When studying the diagnosis of mental illness it is essential to remember two crucial elements. First, the context of the abnormal behaviors. Second, there is a vast continuum of mental health disorders pertaining to severity.

When looking at the diagnosis of mental illness it is paramount to understand that disorders generally fall on a spectrum, or continuum. Ranging from mild to severe, with everything between. The range of behaviors will share a similarity in types of symptoms, but the severity, frequency, and intensity of those symptoms can all vary between people, or at certain times.

Take for example two people who are both diagnosed with Post Traumatic Stress Disorder (PTSD). Going even deeper let’s say that the trauma that they both experienced was from fighting the war in Iraq. Two people, same diagnosis, similar circumstances acting as a triggering event. Yet, the severity of symptoms is significantly different.

Case in Person 1- Tom

Tom was recently honorably discharged from the Army after multiple tours in Iraq, he has a great record and was a model soldier. He saw some horrific things in his tours and is having some lasting mental health issues. He saw friends be killed, children die, and had a bomb detonate and nearly kill him and his entire team. He is functioning fairly well but is having some issues dealing with the things that he saw.

Currently, he is holding a job as an EMT, but is having some concerns with his work and is on probation. He feels on edge all the time, has occasional flashbacks to the horrors he saw, and is slightly depressed. He has nightmares about the incident a couple times a month. He got really uncomfortable when avalanche blasts sounded while doing control blasts, it reminded him of being in Iraq.

Tom has a girlfriend, Sarah. She is worried about him as she thinks he seems sad and worried. He is very protective of her and said he is always trying to “protect” everyone. He gets really irritated sometimes, but is generally able to control his anger. He has some friends, but is withdrawing from social interactions.

Under the DSM-5 criteria for Post Traumatic Stress Disorder, Tom would meet the criteria of having PTSD.

Case in Person 2- Danny

Danny was also honorable discharged from the Army after multiple tours in Iraq. Unlike Tom, Danny does not have as clean of a record and was always in trouble as a soldier. He received low marks in multiple areas. He also saw significant tragedy while overseas and is having problems adjusting.

He just got fired from his fourth job in two months. He is working an array of jobs and is always having issues with his superiors, customers, and co-workers. Danny is aggressive, irritable, and mean. He seems to have flashbacks daily and often thinks he is back in combat. When this happens he becomes very aggressive and suspicious of the people around him.  He has even pulled a gun on a customer who he thought was a terrorist, which resulted in the police coming, a subsequent arrest, and a law suit.

When home, his problems do not get better. He cannot sleep because he has such vivid and terrifying nightmares. Danny does not want anyone around him and is pretty much a shut in when not at work. He has numerous firearms and has expressed that he does not care to live. His family is concerned with his safety are worried he will kill himself or hurt someone else.

Under the DSM-5 criteria for Post Traumatic Stress Disorder, Danny would also meet the criteria of having PTSD.

The Continuum of Mental Health Disorders-Tom and Danny

Both Tom and Danny meet the criteria for PTSD. However, their symptoms are vastly different. Tom has a moderate case of PTSD and likely needs some counseling, but his prognosis is likely to be good if he gets a little help. He has a good chance of living a happy, healthy, productive life if he can process the traumatic events and create some healthy coping mechanisms, and move forward.

Danny on the other hand has a severe case of PTSD. He likely need far more serious care. He may need to go into a residential facility, take medications, and will need intensive counseling. If Danny does not get the proper help he is in danger of hurting himself or others. For him to have a positive prognosis significant work will be necessary.

While the diagnosis is the same, the severity is different, so the prognosis, treatment methods, and need for care. Something needs to be done to help Danny immediately before he hurts someone, and he is probably going to need intense care, possibly a police/military escort to a hospital. Where as Tom, could schedule an appointment to meet with a therapist at their office next week.

Severity of Symptoms

The DSM-5 does recognize this deviation in symptoms. Many of the disorders will have specific identifiers to help determine if the person has a mild, moderate, or severe mental health disorder. This can be done by evaluating the behaviors in several ways. Looking at all of the following will help to determine severity of a disorder. Remember to look at the context of the behavior and all relevant information as well as the following factors:

• Number of Symptoms To be diagnosed with a disorder, a person needs to demonstrate X amount of symptoms of that disorder. For example, to have a diagnosis of Anti-Social Personality Disorder a person must meet 3 of the 7 pieces of criteria for that ASPD (see below). A person with a mild case could have 3 symptoms, moderate 4-5 symptoms, and severe would likely have 6-7 symptoms.
• Severity of Symptoms Maybe a person only demonstrates 3 characteristics, but that 3 symptoms are extreme a person could be diagnosed with a severe case of ASPD. Or vice-versa, a person with all 7 symptoms, but maybe not severe as could have mild or moderate case. The severity of the symptoms will vary greatly depending on the disorder. The severity of symptoms includes the intensity, frequency, and timing of the symptoms.
• The DSM Sometimes identifies Disorder Specific Criteria for Severity Frequently, the DSM will have specific criteria to help determine the severity. It will have some disorder-specific symptoms, traits, or other indicators or severity. These obviously should be followed and analyzed when making the diagnosis.
• Other Tests and Measurements Can Indicate Severity Tests, assessments, and other measurements have been created to gauge severity. There are hundreds of tests to measure anxiety levels. The score on a certain test or measurement can help to determine severity of a mental health disorder.

Criteria For Anti Social Personality Disorder According to Behavenet from the DSM-5:

• A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
  • (1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
  • (2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
  • (3) impulsivity or failure to plan ahead
  • (4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
  • (5) reckless disregard for safety of self or others
  • (6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
  • (7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

People Don’t Always Fit Perfectly Into a Category

A second way that mental illness can fall on some what of a continuum is within categories of disorders. For example, mental illnesses are broken down into categories (depressive disorders, anxiety, personality, eating, etc.), all of the disorders in that category will share similarities of traits, but also have unique differences. Yet, people may not fit perfectly into a specific diagnosis and may just manifest traits from multiple disorders in a category.

If a person fits the traits for two to three different disorders in a category they could be on a continuum of that category. There are 10 Personality Disorders, a person may not exactly have Narcissistic Personality Disorder or Anti-Social Personality, but they have symptoms of both. So they could be on the spectrum or continuum of Personality Disorders. Within the categories there is overlap of symptoms.

Summary

Looking at the continuum of severity of diagnosis is incredibly important to understanding the diagnosis. There is a substantial range between mild and severe mental health disorders which can have a significant impact on prognosis, treatment, and overall approach. Also remembering that people are complex and unique and may not fit into a small group of categories, but still could have mental health issues.