Most people would agree that someone who is too depressed to get out of bed for weeks at a time has a psychological disorder. But what about those who, having experienced a loss, are unable to resume their usual social activities? Where should we draw the line between sadness and depression? Between zany creativity and bizarre irrationality? Between normality and abnormality? Let’s start with these questions:

15-1 How should we draw the line between normality and disorder?

A psychological disorder is a syndrome (collection of symptoms) marked by a “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior” (American Psychiatric Association, 2013). Disturbed, or dysfunctional thoughts, emotions, or behaviors are maladaptive—they interfere with normal day-to-day life. Believing your home must be thoroughly cleaned every weekend is not a disorder. But if cleaning rituals interfere with work and leisure, as Marc’s did in this chapter’s opening, they may be signs of a disorder. And occasional sad moods that persist and become disabling may likewise signal a psychological disorder.

Distress often accompanies dysfunctional behaviors. Marc, Greta, and Stuart were all distressed by their behaviors or emotions.

Over time, definitions of what makes for a “significant disturbance” have varied. From 1952 through December 9, 1973, homosexuality was classified as a psychological disorder. By day’s end on December 10, it was not. The American Psychiatric Association made this change because more and more of its members no longer viewed same-sex attraction as a psychological problem. Such is the power of shifting societal beliefs. (Later research revealed, however, that the stigma and stresses that gay, lesbian, and transsexual people often experience can increase the risk of mental health problems [Hatzenbuehler et al., 2009; Meyer, 2003].) In the twenty-first century, other controversies swirl over new or altered diagnoses (such as attention-deficit/hyperactivity disorder) in the most recent classification tool for describing disorders. (You’ll hear more about this later.)

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15-2 How do the medical model and the biopsychosocial approach influence our understanding of psychological disorders?

The way we view a problem influences how we try to solve it. In earlier times, people often viewed strange behaviors as evidence that strange forces—the movements of the stars, godlike powers, or evil spirits—were at work. Had you lived during the Middle Ages, you might have said “The devil made him do it.” Believing that, you might have approved of a cure that would drive out the evil demon. Thus, people considered “mad” were sometimes caged or given “therapies” such as genital mutilation, beatings, removal of teeth or lengths of intestines, or transfusions of animal blood (Farina, 1982). Barbaric treatments for mental illness linger even today. In some places, people are chained to a bed, locked in their rooms, or even locked in a room with wild hyenas, in the belief that the animals will see and attack evil spirits (Hooper, 2013). Noting the physical and emotional damage of such restraint, the World Health Organization launched a “chain-free initiative” that aims to reform hospitals “into patient-friendly and humane places with minimum restraints” (WHO, 2014).

Brutal treatments may worsen, rather than improve, mental health. Reformers, such as Philippe Pinel (1745–1826) in France, opposed such brutal treatments. Madness is not demon possession, he insisted, but a sickness of the mind caused by severe stress and inhumane conditions. Curing the illness, he said, requires “moral treatment,” including boosting patients’ morale by unchaining them and talking with them. He and others worked to replace brutality with gentleness, isolation with activity, and filth with clean air and sunshine.

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By the 1800s, the discovery that syphilis infects the brain and distorts the mind drove further gradual reform. Hospitals replaced asylums, and the medical model of mental disorders was born. This model is reflected in the terms we still use today. We speak of the mental health movement: A mental illness (also called a psychopathology) needs to be diagnosed on the basis of its symptoms. It needs to be treated through therapy, which may include time in a psychiatric hospital.

The medical perspective has gained credibility from recent discoveries that genetically influenced abnormalities in brain structure and biochemistry contribute to many disorders. But as we will see, psychological factors, such as chronic or traumatic stress, also play an important role.

To call psychological disorders “sicknesses” tilts research heavily toward the influence of biology and away from the influence of our personal histories and social and cultural surroundings. But in the study of disorders, as in so many other areas, we must remember that our behaviors, our thoughts, and our feelings are formed by the interaction of biological, psychological, and social-cultural influences. As individuals, we differ in the amount of stress we experience and in the ways we cope with stressors. Cultures also differ in their sources of stress and in traditional ways of coping.

Some disorders, such as depression and schizophrenia, occur worldwide. From Asia to Africa and across the Americas, schizophrenia’s symptoms often include irrationality and incoherent speech. Other disorders tend to be associated with specific cultures. In Malaysia, amok describes a sudden outburst of violent behavior (thus the English phrase “run amok”). Latin America lays claim to susto, a condition marked by severe anxiety, restlessness, and a fear of black magic. In Japanese culture, people may experience taijin kyofusho—social anxiety about their appearance, combined with a readiness to blush and a fear of eye contact. The eating disorders anorexia nervosa and bulimia nervosa occur mostly in food-abundant Western cultures. Such disorders may share an underlying dynamic (such as anxiety) while differing in the symptoms (an eating problem or a type of fear) manifested in a particular culture.

Disorders reflect genetic predispositions and physiological states, inner psychological dynamics, and social and cultural circumstances. The biopsychosocial approach emphasizes that mind and body are inseparable (FIGURE 15.1). Negative emotions contribute to physical illness, and physical abnormalities contribute to negative emotions. Epigenetics, the study of how nurture shapes nature, also informs our understanding of disorders (Powledge, 2011). Genes and environment are not the whole story, as we’ve seen in other chapters. It turns out our environment can affect whether a gene is expressed or not, and thus affect the development of various psychological disorders.

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For example, even identical twins (with identical genes) do not share the same risks of developing psychological disorders. They are more likely, but not always destined, to develop the same disorders. Their varying environmental factors influence whether certain culprit genes are expressed.

15-3 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 nourish 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 to describe a complex disorder.

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

To study a disorder, we must first name and describe it.

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 detailed “diagnostic criteria and codes” in 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 15.1.

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

Some of the new or altered diagnoses are controversial. Disruptive mood dysregulation disorder is a new DSM-5 diagnosis for children “who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.” Will this diagnosis assist parents who struggle with unstable children, or will it “turn temper tantrums into a mental disorder” and lead to overmedication, as the chair of the previous DSM edition has warned (Frances, 2012)?

Real-world tests (field trials) have assessed clinician agreement when using the new DSM-5 categories (Freedman et al., 2013). Some diagnoses, such as adult posttraumatic stress disorder and childhood autism spectrum disorder fared well—with agreement near 70 percent. (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, fared poorly.

Critics have long faulted the DSM for casting too wide a net and 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 childish rambunctiousness into ADHD, and bereavement grief into a depressive disorder (Frances, 2013). (See Thinking Critically About: ADHD.) Others respond that hyperactivity and depression, though needing careful definition, are genuine disorders—even when the depression was triggered by a major life stress such as a death when the grief does not go away (Kendler, 2011; Kupfer, 2012).

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 elicited the behaviors they expected (Snyder, 1984). Someone who was led to think you are nasty may treat you coldly, leading you to respond as a mean-spirited person would. Labels can be self-fulfilling. They create expectations that guide how we perceive and interpret people.

The biasing power of labels was clear in a now-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.

Should we be surprised? As one psychiatrist noted, if someone swallows blood, goes to an emergency room, and spits it up, should we fault the doctor for diagnosing a bleeding ulcer? Surely not. But what followed the Rosenhan study diagnoses was startling. Until being released an average of 19 days later, those 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 routine note-taking behavior was misinterpreted as a symptom.

Labels matter. In another study, people watched videotaped interviews. If told the interviewees were job applicants, the viewers perceived them as normal (Langer et al., 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. A label can, as Rosenhan discovered, have “a life and an influence of its own.”

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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 new 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 are (Kolodziej & Johnson, 1996).

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Despite their risks, diagnostic labels have benefits. Mental health professionals use labels to communicate about their cases, to comprehend the underlying causes, and to discern effective treatment programs. Researchers use labels when discussing work that explores the causes and treatments of disorders. Clients are often relieved to learn that the nature of their suffering has a name, and that they are not alone in experiencing this collection of symptoms.

15-6 How many people have, or have had, a psychological disorder? Is poverty a risk factor?

Who is most vulnerable to psychological disorders? At what times of life? To answer such questions, various countries have conducted lengthy structured interviews with representative samples of thousands of their citizens. After asking hundreds of questions that probed for symptoms—“Has there ever been a period of two weeks or more when you felt like you wanted to die?”—the researchers have estimated the current, prior-year, and lifetime prevalence of various disorders.

How many people have, or have had, a psychological disorder? More than most of us suppose:

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What increases vulnerability to mental disorders? As TABLE 15.3 indicates, there is a wide range of risk and protective factors for mental disorders. But one predictor of mental disorder, poverty, crosses ethnic and gender lines. The incidence of serious psychological disorders has been doubly high among those below the poverty line (CDC, 1992). Like so many other correlations, the poverty-disorder association raises further questions: Does poverty cause disorders? Or do disorders cause poverty? It is both, though the answer varies with the disorder. Schizophrenia understandably leads to poverty. Yet the stresses and demoralization of poverty can also precipitate disorders, especially depression in women and substance abuse in men (Dohrenwend et al., 1992).

In one natural experiment on the poverty-pathology link, researchers tracked rates of behavior problems in North Carolina Native American children as economic development enabled a dramatic reduction in their community’s poverty rate. As the study began, children of poverty exhibited more deviant and aggressive behaviors. After four years, children whose families had moved above the poverty line exhibited a 40 percent decrease in the behavior problems. Those who continued in their previous positions below or above the poverty line exhibited no change (Costello et al., 2003).

At what times of life do disorders strike? Usually by early adulthood. “Over 75 percent of our sample with any disorder had experienced [their] first symptoms by age 24,” reported Lee Robins and Darrel Regier (1991, p. 331). Among the earliest to appear are the symptoms of antisocial personality disorder (median age 8) and of phobias (median age 10). Alcohol use disorder, obsessive-compulsive disorder, bipolar disorder, and schizophrenia symptoms appear at a median age near 20. Major depressive disorder often hits somewhat later, at a median age of 25.

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