Consult-Liaison Education Medicine


I never did follow up here on the talk I gave to attorneys about “Psychiatry 101“. Teaching the foundations of any subject is both challenging and rewarding. It is also an excellent way to remind ourselves of the importance of the basics. Foundations anchor and guide us, particularly when we start getting lost in complex or unusual situations.

During my talk I review the definition of “mental disorder”.[1. I dislike the term “mental disorder”, primarily because of the stigma attached to it. The term focuses on what is wrong, not what is going well. We also get so caught up talking about “disorders” that we stop talking about “people”.] DSM-5 states that a mental disorder has two components:

  1. disturbance in cognition, emotion regulation, and/or behavior (the assumption is that pathology in the brain/mind manifests as this disturbance)[2. The underlying assumption that “disturbances” reflect pathology in the brain/mind is up for discussion, given that we don’t know if there is a distinction between the brain and the mind. The two seem related, but how they are related remains unclear. Furthermore, some people would argue that not all disturbances represent pathology. Context matters. People who choose not to eat during a hunger strike against the government are demonstrating a “disturbance” in behavior. Does that represent pathology?] AND
  2. the disturbance leads to distress OR impairment/disability

Both conditions must be met. However, the second criterion has two parts. This complicates the definition of a mental disorder. Distress does not equate to disability. People can experience low distress and high disability: Consider the person who has lost all his relationships and is unable to hold a job because he believes that he is the Messiah. People can also have high distress and low disability: Take someone grieving the loss of his spouse.

Symptoms help define diagnosis, and diagnosis guides treatment. Danger arises when psychiatrists treat symptoms without a clear diagnosis. An analogy: Say you are lost in a city. You call your friend to pick you up.

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“Main Street.”

“Main Street and what?”

“Um… Main Street and Popcorn Alley.”

“Okay. Stay there are I’ll be there in about 15 minutes,” your friend says to your relief. You and your friend were able to define where you were located, which allowed your friend to figure out how to get from his house to Main Street and Popcorn Alley.

But what is the conversation went like this?

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“I don’t know. The streets don’t have signs on them.”

“Okay. What do you see around you?”

“Uh… there’s a coffee shop on one corner and a sandwich shop on the other corner.”

“What else do you see?”

“Well, there’s a parking lot across the street.”

At best your friend would probably express gentle frustration with your lack of clarity: There are many coffee shops, sandwich shops, and parking lots in the city. How is he supposed to find you with such vague directions? At worst your friend would say, “Okay, I’ll find you,” and then hop into his car and drive around, looking for the triad of coffee shop, sandwich shop, and parking lot. The diagnosis (location) is unclear, so the treatment (picking you up) is also unclear (and frustrating and wasteful).

There is variability in how psychiatrists approach diagnosis of a “mental disorder”. The criterion of “disturbance in cognition, emotion regulation, and/or behavior” is often the easier of the two to determine: Most people would agree that people who cut themselves, refuse to eat, or feel so hopeless that they literally can’t get out of bed are experiencing a “disturbance”.

If the disturbance leads only to distress, but not disability, does that mean a mental disorder is present?

Here are several instances of disturbance AND distress WITHOUT disability:

  • hearing voices say unusual things to you
  • having self-doubts and feeling terrible following a breakup
  • suspecting others of sabotaging your work

If these things happen to you, does this mean you have a mental disorder? Maybe, but not necessarily.

Here are several instances of disturbance AND impairment WITHOUT distress:

  • hearing voices say that you are God and that you should touch everyone to bless them
  • having beliefs that you do not need to eat or drink to live; air alone will sustain you
  • suspecting others of sabotaging your work, so you stop going into the office, never talk to anyone, and don’t share any of your data (some distress is probably associated with this)

If these things happen to you, does this mean you have a mental disorder? The impairment component makes it more compelling that a disorder is present. (Why, yes, I know my bias is showing.)

If we do not exercise diligence in our diagnosis of a “mental disorder”, then we may suggest an intervention that is incorrect or insufficient. Even worse, the treatment may be unhelpful or harmful.

We work with our patients to discern whether a mental disorder is, in fact, present. Together we then clarify what the mental disorder is. Lastly, we survey possible interventions.

This is the value of returning to foundations.