Thinking outside the (diagnostic) box

Inside any therapist’s office you’ll find a massive manual — either the ICD-11 or the American DSM-5 — that lists each and every mental health condition. For decades, psychologists have separated mental health problems into dozens of distinct categories, each with their own symptoms and subtypes.

But head to the office building next door and you won’t find many people whose mental health problems directly match those diagnostic manuals. What we know is that 80% of employees suffering from poor mental health have multiple mental health problems at once, such as anxiety and poor sleep. This overlap of conditions is one reason why many mental health clinicians believe that our diagnostic approach needs updating.

While distinct categories are useful for many things, such as insurance reimbursement and research, we can also focus on what mental health conditions have in common. This is called a transdiagnostic approach — and as the name suggests — it involves honing in on the tendencies that cut across diagnostic labels.

There are two main advantages of a transdiagnostic approach

1. It’s more accurate to the real world.

Mental health issues overlap in several ways. First, a given symptom can be present across multiple conditions. For example, sleep difficulties are the trademark symptom of insomnia, but they’re also found in generalized anxiety disorder, depression, and post-traumatic stress disorder. Plus, it’s extremely common for a person to have multiple mental health conditions at once. And in many cases, symptoms don’t fit perfectly into one diagnostic category. Therefore, to improve mental health over the long-term — and teach people broadly applicable coping skills — it’s useful to take a treatment approach that’s relevant to overall tendencies, rather than a single mental health condition.

2. It’s more efficient for treatment.

Most mental health problems develop from similar underlying causes. The transdiagnostic approach seeks to treat that underlying cause directly. In doing so, people can learn coping skills that will be relevant to a variety of mental health problems, improving their overall mental health now and in the future.

To illustrate, let’s imagine Sam. Sam is a 41-year-old female juggling the pressures of managing 10 direct reports and trying to find a long-term partner. She has trouble falling asleep at night, and also experiences symptoms of anxiety, like uncontrollable worrying, and symptoms of depression, like low mood. But to say that Sam has three separate problems, and to treat each of them individually, wouldn’t make much sense. Even though Sam’s main goal is to sleep better, it’s not clear whether Sam is sleeping poorly because of insomnia, anxiety and worry, or low mood. Therefore, it makes more sense for Sam to learn coping skills that are applicable to the shared tendencies that all of her difficulties have in common.

What are these “common tendencies”?

Seeing the negative

This involves being more prone to unpleasant emotions overall, often because of a tendency to see the negative. For example, assuming the worst will happen, or focusing excessively on your own flaws.

After a night of poor sleep, Sam wakes up feeling tired and unmotivated. She declares, “I feel lousy. My day is ruined.” She tries to distract herself by opening a dating app. But her immediate thought is, “The fact that I’ve been single for so long means I’ll never find a partner. I will be alone forever.”

Judging emotions

This tendency involves finding unpleasant emotions very distressing, and judging them as bad: “I shouldn’t be feeling this way. This feeling is unacceptable/uncontrollable. I can’t handle it!”

When Sam feels down, she thinks, “What’s my problem? My life isn’t even that hard. Maybe I’m just lazy.” When she can’t fall asleep, she beats herself up, “Just relax already! This is so stupid. Now I’ll never fall asleep.”

Avoidance

Trying to avoid, escape, or suppress unwanted emotions. This usually backfires in the long term because it makes it impossible to practice coping with negative emotions directly.

When Sam is feeling depressed, her hobbies feel like too much effort, so she spends the weekends in bed. But that doesn’t make her feel better. Instead, she thinks: “See? I am lazy after all.” In addition, the thought of another awkward date makes Sam nervous, so she turns down a first-date invitation. She feels relieved in the short-term, but over time, avoiding dating just makes her more anxious about it, which stands in opposition to her ultimate goal of finding a partner.

If mental health conditions are all connected, where do you start with care?

Here’s the good news: Taking a transdiagnostic approach to mental health means care can start anywhere. Because there’s so much overlap in what drives common mental health problems, using transdiagnostic skills to help people cope can have a positive impact on a range of mental health difficulties and can prevent future problems.

Let’s see how Sam might tackle her mental health difficulties with a transdiagnostic approach. First, she might work on changing negative thinking patterns — which are playing into all three of her issues — by using a transdiagnostic skill called cognitive restructuring. This skill teaches Sam how to stop and evaluate whether her thoughts are accurate and helpful. If not, she learns how to intentionally take a new perspective on the difficult situation.

Additionally, Sam might challenge herself to face the situations that she’s been avoiding, such as going on dates, and planning activities that get her out of bed even when she’s feeling down. This transdiagnostic skill of reducing avoidance would help her learn that she’s able to tolerate and even overcome challenging situations. On top of that, she could learn relaxation or tension-reduction techniques to manage her anxiety in the moment of need and help her fall asleep.

Ultimately, the transdiagnostic approach is a hopeful one: It means that once people have access to a convenient and flexible source of coping skills, they can work on any and all of their mental health needs.

The transdiagnostic approach to Sleepio and Daylight

Our digital therapeutics — Sleepio for poor sleep and Daylight for worry and anxiety — help people overcome the most common mental health challenges by teaching them core transdiagnostic skills. While reducing worry and anxiety and improving sleep are helpful in their own right, addressing the underlying cause of most mental health conditions empowers people to improve their well-being more broadly. The transdiagnostic approach allows us to achieve our mission of helping millions back to good mental health — now and in the future.