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ANSWER TO A QUESTION ABOUT "WHAT IS NORMAL?"
-- Originally Posted March 17, 2003 --

The Question From Looking For What's Normal.

    Dear Shrink: I was recently diagnosed as having an adjustment disorder, which my therapist described to me as an "adjustment disorder with mixed depression and anxiety." I have been told that this diagnosis falls within the realm of normal psychology. If this is true, then why is it considered a mental illness? It makes a difference to me whether I am classified as mentally ill, which seems like something very serious, or whether I am just having a difficult time coping with my recent divorce. Thank you. Signed: Looking for What's Normal.

The Answer.

    Dear Looking for Normal:   Thank you for this question! This goes into my Top 10 list of favorite questions because it allows me to rant a bit about the medical system. Therefore, please keep in mind that what I say in this column today may not conform to the standard party line of my psychiatric colleagues.

    With the word “normal,” you simply have to take a stand. It means either “ideal” or “average”; it can't mean both. I use normal to mean only and always “average.” No confusion.

    The short answer to your question about mental illness is that an Adjustment Disorder with Mixed Anxiety and Depressed Mood is officially a disorder found in the current United States classification of mental disorders known as—take a deep breath—the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (a.k.a. the DSM).

    Hmmm ... This may not be very reassuring to you. Hang in there. I am going to give you a longer answer, which should help you debug the word “disorder.”

    The National Institute of Mental Health (NIMH) posts the following definition on its Web site in a strategic plan called "Pathways to Health: Charting the Science of Brain, Mind, and Behavior" -- “Mental illness refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking, mood or behavior … associated with distress and/or impaired functioning.” So, according to the NIMH, you are not only suffering from a disorder, but you are also experiencing a mental illness, since all disorders are illnesses.

    Here is the big question for the NIMH: If a mental disorder is a health “condition,” why not just leave it at that? Why go down the rocky road of “disorder”? For most people, the word “disorder” amps the stigma and fear factor way up.

    Unfortunately, illness has been defined as a “disease of body or mind.” Can you really have a disease of the mind? It is a fundamental flaw of the dictionary to define illness as a disease of the mind. The mind is not a physical entity, so how can it have a disease? Look up “disease”: “a pathological condition in an organism resulting from infection or genetic defect.”

    “Mind” refers to consciousness. Thoughts, reactions, perceptions and programming of the mind can lead to destructive behavioral problems and flawed thinking, but these are hardly diseases. They are conditions.

    Give psychiatrists a chance to make something more complex than it has to be, and they can do a pretty good job of it. In my humble opinion, the DSM should be called “The Official List of Mental and Emotional Conditions.” Some of those conditions will be illnesses or disorders; many of them will not. A good dose of skepticism is appropriate when the seriousness of a condition's name can potentially yield a higher payment from a health insurance provider.

    Psychology types have discussed the question of what word to use when referring to something not so average—”difficulty”? “problem”? “condition”? “disorder”? “illness”?—for many years. Most psychiatrists stand by the DSM disorder language. This does not mean that you have to. To a certain extent, we can each decide what word we want to use to describe our situation.

    Your "disorder" equation goes like this: You have been diagnosed with a disorder. The word “disorder” comes from a scientific manual which uses that word in such a way that it can make a condition sound more serious than it is. Your condition is average, and thus, normal. There are very few people who have not met the criteria for adjustment disorder at some point in their lives. “Condition” is a better word for what you are experiencing than “disorder.”

    The good news is that most adjustment conditions last only about six months. You are working on your concerns, so you are well on your way to finding solutions and relief. Even people with average conditions can benefit from good therapy.

    However, for the sake of our society, we either need to get better at not taking the word “disorder” so seriously, or we need to change some of the words we use for mental and emotional difficulties so they more accurately reflect the wide range of conditions.

    I hope that helps. Take care, and thank you for writing!
    Posted by:  Ron Sterling, M.D.  Read our Disclaimer.

    More Information About the Terms Mental Illness and Mental Disorder --

      The 16 categories of Mental Disorders found in the DSM-IV are below. You can review a lot of material on the Internet about the DSM-IV by searching for DSM-IV at any major search engine.

        Disorders usually first diagnosed in infancy childhood, or adolescence. These include learning and developmental disorders, mental retardation, and attention-deficit hyperactivity disorder.

        Delirium, dementia, amnesia, and other cognitive disorders. These include dementia related to Alzheimer's disease, head injury, and central nervous system infection; and substance-induced delirium.

        Mental disorders due to a general medical condition. Medical/mental conditions that are not classified in other areas of the DSM-IV are found in this category.

        Substance-related disorders. Disorders related to alcohol and drug use, abuse, dependence, and withdrawal are included in this category.

        Schizophrenia and other psychotic disorders. These include the schizoid disorders (schizophrenia, schizophreniform, and schizoaffective disorder), delusional disorder, and psychotic disorders.

        Mood disorders. Depressive disorders (major, dysthymic) and bipolar disorders are classified as mood disorders.

        Anxiety disorders. This classification includes panic disorder, agoraphobia, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorders, all disorders in which a certain situation or place triggers excessive fear and/or panic symptoms (i.e., dizziness, racing heart).

        Somatoform disorders. Somatoform disorders involve clinically significant physical symptoms that cannot be explained by a medical condition. Somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder.

        Factitious disorders. These are disorders in which the individual creates and complains of symptoms of a non-existent illness in order to assume the role of a patient (or sick role).

        Dissociative disorders. These disorders involve a change in memory, identity, and/or consciousness. They include dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder.

        Sexual and gender identity disorders. Disorders of sexual desire, arousal, performance, and pain are included here, as is gender identity disorder. It should be noted that the inclusion of gender identity disorder as a mental illness in the DSM-IV has been a point of some contention among mental health professionals.

        Eating disorders. Anorexia and bulimia are both eating disorders.

        Sleep disorders. Insomnia, narcolepsy, hypersomnia, and parasomnias (nightmares and sleepwalking) are all considered sleep disorders.

        Impulse-control disorders not elsewhere classified. Includes kleptomania and pyromania.

        Adjustment disorders. Adjustment disorders involve an excessive emotional or behavioral reaction to a stressful event.

        Personality disorders.These are maladjustments of personality, including paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive personality disorder (not to be confused with the anxiety disorder OCD).

      A 2002 Court Decision Affecting the Definition of Mental Illness --

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