Practicing psychologists face the question you encountered in this chapter’s opening: Who is, and is not, suffering from a psychological disorder? Many people feel sad or anxious. Many display behavior that’s “quirky.” Are they all suffering from a mental disorder?

In principle, the definition of “psychological disorders”—prolonged experiences of unusual psychological distress or poor psychological functioning—might seem to answer this question. But the definition leaves some significant questions unanswered: How prolonged? How unusual? What level of distress? Who judges that functioning is “poor”? Essentially, what “counts” as a psychological disorder?

That question has no simple answer. There are no sharp boundaries of “normality” and “abnormality” (McNally, 2011). Even highly unusual behavior may not signal a psychological disorder. To see this, let’s return to the three cases in the chapter opening: the anxious girl, babbling man, and political activist working to improve the welfare of hospitalized patients.

What did you think of the people described in the opening of this chapter? The girl seemed weird: constantly anxious and jumping into her father’s bed every night. The man seemed weirder: babbling incoherently and breaking into tears. The woman, though, seemed quite normal: working diligently to benefit people in need. Now let’s learn more about them.

The anxious teenager is Anne Frank, a Jewish girl living in Amsterdam when it was occupied by Nazi Germany during World War II. The Frank family needed to hide from the Nazis; if found, they would be arrested and likely killed. (Ultimately, this is exactly what happened; Anne Frank died in a Nazi concentration camp.) The Franks went into seclusion, hiding for years in a secret apartment hidden behind an office. Throughout this period, the family lived under constant threat of detection. No wonder she was so anxious! As her remarkable diary (Frank, 1952) shows, Anne Frank was not psychologically disordered. Her extreme anxiety was a perfectly normal reaction to an extremely disordered environment. The problem lay not in Anne Frank, but in the war-torn world in which she lived.

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The babbling man is a Pentecostal Christian (Higley, 2007). Pentecostals believe in the power of speaking in tongues, an ability that they trace back to a New Testament event in which the Holy Spirit gave the Disciples of Christ the power to speak in multiple languages (Macchia, 2006). To Pentecostals, the man’s speaking is perfectly normal—not crazy babbling, but a meaningful gift from God. His crying was normal, too: an expected emotional reaction to a profoundly moving religious event.

In both cases, Anne Frank and the Pentecostal, social context is critical. The behavior seems “weird.” You might think the person is “crazy.” But when you understand the context in which the person lives, you recognize that the behavior was a normal response to a situation with which you were unfamiliar.

What about the third case from the chapter opening, that of the political activist? She seemed normal. Yet, soon after her newspaper article appeared, government officials “forcibly detained [her] in a psychiatric clinic” (Gee, 2007). The government ran the hospitals she investigated, reportedly felt threatened by her article, and responded to the threat by labeling her “mentally ill.” Her case is not unique. Soon after, Russian government officials labeled a political protestor a “confused and paranoid lunatic” and, similarly, confined him to a mental hospital (Holdsworth, 2008). Doctors claimed that when he was hauled away to the insane asylum, he seemed “stressed … suspicious of others, argumentative and confused.”

“It’s hardly surprising I seemed like that,” the man later noted, “given the circumstances” (Holdsworth, 2008).

Such cases raise a critical question: Who judges that a person is mental ill? People in society differ enormously in power, that is, their degree of influence over social events and others’ lives. Typically, people with greater power judge the mental health or illness of people with less power (Foucault, 1965). Government officials can call protesters “mentally ill” and, in some countries, send them to asylums. Protestors can’t do the same to government officials.

Social and historical factors also affect judgments about mental illness. Behavior that seems normal in one time period can seem abnormal in another. For instance, modern professionals do not view any sexual orientation as disordered—yet a half-century ago, they did. In the 1950s and 1960s, psychiatrists classified homosexuality as a mental illness. Millions of people, merely as a result of their sexual orientation, were said to have a mental disorder. It was not until the early 1970s that psychiatrists changed their stance, voting to drop homosexuality from the list of mental illnesses (McNally, 2011).

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As these examples make clear, claims that a person is mentally ill must be made cautiously. Sometimes unusual behavior reflects unusual life circumstances. Behavior that appears abnormal in one social or historical setting may seem completely normal in another.

Despite these cautions, there is no question that millions of people the world over suffer from serious psychological disorders. A first step in helping them is to diagnose their disorders, that is, to classify them as being of a certain type. Just as physicians diagnose and classify physical problems as a first step in formulating medical treatment, mental health professionals diagnose and classify psychological problems as a first step in formulating therapy.

THE DIAGNOSTIC AND STATISTICAL MANUAL (DSM). The tool that psychologists use to classify disorders is a book: the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The DSM comprehensively lists and organizes the mental disorders identified by health care professionals. Each listing specifies behavioral and emotional responses a person must experience to be classified as having the given disorder. Here’s an example.

Imagine you’re a clinical psychologist whose client says that she’s extraordinarily anxious in social settings and that the anxiety is disrupting her life. If you open your copy of the DSM, you’ll find a relevant diagnostic category: Social Anxiety Disorder. Furthermore, you’ll find specific criteria for determining whether your client’s condition qualifies as a case of this disorder. The DSM criteria for Social Anxiety Disorder include the following (American Psychiatric Association, 2013):

You would then talk to the client; assess the frequency, severity, and duration of her anxiety; and use that information to determine whether she qualifies as having the disorder. The DSM includes guidelines of this sort for each of an enormous variety of disorders, including all the disorders mentioned in this chapter and the next.

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When diagnosing clients using the DSM, therapists recognize that any given client could have more than one disorder; psychological disorders often are comorbid. Comorbidity refers to the presence of symptoms of two or more disorders in any one individual (Kessler et al., 1994). Comorbidity can occur for a number of reasons. A biological factor (e.g., a genetic predisposition) could contribute to more than one disorder. One disorder may trigger another; for example, a person may become depressed about her persistent social anxiety. Alternatively, comorbidity can occur simply because disorders overlap; that is, some psychological experiences are, according to the DSM, symptoms of more than one disorder (Cramer et al., 2010).

THE DSM: NOBODY’S PERFECT. The DSM is the most influential book in the field of mental health. Its diagnostic categories provide therapists, researchers, drug companies, insurance companies, and government agencies with a common language for identifying and communicating about mental disorders. Many countries outside the United States use a different diagnostic system, the International Classification of Disorders, or ICD; however, the ICD’s content has been shaped significantly by the categorization system of the DSM (APA Monitor, 2009), thus extending the DSM’s influence. Given the widespread use of the DSM’s diagnostic categories, it is important to examine them critically. Three points stand out:

Feminist scholars raise another concern. Historically, the professionals who have formulated the DSM and used it to diagnose patients have been men. Some male clinicians may misunderstand women’s experiences. Others may hold gender biases that cause them to treat women negatively. These factors could cause male clinicians to mistakenly judge psychologically normal women as mentally ill (Chesler, 1997). Research shows that clinicians’ views of mental health can be gender-biased. When clinicians described (1) a normal male, (2) a normal female, or (3) a “healthy, mature, socially competent adult” (Broverman et al., 1970, p. 2), their descriptions of a healthy adult resembled their descriptions of a normal male and differed from their descriptions of a normal female. Clinicians’ beliefs about psychological normality, then, were biased against women.

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Finally, cultural and social group differences might cause disorders to be overdiagnosed. Consider cultural differences in reactions to tragedy. In some cultures, such as in urban societies in Cairo, Egypt (Rosenblatt, 1993), grief reactions are extremely prolonged. Just within the United States, grief after the loss of a loved one is, on average, more prolonged among African American college students than European American students (Laurie & Neimeyer, 2008). A mental health professional unaware of these cultural differences might classify as “abnormal” grief reactions that are typical, and perfectly normal, among individuals of the given culture.

Despite its limitations, the DSM is the “gold standard”—the book that holds the greatest authority when professionals classify the different types of mental disorders that require therapy. Now that you’ve learned about this diagnostic tool, let’s look at those therapies.