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Most of us would agree that a family member who is depressed and stays mostly in bed for three months has a psychological disorder. But what should we say about a grieving father who can’t resume his usual social activities three months after his child has died? Where do we draw the line between clinical depression and understandable grief? Between bizarre irrationality and zany creativity? Between abnormality and normality?

In their search for answers, theorists and clinicians ask:

LOQ LearningObjectiveQuestion

A psychological disorder is a syndrome (a collection of symptoms) marked by a “clinically significant disturbance in an individual’s cognitions, emotion regulation, or behavior” (American Psychiatric Association, 2013).

Such thoughts, emotions, or behaviors are dysfunctional or maladaptive—they interfere with normal day-to-day life. An intense fear of spiders may be abnormal, but if it doesn’t interfere with your life, it is not a disorder. Believing that your home must be thoroughly cleaned every weekend is not a disorder. But when 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 thoughts, emotions, or behaviors. Marc, Greta, and Stuart were all distressed by their behaviors or emotions.

The diagnosis of specific disorders has varied from culture to culture and even over time in the same culture. The American Psychiatric Association classified homosexuality as a disorder until 1973. By that point, most mental health workers no longer considered same-sex attraction as inherently dysfunctional or distressing, and it was removed from the list. On the other hand, high-energy children, who might have been viewed as normal youngsters running a bit wild in the 1970s, may today receive a diagnosis of attention-deficit/hyperactivity disorder (ADHD). (See Thinking Critically About: ADHD—Normal High Energy or Disordered Behavior?) Times change, and research and clinical practices change, too.

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The way we view a problem influences how we try to solve it. In earlier times, people often thought that strange behaviors were evidence of strange forces at work. Had you lived during the Middle Ages, you might have said, “The devil made him do it.” To drive out demons, “mad” people were sometimes caged or given “therapies” such as beatings, genital mutilations, removal of teeth or lengths of intestine, or transfusions of animal blood (Farina, 1982).

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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 sickness 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.

In some places, cruel treatments for mental illness—including chaining people to beds or locking them in spaces with wild animals—linger even today. In response, the World Health Organization has launched a plan to transform hospitals worldwide “into patient-friendly and humane places with minimum restraints” (WHO, 2014a).

The Medical Model

In the 1800s, a medical breakthrough prompted a new perspective on mental disorders. Researchers discovered that syphilis, a sexually transmitted infection, invades the brain and distorts the mind. This discovery triggered an excited search for physical causes of other mental disorders, and for treatments that would cure them. Hospitals replaced madhouses, and the medical model of mental disorders was born. This model is reflected in words we still use today. We speak of the mental health movement. A mental illness needs to be diagnosed on the basis of its symptoms. It needs to be cured through therapy, which may include treatment in a psychiatric hospital. Recent discoveries that abnormal brain structures and biochemistry contribute to some disorders have energized the medical perspective. A growing number of clinical psychologists now work in medical hospitals, where they collaborate with physicians to determine how the mind and body operate together.

The Biopsychosocial Approach

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 as we have seen throughout this text, our behaviors, our thoughts, and our feelings are formed by the interaction of our biology, our psychology, and our social-cultural environment. As individuals, we differ in the amount of stress we experience and in the ways we cope with stress. Cultures also differ in the sources of stress they produce and in the traditional ways of coping they provide. We are physically embodied and socially embedded.

The environment’s influence can be seen in syndromes that are specific to certain cultures (Beardsley, 1994; Castillo, 1997). In Malaysia, for example, a sudden outburst of violent behavior is called amok, as in the English phrase “run amok.” Traditionally, this aggression was believed to be the work of an evil spirit. Anxiety may also wear different faces in different cultures. In Latin American cultures, people may suffer from 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 disorder bulimia nervosa occurs mostly in food-abundant Western cultures. Increasingly, however, such North American disorders, along with fast-food chains and processed foods, have spread across the globe (Watters, 2010).

Two other disorders—depression and schizophrenia—occur worldwide. From Asia to Africa and across the Americas, people with schizophrenia often act irrationally and speak in disorganized ways. Such disorders reflect genes and physiology, as well as psychological dynamics and cultural circumstances.

The biopsychosocial approach reminds us that mind and body work as one. Negative emotions contribute to physical illness, and abnormal physical processes contribute to negative emotions. As research on epigenetics shows, our DNA and our environment interact. In one environment, a gene will be expressed, but in another, it may lie dormant. For some, that will be the difference between developing a disorder or not developing it.

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In biology, classification creates order and helps us communicate. To say that an animal is a “mammal” tells us a great deal—that it is warm-blooded, has hair or fur, and produces milk to feed its young. In psychiatry and psychology, classification also tells us a great deal. To classify a person’s disorder as “schizophrenia” implies that the person speaks in a disorganized way, has bizarre beliefs, shows either little emotion or inappropriate emotion, or is socially withdrawn. “Schizophrenia” is a quick way of describing a complex set of behaviors.

But diagnostic classification does more than give us a thumbnail sketch of a person’s disordered behavior, thoughts, or feelings. In psychiatry and psychology, classification also attempts to predict the disorder’s future course and to suggest treatment. And it prompts research into causes. 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).¹ Physicians and mental health workers use the detailed listings 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 the criteria in TABLE 13.2.

Source: American Psychiatric Association, 2013.

In the new DSM-5, some diagnostic labels have 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.

In real-world tests (field trials) assessing the reliability of the new DSM-5 categories, some diagnoses have fared well and others have fared poorly (Freedman et al., 2013). Clinician agreement on adult posttraumatic stress disorder and childhood autism spectrum disorder, for example, was 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.) But for antisocial personality disorder and generalized anxiety disorder, agreement was closer to 20 percent.

Critics have long faulted the DSM manual 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 bereavement grief into a depressive disorder and childish fidgeting into ADHD (Frances, 2013, 2014). Others respond that relentless grief-related depression and enduring hyperactivity are genuine disorders (Kendler, 2011; Kupfer, 2012).

Other critics register a more basic complaint. At best, they say, these labels represent subjective, personal opinions. At worst, these labels represent personal opinions disguised as scientific judgments. Once we label a person, we view that person differently (Bathje & Pryor, 2011; Farina, 1982; Sadler et al., 2012b). Labels can change reality by putting us on alert for evidence that confirms our view. If we hear that a new co-worker is a difficult person, we may treat her suspiciously. She may in turn respond to us as a difficult person would. Teachers who were told certain students were “gifted” then acted in ways that brought out the creative behaviors they expected (Snyder, 1984). Labels can be self-fulfilling.

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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 of these healthy people were misdiagnosed with disorders.

Should we be surprised? Surely not. As one psychiatrist noted, if someone swallows blood, goes to an emergency room, and spits it up, we wouldn’t blame the doctor for diagnosing a bleeding ulcer. But what followed the diagnosis in the Rosenhan study 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 routine note-taking behavior was misinterpreted as a symptom.

Labels matter. When people in another experiment watched videotaped interviews, those told that they were watching job applicants perceived the people as normal (Langer & Abelson, 1974; Langer & Imber, 1980). Others, who were told they were watching cancer or psychiatric patients, perceived them as “different from most people.” One therapist described the person being interviewed 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.”

The power of labels is just as real 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. That reaction 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.

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

In the rest of this chapter, we will discuss some of the major disorders classified in the DSM-5. In Chapter 14, we will consider their treatment.