When psychologists say that the behavior and thinking of someone with a disorder are “abnormal,” what do they mean? How do psychologists decide when someone’s behavior or thinking has crossed over the line from normal to abnormal? First, it is important to realize that psychologists do not use the terms sane and insane in their decisions about the normality or abnormality of a person’s behavior and thinking. These are primarily legal terms that are used to assess responsibility in a criminal case. A person accused of a crime can plead “not guilty by reason of insanity.” The person acknowledges that he committed the crime, but argues that he is not responsible for it because of mental illness. There is a misperception that this defense is overused and used most frequently in heinous crimes. This misperception is likely due to the defense’s frequent occurrence on television and in movies and the high profile nature of some of the cases in which it is used. However, research (Borum & Fulero, 1999, for example) has found that it rarely occurs in real life (less than 1% of felony cases) and is even more rarely successful (about 15% to 20% of the time).

So how do psychologists go about deciding whether a person’s behavior and thinking are abnormal, that he is suffering from a mental disorder? They use four key criteria. It is important to realize that if a person’s behavior or thinking meets one or more of these criteria, this does not necessarily mean that the person is suffering from a disorder. This will become clear as we discuss each of the criteria, which can be posed as questions.

First, is the behavior or thinking atypical (statistically infrequent)? Of course, not all statistically infrequent behavior or thinking is abnormal. Consider skydiving. That’s an atypical behavior in our society, but it does not mean that a person who skydives has a disorder. Having hallucinations, however, is an atypical behavior that likely does reflect a disorder.

Second, is the behavior or thinking maladaptive? Maladaptive behavior or thinking prevents the person from successfully functioning and adapting to life’s demands. Thus, a disordered person is not able to function in daily life. For example, being afraid to leave one’s home is atypical and maladaptive behavior that would interfere with daily functioning.

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Third, is the person or are others distressed by the behavior or thinking? Perhaps a young man is attempting, but failing, to make a living doing odd street stunts. His behavior is atypical and maladaptive (he will soon be penniless), but if he is not disturbed and if his stunts are not disturbing others, then he is not considered disordered.

Fourth, is the behavior or thinking rational? For example, a fear of birds might be so strong that even thinking about them causes great anxiety. The person may realize that this atypical, maladaptive, disturbing fear is not rational but still be unable to suppress the anxiety, and he would therefore be considered disordered.

These criteria help to determine whether a person’s behavior and thinking may be “abnormal,” but how do we know exactly what disorder the person has? The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published in 2013 by the American Psychiatric Association (APA), is the most widely used diagnostic system for mental disorders, informally referred to as “the bible of mental disorders.” The intent of the DSM-5 is to serve both as a guide and an aid in the accurate diagnosis and treatment of mental disorders. It bases the classification of each disorder upon behavioral and psychological symptoms and defines the diagnostic guidelines for each disorder. The APA published the DSM-5 in print and also plans to publish it as a “living document” that can be updated as new research emerges. These incremental updates will be online and identified with decimals; i.e., DSM-5.1, DSM-5.2, and so on. Previous editions of the DSM were labeled using Roman numerals (e.g., DSM-IV), but the APA changed to Arabic numerals to facilitate the labeling of the versions of the living document.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) first appeared in 1952, was only 86 pages long, and described about 60 disorders (Cordón, 2005), whereas the DSM-5 is almost 1,000 pages long and describes approximately 400 disorders. Why has the number of disorders in the DSM increased so dramatically, causing the DSM to go from a thin, spiral-bound book to a weighty tome across its five editions? A major reason is that over the last 60 years or so, we have learned a lot about various disorders and how to differentiate them, leading to more and more disorder classifications over successive versions of the DSM. This ability to make better differentiations between disorders has also led to more diagnostic reliability. In fact, the framers of the DSM-5 followed procedures in the development of the manual that would lead to it having greater reliability than previous editions, which were at best only moderately reliable (Regier, Narrow, Kuhl, & Kupfer, 2011). For example, they conducted extensive reviews of research, consulted with numerous clinicians about diagnostic difficulties, and developed new categories and diagnostic criteria for categories that in the past have not been reliable. Thus, a major strength of the DSM-5 is that clinicians using it should be able to make more reliable classifications, which means that clinicians should more frequently agree on a particular diagnosis for a particular patient. The DSM-5 framers also conducted extensive research to ensure its validity. They were mainly concerned with the DSM-5’s predictive validity (discussed in Chapter 6), the ability to predict future symptoms and behavior of the people classified in the various disorder categories. Thus, as with its reliability, the DSM-5’s validity should be greater. Despite these efforts of the framers of DSM-5, some critics still have concerns about its reliability and validity (Frances, 2013; Freedman et al., 2013).

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In addition to these concerns about its reliability and validity, the DSM-5 has been heavily criticized on other dimensions, causing quite a kerfuffle among mental health professionals (e.g., Frances, 2013; Greenberg, 2013). A major criticism is that disorder classification in the DSM-5 is out of control, leading many aspects of normal behavior and ordinary life to fit the criteria for diagnosis of a mental disorder. For example, mental decline that goes a bit beyond normal aging may now be given the new DSM-5 diagnosis of “mild neurocognitive disorder” (giving “senior moments” clinical significance) and children who have recurrent temper outbursts may be given the new DSM-5 diagnosis of “disruptive mood dysregulation disorder.” The DSM-5 has also eliminated the bereavement exclusion for the diagnosis of major depressive disorder. Past versions of the DSM excluded people who had lost a loved one from receiving this diagnosis for the first two months of their bereavement. Thus, many people undergoing a normal grief reaction to the loss of a loved one may now receive a diagnosis of major depressive disorder. Allen Frances, who served as chairman of the DSM-IV task force, argues that the new diagnoses in the DSM-5 turn “everyday anxiety, eccentricity, forgetting, and bad eating habits into mental disorders” (Frances, 2013, pp. xv–xvi). According to Frances, such overdiagnosis will lead not only to a bonanza for the pharmaceutical industry but also to great costs (e.g., unnecessary and possibly harmful drug therapy) for all of the false-positive patients (people falsely diagnosed as having a mental disorder). Remember, we discussed the costs of false positives in the context of medical screening tests in Chapter 6. According to critics such as Frances, the DSM-5 with its excessively wide diagnostic net creates an analogous situation in psychiatric diagnosis.

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In spite of all of its possible flaws, the DSM-5 serves many useful purposes. It provides a common language and useable classification system for clinicians and clinical researchers to describe, discuss, evaluate, treat, and conduct research on mental disorders. It also serves an important practical purpose—health insurance companies require a DSM-5 disorder classification before paying for therapy. The DSM-5 should be thought of as a work in progress. As our knowledge about mental disorders evolves, so will the DSM. For now, however, the DSM-5 is the classification system in use; so, how does it work?

The DSM-5 has abandoned the multiaxial diagnostic system used in the DSM-IV and moved to a nonaxial assessment system in which a diagnosis requires a clinician to identify the disorder (or disorders) indicated by the person’s symptoms along with dimensional judgments on the severity of the person’s present symptoms and impairment. The DSM-5 provides specific diagnostic criteria, the key clinical features, and background information (such as prevalence rates) for approximately 400 disorders. Some disorders share certain symptoms, so the DSM-5 clusters these disorders into a major category. For example, several disorders that share anxiety as a symptom, such as phobic and panic disorders, are categorized as anxiety disorders. There are 20 major categories in the DSM-5. We will consider some disorders from six of these categories—Anxiety Disorders, Obsessive-Compulsive and Related Disorders, Depressive Disorders, Bipolar and Related Disorders, Schizophrenia Spectrum and Other Psychotic Disorders, and Personality Disorders. It is important to remember that the DSM-5 classification system applies to a pattern of symptoms and not to the person, so it refers, for example, to “a person with schizophrenia” and not a “schizophrenic.”

In classifying mental disorders, regardless of the system used, labels are attached to people, possibly leading to a disquieting effect—negatively biasing our perception of these people in terms of the labels. Our perception may no longer be objective. Think about the words that are often used to describe people with mental disorders—for example, “crazy,” “lunatic,” “deranged,” “insane,” or “mad.” These words have strong negative connotations. Similarly, diagnostic disorder labels may lead to negative perceptions and interpretations of a person’s behavior in terms of the label. The label may guide our perception. In sum, it seems tenable that labeling mental disorders may lead to a stigmatizing effect, but is there evidence that it actually does?

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There is a famous participant observational study that we briefly mentioned in Chapter 1 that deals with this possible perceptual-biasing effect of labeling (Rosenhan, 1973). Like Milgram’s obedience study and Zimbardo’s Stanford prison study discussed in Chapter 9, Rosenhan’s “On Being Sane in Insane Places” study is a contentious classic. Between 1969 and 1972, David L. Rosenhan, then a psychology professor at Swarthmore College, and seven others (a psychology graduate student, three psychologists, a pediatrician, a housewife, and a painter) went to several different hospitals in five states and tried to gain admission. They each faked a major symptom of schizophrenic disorders: auditory hallucinations (hearing voices). The voice in these cases was saying the words “empty,” “hollow,” and “thud.” Other than this sole symptom, the researchers acted normal and only lied about their true identities. First, they wanted to see whether they would be admitted given this singular symptom. Second, they wanted to see what would happen after they were admitted if they acted normal and said that they no longer heard the voices and that they were feeling normal again. According to Rosenhan, here’s what happened. In brief, all of the pseudopatients (fake patients) were admitted, one diagnosed with manic depression and all the others with schizophrenia. They were placed in psychiatric wards where they remained for periods ranging from 8 to 52 days. Rosenhan argued that their subsequent normal behavior was misinterpreted in terms of their diagnoses, illustrating the perceptual biasing of labels. For example, one person’s excessive note taking was interpreted as a function of his illness when, in fact, he was just trying to take notes to document the study. What kind of treatment did they receive? For the most part, they were given antipsychotic medications—an estimated 2,100 pills, though only two were taken. The pseudopatients just pretended to take the pills, pocketed them, and flushed them down the toilet. Ironically, some of the true patients realized that the pseudopatients were not true patients, but according to Rosenhan, the staff, guided by the diagnostic labels, did not. Even when the pseudopatients were released (an average stay of 19 days), they all had psychiatric labels on record upon discharge from the hospitals.

Rosenhan’s bold interpretations of his findings did not go unchallenged. As Ruscio (2004, 2015) points out, there was a flurry of responses starting with a series of letters published in Science in 1973 and continuing with a special section of the Journal of Abnormal Psychology in 1975 devoted to responses to Rosenhan’s contentions. Several detailed critiques, such as Millon (1975), Spitzer (1975, 1976), and Weiner (1975), also followed. According to Ruscio, these critics argued that Rosenhan used seriously flawed methodology, ignored relevant data, and reached unsound conclusions and that the greatest difficulty in accepting Rosenhan’s conclusions revolved around the discharge diagnoses for the pseudopatients. All but one were diagnosed with “schizophrenia in remission.” The other pseudopatient was diagnosed with “manic depression in remission.” Spitzer (1976) provided data that indicated that these classifications were rarely used in psychiatric hospitals at the time of Rosenhan’s study. Given this, Spitzer argues that this almost unaminous agreement across diagnosticians in very different settings and for different patients (1) contradicts Rosenhan’s assertion that diagnoses are unreliable and (2) indicates that the clinicians’ initial diagnoses of psychosis appear not to have significantly influenced their perceptions because their discharge diagnoses appear to have been based on their observation of the absence of the psychotic symptoms in the patients. Hence, according to his critics, Rosenhan’s own findings suggest that the clinical decisions about the pseudopatients relied more on their post-diagnostic behavior than their initial diagnoses. It is also worth noting that Spitzer asked Rosenhan for access to his data to verify his conclusions, but he never received them. In addition, there is a substantial body of labeling research that indicates that the claim that psychiatric labels per se cause harm by stigmatizing people is a myth (Lilienfeld, Lynn, Ruscio, & Beyerstein, 2010). This does not mean that a stigma of mental illness does not exist, it does. The stigma, however, is more a product of other factors such as the behaviors of those given psychiatric labels and not the labels themselves (Ruscio, 2004). Finally, it is important to realize that in spite of all the scathing criticism of it, Rosenhan’s study did draw attention to possible problems in the classification (diagnosis and labeling) of mental disorders. As already discussed, claims of such problems have persisted and followed the development of the DSM throughout its history and are especially prevalent for the DSM-5 (e.g., Frances, 2013, and Greenberg, 2013).

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There was, however, a second study reported in Rosenhan (1973) that is not often mentioned, but it is interesting because it provides a clear demonstration of perceptual set, which we discussed in Chapter 3. The staff of a well-known research and teaching hospital, which was aware of the results of Rosenhan’s initial study, claimed that similar errors would not be made at their hospital. In response, Rosenhan set up a test for them. He informed them that over a three-month period, one or more pseudopatients would attempt to gain admission to the hospital and that the staff should rate every incoming patient with respect to the likelihood that they were pseudopatients. What happened? Out of the 193 real patients who came to the hospital for admittance with symptoms of a disorder, 83 (43%) were either suspected or confidently judged to be a pseudopatient by at least one psychiatrist or staff member. However, Rosenhan had not sent any pseudopatients. All of the patients that the staff had judged or suspected to be pseudopatients were real patients. Rosenhan got the psychiatrists and staff members perceptually set to see pseudopatients, and so they did even when none came to the hospital. Remember from Chapter 3, seeing is believing, but it isn’t always believing correctly.

Our perception of people with disorders is further complicated by the misrepresentation of disordered people on television and in other media. They are often depicted as violent and dangerous to others when the vast majority of people with disorders are not a threat to anyone except maybe themselves (Applebaum, 2004; Lilienfeld et al., 2010; Teplin, 1985). In addition, because these media depictions are typically very dramatic, they tend to stick in our memories and hence may lead us to think that such incidents are more prevalent than they really are, because of our use of the availability heuristic that we discussed in Chapter 6. They are not prevalent. We also need to be aware that these incidents are not representative of the behavior of the vast majority of people with mental disorders. Most people with mental disorders are experiencing a troubled period in their lives and are just finding it difficult to adjust. We need labels in order to know how to treat people with these disorders and for health professionals to communicate with one another about such disorders as well as to conduct research on them, but there is much more to a person than a label. Remember to distinguish between the person and the label.

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Now that we have a general understanding of the diagnostic classification system and its strengths and weaknesses, we will consider some of the specific mental disorders (labels) that are identified in the DSM-5.

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