Introduction to Psychological Disorders and the History of Psychiatric Diagnosis
Early Mental Health Reform: Nellie Bly and the Asylums
In , a journalist named Elizabeth Cochran, operating under the alias Nellie Bly, conducted an undercover investigation into the conditions of psychiatric hospitals, which were then referred to as asylums.
To gain access, Cochran feigned mental illness. Her findings were published in the famous expose titled "Ten Days in a Mad House."
Cochran documented a variety of horrific conditions, including:
Rotten food consumed by patients.
Patient exposure to cold showers.
Prevalent infestations of rats.
Abusive behavior from the nursing staff.
Patients being physically tied down.
While these conditions had been standard for centuries in mental health treatment, Cochran's work was a primary catalyst for mental health reform in the United States.
The Rosenhan Experiment: "On Being Sane in Insane Places"
In , American psychologist David Rosenhan published a paper titled "On Being Sane in Insane Places," documenting a two-part experiment challenging the validity of psychiatric institutionalization and diagnosis.
The first part of the experiment involved sending pseudopatients to psychiatric institutions:
The group consisted of mentally sound associates, including Rosenhan himself.
Their task was to knock on the doors of institutions and falsely report hearing voices.
Once the pseudopatients were admitted, they immediately ceased all fake symptoms and behaved as they normally would, waiting for staff to recognize their sanity.
The findings of the first part reflected several issues in the system:
It was significantly easier to be admitted to an institution than to be released.
Participants were detained for an average of days, with one participant kept for days.
Patients were forced to take psychotropic medications, which they secretly avoided by spitting them out.
All participants were eventually discharged with a diagnosis of "paranoid schizophrenia in remission."
Rosenhan criticized the term "in remission" because it implies the mental illness is an irreversible condition—similar to a personality trait—rather than a curable illness.
The second part of the experiment took place at a teaching hospital:
Rosenhan shared his earlier results and informed the staff he would send more pseudopatients over the following months, challenging the staff to identify them.
Of the new patients admitted, hospital staff identified as likely or suspected pseudopatients.
In reality, Rosenhan never sent any pseudopatients during that period.
Conclusion: Rosenhan concluded that psychiatric diagnoses often reveal more about the environment or situation of the patient than the patient's actual condition. For instance, a single mention of hearing voices carries more weight than weeks of consistently normal behavior.
Defining Psychological Disorders
According to a World Health Organization (WHO) report, approximately people worldwide suffer from some form of mental or behavioral disorder, across all societies.
The field of psychology seeks to understand, diagnose, and treat these conditions, ranging from common struggles to serious dysfunctions requiring intensive care.
Cultural misconceptions and stigma surround these disorders, often perpetuated by dramatic stereotypes in media and fiction (e.g., characters from Arkham Asylum).
Mental health clinicians formally define psychological disorders as deviant, distressful, and dysfunctional patterns of thoughts, feelings, or behaviors:
Deviant: Thoughts and behaviors that differ significantly from the majority of the individual's cultural context. Standards for deviance change over time and vary by culture (e.g., killing in combat vs. domestic murder; speaking to spirits in religious contexts vs. social bars).
Distress: A subjective feeling that something is significantly wrong, experienced by the individual or those around them.
Dysfunction: A measurable impairment in a person's ability to maintain a job, live independently, or function in daily life.
Evolution of Mental Health Perspectives: Medical and Biopsychological Models
During the and centuries, the Western world began viewing mental health issues as sicknesses of the mind rather than moral or spiritual failings.
In the s, doctors discovered that advanced syphilis could cause serious neurological issues, such as dementia, irritability, and mental disorders. This led to moving patients from asylums to medical hospitals for holistic treatment.
The Medical Model: This perspective suggests that psychological disorders have physiological causes that can be diagnosed based on symptoms, treated, and often cured. It replaced the older practice of simply locking individuals away.
The Biopsychological Approach: Modern psychologists often view the medical model as too narrow. This approach is holistic, operating on the principle that everything psychological is simultaneously biological. It considers:
Biological factors: Genetics and brain chemistry.
Psychological influences: Stress, trauma, and memories.
Socio-cultural influences: Cultural expectations and definitions of normal behavior.
This broader view allows for the understanding that some disorders are curable, some are manageable through coping mechanisms, and some may cease to be classified as disorders as cultural acceptance changes.
Classification and Standardization: The DSM-5
The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (DSM-5).
It is the primary tool used by clinicians, insurance companies, drug manufacturers, policy makers, and the legal system to standardize the diagnosis and treatment of mental health.
Historical Timeline of the DSM:
First edition released: .
Third edition released: (notably removed the classification of homosexuality as a pathology).
Previous version: Released in the year .
Current version (DSM-5) released: .
The DSM is designed to be a continuous "work in progress," evolving alongside research and changing social values.
Examples of changes in the DSM-5:
Updated understanding and symptoms for Post-Traumatic Stress Disorder (PTSD).
Renaming Childhood Bipolar Disorder to Disruptive Mood Dysregulation Disorder to prevent the over-diagnosis and over-treatment of children.
Exploration of new diagnoses, such as Gambling Addiction and Internet Gaming Disorder.
Critiques of the DSM include concerns that it inadvertently promotes over-diagnosis or misdiagnosis and that diagnostic labels create vulnerabilities to social judgment and preconceptions.
Questions and Discussion
The Rosenhan experiment and subsequent reforms raised several critical questions for the field of psychology:
How should mental disorders be defined, diagnosed, and classified?
At what specific threshold does a normal emotion like sadness become a disorder like depression?
When does a personality trait like being "quirky" cross the line into Obsessive-Compulsive Disorder (OCD)?
At what point does high energy become classified as hyperactivity (ADHD)?
What are the inherent risks and benefits of labeling patients with a diagnosis?