Psychologist's secret - why we're so bad at diagnosing 'crazy' cover image

Psychologist's secret - why we're so bad at diagnosing 'crazy'

Dorian Minors • July 8, 2016

This is an archived article from our predecessor website, The Dirt Psychology. The idea there was to take psychological scholarship and turn it into wisdom. The Armchair Collective tries to go a little further than just psychology. As such, these articles live here in archive form, until they're updated.

Are you crazy? Don't be so quick to answer. Defining what makes someone ill and another person well is a very thin grey line. Here's why.

While we've moved on from perforative words like 'crazy' and 'insane', a diagnosis still holds a lot of stigma in many societies. This is a problem. In essence, the study of mental disorders or 'psychopathology', is the study of "abnormality". But what makes something 'abnormal'? Psychologists and psychiatrists have a very hard time figuring out just what typifies a mental disorder or 'abnormal' behaviour and no single objective definition exists.

If it's hard to figure out for them what about the general public? Statistics say just over half of (or as many as two in three) people will meet clinical criteria for a mental health disorder. About 25%  within the last year. And that's likely an underestimate, as all surveys are. That means, more than likely, that's you. So this kind of a big deal. To help you understand how psychologists determine what is 'abnormal', today I'm going to break down the four major 'rules' or models they use to figure it out.

. These days, it's a whole different kind of Looking Glass that Alice has to step through before the madness begins.

Is culture always a good thing?

“The Cultural/Social model looks at whether the behaviour ‘breaks the rules’ of a society.”

You might be thinking, 'well isn't abnormality just something that people think is weird?' If so, kudos 'cause you're kind of right. Psychologists often use the 'Cultural/Social model' to determine abnormality. Basically, if certain types of behaviour break the implicit rules of a society; that is, if the stuff you're doing is seen as 'strange' or 'inappropriate' by most people then we can use this to diagnose someone. Unfortunately, there are some pretty obvious problems. Firstly, it's super subjective, so how does one measure it? I know plenty of people who act weird but where do we draw the line? How much weirdness is abnormal? Secondly, social norms vary wildly across time and culture. What's abnormal for me or you might not be abnormal the next country over, or fifty years ago, or more pressingly, fifty years from now. It might be a disorder today, but in twenty years it might not be the cultural norm! But perhaps most importantly, this particular model is necessarily stigmatising; by definition it highlights one's isolation from their community.

Logic doesn't always hold the day...

“The Statistical model tries to find out what’s ‘abnormal’ by the rarity of the behaviour.”

So maybe we look at something a little more objective. Approaching the problem using the 'Statistical model' means we  look at behaviours that are statistically rare. Let's say only 5% of people are doing something, we might say that's sufficiently rare enough to classify as 'abnormal'. And that doesn't stigmatise either, it's simply the way things are. It's also really easy to measure because it's so clearly defined - numbers don't lie, man. But, you now have another problem on your hands - all things that a weird are not harmful. I might collect a jar of my toenail clippings. It's weird, it's gross, but really why should that matter to anyone but me? Also, where do we determine the cut off for these things? Who gets to decide that some proportion of people is sufficiently rare? Based on what? And why?

. Alright team, I think we've got enough formulas and diagrams to confuse anyone who asks. Let's go grab a beer.

Even the things that are cut and dried leave room to stumble

“The Danger model approaches the issue by determining whether the person is at risk of doing harm to themselves or others.”

Ok, what about if they are a danger to themselves or others, that's pretty clearly harmful right? So perhaps we look at the 'Danger model'. If you pose a risk to yourself or others, then you can be considered 'abnormal' under this rule. And it can be really good, it has an inherent protective value. Instantly, treatment can be organised to reduce that risk of harm. We know that common illnesses like depression and anxiety can contribute to self-harming or suicidal behaviours. We know that panic attacks aren't awesome for our health. We know that PTSD is a risk factor for Domestic Violence, especially in our under-treated servicemen and women. We know that less common illnesses like schizophrenia can occasionally result in violence too. Oh wait, a schizophrenic is less likely than your average joe to mess someone up? Looks like this protective model can swing the other way too. Since it's kind of hard to define who is at risk (how many times have you said 'I'm going to kill that person'?), it can be really easy to abuse. How many political prisoners all over the world do you think get incarcerated for reasons like this?

But some things are just pretty straightforward

“The Distress model simply asks the person or their family and friends how bad they feel it is.”
Alright, so maybe we can just ask the person or those around them what they think. Instead of looking at all these external facets of mental illness, Psychologists can just ask the client how they feel. This is called the 'Distress model'. Basically, if the behaviour is personally distressing or interfering significantly with the persons life or the lives of those around them, it can be seen as 'abnormal'. This is really nice and easy to measure because it's self-defined, and people get help when the need it (rather than having it forced upon them as in the other examples). It's well known that different people have different tolerance to stress and different coping mechanisms. Unfortunately, there is such a thing as a hypochondriac. We've got to be careful we don't convince ourselves that a short period of distress is a mental disorder. In fact, common diagnostic tools rarely consider the events preceding the onset of an illness, but instead only focus on the symptoms. That means, say, if your grieving process involves lying low for a couple of weeks, you might qualify for a sweet new diagnoses, even though you know you'll bounce back any minute.
. Careful Diane, I see a Psychiatrist coming! Pretend you're sneezing.
I feel like you probably know where I'm going with this. It's impossible to just look at one facet of someone's mental health or presentation and decide whether that person is 'abnormal'. It's got to be a considered approach evaluating each of these four areas to determine what's going on. And in fact, many psychologists will simply decide that despite two or three models fitting something, it still isn't 'abnormal'. It's just a bit odd. Fortunately, two diagnostic tools, the ICD-11 and the DSM-IV have been developed to help psychologists make their decision. So, please, use what you know now to treat mental illness with a bit of respect. Diagnosis is hard, and treatment even harder and that's when all the medicos gets it right (which they often don't). Next time you come up against someone with one of these labels, realise just how little that explains about that person and let them guide you in how to treat them. What do you guys think? Are these four rules enough to determine someone's mental wellbeing? There's another reason why understanding the mind is so hard - some scientists are actively lying to you. And while we're on the subject of just how much society determines what we think and feel, learn the real answer to the adage 'would you jump of a bridge if everyone else was doing it?' Hint, yes, you probably would. Turning scholarship into wisdom without the usual noise and clutter, we dig up the dirt on psychological theories you can use. Become an armchair psychologist at The Dirt Psychology.

Turning scholarship into wisdom we can use at The Armchair Collective.

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Dorian Minors

I mostly do brain science. Sometimes I train honeybees. I promise they're related. I made this site because there's no reason why scholars should be the only ones to own knowledge. My special interests are interpersonal relationships, the science of community, spirituality and the brain, and the neural basis of complex behaviour. I hope this stuff is as interesting to you as it is to me. You can find out more about me here.