PART 14: Psychological Disorders

40.2 Classifying Disorders—and Labeling People

40-3 How and why do clinicians classify psychological disorders, and why do some psychologists criticize the use of diagnostic labels?

In biology, classification creates order. To classify an animal as a “mammal” says a great deal—that it is warm-blooded, has hair or fur, and produces milk to feed its young. In psychiatry and psychology, too, classification orders and describes symptoms. To classify a person’s disorder as “schizophrenia” suggests that the person talks incoherently, has bizarre beliefs, shows either little emotion or inappropriate emotion, or is socially withdrawn. “Schizophrenia” is a quick way of describing a complex disorder.

Sidney Harris

But diagnostic classification gives more than a thumbnail sketch of a person’s disordered behavior, thoughts, or feelings. In psychiatry and psychology, classification also attempts to

predict a disorder’s future course.
suggest appropriate treatment.
prompt research into a disorder’s causes.

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DSM-5 the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; a widely used system for classifying psychological disorders.

The most common tool for describing disorders and estimating how often they occur is the American Psychiatric Association’s 2013 Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DSM-5). Physicians and mental health workers use the DSM-5 to guide medical diagnoses and treatment. For example, a person may be diagnosed with and treated for “insomnia disorder” if he or she meets all of the criteria in TABLE 40.1.

Table 14.1: TABLE 40.1
Insomnia Disorder (American Psychiatric Association, 2013)

Feeling unsatisfied with amount or quality of sleep (trouble falling asleep, staying asleep, or returning to sleep)

Sleep disruption causes distress or diminished everyday functioning

Happens three or more nights each week

Occurs during at least three consecutive months

Happens even with sufficient sleep opportunities

Independent from other sleep disorders (such as narcolepsy)

Independent from substance use or abuse

Independent from other mental disorders or medical conditions

In the new DSM-5, some diagnostic labels changed. The conditions formerly called “autism” and “Asperger’s syndrome” were combined under the label autism spectrum disorder. “Mental retardation” became intellectual disability. New categories, such as hoarding disorder and binge-eating disorder, were added.

Real-world tests (field trials) have assessed the reliability of the new DSM-5 categories (Freeman et al., 2013). Some diagnoses—such as adult posttraumatic stress disorder and childhood autism spectrum disorder—fared well, with clinician agreement near 70 percent (meaning that if one psychiatrist or psychologist diagnosed someone with one of these disorders, there was a 70 percent chance that another mental health worker would independently give the same diagnosis). Others, such as antisocial personality disorder and generalized anxiety disorder, have fared poorly, with about 20 percent agreement.

Critics have long faulted the DSM for casting too wide a net, and for bringing “almost any kind of behavior within the compass of psychiatry” (Eysenck et al., 1983). Some now worry that the DSM-5’s even wider net will extend the pathologizing of everyday life—for example, by turning bereavement grief into a depressive disorder and childish rambunctiousness into ADHD (Frances, 2013). (See Thinking Critically About: ADHD—Normal High Energy or Disordered Behavior? below.) Others respond that enduring hyperactivity and grief-related depression are genuine disorders (Kendler, 2011; Kupfer, 2012).

THINKING CRITICALLY ABOUT

ADHD—Normal High Energy or Disordered Behavior?

40-4 Why is there controversy over attention-deficit/hyperactivity disorder?

Eight-year-old Todd has always been energetic. At home, he chatters away and darts from one activity to the next, rarely settling down to read a book or focus on a game. At play, he is reckless and overreacts when playmates bump into him or take one of his toys. At school, Todd fidgets, and his exasperated teacher complains that he doesn’t listen, follow instructions, or stay in his seat to do his lessons. As Todd matures to adulthood, his hyperactivity likely will subside, but his inattentiveness may persist (Kessler et al., 2010).

attention-deficit/hyperactivity disorder (ADHD) a psychological disorder marked by extreme inattention and/or hyperactivity and impulsivity.

If taken for a psychological evaluation, Todd may be diagnosed with attention-deficit/hyperactivity disorder (ADHD). Some 11 percent of American 4- to 17-year-old children receive the diagnosis after displaying its key symptoms (extreme inattention, hyperactivity, and impulsivity) (Schwarz & Cohen, 2013). Studies also find 2.5 percent of adults—though the number diminishes with age—exhibiting ADHD symptoms (Simon et al., 2009). The looser criteria for adult ADHD in the DSM-5 has led critics to fear increased diagnosis and overuse of prescription drugs (Frances, 2012, 2014).

To skeptics, being distractible, fidgety, and impulsive sounds like a “disorder” caused by a single genetic variation: a Y chromosome (the male sex chromosome). And sure enough, ADHD is diagnosed three times more often in boys than in girls. Does energetic child + boring school = ADHD overdiagnosis? Is the label being applied to healthy schoolchildren who, in more natural outdoor environments, would seem perfectly normal? Is ADHD a disease that is marketed by companies offering drugs that treat it (Thomas, 2015)?

Skeptics think so. In the decade after 1987, they note, the proportion of American children being treated for ADHD nearly quadrupled (Olfson et al., 2003). Minority youth less often receive an ADHD diagnosis than do White youth, but this difference has shrunk as minority ADHD diagnoses have increased (Genahun at al., 2013). How commonplace the diagnosis is depends in part on teacher referrals. Some teachers refer lots of kids for ADHD assessment, others none. ADHD rates have varied by a factor of 10 in different counties of New York State (Carlson, 2000). Depending on where they live, children who are “a persistent pain in the neck in school” are often diagnosed with ADHD and given powerful prescription drugs, notes Peter Gray (2010). But the problem may reside less in the child than in today’s abnormal environment, which forces children to do what evolution has not prepared them to do—to sit for long hours in chairs. In more natural outdoor environments, these children might seem perfectly healthy. When given cognitive tests, children with ADHD concentrate better when allowed to fidget (Hartanto et al., 2015).

Not everyone agrees that ADHD is being overdiagnosed. Some argue that today’s more frequent diagnoses of ADHD reflect increased awareness of the disorder, especially in those areas where rates are highest. They acknowledge that diagnoses can be inconsistent—ADHD is not as clearly defined as a broken arm. Nevertheless, declared the World Federation for Mental Health (2005), “there is strong agreement among the international scientific community that ADHD is a real neurobiological disorder whose existence should no longer be debated.” A consensus statement by 75 neuroimaging researchers noted that abnormal brain activity often accompanies ADHD (Barkley et al., 2002).

What, then, is known about ADHD’s causes? It is not caused by too much sugar or poor schools. ADHD often coexists with a learning disorder or with defiant and temper-prone behavior. ADHD is heritable, and research teams are sleuthing the culprit genes and abnormal neural pathways (Lionel et al., 2013; Poelmans et al., 2011; Volkow et al., 2009; Williams et al., 2010). It is treatable with medications such as Ritalin and Adderall, which are considered stimulants but help calm hyperactivity and increase one’s ability to sit and focus on a task—and to progress normally in school (Barbaresi et al., 2007). Psychological therapies, such as those focused on shaping classroom and at-home behaviors, also help to address the distress of ADHD (Fabiano et al., 2008).

The bottom line: Extreme inattention, hyperactivity, and impulsivity can derail social, academic, and vocational achievements, and these symptoms can be treated with medication and other therapies (Hinshaw & Scheffler, 2014). But the debate continues over whether normal high energy is too often diagnosed as a psychiatric disorder, and whether there is a cost to the long-term use of stimulant drugs in treating ADHD.

Other critics register a more basic complaint—that these labels are at best subjective and at worst value judgments masquerading as science. Once we label a person, we view that person differently (Bathje & Pryor, 2011; Farina, 1982; Sadler et al., 2012). Labels can change reality by putting us on alert for evidence that confirms our view. When teachers were told certain students were “gifted,” they acted in ways that brought out the creative behaviors they expected (Snyder, 1984). If we hear that a new co-worker is a difficult person, we may treat this person suspiciously. He or she may in turn react to us as a difficult person would. Labels can be self-fulfilling.

The biasing power of labels was clear in a classic study. David Rosenhan (1973) and seven others went to hospital admissions offices, complaining (falsely) of “hearing voices” saying empty, hollow, and thud. Apart from this complaint and giving false names and occupations, they answered questions truthfully. All eight healthy people were misdiagnosed with disorders.

Struggles and recovery During his campaign, Boston Mayor Martin Walsh spoke openly about his past struggles with alcohol. In the process, he moved beyond potentially biasing labels, and won a close election.

Gretchen Ertl/The New York Times/Redux

Should we be surprised? Surely not. As one psychiatrist noted, if someone swallowed blood, went to an emergency room, and spat it up, would we blame a doctor for diagnosing a bleeding ulcer? But what followed the Rosenhan study diagnoses was startling. Until being released an average of 19 days later, these eight “patients” showed no other symptoms. Yet after analyzing their (quite normal) life histories, clinicians were able to “discover” the causes of their disorders, such as having mixed emotions about a parent. Even the patients’ routine note-taking behavior was misinterpreted as a symptom.

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In another study, people watched videotaped interviews. If told the interviewees were job applicants, the viewers perceived them as normal (Langer & Abelson, 1974, 1980). Other viewers who were told they were watching psychiatric or cancer patients perceived the same interviewees as “different from most people.” Therapists who thought they were watching an interview of a psychiatric patient perceived him as “frightened of his own aggressive impulses,” a “passive, dependent type,” and so forth. As Rosenhan discovered, a label can have “a life and an influence of its own.” Labels matter.

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Labels also have power outside the laboratory. Getting a job or finding a place to rent can be a challenge for people recently released from a mental hospital. Label someone as “mentally ill” and people may fear them as potentially violent (see Thinking Critically About: Are People With Psychological Disorders Dangerous?). Such negative reactions may fade as people better understand that many psychological disorders involve diseases of the brain, not failures of character (Solomon, 1996). Public figures have helped foster this understanding by speaking openly about their own struggles with disorders such as depression and substance abuse. The more contact we have with people with disorders, the more accepting our attitudes become (Kolodziej & Johnson, 1996).

THINKING CRITICALLY ABOUT

Are People With Psychological Disorders Dangerous?

40-5 Do psychological disorders predict violent behavior?

September 16, 2013, started like any other Monday at Washington, DC’s, Navy Yard, with people arriving early to begin work. Then government contractor Aaron Alexis parked his car, entered the building, and began shooting people. An hour later, 13 people were dead, including Alexis. Reports later confirmed that Alexis had a history of mental illness. Before the shooting, he had stated that an “ultra low frequency attack is what I’ve been subject to for the last three months. And to be perfectly honest, that is what has driven me to this.” After a horrifying mass shooting in a Connecticut elementary school in 2012, New York’s governor declared, “People who have mental issues should not have guns” (Kaplan & Hakim, 2013). These devastating mass shootings, like many others since then, reinforced public perceptions that people with psychological disorders pose a threat (Barry et al., 2013; Jorm et al., 2012). So did an incident in March of 2015, when Germanwings co-pilot Andreas Lubitz, who had a history of mental illness, killed 150 people by locking his pilot out of the cockpit and intentionally crashing a commercial jet into the French Alps.

Does scientific evidence support the governor’s statement? If disorders actually increase the risk of violence, then denying people with psychological disorders the right to bear arms might reduce violent crimes. But real life tells a different story. Most people with mental disorders commit no violent crimes, and the vast majority of violent crimes are committed by people with no diagnosed disorder (Fazel & Grann, 2006; Skeem et al., 2015; Walkup & Rubin, 2013).

People with disorders are more likely to be victims than perpetrators of violence (Marley & Bulia, 2001). According to the U.S. Surgeon General’s Office (1999, p. 7), “There is very little risk of violence or harm to a stranger from casual contact with an individual who has a mental disorder.” The bottom line: Psychological disorders only rarely lead to violent acts, and focusing gun restrictions only on mentally ill people will likely not reduce gun violence (Friedman, 2012).

How to prevent mass shootings? Following the Newtown, Connecticut, slaughter of 20 young children and 6 adults, people wondered: Could those at risk for violence be identified in advance by mental health workers and reported to police? Would laws that require such reporting discourage disturbed gun owners from seeking mental health treatment?

Adrees Latif/Reuters/Landov

If mental illness is not a good predictor of violence, what is? Better predictors are a history of violence, use of alcohol or drugs, and access to a gun. The mass-killing shooters have one more thing in common: They tend to be young males. “We could avoid two-thirds of all crime simply by putting all able-bodied young men in cryogenic sleep from the age of 12 through 28,” said one psychologist (Lykken, 1995).

Mental disorders seldom lead to violence, and clinical prediction of violence is unreliable. What, then, are the triggers for the few people with psychological disorders who do commit violent acts? For some, the trigger is substance abuse. For others, like the Navy Yard shooter, it’s threatening delusions and hallucinated voices that command them to act (Douglas et al., 2009; Elbogen & Johnson, 2009; Fazel et al., 2009, 2010). Whether people with mental disorders who turn violent should be held responsible for their behavior remains controversial. U.S. President Ronald Reagan’s near-assassin, John Hinckley, was sent to a hospital rather than to prison. The public was outraged. “Hinckley insane. Public mad,” declared one headline. They were outraged again in 2011, when Jared Lee Loughner killed six people and injured several others, including U.S. Representative Gabrielle Giffords. Loughner was diagnosed with schizophrenia and twice found incompetent to stand trial. He was later judged competent to stand trial, pled guilty to 19 charges of murder and attempted murder, and was sentenced to life in prison without parole.

Which decision was correct? The first two, which blamed Loughner’s “madness” for clouding his judgment? Or the final one, which decided that he should be held responsible for the acts he committed? As we come to better understand the biological and environmental bases for all human behavior, from generosity to vandalism, when should we—and should we not—hold people accountable for their actions?

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Better portrayals Old stereotypes are slowly being replaced in media portrayals of psychological disorders. Recent films offer fairly realistic depictions. Iron Man 3 (2013) portrayed a main character, shown here, with posttraumatic stress disorder. Black Swan (2010) dramatized a lead character suffering a delusional disorder. A Single Man (2009) depicted depression.

Paramount Pictures/Photofest

“What’s the use of their having names,” the Gnat said, “if they won’t answer to them?”

“No use to them,” said Alice; “but it’s useful to the people that name them, I suppose.”

Lewis Carroll, Through the Looking-Glass, 1871

Despite their risks, diagnostic labels have benefits. They help mental health professionals communicate about their cases and study the causes and treatments of disorder. Clients are often relieved to learn that the nature of their suffering has a name, and that they are not alone in experiencing their symptoms.

To test your ability to form diagnoses, visit LaunchPad’s PsychSim 6: Classifying Disorders.

RETRIEVE IT

Question

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ANSWER: Therapists and others apply disorder labels to communicate with one another using a common language, and to share concepts during research. Clients may benefit from knowing that they are not the only ones with these symptoms. The dangers of labeling people are that (1) people may begin to act as they have been labeled, and (2) the labels can trigger assumptions that will change people's behavior toward those labelled.