Clarifying the Boundary between Normality and Disorder: A Fundamental Conceptual Challenge for Psychiatry

Guest EditorialThis issue inaugurates a 2-part In Review section focusing on the concept of mental disorder and the challenge of how to distinguish between normal human suffering and psychopathology, which we refer to as the normal-disordered boundary. Part 1 includes papers by 2 leading philosophers of psychiatry, Dr Rachel V Cooper1 and Dr Derek Bolton,2 followed by a Perspective by the section's editors.3 Part 2, to be published in the December issue, will include papers by nosologists who have written on the normal-disorder boundary and were involved in debates over proposed changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, including Dr Dan J Stein4 and the editors.5-6 Taken together, the 2 parts of this In Review provide multiple perspectives on the most perplexing and controversial conceptual challenge facing psychiatry.Why should the clinician care about clarifying the normal-disordered boundary? Most negative mental states, such as sadness, despair, anxiety, fear, agitation, and anger, are not abnormalities but normal responses to life's vicissitudes. Mental health professionals are routinely consulted about such problems and seek to help people, whatever the cause of their suffering. In fact, the DSM includes a section of V code (or Z code) diagnoses explicitly intended for such clinical scenarios entitled "Other Conditions That May Be a Focus of Clinical Attention." The decision as to whether a suffering person is responding normally to difficult circumstances or experiencing pathological psychological processes often has broad implications for how the clinician thinks about treatment.7 Because there is often an overlap between the symptoms of normal suffering and of mental disorders, the 2 types of problems can be easily confused, leading to mistaken false-positive diagnoses of normal suffering as mental disorder. Making that distinction as validly as possible helps to ensure appropriate treatment for those people who need it and to protect people without a mental disorder from receiving needless or excessively aggressive treatment and stigma.For example, it is common after the loss of a loved one for a person to experience symptoms of sadness, diminished interest in usual activities, loss of appetite, trouble concentrating, and trouble sleeping.8 Because these are also part of the defining symptoms of a major depressive disorder (MDD), the clinician is faced with the challenge of deciding whether the person's reaction to the loss represents a normal grief reaction or is better considered to be MDD. Making the wrong decision in either direction can result in either overtreating and stigmatizing someone who is experiencing a normal grief reaction or depriving someone with MDD of needed treatment.The normal-disordered judgment is especially crucial for research efforts that depend on selecting research subjects who are as homogeneous as possible regarding underlying pathogenesis and likely treatment response. If samples consist of heterogeneous mixes of normal and disordered people, research results will not be easily generalizable or interpretable.The normal-disordered discrimination has taken on increasing importance as psychiatry has shifted from a focus on severe cases of mental illness in the asylum to today's primary concern with mental disorder in the community, outpatient treatment, community screening, and epidemiologic research on unmet need among the general population. Whereas the primary differential diagnosis challenge at one time was to distinguish among inpatients with schizophrenia and manic depression who were likely all psychotic, the challenge today is to distinguish broad-gauge mental disorders, such as major depressive disorder and generalized anxiety disorder, from the vast reservoir of normal distress and suffering in the community that can closely resemble mental disorder in terms of symptoms.Psychiatry's attempt to clarify its most basic conceptual assumptions about normality and disorder was also part of psychiatry's response to growing antipsychiatric sentiment in the 1960s and 1970s that accused psychiatry of overstepping the bounds of medical disorder and using medical power to control socially undesired behaviour. …