When And Why Do Symptoms Get Pathologized?
By Sarah Fader
Updated December 18, 2018
Reviewer Whitney White, MS. CMHC, NCC., LPC
Pathologizing refers to the process, in medicine and psychiatry, where physical symptoms or behavior are classified as unhealthy or abnormal. In medicine, these should not be as a result, or consequence of lifestyle factors or circumstances. When a symptom or a form of behavior is pathologized, it gets classified, and referred to, as a disorder or a disease. Lexicons are compiled with these classifications and revised every few years.
As an example, high blood pressure, or hypertension, is often called a disease or disorder. It is a symptom and causative risk factor in hypertensive heart disease, which is a group of disorders that relate to cardiac muscles and arteries. Hypertension itself is most often caused by lifestyle problems such as a poor diet, no exercise, and uncontrolled stress, and therefore something most people can control.
When pathologizing behavior in psychiatry and psychology is considered, however, the discourse becomes a bit more complex.
Who decides what normal vs. abnormal behavior is, and what are the reasons for these decisions?
What Is Normal Behavior?
This is not a question with a simple answer and remains a subject of much debate. The definition of normal behavior keeps changing, depending on societal norms and standards. What is considered normal differs from one culture to the next. Even within a community, there can be differing views as to what constitutes 'good' and acceptable behavior.
For instance, homosexuality, or gay, lesbian and bisexual orientations, were considered abnormal sexual practice in most Western countries until 1973. In the first Diagnostic Statistical Manual of Mental Disorders (DSM), homosexuality was classified as a sexual paraphilia. 45 years ago, that changed, and today in many modern societies homosexuality is viewed as an inborn sexual preference unto itself and is not pathologized. As homosexuality was found to be harmless to those who experience it, and not dangerous to others, there was no argument to continue its place as a pathologized behavior.
Another example that demonstrates how normal behavior can be subjectively demonized in a specific socio-political milieu is the coining of drapetomania as a mental disorder.
Dr. Samuel Cartwright defined the inexplicable longing of a slave for freedom as a disorder, then-called drapetomania, in the 19th century. Cartwright was not a psychiatrist or psychologist and drapetomania was never included in any diagnostical manuals. His pathologizing of this feeling and behavior was based on socio-political attitudes of his time and has been discarded.
Is this pathologizing of normal behavior still something that happens today, though? Some think so.
What Is Abnormal Behavior?
Despite challenges in defining what is normal or not, guidelines for diagnoses and mental illness are necessary to help support effective treatments. Internationally, there exist different systems of classification, with the International Classification of Diseases (ICD) and the previously-mentioned DSM, now on its 5th revision, being the most widely used.
International Classification Of Diseases (ICD)
The first edition of the ICD was known as the 'International List of Causes of Death.' The International Statistical Institute adopted it in 1893 and entrusted to the World Health Organization (WHO) at its inception in 1948. The WHO is a "specialized agency of the United Nations with primary responsibility for international health matters and public health." Since then, the ICD has been subdivided into more classifications, including:
- the International Classifications of Diseases for Oncology (ICD-O),
- the Application of the International Classification of Diseases to Neurology (ICD - 10 - NA),
- the Application of the International Classification of Diseases to Dentistry and Stomatology (ICD - DA), and
- Two ICD Classifications of Mental and Behavioral Disorders - one for clinical descriptions and diagnostic guidelines, and one for diagnostic criteria for research. Mental and behavioral classifications were included in the ICD's sixth edition.
In the 1960's, the WHO mobilized its Mental Health Program to improve the diagnosis and classification of mental disorders in the ICD, which was, at the time, close to its eighth revision. The WHO convened this with the help of an international group of representatives from multiple disciplines and various schools of thought in psychiatry. Simultaneously, a network of centers and individuals were established across the world, with the aim being to improve the work of psychiatric classification.
In the words of Norman Sartorius, former Director of the Division of Mental Health, WHO: "A classification is a way of seeing the world at a point in time. There is no doubt that scientific progress and experience with the use of these guidelines will require their revision and updating."
The WHO continues to collaborate with many around the world, including the American Psychiatric Association (APA), which is responsible for the updating and revision of the Diagnostic Statistical Manual.
Diagnostic Statistical Manual Of Mental Disorders (DSM)
In 1952, the American Psychiatric Association (APA) adapted the ICD-6, and this adaptation became the first edition of the DSM. It contained descriptions of the diagnostic categories and is known as the first official manual of mental disorders, with its focus on clinical use in the fields of psychiatry and psychology. Since then, the DSM has been revised four times, with the latest (DSM-V) having appeared in 2013. It was compiled by work groups who created a research agenda, starting in 2000. These groups produced hundreds of white papers, monographs, and psychiatric journal articles to provide a summary of the state of psychiatric science relevant to diagnosis. The purpose of this was also to determine where research showed gaps. In 2007, a specially designated DSM-V Task Force was formed to begin revising the previous DSM. Thirteen work groups also focused on some disorder areas.
Symptoms become pathologized through the process of extensive research, evaluation, classification, and categorization that has been an ongoing work since the 19th century. The diagnostic manuals are constantly evolving based on input from expert analysis and research taking place all over the world.
The purpose of classification is to assist clinicians in the understanding and treatment of specific problems. If clinicians do not have a working list of classifications and symptoms, they are unable to coordinate or understand what treatments best help the individual. For example, if the flu was called something else in another country, and the symptoms weren't recorded, their research data wouldn't be helpful in assisting doctors in the United States in treating patients here. Because doctors have agreed on names and contributed symptoms they commonly find within those issues, problems can be identified, and then matched with relevant proven treatment and research data.
ICD and DSM classifications also assist insurance companies and treatment providers in paying and receiving payment for services. Insurance companies determine what illnesses of any type are covered. By requiring doctors and other providers to use a standard set of diagnostic labels and symptoms, insurance companies can determine quickly if treatment will be covered, and if the treatment provided is something they approve of. Insurance companies typically only cover research-driven treatments that have demonstrated helpful with a given condition.
Despite the constant growth of diagnostic tools and the helpful purposes of their use, they remain controversial. This controversy stems from the stigma that is associated with some of the diagnostic labels given to patients, and from research that has shown that labels can affect a person's behavior and treatment outcome. Some mental health professionals decline to use diagnostic labels for this reason. If being diagnosed concerns you, speak with your treatment provider about your concerns
For some people, understanding their diagnosis and the accompanying label feels helpful, as it gives them a name for an experience. That diagnostic experience or label is now something they share with others and the feeling of isolation can decrease for some.
If More Guidance Or Advice Is Needed
If you're uncertain about your diagnosis for any reason, speak with your treatment provider. You can also request a second opinion from a different provider. Treatment and help in determining your individual and unique issues can be done through BetterHelp where licensed mental health professionals are available for chat, call, and video.