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PSYCHIATRICCOMORBIDITY:FACTORARTEFACT?

HannaM.vanLoo
JanWillemRomeijn

H.M.vanLoo(correspondingauthor)
InterdisciplinaryCenterPsychopathologyandEmotionRegulation(ICPE),Departmentof
Psychiatry,UniversityofGroningen,UniversityMedicalCenterGroningen,Hanzeplein1,
POBox30.001,9700RB,Groningen,TheNetherlands.
email:h.van.loo@umcg.nl

J.W.Romeijn
FacultyofPhilosophy,UniversityofGroningen,TheNetherlands.
email:j.w.romeijn@rug.nl

J.W.RomeijnisalsoappointedasresearchfellowatthePhilosophyDepartmentofthe

UniversityofJohannesburg.

Abstract
Thefrequentoccurrenceofcomorbidityhasbroughtaboutanextensivetheoretical
debateinpsychiatry.Whyaretheratesofpsychiatriccomorbiditysohighandwhatare
itsimplicationsfortheontologicalandepistemologicalstatusofcomorbidpsychiatric
diseases?Currentexplanationsfocuseitheronclassificationchoices,oroncausalties
betweendisorders.Basedonempiricalandphilosophicalarguments,weproposea
conventionalistinterpretationofpsychiatriccomorbidityinstead.Wearguethata
conventionalistapproachfitswellwithresearchandclinicalpracticeandresolvestwo
problemsforpsychiatricdiseases:experimentersregressandarbitrariness.

1.Introduction

Thispaperinvestigatesthenatureofcomorbidityamongpsychiatricdiseases,and
considershowthisreflectsonpsychiatricdiseaseclassification.Psychiatricdisordersas
describedintheDiagnosticandStatisticalManualofMentalDisorders(DSM)aretopic
ofacontinuousdebate.1Thisdebatereachedaclimaxwiththedevelopmentofthe
fifthedition(DSM5),whichspikedconsiderablecontroversyinthefieldofpsychiatry,
aswellasinabroadercommunity(e.g.,First2009;Frances2010;Batstra&Frances
2012).Thecontroversytouchedonawiderangeofissues:thetransformationof
normalemotionalexperiencestodisorders,theprosandconsofdefiningdisordersin
dimensionsinsteadofcategories,theinfluenceofthepharmaceuticalindustryonthe
developmentofnewcategories,andsoon.Manyofthoseissuesareinextricably
connectedtoafundamentalquestionaboutthestatusofcurrentpsychiatric
disorders,towit,howshouldweinterpretcategoriesintheDSM?Whatkindof
structuresarethey?Dotheyrefertosomethingreal,oraretheyrathertheproductof
ourowncategorizingefforts?

Comorbidityinpsychiatry
Wewillapproachthesequestionsbyananalysisofthephenomenonofcomorbidityin

1
Inwhatfollowswewillusethetermsmentaldisorder,psychiatricdisease,mental
illnessandpermutationsthereofinterchangeably,asiscustomintheliterature.

psychiatry,i.e.,thepresenceoftwoormorementaldisordersinoneindividual.
Comorbidityisanimportantconcernforprofessionalsandresearchers.Itoccurs
frequentlyinpsychiatry:asmanyas45%ofpatientssatisfythecriteriaformorethan
onedisorderinthecourseofayear.Disordersthatcooccuroftenaremoodand
anxietydisorders,suchasmajordepressivedisorder(MDD)andgeneralizedanxiety
disorder(GAD)(Kessleretal.2005).Inaddition,comorbidityisassociatedwithamore
severecourseofillness.PatientssufferingfrombothMDDandGADtendtohavea
poorerprognosisandadisproportionallyhigherfunctionaldisabilitywhencompared
topatientssufferingfromonlyonedisorder(Schoeversetal.2005).

Comorbidityshighprevalenceanditsinfluenceondiseaseseveritymakeitan
importantsubjectofstudy,certainlyinsofarastheaimofresearchistoimprovethe
lotofpsychiatricpatients.Inadditiontothis,comorbiditypatternshaveledtomore
theoreticaldebatesonthenatureofdiseaseclassificationinpsychiatricscience.The
debatewewillfocusonhereconcernstheartificialityorelserealityofhighratesof
comorbidity.Somearguethatcomorbidityisanartefactofourcurrentdiagnostic
system,causedbyalltypesofclassificationchoices(Maj2005;Vellaetal.2000;
Aragona2009).Otherresearchersinpsychiatrycontendthatpsychiatriccomorbidityis
indicativeofsomethinggenuineaboutthenatureofpsychiatricdiseasebypointingto
commonalitiesinthecausalbackgroundofdifferentdisorders(cf.Andrewsetal.2009,
andtosomeextentZachar2009,2010).Thediscussionofcomorbidityisthus

reminiscentofthemainpositionsontheepistemologicalandontologicalstatusof
psychiatricdisordersingeneral,whichcanbedividedintoaconstructivistandrealist
camp.

Aimsofthispaper
Theaimofthispaperistoscrutinizethephenomenonofcomorbidityinpsychiatry,
andtherebyshedlightonthenatureofpsychiatricdiseaseclassification.Dothose
categoriesrevealsomethingrealandrobustaboutthepsychiatricdomain?Orarethey
rathertheresultofourownwayoforganizingthesubjectmatter?Ratherthanopting
foreitheroftheseextremepositions,wewillargueforaconventionalistposition,
whichescapestheoppositionabove:categoriesintheDSMofferarobustpictureof
theworldofpsychiatricdisorders,yettheydosorelativetoanumberofconventions.
Thiswayofviewingpsychiatricdisordersresolvestwoparticularproblemsforthe
DSM,todowithdefinitionalcircularityandarbitrariness.Moreover,wewillarguethat
conventionalismmightbenefitpsychiatricsciencebyclarifyingthedefinitionalstatus
oftheDSMwithoutdiscardingcurrentempiricalfindingsasartificial.

Thepaperissetupasfollows.Westartbyreviewingthedebateoverpsychiatric
comorbidity,showingthatthisdebatecanbestructuredbygroupingauthors
accordingtoconstructivistandrealistsympathies.Wethenillustrate,byanalysing
comorbiditydatafromtheNetherlandsMentalHealthSurveyandIncidenceStudy

(NEMESIS,Bijletal.1998),thatbothtypesofexplanationareinsufficienttoaccount
forthehighratesofcomorbidityinpsychiatry.Usingourempiricalexample,wewill
spelloutconventionalismregardingmentalillnessasanalternative.Weillustratethis
positionbyreferringbacktoadebateinthephilosophyofscience,todowiththe
ontologicalandepistemologicalstatusofgeometricaldescriptionsofphysicalspace
(Poincar1905;Reichenbach1958;VanFraassen2008).Furthermorewewillgointo
thedefinitionalcircularityandrelatedproblemsfortheDSM.Theupshotofthepaper
isanimprovedunderstandingofcomorbidityinpsychiatry,andofpsychiatricdisease
classificationingeneral.

2.TheDSMandcomorbidity

TheDSMisthemostimportantclassificationsysteminpsychiatry:itprovides
definitionsforpsychiatricdisordersandisintensivelyusedinclinicalpracticeand
research.2Thenewedition(DSM5)describesafewhundredpsychiatricdisorders
varyingfromschizophrenia,depressivedisordersanddementiatofeedingandeating
disorders(APA2013).Mostpsychiatricdisordersaredefinedintermsofasetof
symptoms,ofwhichacertainnumberisnecessaryandsufficient.

2
Similar conclusions hold for mental disorders described in the International
ClassificationofDisease(ICD,WHO1992).

Comorbidityasdependentonclassificationchoices
SpecificdefinitionalchoicesmadeintheDSMplayacentralroleinthetheoretical
debateoncomorbidity,asabroadrangeofthesechoicesisthoughttoinfluencethe
ratesofcomorbidity.Thisleadssomeauthorstostatethatcomorbidityratesare
overrated,andperhapsentirelyartificial.Anoftenmentionedexampleofthose
choicesisthecontinuouslyincreasingnumberofdiseasesintheDSM.Theideaisthat
theproliferationofpsychiatriccategoriesincreasescomorbidityrates(Maj2005).
Secondly,comorbidityratesarethoughttoincreasebyloweringthenecessarynumber
ofcriteriatobesatisfiedfordiagnoses,thesocalledthreshold(Vellaetal.2000,27).
Incaseofanorexianervosa,thenumberofcriteriaforthediagnosisintheDSM5is
reducedfromfourtothreenecessarysymptoms,whichinvokestheideathatmore
individualswillsufferfromanorexianervosa,andthusincreasecomorbidityrates(APA
2013).Third,theprogressivereductionofexclusionaryrulesisassumedtoincrease
ratesofcomorbidity(Maj2005;Aragona2009).Somediseasedefinitionscontain
exclusionaryrulesthatexcludethediagnosisincaseofthepresenceofcertaincriteria.
Forexample,thediagnosisMDDisexcludedifthesymptomsforamixedepisodeare
met,orifthesymptomsderivefromsubstanceabuseoranothermedicalcondition
(APA2013).

Afourth,andoftendiscussedphenomenonisthepresenceofsymptomoverlap:some

symptomsarepartofthedefiningsetsofmorethanonedisorder,andarethus
overlapping.Forinstance,thesymptomsofsleepdisturbance,difficultyin
concentrating,andfatiguearepartofthedefiningsetsofbothMDDandGADinthe
DSM5.Overlappingsymptomsarethoughttoincreasethecooccurrenceofdiseases
withsimilarsymptomsintheirdefiningsets(Goldbergetal.2009;Neale&Kendler
1995).Alastpointofconcernisthenonspecificityofdefiningsymptoms.Symptoms
arenonspecificforadiseaseiftheyalsooccurfrequentlyinindividualswithoutthis
particulardisease.E.g.,allpatientssufferingfromdepressionarethoughttosuffer
fromfeelinggloomy,sleepingbadly,etc.butthesesymptomsalsooccurregularlyin
personswithotheremotionaldisordersinwhichthesesymptomsarenotincludedas
definingcriteria(Goldbergetal.2009).Theadditionofnonspecificsymptoms
(accessory)todefinedisordersissupposedtoincreaseratesofcomorbidityaswell
(Vellaetal.2000).

Comorbidityasdependentoncausality
Insteadofascribingcomorbiditytoclassificationchoices,otherauthorshave
emphasizedtherealcharacterofpsychiatriccomorbidity,byreferringtocommon
causalstructures(e.g.Neale&Kendler1995;Andrewsetal.2009;Zachar2009,2010).
Theystressthatifthereisacommoncausalstructurefortwodiseases,thosetwo
diseaseswillcooccurmoreoftenthanexpectedbychance.Consequently,
comorbidityisseenasasignalthatcurrentdiagnosesdonottrackalltheunderlying

causes,andhenceasaguideforimprovingourclassificatorysystem.Inotherwords,
thehighratesofcomorbidityinpsychiatryarebelievedtoindicatethecausal
connectionsbetweendisordersastheyarecurrentlydefined.

Recently,adebateevolvedonthelevelatwhichthesecausallinksbetween
psychiatricdisordersoccur.Inpsychometrics,disordersarestandardlyapproachedas
latentvariablemodels.Accordingtosuchmodels,correlationsamongthesymptoms
canbetracedbacktounderlyingconstructs,i.e.,variablesthatarelatentandhence
notdirectlyobservable.Thecomorbidityoftwodisorderscanthenbeexplainedbya
causalconnectionbetweentheunderlyingconstructs(figure1).3Forexample,the
latentdisorderGADmightcausethelatentdisorderMDD,orviceversa,andsuch
relationsbetweendisorderscanbemeasuredbythedevelopmentofdepressed
mood,anhedonia,andsoon.Inthissetup,thesymptomsthemselvesaresupposedto
becausallyunconnected.

3
Itisnotinherenttoalatentvariableapproachthatthelatentvariablesfunctionas
entitiesandobtainacausalrole,butoftenresearchersdointerpretthelatentvariablesin
thisway(Borsboom2008).

Figure1(derivedfromCrameretal.2010,withminoradjustments)
Amodelofcomorbiditybetweendisorders1and2,underthestandardassumptionsof
latentvariablemodeling.Thecirclesrepresentthedisorders(i.e.,latentvariables)and
therectanglesrepresenttheobservablecoresymptomsofthosedisorders(i.e.,X1X5
fordisorder1,andY1Y5fordisorder2).Inthismodel,comorbidityisviewedasa
correlationbetweenthelatentvariables,visualizedbythethickbidirectionaledge
betweendisorders1and2.

Alternatively,psychiatricdisorderscanbemodelledasnetworksinwhichsymptoms
aredirectlycausallyconnected(figure2,Crameretal.2010;Borsboom&Cramer
2013).Inthisunderstandingofpsychiatricdisorders,theleveloflatentvariablesis
missing,andallthecausalrelationsamongdisordersarerealizedintermsofthose
causalrelationsbetweensymptoms.Thepresenceofonesymptom(sayinsomnia)
mightstimulatethedevelopmentofahostofconnectedsymptoms(e.g.fatigue,
concentrationdifficultiesanddepressedmood).Becausesymptomsbelongingto
differentdiseaseswillmaintaincausalties,onediseasewilltriggerthemanifestation
ofanotherandhenceincreasecomorbidityrates.Summingup,accordingtoboththe

traditionalpsychometricandthenetworkmodels,comorbiditycanbetracedbackto
causallinksbetweenthedisorders,althoughtheselinksarelocalizedondifferent
levels.Thissupportstheviewthatcomorbidityreflectsarealphenomenonin
psychiatry.

Figure2(derivedfromCrameretal.2010,withminoradjustments)
Comorbidityunderanetworkapproach.Disorder1consistsofbidirectionallyrelated
symptomsX1X5,anddisorder2consistsofsymptomsY1Y5.SymptomsB1andB2are
bridgesymptomsthatoverlapbetweendisorders1and2.Inthismodel,comorbidity
arisesasaresultofdirectrelationsbetweenthebridgesymptomsoftwodisorders.

Arbitrarinessandcircularity
Inshort,wecaninterpretcomorbidityintwodifferentways:eitherthecomorbidity
ratesaredeterminedbyclassificationchoicesintheDSMandthereforeartificially
high,ortheyresultfromcausalrelationsbetweenpsychiatricdisorders.4Wecould
ask:shouldweinterpretcomorbidityasreal,orratherastheresultofour
constructions?Towhatextentarethesetwoviews,whichwemightsomewhat
tentativelycallrealistandconstructivist,rightinexplainingcomorbidity?Primafacie
thelattermightseemthemoreattractiveoption.Itseemsundeniablethatatleast
somecomorbidityistheresultofclassificationchoices.Furtherargumentsinfavourof
thisreadingofcomorbidityderivefromtwocloselyconnectedproblemsfortheDSM,
todowiththeideathatcurrentdiagnosesarearbitraryanddonotcutnatureatits
joints,andwiththedefinitionalcircularitythatbesetstheoryandmeasurement
device.Webrieflydiscusstheseproblemshere.

4
Both positions in the debate agree that causal disease models are preferable to non
causal disease models (Van Loo et al. 2013). The disagreement is in the signal that
comorbidity is supposed to give: either it suggests that our current disorders are fuzzy
symptom sets without any relation to causal structures and need to be replaced by
completelynewdefinitions,oritsuggeststhattherearecausallinksbetweenourcurrent
disorders, and therefore the current diagnoses should be integrated in a more general
causalstructure.

First,considerthepossiblearbitrarinessofthesymptomsetsasdefinitionsfor
psychiatricdisorders.Oftentimespsychiatricdisorderscannotbeassociatedwith
distinctsetsofsymptoms.Ifwedepicttheempiricaldistributionofpatientsinan
abstractspaceofsymptomcombinations,groupsthatsufferfromMDDandGADform
acontinuouswhole.Inotherwords,whenitcomestotheempiricalfactsabout
patientgroupsandthesymptomsthattheypresent,thereisnoclearzoneofrarity
thatseparatesthem.Thequestioniswhetheritissensibleatalltospeakoftwo
separatedisordersinsteadofonedepressionanxietydisorder(cf.Clark&Watson
1991).Absentzonesofrarityarespecificallyproblematicforadvocatesofcausal
diseasemodels,asfuzzydiseaseboundariesseemtobeatoddswiththeideathat
diseasesareidentifiablebearersofcausalrelationsamongdisorders(Kendell&
Jablensky2003;VanLooetal.2013).

ArelatedpointconcernstheapparenttwofoldfunctionoftheDSM.First,the
structureoftheDSMcanbeinterpretedasarepresentationofthestructureof
psychiatricdisorders,andhenceasatheoryaboutwhatpsychiatricdisordersare
(Borsboom&Cramer2013).Butthesamestructureisalsousedasameasurement
deviceintendedtoprovideepistemicaccesstopsychiatricdisorders.Sodefinitionand
measurementofpsychiatricdisorderscoincideexactly.Theresultofthisdouble
functionisacircularityinthedefinitionofthetheoreticaltermsusedintheDSM,

becausetheDSMistellingussimultaneouslywhatitisthatwearemeasuring,and
howweshouldgoaboutmeasuringit.Nowinmostempiricalsciences,theoryand
deviceshowacertainindependenceofoneanother,sothatthiscirclecanbebroken.
ThisisunfortunatelynotthecasefortheDSM,andthisleadstoadefinitional
circularity.5

ThestatusoftheDSM
Allinall,acausalreadingofcomorbiditymightlooksomewhatunattractive.But
despitetheseconceptualproblemsmanypsychiatristshavethefirmconvictionthat
disordersarenotarbitrary,andthattheycanplayacausalrole.Asweindicated,the
twopositionsregardingcomorbidityarerelatedtowhatmaybecalledtheontological
statusofpsychiatricdiseasecategories.Thebasicoppositionistheonebetween
constructivistsandrealists,andinthisoppositionpsychiatristsoftenleantowardsthe
realistside.6Despitetheproblemsthatbesetrealismaboutpsychiatricdisorders,we

5
Theproblemissimilartotheexperimentersregress,whichwefindmorebroadlyin
science(cf.Collins1985).Aswillbearguedfurtherdown,wethinkthattheregressis
particularlypressinghere.
6

Thisisarathercoarsedescriptionofthepositionsonemighttaketowardspsychiatric

diseaseclassification.Insection4wewillbemorespecificonthephilosophicalviews
againstwhichourownviewsareoffset.

shouldnotgiveuprealistaspirationstoosoon.

Inwhatfollowswewillinthefirstplaceclarifythenotionofcomorbidityfurther,and
arguethatbothpositionsi.e.comorbidityasfactorartefactareinsufficientintheir
explanationofthephenomenonofcomorbidity.Instead,comorbidityistheresultof
theinterplaybetweenbothclassificationchoicesandpopulationcharacteristics.We
willillustratethisinSection3byshowingvarioussimplediseasemodelsincludingtheir
potentialcapacityforcomorbidity,afterwhichwewillanalysetheactualcomorbidity
byusingdatafromtheNetherlandsMentalHealthSurveyandIncidenceStudy.In
Section4,wewillthenputthisviewinabroaderphilosophicalperspective,andapply
ittopsychiatricdiseaseclassificationsmorebroadly.

3.Comorbidityistheresultofclassificationchoicesandpopulationcharacteristics

Togetagriponpsychiatriccomorbidity,twoelementsareimportant:(i)howdiseases
aredefinedintermsofsymptomsand(ii)howfrequentlycombinationsofsymptoms
occurinapopulation.7Inthissection,wewillintroduceadiagrammatic
representationinwhichbotharevisualized.Thediagramsrevealthatcomorbidityis
theresultoftheinterplaybetweenspecificsofapopulationandthewaydiseasesare
modelled.Thisestablishesanempiricalargumentagainstunivocalexplanationsof
comorbidity:wecannotexplaincomorbiditysolelybyreferencetoclassification
choices,andneithercanwefullyexplainitbyviewingthediseasesasentitiesandby
pointingtorelationsbetweenthem.Theempiricalstudyratherprovidesanargument
fortheadoptionofaconventionalistview.

Diagrammaticrepresentation
Inthediagramssymptomsareusedasdefiningcriteriaforpsychiatricdiseasessoasto
mimicdiseasedefinitionsintheDSM.Eachsymptomcanbeeitherabsentorpresent.

7
For reasons of simplicity, we assume independence in the sense that a change in the
diseasedefinitionwillnotleadtoachangeinthesymptomdistributioninapopulation,
althoughweacknowledgethatsuchachangemightinfluenceadistributionofsymptoms
(Hacking1995).Theindependenceisnotrequiredforourargument.

Everysymptomcombinationconsistsofthetotalnumberofdiscernedsymptoms,with
everysymptomindicatedasabsentorpresent.Ifnsymptomsaredefined,thetotal
numberofpossiblesymptomcombinationsis2n.Oneextremeofallcombinationsis0
ofnsymptomspresent;theotherextremeisallsymptomspresent.Therestofthe2n
symptomcombinationsconsistofallcombinationsofoneormoreandlessthann
symptomspresent.Inourexamplethenumberofdiscernedsymptomsislimitedto
fourintotal,denotedbyA,B,C,D.8

Diseasesaredefinedintermsofthediscernedsymptoms.Differentdiseasemodels
areconstructedinthediagramsoffigure3,illustratingsomecharacteristicsof
disordersintheDSM.Figure3ashowstwomonotheticdiseases(D1andD2),each
consistingoftwocriteria(D1:AB;D2:CD).FoursymptomcombinationssatisfyD1
(A,B,C,D;A,B,C,D;A,B,C,D;A,B,C,D)andfoursymptomcombinationssatisfyD2
(A,B,C,D;A,B,C,D;A,B,C,D;A,B,C,D).IncaseofthepresenceofA,B,CandD,there
iscomorbidityofD1andD2(*).

Figures3band3cshowdifferentvariantsofthebasicmodelwithseveralfeatures
occurringintheDSM:apolytheticmodel(figure3b)andamodelwithanexclusionary
rule(figure3c).Thenumberofsymptomcombinationssatisfyingbothdiseasesis

8
ThediagramsareknownasKarnaughmaps.

obviouslydependentondefinitionchoices.Anincreasingnumberofthesepotential
comorbidsymptomcombinationssubstantiatestheclaimthatadjustmentsofdisease
definitionsresultinhighercomorbidityrates,andthussupportstheideathat
comorbidityisartificial.However,thisisnotnecessarilytrue.Togetacomplete
pictureofhowtheratesofcomorbiditydependonclassificationchoices,the
distributionofsymptomsinthepopulationmustbetakenintoaccount.Afterall,ifno
individualshavetheadditionalcomorbidsymptomcombinations,ratesofcomorbidity
willnotchangeatall.

Figure3a

Figure3b

Figure3c

Figure3
Differentdiseasemodelsandtheirpotentialforcomorbidity.D1solidline;D2dashed
line;*potentialcomorbidsymptomcombinations.Figure3a:Twomonotheticdisease
models(D1:AB;D2:CD).Figure3b:D1asapolytheticmodel(D1:AB;D2:CD).
Figure3c:D2includesexclusionaryrules(D1:AB;D2:ABCD).

NEMESISstudy
Toillustratetheinfluenceofpopulationcharacteristicsonratesofcomorbidity,we
haveuseddatafromtheNetherlandsMentalHealthSurveyandIncidenceStudy
(NEMESIS).InNEMESIS,arepresentativesamplewasdrawnfromthegeneralDutch
populationintheagesbetween18and64(n=7147).Thissamplewasinterviewedwith
aDutchversionoftheCompositeInternationalDiagnosticInterview(CIDI).TheCIDIis
astructuredpsychiatricinterviewcoveringaverybroadrangeofpsychiatric
complaints.Ultimately,thisledtoadatasetof7076individuals.Bijletal.provideda
detaileddescriptionoftheobjectivesanddesignofNEMESIS(Bijletal.1998).From
thisdataset,weselectedeightsymptomsfortwoanalyses.

Analysis1
Forthefirstanalysiswestudiedthepresenceofsymptomsofanxiety(ANX,i.e.feeling
anxious,nervousorworrisome);depressedmood(DEP,i.e.feelingdepressed,gloomy,
orinthedumps);insomnia(INS);andconcentrationdifficulties(CONC),forthe
majorityofthetimeduringaperiodofatleast2weeks(oratleast4weeksincaseof
anxiety)duringlifetime.ThesesymptomsarepartofMDDandGAD,whichare
diseasescooccurringveryfrequently(Andrewsetal.2002).Withthosesymptomswe
aimedtofindanexampleinwhichallsymptomcombinationsoccurregularlyandasa
result,adjustmentsofdiseasemodelsindeedchangescomorbidityrates.Inthe

NEMESISstudy,wedeterminedthefrequenciesofeachuniquesymptomcombination
in7072individuals(n=7072,missingdataincaseof4individuals).All16possible
combinationsoccurredregularly(min.94,max.2390).Anumberof2390(33.8%)
individualsdidnotsufferfromanysymptomduringtheirlives,whichwasthemost
frequentfinding.Notably,incaseofsymptomsbeingpresent,themostfrequent
symptomcombinationidentifiedwasallsymptomspresent(n=1084,15.3%).Least
frequentwasthecombinationofsleepproblemsandconcentrationproblems,without
depressedmoodandwithoutanxiety(1.3%).

Twosimplemonotheticdisorders(D1andD2)areconstructedinfigure4a.D1is
definedasthecombinationofdepressedmoodandinsomnia(D1:DEPINS);D2
consistsofthemonotheticsetanxietyandconcentrationdifficulties(D2:ANXCONC).
Intotal,1923patientssatisfiedD1;1675patientssatisfiedD2.Ofthosepatients,1084
patientssatisfiedD1andD2andthussufferedfromcomorbidity.Infigure4b,D2is
adjustedinapolytheticdisorder(D2):anxietyisstillarequiredsymptombutin
additionapatientmaysufferfromconcentrationdifficultiesorsleepproblemsorboth
(D2:ANX(CONCINS)).Therefore,twoextracombinationsofsymptomsalsosatisfied
thisdiagnosis(ANX,INSandANX,INS,DEP),ofwhichthelatterimpliescomorbidityof
D1andD2.Asaconsequence,moreindividualssatisfiedD2,andmoreindividuals
sufferedfrombothdisordersD1andD2.Amongtheindividualssatisfyingadisorder,
thepercentageofcomorbidpatientsincreasedfrom43%to54%.

Figure4

Figure4a

Figure4b

HistogramwithresponsesonHaveyoueversufferedfrom?Answers:ANX:anxiety,
worrisomeperiodofatleastonemonth;DEP:depressedmoodforatleast2weeks;
INS:insomniaforatleast2weeks;CONC:concentrationproblemsforatleast2weeks.
*markscomorbiditywithratesof43.1%infigure4ato53.9%in4b.

Analysis2
Forthesecondanalysis,weselectedsymptomsofwhichweexpectedthatcertain
symptomcombinationswereveryunlikelytooccurfrequently.Thesesymptomswere
lifetimeobsessions(OBS,i.e.persistentthoughtsorurgesthatareexperiencedas
intrusiveandunwanted),compulsions(COMP,i.e.repetitiveandunwantedbehaviors

suchascheckinglocksofdoorsorwashinghands),manicmood(MAN,i.e.aperiodof
twodaysoffeelingextremelycheerfulleadingtoproblems,worriesamongrelativesor
diagnosisofmania)anddruguse(DR,i.e.useofaspecificdrugmorethanfivetimes).
Basedonclinicalexperienceweexpectedespeciallycombinationsbetweenobsessions
orcompulsionsanddrugusetobeveryrare.Ananalysisofthefrequenciesofall
symptomcombinationsindeedledtoverydifferentresultscomparedtoanalysis1.Of
the7076individuals(nomissingdata),agreatmajorityofindividualsdidnotreport
anyofthefoursymptomsduringlifetime(83.2%).Theremaining1187individuals
reportedatleastonesymptom.Themostfrequentsymptomcombinationwasdrugs
useasanisolatedsymptom(9.7%).9Furthermore,ofthe16possiblesymptom
combinations,6wereveryrare,i.e.occurringinlessthan0.5%oftheindividualswith
atleastonesymptomduringlifetime.Thisisdifferentfromanalysis1,inwhichno
combinationswerefoundlessfrequentlythan94times(i.e.in2.0%ofthe4682
individualswithatleast1symptom).

Asinanalysis1,twosimplemonotheticdisorders(D1andD2)aredrawninfigure5a.D1
isdefinedasthecombinationofobsessionsandcompulsions(D1:OBSCOMP);D2

9
Thecombinationofdruguseandobsessionswasmoreprevalentthanthecombination
ofobsessionsandcompulsions,whichmightbeduetotherelativelyhighlifetime
prevalenceofdruguseasopposedtothelowlifetimeprevalenceofcompulsions.

consistsofthesetmanicmoodanddrugsuse(D2:MANDR).Intotal,36patients
satisfiedD1;41patientshadD2.Ofthosepatients,5patientssatisfiedD1andD2and
thussufferfromcomorbidity.Infigure5b,D1isredefinedasthecombinationof
compulsionsandobsessionsand/ordrugs(D1:COMP(OBSDR)).Thisleadstoan
extrasymptomcombinationbeingpotentiallycomorbid,viz.thecombinationof
COMP,MAN,DR.Yet,asthissymptomcombinationdoesnotoccurinthesample,the
numberofcomorbidityremainsequallylow(n=5).Thus,inthiscase,comorbiditydid
notincreasewithachangeofdiagnosis;theproportionofpatientssufferingfrom
comorbidityevendecreased.

Figure5

Figure5a

Figure5b

HistogramwithresponsesonHaveyoueversufferedfrom?Answers:OBS:
obsessions;COMP:compulsions;MAN:manicmoodforatleast2days;DR:druguse.*

markscomorbiditywithratesof6.9%infigure5ato6.5%in5b.10

Conclusionsoftheanalyses
Withsimplehypotheticaldiagnoseswehaveillustratedthatratesofcomorbidity
dependontheinterplaybetweendiseasedefinitionsandsymptomdistributionsin
populations.Neitherofthoseelementsinisolationissufficienttoexplainratesof
comorbidity.Therefore,ratesofcomorbiditycannotbelabeledaseitherresulting
fromclassificationchoices,andhenceartificial,orfromrealrelationsamongthe
diseases,andhenceafact.Theyarenotjustanartefactsincetheratesdodependon
arealsymptomdistributioninapopulation.Ontheotherhandwecannotsaythat
comorbidityisafactindependentlyofourchoices,sincetheratesalsodependon
choicesindiseaseclassificationandhowthisclassificationcapturespartofthe
population.

Ofcourseourexamplesfeaturestronglysimplifiedversionsofactualpsychiatric
disorders,whicharedefinedinfarmoreintricateandreasonedways(Andrewsetal.
2009;Regieretal.2009).Moreover,inactualdisordersthesymptomsdonotbehave
liketheneutralandatomicunitsthatappearintheillustrations.First,thesymptoms

10
Thecolumnrepresentingthen=5889individualswithoutsymptomshasbeenomitted
toimprovethevisibilityoftheindividualssufferingfromoneormoresymptoms.

mayhavebeenchosenwiththeaimofmanifestinghighcorrelations.Ifwearein
searchofaparticularpsychiatricdisorder,wemaybetemptedtochoosedefining
symptomsthatareoftenobservedtogether(asaclinicalsyndrome)andthatare
thereforehighlycorrelated.Similarly,andsometimesratherconfusingly,symptoms
areoftendefinitionallyrelated.Forexample,muscletensionisonlyasymptomofGAD
ifthesubjectalreadysuffersfromanxietyandifthelattersymptomisnotpresent,the
muscletensionisnotincludedassymptom.Andfinally,differentquestionnaireswill
targetsubtlydifferentsetsofsymptoms,owingtoslightvariationsinhowquestions
aregroupedandformulated(VanLooetal.2012).Itis,forallthesereasons,notclear
thatthedistributionofsymptomsinthepopulationisacrudeempiricalfactthatdoes
notrelyontheoreticalchoices.

Weneverthelessbelievethattheinsightsfromthesesimpleexamplesapplygenerally.
Theyholdalsoformorecomplexandreasoneddefinitionsofpsychiatricdisorders,
andforbothlatentvariableandnetworkmodels.Moreover,theycanbemaintained
againstthebackgroundofdatasetsthatarethemselvesinfusedwiththeoretical
choicestodowiththeselection,definition,andoperationalizationofsymptoms.As
longasthosedatarestonempiricalinput,theresultingmeasurementsinpsychiatry
willdependsimultaneouslyonthetheoreticallymotivatedchoicesandonthe
constraintsthatthatempiricalinputplaces.

Theseanalysesareafirstandrathermodeststartinexplainingthephenomenonof
comorbidity.Moreover,itseemstosuggestapositioninbetweentwoextremeviews
oncomorbidity,whichweassociatedwithconstructivismandrealism.Nowitmaybe
thatmanyauthorswillagreewithsuchaninbetweenexplanation.However,thisin
betweenisarathervagueindication,anditleavestheproblemsofcircularityand
arbitrarinessunanswered.Inwhatfollowswewillgointotheseproblems,and
elaboratethemiddlingpositionmoreprecisely.

4.Conventionalismaboutdisorders

Abovewearguedthatcomorbidityinpsychiatricdiagnosescannotbetracedback
exclusivelytothespecificsofthecategorizationsystem,nortotherealityofthe
disorders.Psychiatriccomorbidityisacoproductionofclassificationchoicesand
empiricalconstraints:wedeterminethesetofrelevantsymptomsandtheclustering
criteria,butrelativetothat,theempiricalfacts,inparticulartheratesofcomorbidity,
aremanifest.Inwhatfollowsweclarifythatthisparticularviewoncomorbidity
exemplifiesamoregeneralideaontherelationbetweenscientifictheoryand
empiricalfact,whichhasalonghistoryinthephilosophyofscience:conventionalism
(Poincar1905,Reichenbach1958).Wewillmaketheideaofconventionalismmore
precisebyfirstdiscussingtheproblemsofthecircularityandarbitrarinessofdisease

classification,asmentionedearlier.Conventionalismputstheseproblemsina
differentlight.

Definitionalcircularityandarbitrariness
Broadlyspeaking,psychiatricdiseaseclassificationsperformadoublefunction.Onthe
onehand,theDSMcanbeviewedasatheoryaboutthepsychiatricrealm,meaning
thattheclassificationservestorepresentthesubjectmatterofpsychiatry.Butitalso
servesasatoolfordiagnosingpsychiatricdisorders,thatis,asadeviceusedfor
measurementandnotasastructureusedforrepresentation.Inwhatfollowswewill
makeprecisehowthedoublefunctionbecomesproblematic,andindicatehowa
conventionalistpositionresolvestheissues.

Noticethatthebroadstrokesoppositionbetweenarealistandconstructivist
perspectiveondiseaseclassificationsworksoutdifferentlyforthetwofunctionsjust
outlined.ConsidertheDSMasatheoryaboutthepsychiatricrealm.Theopposition
concerningthestatusoftheDSMthenrunsparalleltotheoppositionbetweenrealist
andconstructivistleaningsinontology:arealistwouldsaythattermsfromtheDSM
arethentakentorefertoanindependentrealityofmentaldisorders,andtheDSM
mightdescribethesedisordersmoreorlesstruthfully;aconstructivistwouldsaythat
termsfromtheDSMareprojectedontothephenomenaofpsychiatry,andsoprovide
structuretothesephenomena(Hacking1999).

NowconsidertheDSMasatoolfordiagnosingpsychiatricdisorders.Thesame
oppositionbetweenrealistandconstructivistideasthenobtainsamore
epistemologicalreading,andrunsparalleltoawellknownoppositionfromthe
philosophyofexperiment(cf.VanFraassen2008):eithertheDSMfacilitatesa
representationofpsychiatricphenomena,i.e.,providingpassiveepistemicaccessto
thephenomena,oritisbetterseenasinvolvedintheproductionofpsychiatric
phenomena,i.e.,activelycreatingthephenomena.Clearlytheseoppositionsconcern
thesameunderlyingtension,whicharguablypermeatesthewholeofscience:should
wetracescientificknowledgebacktoanindependentreality,orisitrathertheresult
ofourownepistemicdoing?11

Thistensioncansometimesberesolvedinfavouroftherealistcampbywhatis
sometimescalledbootstrapconfirmation(e.g.Glymour1980).Atheoryismorelikely
todescribeanindependentstructureifitissupportedbyresultsfromameasurement
devicethatreliesonentirelydifferenttheory.Andinturnameasurementdeviceis

11
Werealizethatthephilosophyofpsychiatryprovidesamorenuancedpictureofthe
tensionbetweenrealismandconstructivism(see,e.g.,KendlerandParnas(2012)).But
forthepurposeshereclarifyingaparticularmiddlingperspectiveonclassificationitis
notnecessarytospelloutthistensionindetail.

morelikelytoprovideaneutralrepresentationofthephenomenaifitalsoworksto
confirmtheoriesthatpertaintoentirelydifferentphenomena.Takeforexamplean
MRIscanner,whichisdevelopedbymeansofphysicsbutcanbeusedtosupport
theoriesinneuroscience.Itisunlikelythatsystematicerrorsinhowthescannerworks
aresuchthattheybecomemisleadingfortheneuroscientists.Andevenifwerunthis
risk,wecancheckforsystematicerrors,orcalibratethescanner,byrelyingon
physics.12NowtheproblemfortheDSMisthatmeasurementdeviceandtheory
coincideexactly.

Thisistheexactpointwherethedefinitionalcircularityreferredtoearlierbecomesa
seeminglyviciousone,andwherethesocalledexperimentersregressbecomesa
pressingissue(cf.Chang2004).Theregressisthatwedefinewhatweobserveby
referencetothecorrectmethodofobservingit,butwealsodefinethecorrect
methodbyreferencetowhatwearesupposedtoobserve.Forexample,wemightsay

12
Following a remark by Duhem (1906), psychiatry is not the only scientific discipline
unable to test theories by means of bootstrap confirmation or triangulation: the
experimentaltestingofatheorydoesnothavethesamelogicalsimplicityinphysicsasin
physiology. In physiology, theories are tested by means of laboratory instruments that
are based on theories of physics, but in physics, it is impossible to leave outside the
laboratorydoorthetheorywewishtotest(citedinChang2004,221).

thattemperatureisthatwhichismeasuredbyathermometer,andthenaddthata
thermometerisanydevicethatmeasurestemperature.Somethingsimilarseemsto
occurformentaldisorders:wesaythatMDDcanbeidentifiedbycheckingforasetof
symptoms,butthenwemotivatetheuseofthosesymptomsforidentifyingMDDby
referencetoMDDasapregivenmentaldisorder.

Assaid,theusualresolutionofthisistofinddifferentmethodsofobservingthesame
phenomenon,i.e.,triangulation,orelsetofinddifferentphenomenatoapplythe
samemethodofobservationto,i.e.,calibration.Bothleadtoanindependentcheckof
themeasurementprocedureatstake.However,inthecaseofmentalillness,we
cannotcalibratetheuseofatoolforonetheorybyrelatingittoanotherone,and
neithercanwetriangulatethetheorybyfindingtwodifferenttoolsthatprovide
independentsupport.Insteadofthat,weareleftwithatheoreticalstructurethat
doublesupasitssolemeasurementdevice.Itseemsinevitablethatthisdevice
providesuswithmeasurementoutcomesthatfitthetheoreticalstructure.Soweare
ledtotheconclusionthatthewholeschema,consistingofboththeoryandtool,isof
ourowndoing,i.e.,anarbitraryconstructionthatisimposedonrealityratherthana
structureuncoveredinit.

Resolution:coordinativeprinciples
Thepositionsuggestedintheforegoingoffersanescapefromthiscircularity,and

therebypresentsanalternativetotheconclusionthatdiseaseclassificationsare
merelyconstructionsimposedonthephenomena.Admittedly,wecannotavoida
numberofconventionsondisordersandtheirstructure.Wecannotgainaccesstothe
structureofmentaldisordersotherthanbymeansofdiagnostictoolsormeasurement
devicesthatprovidesomestructurethemselves.Forexample,weuseasetofnine
symptomsasanindicationofthedisorderdepression.Butwehavenootherwayof
determiningwhetherornotsomeonesuffersfromdepressionthanbyfindingoutif
theyhaveatleastfiveoutofthoseninesymptoms.Effectively,westipulatethatthose
ninesymptomsareconstitutiveofdepression.

Ourpointisthatsuchstipulations,ormoreappropriately:coordinativeprinciples,
improveourgriponthesubjectmatterofpsychiatry.Thedefinitionofthedisorders
occasionstheexpressionofassociationsthatwouldotherwisebeveryhard,ifnot
impossible,topindown.Oncewestipulatecertainconcepts,likeMDDandGAD,
specificpatternswillbecomeapparentinthemeasurementresults.Andthese
patternsdoconveysomethinggenuineandinformativeabouttheworldofpsychiatric
phenomena.Intermsofourexample,itsohappensthatMDDshowsstrong
correlationswithGAD.WhiletheassociationofMDDandGADmaybepartlydueto
stipulations,thereisevidentlysomeempiricalfactofthemattertowhichthis
associationcanbetracedback.Afterall,theoppositecouldalsohavebeenfound:that
MDDandGADwerenegativelycorrelated,ornotcorrelatedatall.Thus,measurement

resultsthatarecouchedintermsoftheDSMrevealsomethinggenuineabout
psychiatricdisorders.

Withthisinmind,letusreturntothepossiblyviciouscircularityinthestudyof
mentaldisorders.Wedonothaveanindependentwayofverifyingthatasubject
indeedsuffersfromMDD,soastoanchororsubstantiatetheconventionalchoices
thatdefinedepression.Butweneednotdoso.Theclaimthatsomesetofsymptoms
constitutesMDDdoesnotbyitselfcarryanyweight.Yetwecanemploythe
conventionthatparticularsymptomsconstitutedepression,tosaysomethingabout
depressedpatientsthatwouldbetootedioustoexpressotherwise.Inotherwords,
thefactthatdepressionisconstitutedbythesesymptomsisnotitselfasubstantive
claimabouttheworldofpsychiatricphenomena,whichitcouldbeifwehadsome
wayofresolvingthecircularity,e.g.,someotherepistemicaccesstodepressionthan
throughthosesymptoms.Thepointisthatthisconvention,orcoordinativeprinciple,
occasionssubstantiveclaimsaboutmentaldisorders,someofwhichcouldotherwise
notbemade.Forexample,wecanclaimthatantipsychoticsalonearelesseffective
thanantidepressantsintreatingpsychoticdepression(Wijkstraetal.2009),because
wehavelaiddownausefulconventionaboutwhatconstitutesdepression.

Thesesubstantiveclaimsprovideawayoutoftheviciouscircularityandarbitrariness
ofmentaldisorders.Obviously,somedefinitionsofmentaldisorderswillbemore

successfulinoccasioningthosesubstantiveclaimsthanothers.Becauseofthis,the
coordinativeprinciplesaremorethaneliminableshorthandsformorecomplicated
relationsthatobtainamongthesymptoms.Someprincipleschimebetterthanothers
withtheempiricalpatternsonwhichtheyrest.Similarly,someprinciplestrackthe
causalstructureofpsychiatricphenomenabetterthanothers.Inotherwords,a
conventionalistinterpretationofpsychiatricdisordersdoesnotamounttoan
anythinggoesattitude:notanyrandomcollectionofsymptomsconstitutesauseful
diseaseclassification.Becauseofthevariationinmoreandlesssuccessfulsubstantive
claimsthatmayfollowcoordinativeprinciples,weescapetheconclusionthatthe
wholeedificeofpsychiatricdiagnosisisselfcongratulatoryandsubjective.Thoughthe
coordinativeprinciplescannotbetrueorfalsetheyaremereconventions
somethingcanbeobjectivelyrightaboutthem.13

13
Wemightsaythataclassificationsystemistherebytriangulated,orcalibrated:oncea
classificationchoiceallowsustorelateadiversesetofpsychiatricandsomatic
phenomena,wemightsaythatthischoicehasitselfbeenconfirmed.However,wethink
thatitisnotappropriatetoviewclassificationchoicesassubstantialclaimsthatcanbe
confirmed,supported,orfalsifiedbyempiricalfact.Conventionshavequalitycriteria,but
theyshouldnotbeviewedastruthconditions.

Conventionalism
Wenowexplaintheforegoingperspectiveondisordersbyfallingbackonlong
standingideasaboutconventionalismandcoordinativeprinciplesinthephilosophyof
science.Examplesareabundant:thenatureoftemperaturevisvisthestatusofthe
thermometer,thenatureofcolorasaphysicalphenomenonandasexpressedbya
colorspace,andthenatureofphysicalspaceinrelationtothestatusofour
mathematicalmodelsofit(Chang2004;VanFraassen2008).Itisinsightfultorelate
theforegoingtothisbroaderdebate.

Letusbrieflyfocusonconventionalismaboutspaceandtimeinphysics.Followingthe
receivedviewonconventionalism(Reichenbach1958),thereisnoobjectivefactasto
whatconstitutesastraightlineinphysicalspace.Astraightlineisamathematical
notion,whereasphysicalspaceispresumablyoutthere,asacoordinatesystemfor
objectsorperhapsevenasasubstance.Itisnotgiveninadvancehowthe
mathematicalnotionsaresupposedtobeappliedtophysicalspace.Thisisrather
somethingthatneedstobestipulated,orlaiddowninconventionsorcoordinative
principles.However,oncewehaveassociatedthetrajectoryfollowedbyafreely
fallingtestparticlewiththemathematicalconceptofageodeticcurve,variousother
claimsaboutgeodeticcurvesbecomesubstantive,andinfacthighlyinformative.For
instance,owingtoconventionswecanclaimthatlightfollowssuchgeodeticcurves
andsoisdeflectedinagravitationalfield.Notably,thisisachievedwithoutcalibrating

thetrajectoryofthefreelyfallingbodyortriangulatingthegeometryinwhichthe
geodesicsaredescribed.Neitherofthesetwoevenmakessensebecausegeodesicand
trajectoryareassociatedbyconvention.Theconventionsthemselvesdonotamount
toclaimsthatmaybetrueorfalse.Nevertheless,theconventionoccasions
substantiveclaimsaboutthegeometryofphysicalspace,whichcanbetrueorfalse.
Moreover,somesystemsofconventionsareclearlymoreeconomicorsuccessfulthan
others.

Oursuggestionisthatpsychiatricdiseaseclassificationsareconventionsinmuchthe
sameway.Noticethespecificmeaningthatisattachedtothenotionofconvention
here.Theyhelptocoordinateatheoreticalstructuretoanempiricalone,andthey
varyinhowsuccessfultheyareatthat.Sothetermconventionshouldcertainlynot
giveofftheimpressionthatanythinggoes.Moreover,inthecaseofpsychiatric
classificationsaswellasinthecaseofphysicalgeometry,weneedtotakecarein
interpretingclaimsthatareherecalledsubstantiveandwhich,inthevocabulary
employedearlierinthisarticle,expresssomethingreal,genuineorrobustaboutthe
subjectmatter.Thesetermsarenotintendedtosignalthatallthenotionsemployed
havetheirreferentinsomerealistworldpicture.Nosuchpositioninthespectrum
betweenscientificrealismandempiricismisimpliedbythesubstantivenessofthe
claims.Whatismeantisthatsubstantiveclaimseventuallyfindtheirbasisin
somethingotherthantheconventions,beitsomeempiricalpatternsoraprincipleor

mechanismunderlyingthosepatterns.So,pickingupourexampleaboutclaims
concerningthecomorbidityofMDDandGADasrevealingsomethinggenuineabout
thesepsychiatricdisorders,whatismeantisthattheircomorbiditycannotbetraced
backinitsentiretytoconventionsadoptedtodelineatethesedisorders.Their
comorbiditypointstosomethinggenuine,beitstrictlyonthelevelofempiricalfact,or
onthelevelofcausalrelations.

Ourproposaltoviewpsychiatricdiseaseclassificationsasconventionsisbynomeans
intendedasafullyfledgedtheoryofwhatdiseaseclassificationsare,orasarivalto
extantaccountsoftheontologicalandepistemologicalstatusofmentaldisorders(see
e.g.,KendlerandParnas2012).Wedonotoptforanyspecificrealist,antirealist,or
constructivistviewpointbyproposingconventionalism.Moreover,inthispaperwe
saylittleaboutthewayinwhichconventionsarechosenandevaluatedbyusersofa
theory.Webelievethatpragmaticconsiderations,whichdirectourchoicesfor
scientifictheoriesandmodels(Douglas2009),couldbecentraltothechoiceof
conventionstoo,butwedonotargueforthisinthispaper.Herewemerelypropose
andillustrateaparticularviewoncomorbidity,anditsreflectiononpsychiatricdisease
classificationmoregenerally.Anaccountofhowthismighttransformthedebateover
thestatusofdiseaseclassificationsisbeyondthescopeofthispaper.

Ontheotherhand,ourproposalcountersextremepositionsinthespectrumof

realismandconstructivism.Atheoristwithstrongconstructivistsympathiesmight
frownuponthesuggestionthatthereisanythinggenuinewithoutthesupportof
constructionwork.Andworkingpsychiatristsinturnmightfrownuponphilosophers
whodebatetherealityofdisordersthattheyareconfrontedwithonadailybasis,and
whichexertsuchrealcausalpoweroverpeople.Weinvitebothsidestoapproachthe
issuesinarelaxedmood.Independentlyoftheontologicalstatuseventuallygivento
mentaldisorders,wearguethattheirstructurecanonlybecapturedafterlayingdown
conventions.Thoseconventionsarelocatedsomewhereoutsidetheforcefield
betweenconstructivismandrealism.14

5.Conclusion

Sohowshouldweinterpretpsychiatriccomorbidityandwhatdoesitillustrateabout
psychiatricdisorders?Whilesomeemphasizedtheconstructivistcharacterofthis
phenomenon,pointingtoclassificationchoicesintheDSM,othersstressedthereality

14
AverysimilarmiddlingpositionhasbeendevelopedinKuipers(2000)underthename
ofconstructiverealism.OurideashavebeeninspiredbyKuiperspositionthatrealityis
bestunderstoodasacoproductionofsubjectandobject,whichitselfmaybelikenedtoa
relativizedordynamicKantianview(Friedman2001).

ofcomorbidity,pointingtounderlyingcausalmechanisms.Weshowedbyempirical
andconceptualargumentsthatbothpositionsareinsufficienttoaccountfor
comorbidity.Wethenarguedforaconventionalistapproach:ratesofcomorbidity
dependontheinterplaybetweenclassificationchoicesandempiricalreality,and
classificationsinpsychiatryarebestseenascoordinativeprinciples.Importantly,this
doesnottakeawaythefactthatthoseclassificationsmayoccasionanobjective,
informativeandnonarbitrarydescriptionofpsychiatricreality.

Asweargued,thedebateoncomorbidityechoesrealistorconstructivistintuitions
aboutpsychiatricdisordersingeneral.Butbroadlyspeaking,bothpositionsignore
importantaspectsofpsychiatricdisorders.Ontheonehand,arealistviewcommitsus
totheactualexistenceoftheentitiesandstructureofpsychiatricdisorders,andthus
neglectstherelativityofmeasurementresultsbasedonDSMclassifications.The
realistideathatcurrentdisordersrefertotherealstructureintheworldmightthus
leadtohastyreification,andenhancethesearchforcausalmechanismsand
treatmentsforextantdisorders,withouttakingintoconsiderationtheadequacyofthe
classificationsthemselves.Ontheotherhand,aconstructivistpositionentailsthatthe
DSMcategoriesmakepsychiatricdiseases,whichleadstosharpattacksontheidea
thatpsychiatricdisordersarereal.Thus,constructivistspassoverthefactthatrobust
syndromeshaveoccurredinthepsychiatricdomainlongbeforetheintroductionof
theDSM,asforinstancedepression(Jackson1986).

Wesubmitthataconventionalistpositionfitsbetterwithpsychiatricreality,asit
acknowledgestherelativityofDSMclassificationswhileatthesametimerecognizing
theobjectivityandwealthofknowledgebasedonthoseclassifications.Itcaneasily
dealwiththefactthatdifferentversionsoftheDSMleadtodifferentmeasurement
resultswithoutdiscardingthemindindependentcharacterofthosemeasurements.
Furthermore,conventionalismissuitedtohandletheproblemsofthecircularityand
arbitrarinessofsymptomsets.Thefactthatcoordinativedefinitionsprecedethe
acquisitionofempiricalknowledgedoesnotliftalldemandsfromthosedefinitions.
Coordinativedefinitionsthemselvesaresubjecttoallkindsofconstraints,oftenofa
pragmaticnature,e.g.,coherenceandusefulness.Bywayofcomparison,the
developmentofthethermometershowsthattherewereonceclearreasonstoalter
thedefinitionandmeasurementoftemperature,despitethecloseconnection
betweentheoryandmeasurementdevice(Chang2004).

Inasimilarvein,therearecriteriathatescapethecircularityandarbitrarinessof
currentpsychiatricdiagnoses.Diagnosescouldforinstancebeassessedintermsof
theirsuccessincoincidingwithacausalbackgroundandincreasingunderstanding,in
predictingcourseandoutcome,andinguidingtreatmentdecisions.Anotherdirection
worthwhileintheevaluationofpsychiatricdiagnosesistakingacloserlookat
symptomdistributionsinapopulationandhowtheyarecaughtbydiseasemodels,for

instancebyelaboratingthesimpleanalysesweperformedinSection3.Mappingthe
symptomdistributionsinapopulationmightprovideinsighttowhatextentDSM
modelscatchdiscretedisordersintermsofsymptomsorwhethertheyarenot
separatedbyzonesofrarity.Wetakethispointasavaluablecontributiontothe
philosophicalandmethodologicaldebateoverpsychiatricdisorders.Our
aforementionedmiddlingpositionembracestheconventionalaspectoftheDSMand
utilizesthistoimproveitsapplications,withoutrobbingtheDSMofitsmind
independentcontent.

Werealizetheevaluationofpsychiatricdiseasemodelsisincrediblycomplex.First,
manycriteriaareimportantinevaluatingtheirusefulness,ofwhichthedescriptionof
adiscretesetofsymptomsisonlyonecriterion.Othercriteriaasthepossibilityto
interfere,ortrackingcausalmechanisms,orreliabilityindiagnosingpatientsare
importantconcernsanddonotnecessarilyimprovewithdiseasesasdiscretesetof
symptoms.Second,whatisthecaseforoneDSMdiagnosisdoesnotnecessarilyapply
toallDSMdiagnoses.Onthecontrary,adiagnosisasADHDmayfunctionvery
differentlyonmanycriteriamentionedabovethanadiagnosisasbipolardisorder.A
thirdfactorcomplicatingtheevaluationofpsychiatricdiseasemodelsisthemajor
impactoftheDSMonsociety,politicsandpharmaceuticalindustry.Allthesefactors
togethermaketheevaluationofpsychiatricdiseasemodelsachallengingenterprise.

So,whatarethebenefitsofallthis?Thereisandhasbeenalotofdebateonthe
interpretationofcomorbidityandontheconceptualizationofpsychiatricdiseases
moregenerally.Centralinthisdebatehasbeenthequestion:whatkindofthingsare
psychiatricdisorders?Withourconceptualclarificationwehaveaimedtoproposea
perspectivethatgivesdiseasedefinitionsadifferentstatus,andsofreesupresearch
intoalternativeclassifications.Wehopefutureresearchwillaimatinvestigatingthe
strengthsandweaknessesofeachspecificdiseasemodel,andthusmovepsychiatry
forward.

Acknowledgements
The Netherlands Mental Health Survey and Incidence Study (NEMESIS) is conducted by
theNetherlandsInstituteofMentalHealthandAddiction(Trimbosinstituut)inUtrecht.
WethankRondeGraafformakingtheNEMESISdataavailabletoillustrateourargument.
WethankDennyBorsboom,RachelCooper,NedHall,PeterdeJonge,TheoKuipers,and
Robert Schoevers for their helpful comments on an earlier version of this paper. We
further thank audiences in Amsterdam, Cape Town, Johannesburg, Leusden, New York,
Nijmegen, and Toronto for stimulating discussions and helpful comments. JanWillem
Romeijn is supported by a VIDI grant from the Netherlands Organization for Scientific
Research,andbythefellowshipprogramoftheUniversityofJohannesburg.

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