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Psychometric perspectives on diagnostic systems
Open accessAbstract
The author identifies four conceptualizations of the relation between symptoms and disorders as utilized in diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV; American Psychiatric Association, 1994): A constructivist perspective, which holds that disorders are conveniently grouped sets of symptoms; a diagnostic perspective, which holds that disorders are latent classes underlying the symptoms; a dimensional perspective, which holds that symptoms measure latent continua; and a causal systems perspective, which holds that disorders are causal networks consisting of symptoms and direct causal relations between them. Advantages and disadvantages of these conceptualizations are discussed. The author concludes that the psychometric analysis of diagnostic systems is not settled, and that these systems require deeper psychometric analysis than they currently receive. © 2008 Wiley Periodicals, Inc. J Clin Psychol 64: 1089–1108, 2008.
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“This diversity is not adequately captured by diagnostic disorder categories or the associated disease model, which holds that a given pathology can be explained by a single underlying cause [9].”
From Using person-specific networks in psychotherapy: challenges, limitations, and how we could use them anyway (2020) · cites this paper as [9]
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“A current of research whose foundations can be traced back to the end of the 2000s [7,8] and which has largely developed since then [3,9] is fully in line with the paradigmatic rupture that we evoke.”
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“Introduction In recent years, psychological research is increasingly adopting a network perspective to psychological behavior (Borsboom, 2008; Borsboom et al., 2011; Borsboom & Cramer, 2013; Cramer et al., 2010; Schmittmann et al., 2013) in which psychological constructs are conceptualized as networks of interacting c…”
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“Network analysis has two main components: “nodes,” representing the observed variables, and “edges,” representing the statistical relation between the observed variables (Borsboom, 2008).”
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PTSD and Romantic Relationship Satisfaction: Cluster‐ and Symptom‐Level Analyses
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“The disease model conceptualizes mental disorders, including PTSD, as underlying conditions that give rise to observable symptoms (see Borsboom, 2008; Borsboom & Cramer, 2013; Deacon, 2013; McNally, 2012).”
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“Many researchers have suggested that disorders such as depression should be seen as dimensional; for example, people who suffer from severe depression occupy a higher position on a continuous latent variable rather than being qualitatively different from the normal population (Borsboom, 2008).”
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Bringmann, L. F., Helmich, M. A., Eronen, M. I., & Voelkle, M. C. (2023) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197542521.003.0005 · Cited by 21
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“Under the drive of data, a network composed of nodes and edges can assist with visualizing the relationships among variables (Borsboom, 2008).”
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Ma, Z., Xiao-Yan, C. H. E. N., Tao, Y., Huang, S., Yang, Z., Chen, J., Bu, L., Wang, C., & Fan, F. (2022) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2022.103137 · Cited by 19
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“, describing the possibility that symptom co-occurrence is due to direct symptom-to-symptom relationships rather than a common cause, are needed to help understand the mechanisms and relationships among mental health symptoms (23).”
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Huang, D., Susser, E., Rudolph, K. E., & Keyes, K. M. (2023) · Psychological Medicine · doi:10.1017/s0033291723000132 · Cited by 22
“The network paradigm was proposed based on the thought-provoking hypothesis that mental disorders are networks made up of mental health symptoms causing each other (Borsboom, 2008; Fried, 2015; Kendler, Zachar, & Craver, 2011).”
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“This is a useful tool for exploratory analysis that allows researchers to estimate (and visualize) the relationships between multiple variables (Borsboom, 2008; Cramer et al., 2010; Wagenmakers et al., 2011).”
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“Even more so since depression may itself be understood, in the psychopathological network theory, as a complex network of symptoms where symptom-symptom interactions drive and sustain the depressive symptoms (6, 89, 90).”
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“Accordingly, covariation among individual symptoms should be substantially attenuated after accounting for the presence of the latent disease mechanism; however, this assumption has received limited empirical support (Borsboom, 2008).”
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“In the process of research on practical problems, these indicators can often provide researchers with important insights into the relationship between variables (Borsboom, 2008; Epskamp et al., 2018).”
Neural Substrates of Poststroke Depression: Current Opinions and Methodology Trends
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Is there a contradiction between the network and latent variable perspectives?
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“Hence, such models are consistent with the hypothesis that we may one day find out “what depression really is”; that is, latent variables may “become” observed through a refinement of the conceptual and measurement apparatus used to study them (e.g., Bollen 2002; Borsboom 2008).”
BackgroundMethodInfluentialNetwork modeling of major depressive disorder symptoms in adult women
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Exploratory Graph Analysis in context
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Individual-Specific Animated Profiles of Mental Health
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“Clinical network theory considers mental disorders to be a network of dynamic self-reinforcing causal interactions between symptoms (Borsboom, 2008; Fried et al., 2017).”
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Self-citationA network analysis of two conceptual approaches to the etiology of PTSD
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“, symptoms) are caused by or reflective of a latent construct (i.e., the disorder; Borsboom, 2008).”
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“An alternative approach is network analysis, a novel technique rooted in the mutualistic perspective which proposes that complex psychological constructs are mutually connected and reinforce one another, thus forming a causally connected system (Borsboom, 2008).”
Bulut, O., Cormier, D. C., Aquilina, A. M., & Bulut, H. C. (2021) · Journal of Intelligence · doi:10.3390/jintelligence9030035 · Cited by 16
“Psychometric Network Analysis Following the hierarchical CFA model, we used psychometric network modeling (Borsboom 2008; Borsboom and Cramer 2013) to examine the network structure of the W scores derived from the WJ IV COG subtests.”
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Symptom networks of COVID-19-related versus other potentially traumatic events in a global sample
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“Within a network, certain symptoms may be more or less central to the overall presentation and may activate each other to different degrees and in different ways (Borsboom, 2008, 2017; McNally et al., 2015).”
BackgroundSelf-Dislike and Sadness are Central Symptoms of Depression in College Students: A Network AnalysisPreprint
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An Exploration of Self-Reported Sleep Inertia Symptoms Using Network Analysis
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“In contrast, the network approach assesses interactions between individual symptoms.(9) Second, the possible explanation is that the sex differences in network analysis may be partly masked by the impact of neurophysiological mechanism.”
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“The network approach to psychopathology has been proposed as an alternative framework to generate symptomoriented insights about mental disorders (Borsboom, 2008).”
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Su, Y., Li, M., & Meng, X. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.01.266 · Cited by 14
Mohammadi, Z., Dehghani, M., Lavasani, F. F., Farahani, H., & Ashouri, A. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1372620 · Cited by 16
“The network approach to psychopathology started a decade ago with a simple hypothesis: symptoms may present as a syndrome nurtured by causal relationships between themselves (27, 28).”
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“And because (according to Borsboom and Cramer) we have gotten the ontology of mental illness all wrong in believing that an independently existing underlying pathology (one that is logically distinct from overt phenomenology/symptoms) differentially causes overt symptom clusters for each diagnostic category, our epist…”
BackgroundResultInfluentialPublic Mental Health and Prevention
Radden, J. H. (2017) · Public Health Ethics · doi:10.1093/phe/phx011 · Cited by 14
Deepening the understanding of complicated grief among Chinese older adults: A network approach
Pan, H. (2020) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2020.101966 · Cited by 14
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“This is contradicted by the finding that anhedonia, hopelessness or tiredness usually correlated with each other even when the diagnostic criteria for MDD were not fulfilled (Borsboom, 2008; Santos et al., 2017).”
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Outcome measurement in mental health services: insights from symptom networks
Barbalat, G., van den Bergh, D., & Kossakowski, J. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2175-7 · Cited by 11
“A network conceptualizes HoNOS as a system of mutually interacting HoNOS items [6].”
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“The network analysis, a method developed from Borsboom’s network theory of psychopathology [20], allows for the inclusion of all variables at the same time for analysis and visualization of the connections of them as a network [18].”
MethodCharacteristics of symptoms and development of psychological status in late Chinese adolescence
Zhang, W.-X., Yang, M.-B., Zhang, K., Xi, M., & Si, S. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.05.147 · Cited by 13
Endorsement of metaphysical idealism mediates a link between past use of psychedelics and wellbeing
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“In network analysis psychological processes are modelled as a set of interconnected nodes and edges, representing observed variables and statistical relationships between the variables, respectively 56–59 .”
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“Traditional statistical methods, such as structural equation modeling or regression analysis, commonly posit that the relationships between variables are linear and unidirectional, relying on latent variables to account for the covariation among observed variables (Borsboom, 2008).”
The latent structure of depression symptoms and suicidal thoughts in Brazilian youths
Baptista, M. N., Cunha, F. A., & Filho, N. H. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.05.024 · Cited by 13
Prenatal Symptom Cluster of Psychopathology and Associations With Mindfulness and Rumination
Sun, Y., Chen, Q., Li, Y., Wang, J., Bazzano, A. N., & Cao, F. (2022) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001485 · Cited by 14
“Traditional views on psychopathology presumed that the cooccurrence symptom cluster originated from an underlying common cause (Borsboom, 2008).”
BackgroundFrom analytic to synthetic-organizational pluralisms: A pluralistic enactive psychiatry
Gauld, C., Nielsen, K., Job, M., Bottemanne, H., & Dumas, G. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.981787 · Cited by 14
Network-based methods for psychometric data of eating disorders: A systematic review
Punzi, C., Petti, M., & Tieri, P. (2022) · PLoS ONE · doi:10.1371/journal.pone.0276341 · Cited by 16
Psychopathological network for early-onset post-stroke depression symptoms
Pan, C.-S., Li, G., Sun, W.-Z., Miao, J.-F., Wang, Y.-Y., Lan, Y., Qiu, X., Zhao, X., Wang, H., Zhu, Z., et al. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-04606-1 · Cited by 12
Cognitive diagnostic assessment via Bayesian evaluation of informative diagnostic hypotheses.
Hoijtink, H. J. A., Béland, S., & Vermeulen, J. A. (2013) · Psychological Methods · doi:10.1037/a0034176 · Cited by 13
Two Tell-tale Perspectives of PTSD
Shahid, F., Rahman, W., Islam, A., Paul, N., Khan, N. S., Rahman, M. S., Haque, M. M., & Islam, A. B. M. A. A. (2019) · Proceedings of the ACM on Interactive Mobile Wearable and Ubiquitous Technologies · doi:10.1145/3351259 · Cited by 13
“, PTSD bears the causal relevance for the observed values of each post-traumatic stress symptom [14, 17, 43].”
BackgroundShim, E., Jeong, D., Song, Y. W., Lee, S. H., Kim, N. J., & Hahm, B. (2019) · Psychology and Health · doi:10.1080/08870446.2019.1686150 · Cited by 13
“cognitive and emotional illness representation), which violates the assumption of local independence required for a latent variable model such as factor analysis (Borsboom, 2008), suggesting that a traditional factor analytic may be less suited to examine a construct of IP as measured by the BIPQ.”
MethodYuval, K., Aizik-Reebs, A., Lurie, I., Demoz, D., & Bernstein, A. (2020) · Transcultural Psychiatry · doi:10.1177/1363461520965436 · Cited by 14
“…psychopathological symptoms, as well as novel means to begin to empirically test longstanding assumptions about these symptoms and the mechanisms that may contribute to their onset and persistence (Borsboom, 2008, 2017; Borsboom & Cramer, 2013; Cramer, Waldorp, van der Maas, Han, & Borsboom, 2010).”
BackgroundA Complex Network Perspective on Clinical SciencePreprint
Hofmann, S. G. (2016) · PsyArXiv (OSF Preprints) · doi:10.31234/osf.io/j4wu3 · Cited by 18
Hong, X., Du, W., Quan, X., Yu, P., & Chen, L. (2025) · Acta Psychologica · doi:10.1016/j.actpsy.2025.105482 · Cited by 12
Punzi, C., Tieri, P., Girelli, L., & Petti, M. (2023) · Scientific Reports · doi:10.1038/s41598-023-28743-5 · Cited by 12
Finch, W. H., French, B. F., & Hazelwood, A. (2023) · Applied Psychological Measurement · doi:10.1177/01466216231151700 · Cited by 12
“Given the relative frequency with which this may happen in practice (e.g., Borsboom, 2008; Cramer, et al., 2012; Schmittmann et al., 2013), correctly handling a lack of local independence would appear to be crucial for statistical practice.”
BackgroundMethodThe association between team cohesion and performance: A network analysis of nurses
Wei, H., Zhang, S., Qu, W., Liu, M., Yan, Z., & Luan, X. (2024) · Nursing and Health Sciences · doi:10.1111/nhs.13089 · Cited by 15
Jing, Z., & Ding, F. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.04.009 · Cited by 15
Calderon, A., Baik, S. Y., Ng, M. H. S., Fitzsimmons‐Craft, E. E., Eisenberg, D., Wilfley, D. E., Taylor, C. B., & Newman, M. G. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-06074-7 · Cited by 16
“Network analysis is one methodological approach suited for such an endeavor, given its telos of disentan-gling the complex dynamics of self-reinforcing causal interactions between symptoms [24].”
MethodLuo, X. G., Li, S., Wu, Q., Xu, Y. J., Fang, R., Cheng, Y., & Zhang, B. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-06532-w · Cited by 13
“This method is rooted in traditional psychopathological theories, which typically emphasize the association of individual symptoms with prototypical symptoms of other syndromes rather than highlighting the differences among individual symptoms themselves [16].”
Smits, N. (2015) · Quality of Life Research · doi:10.1007/s11136-015-1199-9 · Cited by 12
“, [23, 24]), but there are two that dominate the literature, which will be used in the simulation.”
BackgroundBodner, N., Bringmann, L. F., Tuerlinckx, F., de Jonge, P., & Ceulemans, E. (2021) · Psychometrika · doi:10.1007/s11336-021-09765-2 · Cited by 15
Jozefiaková, B., Kaščáková, N., Adamkovic, M., Hašto, J., & Tavel, P. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.801812 · Cited by 22
“…the latent variable to the observed indicators, local independence of the indicators after controlling for the latent variable, or that an indicator-level intervention cannot have an effect on the latent variable; see, e.g., Borsboom, 2008; Borsboom and Cramer, 2013; Schmittmann et al., 2013).”
BackgroundValidation of the Geriatric Oral Health Assessment Index in complete denture wearers
Campos, J. Á. D. B., Zucoloto, M. L., Geremias, R. F., Nogueira, S. S., & Marôco, J. P. (2015) · Journal of Oral Rehabilitation · doi:10.1111/joor.12279 · Cited by 12
Gunst, A., Werner, M. A., Waldorp, L., Laan, E. T. M., Källström, M., & Jern, P. (2018) · Scientific Reports · doi:10.1038/s41598-018-34138-8 · Cited by 14
Cross-Cultural Examination of Psychopathy Network in Chinese and U.S. Prisoners
Wang, M., Deng, J. S., Shou, Y., & Sellbom, M. (2022) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-022-09960-0 · Cited by 14
“In existing psychopathology research (Borsboom & Cramer, 2013; Borsboom, 2008; Cramer et al., 2010; Lahey et al., 2012), the common factor model (or reflective model) is the traditional statistical approach used by researchers to study the latent structure of psychopathy (e.”
BackgroundLi, S., Zhao, T., Feng, N., Chen, R., & Cui, L. (2026) · International Journal of Mental Health and Addiction · doi:10.1007/s11469-025-01486-2 · Cited by 11
“Network approaches may provide novel insight into the importance of specific symptoms within the psychological constructs (Borsboom, 2008, 2017).”
Reformulating the network theory of mental disorders: Folk psychology as a factor, not a fact
Maatman, F. O. (2020) · Theory & Psychology · doi:10.1177/0959354320921464 · Cited by 12
“More specifically, in this article I will argue that the arguments proposed by Borsboom et al. (2019) reduce NT to a network interpretation of common folk psychological practice, which provides no further use to clinicians and scientists than being an alternative to biological reduction.”
BackgroundInfluential
Metadata
- Authors
- Borsboom, D.
- Affiliations
- University of Amsterdam (NL)
- Corresponding author
- Borsboom, Denny
- ORCID
- Borsboom, Denny
- Venue
- Journal of Clinical Psychology
- Publisher
- Wiley
- Published
- 2008-08-06
- Volume
- 64
- Issue
- 9
- Pages
- 1089-1108
- ISSN
- 0021-9762 (ISSN-L)
- 1097-4679
- OpenAlex
- W2064794182
- Cited by
- 691
- References
- 48
- Citations by year
- 2026: 53 · 2025: 72 · 2024: 82 · 2023: 82 · 2022: 62 · 2021: 73 · 2020: 67 · 2019: 40 · 2018: 33 · 2017: 27 · 2016: 27 · 2015: 14 · 2014: 11 · 2013: 14 · 2012: 15
- FWCI
- 8.06
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- Nederlandse Organisatie voor Wetenschappelijk Onderzoek (451-03-068)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- diagnostic systems, DSM-IV, constructivist approach, latent class models, dimensional models, causal systems, psychiatric classification
- MeSH terms
- Mental Disorders, Humans, Psychological Theory, Psychometrics, Psychopathology
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