Subthreshold disorders in psychiatry: Clinical reality, methodological artifact, and the double-threshold problem

The introduction of modern operationalized classification systems for menta l disorders has led to the issue of subthreshold disorders. Definitions for illness do not at the same time define health, e.g., in the sense of the W orld Health Organization (WHO) definition from 1947, The threshold not only to define disorders but also to define health is open to discussion. So-ca lled subthreshold disorders require the definition of 2 thresholds. Empiric al research has suggested that these "between-threshold disorders" are asso ciated with increased disability and many other negative consequences. Part of the problem with subthreshold disorders is methodological in nature. Ps ychopathology and the Gestalt characteristic of psychopathological signs ar e ignored,and categorical instead of psychpathological signs are ignored, a nd categorical instead of dimensional concepts are used. Thus, the distinct ion between syndromes and disorders, as well as the hierarchical structure of disorders, is not taken into account, and statistical problems with the prognostic power, which is dependent on the epidemiological distribution, a re not solved. Variations in threshold definitions have important consequen ces for the individual and for society, be it because of the negative effec ts of "diagnostic labeling" or because of the costs to the health care syst em, Treatment options are presently rather insufficient, although modern se quential treatment algorithms and newer treatments (e.g., selective seroton in reuptake inhibitors [SSRIs] and Saint-John's-wort) promise interesting p erspectives. Also in this context, self-help should become an important are a of medical treatment research. Copyright (C) 2000 by W.B. Saunders Compan y.