What Are “Mental Disorders,” and Are They Increasing in Youth?

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Sixteen-year-old Zoe listened expectantly as I began to provide feedback to her and her parents about my diagnostic impressions, following two hours of psychiatric interviewing. When I told them that I didn’t think her anxiety or depression were of clinical proportions and that I didn’t think she needed psychiatric treatment, she appeared crestfallen. When I said that I hoped she would take this as good news, she seemed angry. She shut down and disengaged from the rest of the session—a marked change from her prior eagerness and enthusiasm to participate in the interview process.

Twenty-five years ago, when I first started practicing as a psychiatrist, this kind of feedback would typically have been met with relief. Moreover, my young patients would quite often have been reluctant and embarrassed participants in the first place, often “dragged” to my office by their concerned parents. But Zoe’s reaction is fairly common these days. In fact, consultations with patients like Zoe are frequently initiated and requested by the teenaged patients themselves.

Is mental health worsening?

All this coincides with media reports of a mental health epidemic in young people, and greatly escalating self-reported mental health problems in youth and young adults, a trend that seems to have begun a decade or two ago.

Is the actual rate of mental disorders rising? Is life more stressful now than in the past, thus triggering more mental disorders?¹ Is it that people are now more willing to seek help due to reduced stigma? Maybe we’re now recognising and diagnosing these disorders more readily and effectively? All these questions have been asked by researchers. The data generally point to a combination of a number of factors, but there does not appear to be much rise in the actual rate of mental disorders—particularly major mental illnesses, the rates of which appear to have remained fairly stable.^{2, 3}

How do we define mental disorder?

There is a long history of debate about how to define a mental disorder. We still do not have a satisfactory definition. This is not really surprising, given the complexity of the subject. In fact, even in general medicine the concept of disorder is not sharply definable.

The DSM-5⁴ defines a mental disorder as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as a death of a loved one, is not a mental disorder.”⁵

Contrary to critics of yesteryear who argued that mental illnesses were a myth, there is no doubt whatsoever among credible professionals today that serious mental illnesses are all too real, and are a very major cause of substantial disability. The difficulty is with the vast swath of mental health problems at the boundary of normal and abnormal—psychological distress that may be a normal but intense reaction to stress. To be clear, such distress may be far from trivial, and maintaining good mental health should be a priority in all of our lives. But we needn’t equate intense distress or severe stress with suffering from a mental disorder, and with needing a medical diagnosis or treatment.

A big part of the problem, and the reason why the diagnostic criteria lend themselves to over-diagnosis, is the attempt to divide mental and behavioral phenomena into distinct categories, as if they existed in separate “boxes.” In reality, they are almost always dimensional in nature, i.e. they exist on a continuum with normality. It should therefore be more a question of the degree to which your mental health may be impaired rather than a yes-or-no question of having a disorder or not. The various categories also overlap with each other, so we should not be surprised that it is usual for people to acquire more than one diagnosis. DSM-5 acknowledges the problem of attempting to divide dimensional phenomena into categorical disorders.^{6, 7}

Most psychiatric disorders are probably better conceptualized as representing the tail ends on each side of a bell curve for a given human trait or tendency, with most of the general population in the mentally healthy average range—the central bulge of the curve.⁸ The cut-off for diagnosis is usually defined by “clinically significant distress or impairment in social, occupational (or academic), or other important areas of functioning.”⁹

The publication of the DSM-5 in 2013 met with considerable criticism. Most notably from Allen Francis, chair of the APA task force overseeing the previous edition (DSM-IV, published in 1994), who expressed concern about “diagnostic inflation” due to loosening of some of the diagnostic criteria and addition of new poorly tested diagnostic categories.

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Among other things, Frances was critical of the psychiatric diagnostic system for having over time “opened the door to loose diagnosis by defining conditions that were no more than slightly more severe versions of such everyday problems as mild depression, generalized anxiety, social anxiety, simple phobias, sexual dysfunctions, and sleep disorders.” He warned of the risk of “market-driven diagnostic fads” fueled by pharmaceutical companies, pointing to greatly increased rates of diagnosis of ADHD,¹⁰ bipolar disorder spectrum, and autism spectrum, as examples of this.¹¹

Why might people want to be diagnosed with a mental disorder?

There appears to have been a cultural and generational shift away from feelings of stigma around a mental disorder diagnosis to not only an openness to acquiring such diagnoses, but in some—especially young people, a desire and almost a pressure to acquire such. There may be many possible reasons contributing to this trend. Obvious ones include the emphasis on mental health education in schools, celebrities going public about their mental health problems, the internet, social media, peer influence and social contagion.

The younger generation have bought into the language of mental health and the advice to talk openly about it. Overall this is welcome progress, but today’s youth seem almost to have replaced the use of the word "stress" with "anxiety disorder" or "mental health issue," too quick to self-label with a variety of psychiatric diagnoses.

One teenage girl, who in my opinion did not meet criteria for a definite disorder of any kind, articulated her reasons for seeking a psychiatric consultation honestly and clearly: “I would like a diagnosis so I know that something is going on and I’m not ‘faking it,’ so I have a valid reason to feel awful sometimes and not have people get on my case about it.”¹²

Unrealistic expectations of psychiatry _¹³

There is an unrealistic assumption that psychiatry is the answer to problems of the human condition. This is part of a larger cultural expectation that all problems are fixable or solvable, and a tendency to over-simplify highly complex problems.

Harboring unrealistically optimistic expectations of psychiatric and psychological treatment can lead to tremendous disappointment and frustration when treatment fails to meet those expectations, resulting in worsening despair. To be sure, my profession is guilty of having oversold its role, and of having medicalized common human problems. But the problem is equally our society’s unrealistically high expectations of modern medicine and therapy.

Psychiatrists do what we can to help everyone who comes to us for “treatment,” generally attempting psychotherapy or counseling for mild to moderate problems, and medication for moderate to severe problems.¹⁴ Nonspecific problems, and traits that are simply part of who the person is, don't lend themselves well to specific treatments or therapies. On the other hand, severe disorders such as crippling anxiety that legitimately justify the term mental “illness” and which desperately require more specific treatments can unfortunately be difficult to treat, and for more than a small percentage of sufferers are quite intractable.

Sometimes all we psychiatrists can offer is well-honed empathy, and some insight and perspective. To say this is frustrating would be a great understatement. There are times when we feel as helpless as our patients in the face of the overwhelming complexities and challenges inherent to being human. The reality is that there are no easy answers and solutions to many of life's problems.

Unpredictable positive outcomes

On a more hopeful note, there can be unexpected outcomes for some seemingly intractable psychological and psychiatric problems. Sometimes, after a long line of disappointments, the next treatment simply works—even dramatically. And not infrequently, a positive turn of events occurs that has nothing to do with treatment. Some people who were not initially helped by psychiatric treatment or psychotherapy improve on their own, or learn to adapt to their depressive or anxious tendencies or other problems. People are remarkably adaptable and resourceful, to their own surprise (however, not everyone is resilient, of no fault of their fault own). I have known many people who, over time, amazed everyone by turning their lives around in positive ways, whether by determination, maturation, or circumstance.

Life circumstances and human nature are famously unpredictable, for better and for worse. It’s my privilege to be there with my patients when wonderful improvement happens. But I try to remember to be humble and realistic by not assuming that the treatment or therapy I am providing is the cause of the happy turn of events I am witnessing.