective, DSM-IV differentiates

between those with and without SAD on the basis of the so-
called clinical significance criterion.23 This criterion indicates
that individuals with marked clinical distress, or significant
impairment as a consequence of their symptoms, meet the
criteria for suffering from a clinical disorder. DSM-IV also
differentiates individuals who have generalized SAD; such
individuals fear “most” social situations. The literature
suggests that individuals with generalized SAD have more
severe symptoms, greater impairment, and are more likely to
have a family history of SAD.24 Both “SAD” and “generalized
SAD” seem to be clinically useful categories.

From a dimensional perspective, however, some individuals

with social anxiety symptoms fear only a few different social
situations, and others fear many. Individuals with many social
fears who do not quite meet the clinical significance criterion
may arguably still have significant symptoms, and may be at
significant risk for comorbidity. The question of when to treat
is one that should be decided using considerations such as
cost-effectiveness.1,7 Similarly, there is no specific cut point
that differentiates those with generalized versus non-
generalized social anxiety; instead there is a monotonic dose-
response relationship between number of social anxiety
symptoms and indicators such as increased SAD persistence,
severity, and comorbidity.2 Nevertheless, the distinction
between generalized and non-generalized may be important in
other ways, such as in predicting treatment response.

Obsessive-compulsive disorder (OCD) provides another

interesting exemplar. On the one hand, OCD seems a relatively
homogenous neuropsychiatric entity, at least in comparison
with disorders such as major depression or generalized
anxiety disorder.25 On the other hand, there is growing
evidence of the heterogeneity of OCD.26 For example, there is
good evidence, based on meta-analysis of factor analytic
studies of OCD symptom types, that OCD symptoms fall into a
relatively limited number of key symptom dimensions.27 Also,
there is evidence that OCD patients with and without
comorbid tics may differ in important ways.28

From a categorical perspective, the construct of OCD has long

been supported on the basis of considerations of both
diagnostic validity and clinical utility. On the other hand, the
tic specifier that has been newly proposed for DSM-5 provides
an additional category which allows an even more fine-
grained assessment of patients with OCD. Again, this specifier
seems to have both diagnostic validity as well as clinical
utility. Thus, patients with OCD as well as tics are more likely
to have particular kinds of symptom profiles, they may have
different underlying genetic profiles, and they may respond
differentially to intervention.28

From a dimensional perspective, recording different OCD

symptom dimensions may allow a more fine-grained level of
assessment that is useful in both clinical and research
settings.28 Thus, subjects with hoarding symptoms may have
a different neurobiology and treatment response. Similarly,
each of themajor symptomdimensions in OCD may have some
level of specificity at a neurobiological level. The DSM-5
proposal, however, is to recognize hoarding disorder as a
separate clinical entity (Table I),29 and to describe OCD
symptom dimensions in the text of the OCD section rather
than as formal specifiers.28 This reflects data that hoarding
symptoms represent a unique diagnostic category, while
ratings of other symptom dimensions in OCD are perhaps less
clinically useful.28,29
Finally, there is the question of whether it is useful to assess
obsessive-compulsive symptoms across a range of different
anxiety disorders, and whether it is useful to have a separate
chapter in the nosology on obsessive-compulsive spectrum
disorders. Certainly, it has been suggested that the presence
of obsessive-compulsive symptoms in disorders such as
schizophrenia may have clinical utility.30 Furthermore, it has
been argued that given overlaps in the phenomenology and
psychobiology of several putative obsessive-compulsive
spectrum disorders, it would enhance the scientific validity
and clinical utility of the nosology to group such disorders
together31 (Table II).32 The inclusion of a separate chapter on
these conditions might help raise awareness of overlapping
approaches to their diagnosis, assessment, and treatment.
Several of these disorders may have similar dimensional
specifiers, such as an insight specifier which ranges from
good to poor (Table III).

Table II. Similarities between

obsessive-compulsive disorder
and selected obsessive-compulsive
spectrum disorders.

Abbreviation: OCD, obsessive-compulsive

disorder.
Reproduced from reference 32: Phillips.
Psychiatr Clin N Am. 2002;25:791-809.
© 2002, Elsevier Science (USA).
Table III. Classification of delusional and nondelusional forms
of disorders in DSM-IV.

Abbreviations: DSM, Diagnostic and Statistical Manual of Mental

Disorders; NOS, not otherwise specified; OCD, obsessive-compulsive
disorder.
Reproduced from reference 32: Phillips. Psychiatr Clin N Am.
2002;25:791-809. © 2002, Elsevier Science (USA).

Table IV. Cognitive deficits across anxiety disorders.

Abbreviations: GAD, generalized anxiety disorder; ID/ED,

intradimensional-extradimensional set-shifting task; OCD, obsessive-
compulsive disorder; PD, personality disorder; PTSD, posttraumatic
stress disorder; SAD, society anxiety disorder; SSRT, stop signal reaction
time test; WCST, Wisconsin card sort test.
Reproduced from reference 35: Stein et al. Depress Anxiety.
2010;27:495-506. © 2010, Wiley-Liss, Inc.

At the same time, it should be acknowledged that any

particular metastructure has both strengths and
weaknesses.33,34 Thus, for example, a separate chapter on
obsessive-compulsive and related disorders may lead to
underemphasis of the important overlaps between OCD and
other anxiety disorders (Table IV).35 In addition, a separate
chapter on obsessive-compulsive and related disorders runs
the risk of downplaying important differences in the
diagnosis, assessment, and treatment of different conditions
that fall within this chapter. Placing obsessive-compulsive and
related disorders immediately after the anxiety disorders in
the DSM-5 metastructuremay help emphasize relationships
between these conditions, and itmay be useful to emphasize
in the DSM-5 text that there are important distinctions
between each of the obsessive-compulsive and related
disorders.34

Conclusion

Categorical and dimensional approaches to conceptualizing

and assessing psychiatric syndromes and symptoms are
complementary rather than mutually exclusive, with
dimensional assessments often informing categorical
treatment decisions. Furthermore, categorical ratings can be
transformed into dimensional ones (eg, by summing the
number of diagnostic criteria met) and vice versa (eg, by
using cut points to determine whether a categorical diagnosis
should be made). A categorical approach provides a clinically
useful way to communicate rapidly the main features of a
case, and is also valuable in particular research situations. A
potential disadvantage of categorical approaches is that they
may encourage reification and oversimplification of complex
entities with multiple overt symptoms and underlying
mechanisms. A dimensional perspective allows for a more
fine-grained approach, but also has significant potential
disadvantages. It is useful to employ categorical and
dimensional approaches in tandem, in both clinical and
research settings.4,10 _

Acknowledgment. Professor Stein is supported by the Medical

Research Council of South Africa.
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This publication is supported
by an unrestricted educational
grant from Servier