Definition of a Psychological Disorder

Perhaps the simplest approach to conceptualizing psychological disorders is to label behaviors, thoughts, and inner experiences that are atypical, distressful, dysfunctional, and sometimes even dangerous, as signs of a disorder. For example, if you ask a classmate for a date and you are rejected, you probably would feel a little dejected. Such feelings would be normal. If you felt extremely depressed—so much so that you lost interest in activities, had difficulty eating or sleeping, felt utterly worthless, and contemplated suicide—your feelings would be atypical, would deviate from the norm, and could signify the presence of a psychological disorder. Just because something is atypical, however, does not necessarily mean it is disordered.

For example, only about 4% of people in the United States have red hair, so red hair is considered an atypical characteristic (Figure 1), but it is not considered disordered, it’s just unusual. And it is less unusual in Scotland, where approximately 13% of the population has red hair (“DNA Project Aims,” 2012). As you will learn, some disorders, although not exactly typical, are far from atypical, and the rates in which they appear in the population are surprisingly high.

Figure 1. Red hair is considered unusual, but not abnormal. (a) Isla Fischer, (b) Prince Harry, and (c) Marcia Cross are three natural redheads. (credit a: modification of work by Richard Goldschmidt; credit b: modification of work by Glyn Lowe; credit c: modification of work by Kirk Weaver)

If we can agree that merely being atypical is an insufficient criterion for a having a psychological disorder, is it reasonable to consider behavior or inner experiences that differ from widely expected cultural values or expectations as disordered? Using this criterion, a woman who walks around a subway platform wearing a heavy winter coat in July while screaming obscenities at strangers may be considered as exhibiting symptoms of a psychological disorder. Her actions and clothes violate socially accepted rules governing appropriate dress and behavior; these characteristics are atypical.

Cultural Expectations

Violating cultural expectations is not, in and of itself, a satisfactory means of identifying the presence of a psychological disorder. Since behavior varies from one culture to another, what may be expected and considered appropriate in one culture may not be viewed as such in other cultures. For example, returning a stranger’s smile is expected in the United States because a pervasive social norm dictates that we reciprocate friendly gestures. A person who refuses to acknowledge such gestures might be considered socially awkward—perhaps even disordered—for violating this expectation. However, such expectations are not universally shared. Cultural expectations in Japan involve showing reserve, restraint, and a concern for maintaining privacy around strangers. Japanese people are generally unresponsive to smiles from strangers (Patterson et al., 2007). Eye contact provides another example. In the United States and Europe, eye contact with others typically signifies honesty and attention. However, most Latin-American, Asian, and African cultures interpret direct eye contact as rude, confrontational, and aggressive (Pazain, 2010). Thus, someone who makes eye contact with you could be considered appropriate and respectful or brazen and offensive, depending on your culture (Figure 2).

Figure 2. Eye contact is one of many social gestures that vary from culture to culture. (credit: Joi Ito)

Hallucinations (seeing or hearing things that are not physically present) in Western societies is a violation of cultural expectations, and a person who reports such inner experiences is readily labeled as psychologically disordered. In other cultures, visions that, for example, pertain to future events may be regarded as normal experiences that are positively valued (Bourguignon, 1970). Finally, it is important to recognize that cultural norms change over time: what might be considered typical in a society at one time may no longer be viewed this way later, similar to how fashion trends from one era may elicit quizzical looks decades later—imagine how a headband, legwarmers, and the big hair of the 1980s would go over on your campus today.

The American Psychiatric Association (APA) Definition

Many of the features of the harmful dysfunction model are incorporated in a formal definition of psychological disorder developed by the . According to the American Psychiatric Association (APA) (2013), a psychological disorder is a condition that is said to consist of the following:

• There are significant disturbances in thoughts, feelings, and behaviors. A person must experience inner states (e.g., thoughts and/or feelings) and exhibit behaviors that are clearly disturbed—that is, unusual, but in a negative, self-defeating way. Often, such disturbances are troubling to those around the individual who experiences them. For example, an individual who is uncontrollably preoccupied by thoughts of germs spends hours each day bathing, has inner experiences, and displays behaviors that most would consider atypical and negative (disturbed) and that would likely be troubling to family members.
• The disturbances reflect some kind of biological, psychological, or developmental dysfunction. Disturbed patterns of inner experiences and behaviors should reflect some flaw (dysfunction) in the internal biological, psychological, and developmental mechanisms that lead to normal, healthy psychological functioning. For example, the hallucinations observed in schizophrenia could be a sign of brain abnormalities.
• The disturbances lead to significant distress or disability in one’s life. A person’s inner experiences and behaviors are considered to reflect a psychological disorder if they cause the person considerable distress, or greatly impair his ability to function as a normal individual (often referred to as functional impairment, or occupational and social impairment). As an illustration, a person’s fear of social situations might be so distressing that it causes the person to avoid all social situations (e.g., preventing that person from being able to attend class or apply for a job).
• The disturbances do not reflect expected or culturally approved responses to certain events. Disturbances in thoughts, feelings, and behaviors must be socially unacceptable responses to certain events that often happen in life. For example, it is perfectly natural (and expected) that a person would experience great sadness and might wish to be left alone following the death of a close family member. Because such reactions are in some ways culturally expected, the individual would not be assumed to signify a mental disorder.

Some believe that there is no essential criterion or set of criteria that can definitively distinguish all cases of disorder from nondisorder (Lilienfeld & Marino, 1999). In truth, no single approach to defining a psychological disorder is adequate by itself, nor is there universal agreement on where the boundary is between disordered and not disordered. From time to time we all experience anxiety, unwanted thoughts, and moments of sadness; our behavior at other times may not make much sense to ourselves or to others. These inner experiences and behaviors can vary in their intensity, but are only considered disordered when they are highly disturbing to us and/or others, suggest a dysfunction in normal mental functioning, and are associated with significant distress or disability in social or occupational activities.

The Diagnostic And Statistical Manual of Mental Disorders (DSM-5)

Although a number of classification systems have been developed over time, the one that is used by most mental health professionals in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (2013). (Note that the American Psychiatric Association differs from the American Psychological Association; both are abbreviated APA.) The first edition of the DSM, published in 1952, classified psychological disorders according to a format developed by the U.S. Army during World War II (Clegg, 2012). In the years since, the DSM has undergone numerous revisions and editions. The most recent edition, published in 2013, is the DSM-5 (APA, 2013). The DSM-5 includes many categories of disorders (e.g., anxiety disorders, depressive disorders, and dissociative disorders). Each disorder is described in detail, including an overview of the disorder (diagnostic features), specific symptoms required for diagnosis (diagnostic criteria), prevalence information (what percent of the population is thought to be afflicted with the disorder), and risk factors associated with the disorder. Figure 3 shows lifetime prevalence rates—the percentage of people in a population who develop a disorder in their lifetime—of various psychological disorders among U.S. adults. These data were based on a national sample of 9,282 U.S. residents (National Comorbidity Survey, 2007).

Figure 3. The graph shows the breakdown of psychological disorders, comparing the percentage prevalence among adult males and adult females in the United States. Because the data is from 2007, the categories shown here are from the DSM-IV, which has been supplanted by the DSM-5. Most categories remain the same; however, alcohol abuse now falls under a broader Alcohol Use Disorder category.

The DSM-5 also provides information about comorbidity; the co-occurrence of two disorders. For example, the DSM-5 mentions that 41% of people with obsessive-compulsive disorder (OCD) also meet the diagnostic criteria for major depressive disorder (Figure 4). Drug use is highly comorbid with other mental illnesses; 6 out of 10 people who have a substance use disorder also suffer from another form of mental illness (National Institute on Drug Abuse [NIDA], 2007).

Figure 4. Obsessive-compulsive disorder and major depressive disorder frequently occur in the same person.

The DSM has changed considerably in the half-century since it was originally published. The first two editions of the DSM, for example, listed homosexuality as a disorder; however, in 1973, the APA voted to remove it from the manual (Silverstein, 2009). Additionally, beginning with the DSM-III in 1980, mental disorders have been described in much greater detail, and the number of diagnosable conditions has grown steadily, as has the size of the manual itself. DSM-I included 106 diagnoses and was 130 total pages, whereas DSM-III included more than 2 times as many diagnoses (265) and was nearly seven times its size (886 total pages) (Mayes & Horowitz, 2005). Although DSM-5 is longer than DSM-IV, the volume includes only 237 disorders, a decrease from the 297 disorders that were listed in DSM-IV. The latest edition, DSM-5, includes revisions in the organization and naming of categories and in the diagnostic criteria for various disorders (Regier, Kuhl, & Kupfer, 2012), while emphasizing careful consideration of the importance of gender and cultural difference in the expression of various symptoms (Fisher, 2010).

Some believe that establishing new diagnoses might overpathologize the human condition by turning common human problems into mental illnesses (The Associated Press, 2013). Indeed, the finding that nearly half of all Americans will meet the criteria for a DSM disorder at some point in their life (Kessler et al., 2005) likely fuels much of this skepticism. The DSM-5 is also criticized on the grounds that its diagnostic criteria have been loosened, thereby threatening to “turn our current diagnostic inflation into diagnostic hyperinflation” (Frances, 2012, para. 22). For example, DSM-IV specified that the symptoms of major depressive disorder must not be attributable to normal bereavement (loss of a loved one). The DSM-5, however, has removed this bereavement exclusion, essentially meaning that grief and sadness after a loved one’s death can constitute major depressive disorder.

The International Classification of Diseases

A second classification system, the International Classification of Diseases (ICD), is also widely recognized. Published by the World Health Organization (WHO), the ICD was developed in Europe shortly after World War II and, like the DSM, has been revised several times. The categories of psychological disorders in both the DSM and ICD are similar, as are the criteria for specific disorders; however, some differences exist. Although the ICD is used for clinical purposes, this tool is also used to examine the general health of populations and to monitor the prevalence of diseases and other health problems internationally (WHO, 2013). The ICD is in its 10th edition (ICD-10); however, efforts are now underway to develop a new edition (ICD-11) that, in conjunction with the changes in DSM-5, will help harmonize the two classification systems as much as possible (APA, 2013).

A study that compared the use of the two classification systems found that worldwide the ICD is more frequently used for clinical diagnosis, whereas the DSM is more valued for research (Mezzich, 2002). Most research findings concerning the etiology and treatment of psychological disorders are based on criteria set forth in the DSM (Oltmanns & Castonguay, 2013). The DSM also includes more explicit disorder criteria, along with an extensive and helpful explanatory text (Regier et al., 2012). The DSM is the classification system of choice among U.S. mental health professionals, and this module is based on the DSM paradigm.

The Compassionate View of Psychological Disorders

As these disorders are outlined, please bear two things in mind. First, remember that psychological disorders represent extremes of inner experience and behavior. If, while reading about these disorders, you feel that these descriptions begin to personally characterize you, do not worry—this moment of enlightenment probably means nothing more than you are normal. Each of us experiences episodes of sadness, anxiety, and preoccupation with certain thoughts—times when we do not quite feel ourselves. These episodes should not be considered problematic unless the accompanying thoughts and behaviors become extreme and have a disruptive effect on one’s life. Second, understand that people with psychological disorders are far more than just embodiments of their disorders. We do not use terms such as schizophrenics, depressives, or phobics because they are labels that objectify people who suffer from these conditions, thus promoting biased and disparaging assumptions about them. It is important to remember that a psychological disorder is not what a person is; it is something that a person has—through no fault of his or her own. As is the case with cancer or diabetes, those with psychological disorders suffer debilitating, often painful conditions that are not of their own choosing. These individuals deserve to be viewed and treated with compassion, understanding, and dignity.

Supernatural Perspectives of Psychological Disorders

For centuries, psychological disorders were viewed from a supernatural perspective: attributed to a force beyond scientific understanding. Those afflicted were thought to be practitioners of black magic or possessed by spirits (Figure 5) (Maher & Maher, 1985). For example, convents throughout Europe in the 16th and 17th centuries reported hundreds of nuns falling into a state of frenzy in which the afflicted foamed at the mouth, screamed and convulsed, sexually propositioned priests, and confessed to having carnal relations with devils or Christ. Although, today, these cases would suggest serious mental illness; at the time, these events were routinely explained as possession by devilish forces (Waller, 2009a). Similarly, grievous fits by young girls are believed to have precipitated the witch panic in New England late in the 17th century (Demos, 1983). Such beliefs in supernatural causes of mental illness are still held in some societies today; for example, beliefs that supernatural forces cause mental illness are common in some cultures in modern-day Nigeria (Aghukwa, 2012).

Dig Deeper: Dancing Mania

Figure 5. In The Extraction of the Stone of Madness, a 15th century painting by Hieronymus Bosch, a practitioner is using a tool to extract an object (the supposed “stone of madness”) from the head of an afflicted person.

Between the 11th and 17th centuries, a curious epidemic swept across Western Europe. Groups of people would suddenly begin to dance with wild abandon. This compulsion to dance—referred to as dancing mania—sometimes gripped thousands of people at a time (Figure 6). Historical accounts indicate that those afflicted would sometimes dance with bruised and bloody feet for days or weeks, screaming of terrible visions and begging priests and monks to save their souls (Waller, 2009b). What caused dancing mania is not known, but several explanations have been proposed, including spider venom and ergot poisoning (“Dancing Mania,” 2011).

Figure 6. Although the cause of dancing mania, depicted in this painting, was unclear, the behavior was attributed to supernatural forces.

Historian John Waller (2009a, 2009b) has provided a comprehensive and convincing explanation of dancing mania that suggests the phenomenon was attributable to a combination of three factors: psychological distress, social contagion, and belief in supernatural forces. Waller argued that various disasters of the time (such as famine, plagues, and floods) produced high levels of psychological distress that could increase the likelihood of succumbing to an involuntary trance state. Waller indicated that anthropological studies and accounts of possession rituals show that people are more likely to enter a trance state if they expect it to happen, and that entranced individuals behave in a ritualistic manner, their thoughts and behavior shaped by the spiritual beliefs of their culture. Thus, during periods of extreme physical and mental distress, all it took were a few people—believing themselves to have been afflicted with a dancing curse—to slip into a spontaneous trance and then act out the part of one who is cursed by dancing for days on end.

Biological Perspectives of Psychological Disorders

Figure 7. A person’s risk of developing schizophrenia increases if a relative has schizophrenia. The closer the genetic relationship, the higher the risk.

Findings such as these have led many of today’s researchers to search for specific genes and genetic mutations that contribute to mental disorders. Also, sophisticated neural imaging technology in recent decades has revealed how abnormalities in brain structure and function might be directly involved in many disorders, and advances in our understanding of neurotransmitters and hormones have yielded insights into their possible connections. The biological perspective is currently thriving in the study of psychological disorders.

The Diathesis-Stress Model of Psychological Disorders

Despite advances in understanding the biological basis of psychological disorders, the psychosocial perspective is still very important. This perspective emphasizes the importance of learning, stress, faulty and self-defeating thinking patterns, and environmental factors. Perhaps the best way to think about psychological disorders, then, is to view them as originating from a combination of biological and psychological processes. Many develop not from a single cause, but from a delicate fusion between partly biological and partly psychosocial factors.

The diathesis-stress model (Zuckerman, 1999) integrates biological and psychosocial factors to predict the likelihood of a disorder. This diathesis-stress model suggests that people with an underlying predisposition for a disorder (i.e., a diathesis) are more likely than others to develop a disorder when faced with adverse environmental or psychological events (i.e., stress), such as childhood maltreatment, negative life events, trauma, and so on. A diathesis is not always a biological vulnerability to an illness; some diatheses may be psychological (e.g., a tendency to think about life events in a pessimistic, self-defeating way).

The key assumption of the diathesis-stress model is that both factors, diathesis and stress, are necessary in the development of a disorder. Different models explore the relationship between the two factors: the level of stress needed to produce the disorder is inversely proportional to the level of diathesis.