Do all people with disturbing behavior have a psychiatric illness?

“Hey Doc, this guy needs some help.”

I’ve heard that statement from countless correctional officers over the years. Its meaning is very simple: Someone is exhibiting thoughts or behaviors that the officers find disturbing and “not normal.”

I appreciate the officers expressing concern. Without their input I often would not be aware of cases where I might be able to be of assistance.

But, one of the questions that always pops into my head is whether the situation is one in which I can actually help. I certainly would not expect officers to make this decision, but it’s a point I must consider.

Some inmates could potentially benefit from our help; they might be suicidal, manic, psychotic, or depressed. But unfortunately they might repeatedly refuse to meet with mental health professionals. In such cases we can help assure that they won’t harm themselves, but there’s often little else we can do.

Others may be angry, assaultive and even homicidal. Maybe they have repeatedly destroyed property, have flooded their cells, or have threatened to go on a hunger strike. Such problem behaviors may be present when there is an exacerbation of a treatable mental illness, but more often they occur in the context of a personality disorder that is not likely to be treatable. Antisocial personality disorder or even psychopathy are a couple of common examples.

But some bad behaviors do not have any clinical labels–nor should they. The range of possible disturbing thoughts and behaviors is endless.

It’s quite understandable that lay persons who observe others exhibiting troubling thoughts or behaviors naturally want them to get “help.” Many of these inmates are under stress and may have psychological issues. They absolutely deserve to be evaluated by mental health professionals. It’s important that we not miss potentially treatable conditions.

But the point I want to emphasize is that not all of them have treatable psychiatric illnesses.

It’s often challenging to explain to security staff how a mental health professional cannot do much in some cases.

But it would be quite presumptuous and potentially dangerous if mental health professionals believed that they had the answers in all cases where people were having disturbing thoughts or behaviors.

Not only would such an approach be  dishonest and filled with false promises, but it would lead down the path of medicalizing the human condition. Anything that’s not “normal” or desirable would become a medical problem. I do worry that my profession is veering too far in this direction already.

For example, some psychiatrists have argued that pathological lying should be labeled a mental disorder and added to the DSM (the textbook of psychiatric diagnoses). That’s ludicrous!

And then there are unusual behaviors or beliefs that may not be harmful but may bother others. The question is, where do we draw the line? We’re at risk of psychiatry becoming the social police.

Is your kid’s hair orange? Are you a little “abnormally” interested in UFO’s? Oh, you don’t really care about socializing with others and never have but would prefer to read books instead? Maybe you’d better call a psychiatrist.

What do you think? Is society moving too far in the direction of medicalizing all bad or “different” behavior?

Jeffrey Knuppel is a psychiatrist who blogs at Lockup Doc, where this post originally appeared.

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  • jsmith

    To answer the question at the top of the post: no. Next case.

    • Jeffrey Knuppel, MD

      Yes, it seems obvious. But as a practicing psychiatrist I can tell you that not everyone else sees it so clearly.

  • David Hager, M.D.

    In the correctional world, I’ve been there, done that, and bought the shirt (for several years.)

    The correctional picture is complicated further by a common pattern of those demanding psych meds tending least to need them, while those who refuse meds tend most to need them.

    * * *

    In the broader psychiatric world, I grow increasingly dismayed by our proliferation of diagnoses, expanding the boundaries of illness labels far beyond a core of serious mental illness. Older mentors over the years have confided their opinions that many diagnoses exist to leverage remuneration or to indulge professional reputation.

    We remain, traditionally, a field of idiopathic diagnoses. If etiologies are established, their care falls to other specialties. Thus, we stumble through attempts to cluster murky signs and symptoms (lots of symptoms) into valid entities.

    The forwards to Goodwin and Guze’s “Psychiatric Diagnosis” remain burned into my memory. They tell of just how human we are in our stumbling through the evolution of our profession.

    I remain troubled by the APA seeking public input into the diagnostic nomenclature for the next DSM iteration. It’s not necessarily a bad thing, but it communicates our own profession’s uncertainties about the definitions of mental illnesses – an uncertainty that seems to require us to ask the lay public to assist us. By contrast, I cannot think of an example of internists or surgeons requiring public input into their disease classifications.

    That we can inscribe diagnoses into an official tome does not determine their persistence as valid constructs two decades hence. Even DSM acknowedges that in its preambles that are often ignored by those who use it. (Check page xxxi under “Limitations of the Categorical Approach.”)

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