Making a Diagnosis (The 3 D’s)
While the concept of mental or psychological disorders is difficult to define, and no definition will ever be perfect, it is recognized as an extremely important concept and therefore psychological disorders (aka mental disorders) have been defined as a psychological dysfunction which causes distress or impaired functioning and deviates from typical or expected behavior according to societal or cultural standards. This definition includes three components (3 Ds)
Dysfunction includes disturbances in a person’s thinking, emotional regulation, or behavior that reflects significant dysfunction in psychological, biological, or developmental processes underlying mental functioning. In other words, dysfunction refers to a breakdown in cognition, emotion, and/or behavior. For instance, an individual experiencing the delusion that he is an omnipotent deity has a breakdown in cognition because his thought processes are not consistent with reality. An individual who is unable to experience pleasure has a breakdown in emotion. Finally, an individual who is unable to leave her home and attend work due to fear of having a panic attack is exhibiting a breakdown in behavior.
Distress can take the form of psychological or physical pain, or both at the same time. Simply put, distress refers to suffering. Alone though, distress is not sufficient enough to describe behavior as abnormal. Think about it – the loss of a loved one causes even the most “normally” functioning individual pain and suffering. An athlete who experiences a career ending injury would display distress as well. Suffering is part of life and cannot be avoided. Impairment refers to when the person experiences a disabling condition that limits the ability to engage in activities of daily living (e.g., can no longer maintain minimum standards of hygiene, pay bills) or participate in social events (e.g., attending social events), work or school. Impairment can also interfere with the ability to perform important life roles (e.g., student, caregiver or parent).
A closer examination of the word abnormal shows that it indicates a move away from what is normal, typical, or average. Deviance refers to behavior that violates social norms or cultural expectations because culture determines what is normal. When a person is said to be deviant when he or she fails to follow the stated and unstated rules of society, called social norms. As you might expect there is a lot of cultural variation in acceptable behavior.
Earlier we learned about cultural relativism and what is considered normal by a culture can change over time due to shifts in accepted values and expectations. For instance, just a few decades ago homosexuality was considered taboo in the United States and it was included as a mental disorder in the first edition of the DSM; but today, it is generally accepted. Likewise, public displays of affection do not cause a second look by most people unlike the past when these outward expressions of love were restricted to the privacy of one’s own house or bedroom. In the United States, crying is generally seen as a weakness for males but if the behavior occurs in the context of a tragedy then it is appropriate and understandable. Finally, consider that statistically deviant behavior is not necessarily negative. Cognitive genius is an example of behavior that is not the norm. Abnormality alone is not an indication of a disorder or problem.
Though not part of the DSM -5 conceptualization of what abnormal behavior is, many clinicians add a fourth D – dangerousness to this list. Dangerousness refers to when behavior represents a threat to the safety of the person or the safety of others. Individuals expressing suicidal intent, those experiencing acute paranoid ideation combined with aggressive impulses (e.g., wanting to harm people who are perceived as being out to get them), and many individuals with antisocial personality disorder may be considered dangerous. Mental health professionals (and many other professionals including researchers) have a duty to report to law enforcement when an individual expresses an intent to harm themselves or others. Individuals with depression, anxiety, and obsessive-compulsive disorder are typically no more a threat to others than individuals without these disorders. It is very important to remember that having a mental disorder does not automatically mean that a person is dangerous and most dangerous individuals are not mentally ill.