On the Concept of "Psychiatric Disorder": Incorporating Psychological Injury

There is still a good deal of disagreement about which conditions should be viewed as psychiatric disorders. In the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders, the "bereavement exclusion" distinguished symptoms of non-disordered grief from major depressive disorder, because treating "normal" grief medically was considered inappropriate. In DSM-5, this "bereavement exclusion" was removed, on the grounds that symptoms of grief reaching the intensity and duration of symptoms of major depressive disorder should be treated as "complicated" grief in order to alleviate suffering. This removal was controversial. What was at stake in this change was whether it is better to err in the direction of undertreating or overtreating those with distressing grief. A widespread underlying assumption—on all sides of the controversy—is that normal reactions to major losses should not be classified as psychiatric disorders. I challenge this assumption. This article proposes including a new concept of psychological injury in the broader concept of psychiatric disorder. Psychological injury, like physical injury, can evoke a normal response that calls for clinical attention. When major losses (such as bereavement) are conceptualized as psychological injuries, treatment eligibility can be assured without classifying the patient's reactions to loss as pathological or abnormal. The word "pathological," with its evocations of nineteenth century microscopy, is unhelpful in this psychiatric context. The word "abnormal" is also best avoided here because of its associations with normative judgments. The word "disorder" serves a useful and less stigmatizing role that should not be identified with the terms "pathology" or "abnormality."