Dr. José Alexandre de Souza Crippa
Nearly every psychiatric symptom exists on a spectrum, and impairment is the line where illness begins
STUDY: Crippa JAS, Trends in Psychiatry and Psychotherapy 2026
STUDY TYPE: Editorial
FUNDING: Independent
Background
Psychiatry has moved from yes-or-no categories toward dimensions and spectrums. But if everyone has some anxiety, inattention, or sadness, where does disorder start?
This editorial by a Brazilian psychiatrist draws on epidemiology, autism prevalence data, and his own research on social anxiety.
Summary
Dr. Crippa argues that clinical significance is the main protection against overdiagnosis. It requires that symptoms cause marked distress, impaired function, or both.
He offers three examples:
- Social anxiety vs Shyness: in his study of 355 young adults, people just below the diagnostic threshold had more impairment and comorbidity than controls, but less than those with the full disorder.
- Autism prevalence rose from about 4 in 10,000 in the 1970s to 1 in 31 US children today. Better awareness explains part of the rise, and broader criteria explain part. The diagnoses now covers people with very different needs, which can crowd out services for the most impaired, a problem reaching a crisis point in the UK.
- Ordinary distress: grief, exam nerves, and slips of attention can be intense without being disorders.
Broad categories also blur research, obscuring biomarkers and treatment effects. Dr. Crippa rejects a return to rigid categories and calls for clear thresholds on each dimension, based on severity, persistence, behavioral change (eg, avoidance), developmental context (eg, delayed maturity can look like childhood ADHD), and impairment.
Look for specific impairments: lost work, failed classes, or avoided relationships, and how long they lasted. Use a Disability scale like the WHODAS 2.0.
Practice Implications
- Impairment is a good marker.
- Another way to detect illness is to ask whether the symptoms are likely to be self-resolving. The time cut offs in DSM5 are based in part on this idea. Ask what they’ve done to alleviate the problem and how they responded.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
