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DSM-V – Mental Illness vs Normal Behavior

by Steven Novella, Feb 04 2013

The coming fifth edition of the Diagnostic and Statistical Manual (DSM-V) has rekindled debate over the legitimacy of the very concept of “mental illness.” A recent article by Peter Kinderman, a professor of clinical psychology, takes a strong position against the “mental illness” approach, writing:

But diagnosis and the language of biological illness obscure the causal role of factors such as abuse, poverty and social deprivation. The result is often further stigma, discrimination and social exclusion.

This is a healthy debate to have, as the concepts involved are tricky and there are real implications for societal perception, insurance coverage, and treatment strategies. I do not, however, share Dr. Kinderman’s position, which in my experience is fairly typical for a clinical psychologist. He is essentially saying that his profession’s approach to the question of mental illness is superior to the psychiatric profession. While the debate is legitimate and important, I can’t help feeling that there is a major component of a turf battle here also.

The question is essentially how we should think about symptoms of mood, thought, and behavior. At one extreme we night consider all aspects of human mentality as being part of the normal spectrum, with differences being just that – differences. Those who follow the position of Thomas Szasz consider labels on mental differences to be largely politically and culturally motivated forms of repression.

At the other end is the obsessive partitioning of every nuance of human behavior into one or another abnormal category – the medicalization of all human problems. This may be connected to an overly reductionist approach to psychology, seeing all behavior in terms of neurotransmitters and brain function and giving insufficient attention to higher order situational and cultural factors.

In my opinion the best approach is something in the middle. There is a common pearl of wisdom in clinical science that, before you can recognize the abnormal you have to recognize the full spectrum of what is normal. So – on the one hand we need to recognize the full spectrum of human nature, accept less common and atypical forms of human mood, thought, and behavior, and also recognize the relative roles of biology, situation, and culture (and their interactions) in forming a person’s mental state.

On the other hand, the brain is an organ, it is biology, and it can malfunction biologically just like any other organ. Further, even a biologically healthy brain can be pushed beyond tolerance limits resulting in an unhealthy mental state. We can reasonably define “unhealthy” in this context (probably a more appropriate word than “abnormal”) as follows – a mental state that is significantly outside the range of most people, may represent the relative lack of a cognitive ability that most people have, and results in definable harm. That last bit is critical – it has to be harmful.

It is true that there is an unavoidable amount of subjectivity in the above definition. What is considered harmful? The trap here is that a culture can determine a behavior harmful simply because it does not adhere to the culture’s norms. For example, homosexuality might be considered harmful because it is not accepted by society. It is now generally recognized, however, that such a circular definition of harm is not adequate.

Most of the time harm is determined by the individual – they present for help because they perceive their current mental condition to be harmful. Alternatively, those close to the person may consider their mental state harmful. This is a trickier situation, and psychologists recognize that often the “identified patient” is not the problem so much as the dynamic within a family or other social group. However, some forms of mental illness, like a delusional disorder, may not (by definition) be apparent to the person themselves but obvious to those around them.

It’s easy to get bogged down in semantics in this area, and I am not saying that language is not important to how we think about such things, but semantics aside I think there is general agreement (Szaszians and Scientologists notwithstanding) that many people have mental symptoms that they find unpleasant or functionally impairing with which they would like help.

The important clinical questions are – how should we identify and categorize those with mental complaints, how should we approach research and diagnosis into underlying causes, and which therapeutic interventions are most effective? In my opinion these are independent variables. Beliefs about one question may bias our thinking regarding another – but they don’t have to.

Kinderman seems to think, however, that they are inextricable tied together, leading him to attack what I feel are several straw men. He writes:

Psychiatric diagnoses are not only scientifically invalid, they are harmful too. The language of illness implies that the roots of such emotional distress lie in abnormalities in our brain and biology, usually known as “chemical imbalances”.

I disagree. With respect to mental illness “the language of illness” is much more complex and nuanced than Kinderman is indicating. Many of the diagnoses in the DSM are “disorders” or otherwise contain no implication at all that the underlying cause is a chemical imbalance.

Kinderman is saying that a mental illness diagnosis leads to the assumption of a biological cause and therefore to a medical (pharmacological) treatment. Rather, he argues:

It is relatively straightforward to generate a simple list of problems that can be reliably and validly defined. There is no reason to assume that these phenomena cluster into diagnostic categories or are the consequences of underlying illnesses.

We can then use medical and psychological science to understand how problems might have originated, and recommend therapeutic solutions.

But this is already the accepted approach to mental illness – except the bit about categories, but more on that in a moment. The DSM essentially is the practice of generating a list of problems that can be reliably and validly defined. Sorting such lists into categories does assume a certain amount of clustering of symptoms, and it is really that clustering that Kinderman is opposing. I do not think he has made his case, however.

In reality psychiatrists understand that the categories, or clusters of symptoms, with labels in the DSM are partly labels of convenience – for research, clinical reporting, and insurance coverage. I have personally never spoken to a psychiatrist who thinks that the categories in the DSM are iron clad, or that patients really sort cleanly into these diagnoses. They are at best a first approximation, a starting point, which then need to be individualized to the patient.

Further, I think there is some legitimacy to the clustering. There are syndromes, clusters of symptoms that do tend to occur together. Then there is a great deal of individual variation around the common themes represented by these clusters (which are DSM diagnostic categories).

Most importantly, the question as to which therapeutic approach is most effective can be completely disconnected to how we approach labeling symptoms. Here we should follow the clinical evidence wherever it leads. What I see in the literature, and with practitioners that I have interacted with, is that most take a blended approach – using medication and therapy in some combination as necessary. Some patients may need just therapy, while others require medication. As with all areas of medicine – practitioners can argue endlessly about the optimal balance based upon existing evidence, and different specialties will have their differing biases.

Let us take one specific example to see how this all works in practice. Kinderman writes about the DSM-V:

A wide range of unfortunate human behaviours, the subject of many new year’s resolutions, will become mental illnesses – excessive eating will become “binge eating disorder”, and the category of “behavioural addictions” will widen significantly to include such “disorders” as “internet addiction” and “sex addiction”.

Kinderman thinks that “binge eating disorder” is really just excessive eating, an “unfortunate behavior” that should not be labeled as mental illness. Here are the proposed diagnostic criteria:

Both of the following must be present to classify as Binge Eating Disorder.[5]

  • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
  • Feels loss of control over eating during binge. In other words, they feel that they cannot stop eating and they cannot control what they are eating and how much they are eating.

Also, an individual must have 3 or more of the following symptoms:

  • Eats an unusually large amount of food at one time, far more than an average person would eat .
  • Eats much more quickly during binge episodes than during normal eating episodes.
  • Eats until physically uncomfortable and nauseated due to the amount of food consumed.
  • Eats when depressed or bored.
  • Eats large amounts of food even when not really hungry.
  • Often eats alone during periods of normal eating, owing to feelings of embarrassment about food.
  • Feels disgusted, depressed, or guilty after binge eating.
  • The binge eating occurs, on average, at least twice a week for 6 months.
  • The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course Bulimia Nervosa or Anorexia Nervosa.

The criteria are specifically designed to exclude people who simply overeat or who are overweight. You have to eat an “unusually large amount of food” over a short period of time, eating unusually fast, and usually to the point of physical discomfort. There is a real attempt here to identify those who are significantly outside the range of healthy human behavior, to the point that there might be an underlying problem.

And here is the conventional thinking about the underling cause:

“A correlation between dietary restraint and the occurrence of binge eating has been convincingly shown in several investigations.”

Research is trying to tease apart whether binge eating is due to an underlying problem with eating regulation, or if it is produced by dietary restraint (severe forms of dieting). There is no assumption of biology here, nor is there an assumption that the best treatment approach is medical. Kinderman’s examples do not support his premise.


The diagnosis of mental illness remains complex and challenging. I am not arguing that any profession (psychiatry, psychology) has it exactly right, but I do think that the mental professions generally take a thoughtful approach to the question of what mental illness is and how it should be approached.

I disagree with attempts to restrict the debate on mental illness using semantics (usually taking the form of objecting to the term “mental illness”). I also think there are many common straw men brought up in this debate. I was disappointed in Kinderman’s review of the issues, and found that he was largely tilting at these common straw men.

But when you get past the turf-war posturing and semantic arguments, I find there is actually widespread agreement on the important issues. Human mood, thought, and behavior are complex, there is a wide range of variation in what constitutes human mental states, and any thoughtful approach must consider circumstances, environment, culture, and biological considerations, including their complex interactions. Further, therapeutic approaches should consider the full range of potential interventions and should ultimately be evidence-based.

13 Responses to “DSM-V – Mental Illness vs Normal Behavior”

  1. d brown says:

    “abuse, poverty and social deprivation” have been shown too have no effect in many cases. And in many its there but which came first.

  2. Wscott says:

    Interesting article. It does sound like Kinderman is more worried about stigmatization than actual treatment. But…

    “Kinderman is saying that a mental illness diagnosis leads to the assumption of a biological cause and therefore to a medical (pharmacological) treatment.”

    I can’t speak for the profession as a whole, but in my limited experience watching friends and family who’ve struggled with mental illness, I would have to agree that there are a LOT of psychiatrists out there whose solution to every problem is “Here, take these pills; if they don’t work, we’ll try different pills.”

    One friend describes taking his son to countless sessions with multiple psychiatrists, all of which boiled down to “Let’s try adjusting your meds…” After months of watching his son be subjected to an increasing number of pharmaceuticals with severe side effects & questionable interactions, my friend suggested that maybe they should try taking the kid off the drugs all together to establish some kind of baseline. This seemingly simple – and dare I say scientific – suggestion was greeted not so much with hostility as with blank surprise, as if the idea had never even occurred to them.

    Incidentally, the son is med-free now and doing much better. Yes, I realize that’s just one anecdote. I’m not saying drugs are bad; for the kid in the next chair, they might have been the perfect solution. But they weren’t the best solution for *him* and none of the psychiatrists he visited seemed to even consider that there might be other tools out there. I have other friends who’ve experienced similar problems.

    So I agree with you that a balanced, thoughtful approach is probably best. But I’m not sure that attitude is as common in practice as you think.

  3. d brown says:

    The insurance will only pay for pills. And they are handed out like mad. But mostly they seem, to work when the old non pills way did not. The VA will not even talk about anything but finding the right mix.

  4. harey says:

    Thanks Dr. Novella for this very thoughtful and balanced article.

    I am personally ‘mentally ill’, I am bipolar, also known as manic-depressive and I very much disagree that seeing such disorders as illnesses by itself leads to stigma. For me, my illness means that I have periods of very depressed mood and low energy, followed by such of extremely high energy and generally good mood. Of course, all people experience mood swings to some extent, for me however, they are very extreme that they interfere with my daily life and clearly cannot be explained by external factors. Again, this comes down to the point the article made about harm, as long as a person doesn’t suffer, it’s not mental illness.

    I personally take medication because it helps me control my life and I am what would be considered ‘high-functioning': I have a job, a good education, a normal life, and most people will not notice I am mentally ill. Of course, diagnosis for mental illnesses is somewhat vague and never clear cut, but at least for me, it allows me to better understand what is going on with me and take control.

    I agree with the previous commenter that psychiatrists often (though not always) can be very paternalistic and the general practice in my experience is far from the ideal case described by Dr. Novella. Psychiatrists often make a diagnosis and prescribe medication without discussing much with the patient, especially when the patient is adolescent. This is especially harmful because different medications will treat mental illness in different ways, i.e., depending on which symptoms are most harmful to the patient, quite different medication should be prescribed. This is a decision the patient and not the doctor should make! However, I have had rather good experiences when asking very direct questions to doctors, I always did get reasonable and helpful answers. But it did take a lot of digging and being very specific with questions about medications, something most younger patient might feel much less comfortable about.

    However, nothing beats clinical psychologists when it comes to being paternalistic and condescending to mentally ill patient, I have had psychologists tell me to think happy thoughts when I was in a state where I had quite clearly lost control of my mental state and asking for help. That was a psychologists that told me she doesn’t believe in mental illness and thinks that it only stigmatises. I don’t think this is fair and respectful treatment. She basically told me to go away since I was not open to what she had to offer (i.e. positive thinking!).

    Generally, I think there needs to be more respect for the mentally ill, most of us can and should make decisions about treatments and both psychiatrists and psychologists should be willing to discuss the full range of options and let the patient make a decision. A good way to reduce stigma is to get the population informed about mental illness and certainly not denying its existence. The best way to reduce stigma possibly would be for many of the high-functioning mentally ill to ‘come-out’ and show that mental illness can be managed, though I guess we all fear the stigma.

    • Wscott says:

      Your experiences match with that of a friend who’s bi-polar.
      The more I think about it, the more it seems to me the problem is less that meds are right/wrong and therapy is wrong/right (collectively or for a particular indivuidual), but that we have segregated those two approaches into separate professions that don’t seem to coordinate with one another.

    • Josie says:

      I just want to contribute to this debate – I am a trainee clinical psychologist in the UK – and I’m sorry about the bad experiences people sometimes have with various professionals, especially clin psychs.
      Kinderman is a very well-respected psychologist in the UK,and was chair of the british psychological society, and I think the article reviewed here he possibly wrote for media-purposes as it is a very simplified version of his argument.
      In psychology we do believe that people do experience extreme levels of psychological distress, and that this cannot simply be alleviated by ‘positive thinking’. The point that Kinderman makes about diagnostics is that the established model (from DSM-IV) of segregating symptoms into discrete categories to create diagnositc labels (including for example, the various schizophrenias), is out-dated because there are no common symptoms that underlie the experience of every person with that diagnosis (i.e. you can have two people with the same label and completely different experiences/symptoms) – and thereby, while there are changes on the chemical level in the brain (yes there are in everyone, they are occurring all the time and not necessarily causing distress), it is not that helpful from a clinical perspective to have a diagnosis(i.e. to provide the best support for the person as an individual). In the UK they are working towards a clustering system (which is also very imperfect!) where people’s support needs/interventions will be based on individual needs rather than diagnosis.
      Of course it is crucial for psychologists to work with psychiatry because very often medication is needed to help people to stabilise their symptoms – but again I don’t think that medication should be prescribed on a diagnostic basis but rather on individual needs basis.
      Another model you might be interested in is the Bio-psycho-social model – this means we consider biological factors, psychological and social factors all equally when considering interventions – another model you are referring to is patient-centred working, where we consider you the expert in your own needs, and we are only here to guide and provide helpful strategies/information – if you are having a bad experience with a psychologist, try to give helpful feedback as they are probably only trying to help :) If you think they are not following professional practice guidance and evidence-based practice (positive thinking is NOT evidence-based, but cognitive-behavioural therapy is) then you should complain.
      Hope that helps. please note however that this is my opinion, not perhaps opinion of every psychologist (however well-informed I am!)

  5. Liki Fumei says:

    I deeply agree with remarks/comments #1,2 & 3.

    Regretably, plenty of people ‘committed’ to deal with the so-called ‘mental illnesses / disorders’ are so ideologically, politically, religiously, economically -let’s say- biased, that shoot these Heavyly Charged Semantics against their ‘patients’ ruthlessly to fulfill whatever OWN goals they have in their (frequently automated) minds.

    Dr. Novella notwithstanding, ça va de soi

  6. Tom says:

    Good article. There was a recent New Yorker piece called, “The Science of Sex Abuse” that I thought was very interesting (and troubling).

    It turns out that many sex offenders (particularly pedophiles) are now held in prison far past their original sentences. There is a perception that their particular mental problems make them highly likely to commit crimes in the future. This is true not only of those who have actually abused people, but also those who have perhaps only viewed images online.

    There seems to be no actual scientific basis to assume that someone who has exhibited behavior at some point along that spectrum will be driven by an irresistible compulsion to do something worse once released…and yet they continue to be kept in prison.

    Anyway, Steve’s blog post and that article seem to underline how deficient the science of mental health is at this point.

  7. Laura says:

    People seem to take one of two approaches to psychiatric problems. Psychiatrists generally prescribe medication for them. Then there’s the approach of talking and emotions, which psychologists sometimes offer as an alternative to the bad dehumanizing medicating approach.
    But this can be a false alternative. I escaped from the psychiatric drug-it approach and spent 25 years going to therapy, self-help groups and going through feelings from my past, but it didn’t relieve my torment.
    Then in my 40’s I came down quite ill with what was probably celiac disease. I went through a series of elimination diets and after excluding foods that made me sick after food challenges, there was an incredible surprise: as well as making me more healthy, it also helped enormously with the psychological torment that had occupied my life for decades. I realized there are been a mildly hallucinatory aspect to my vision, and it was gone. I’d been living in a chattery cloud of anxiety, and that dissipated; I got much more cheerful and sociable, and I stopped having suicidal crying jags; and my chronic rage (that I thought came from something in my childhood) vanished as if someone had waved a wand at it. It was a biological answer with no seductive medicate-your-feelings-away aspect.
    Most psychiatrists are probably quite unaware of the emotional effects of celiac disease or non-celiac gluten sensitivity. The only times I’ve heard of a psychiatrist or psychologist suggesting a possible contribution from food sensitivities, have been when the person has obvious symptoms of celiac disease, like diarrhea or abdominal pain. But it seems that psychiatric problems can be caused by a different immune reaction to gluten than that involved in celiac disease, see for example “Novel Immune Response to Gluten in Individuals with Schizophrenia” by Green et al,
    And if you see a psychologist or therapist, they usually entirely ignore any possible biological cause.
    When people have chronic psychological effects from gluten, it seems that gluten gets deeply woven into their self-identity. It becomes part of their identity, for example mildly hallucinatory vision may make someone think of themselves as an artistic type. We as people make up “stories” about ourselves and our experience, and once we’ve found a story that suits us, we cling to it.
    So, some people who are psychologically gluten-sensitive don’t quit, even if they’ve been diagnosed with celiac disease (which can cause cancer etc.). There might also be physical addiction to gluten.
    I did quit – but I was quite sick at the time, and I got sicker from food challenges. It was very persuasive that I just had to quit the foods.

  8. Phea says:

    I find it hard to believe that some feel all mentally ill people are just different, or victims of politically and culturally motivated forms of repression, as Thomas Szasz believes. I understand there is often a fine line between the mentally ill and the eccentric, but who could deny the existence of full-blown psychopaths, who kill and feel no remorse, or empathy, or those unfortunate souls who have lost all touch with reality?

    Great blog Dr. Novella, thank you.

  9. Nick Stuart says:

    “I think there is general agreement (Szaszians and Scientologists notwithstanding) that many people have mental symptoms that they find unpleasant or functionally impairing with which they would like help.”

    Again Dr Novella takes a cheap shot at Thomas Szasz, continually either misunderstanding or deliberately misrepresenting the views of Dr. Szasz. It is disappointing to read such an obvious straw man argument.

  10. David says:

    This is an interesting topic and I’m not entirely sure where I stand in the whole scheme of things. I work as a Cinical Psychologist and I’d be inclined to agree with Dr. Novella that there is a bit of “turf war” between various mental health professionals. The abuses of psychiatry still exist to this day, although they are less overt than in the past. However, such abuses are not confind to psychiatry, psychologists can be guilty of these also.

    DSM does not imply the biological causes are the root of MI in all instances. However, I wonder about the prognostic utility of the diagnoses in the real world. I’ve encountered numerous individuals who have been dagnose with numerous different problems over the years without much change in the symptom profiles and with little change in their quality of life/symptomatology. These are big issues which I think get lost in these debates. What is really helping an individual deal with a problem. Is the quality of life improving. The shit flinging is tiresome. Many psychological therapies are useless or merely a way of making money (for the for the former try NLP and the latter read EMDR). I’m not entirely convinced about the genetics arguments for mental illness, but I’m also no geneticist!

    Semantics is an important aspect of this debate. As a case in point, Dr Novella’s assumption aboout the brain’s level of tolerance seems analogous to a stress-vulnerability model which is often pushed by psychologists as an alternative to the “medical model.” Language is integral to our daily life, it’s the very medium by which we communicate and convey meaning, and the use of language surrounding mental illness does have an impact at a societal level. A diagnosis, physical or mental, can be stigmatizing. But then actions outside of what is considered normal would invoke stigmatizing atitudes in a significiant proportion of people, regardless of whether a “label” was atttached to said behaviour or not.

    Josie, have a re-read of the last paragraph or so of your post and consider how easy it would be for a client/patient to give feedback to a health professional. Would that professional listen? Almost certainly not. If you have a problem with a member of another member of and MDT, try to address it and see what comes of it. An official complaint may prompt a different response, but would be even more difficult for patient/client to instigate. There is a power imbalance in all relationships in the mental health system, regardless of profession, and no amout of “you’re the expert of your own needs” and joint working will bridge that gap. It’s a bit naive to believe otherwise, ultimately, you will be the one making decisions in the future. I don’t want to dent your enthusiasm, but a level of objectivity and realism is essential.

  11. JAK says:

    Dr. Novella, thank you for debunking mental illness denial. You seem to be one of the few in the skeptic community who does. As someone with a mental illness who has to deal with people telling me that my illness doesn’t exist or that the solution is alternative medicine, it’s such a relief to read your opinion on the matter.