CBS’s 60 Minutes used to conclude each program with random observations from resident curmudgeon Andy Rooney, who often began his remarks with ”Did you ever wonder…?” I always enjoyed his recitations (yes, I am dating myself again), and, although I know I cannot match his wit or gravitas, I thought I would nevertheless steal the introduction from him for this edition of my own musings.
Did you ever wonder whether all the different terms for mental health difficulties –mental illness, mental disorder, mental health condition, behavioral health problem– mean the same thing? And, if not, what are the differences?
It is my intent in this blog entry to provide some clarification of these common terms. Please note the modifier “some.” I have no illusions that I will be able to clarify completely, in part because even professionals within the mental health field disagree about what terms are best used for the phenomenon they are all attempting to describe. In addition, most of the terms do mean pretty much the same thing, and their differences are mainly in the more subtle implications they have.
Mental illness: According to a recent study of 340,000 written and spoken language samples, “mental illness” is the most frequently used term to refer to problems in mental health (Haslam & Baes, 2024). The online Oxford English Dictionary (OED) indicates that the term has been in use since the late 1700s and offers this definition: “a condition that alters a person’s thinking or behaviour, esp. one requiring care or treatment.” [Interesting aside: Words, definitions, and examples of word use were solicited from the public in the construction of the first OED. One of the most prolific contributors, with more than 10,000 entries, was W. C. Minor, a man confined to a psychiatric institution at the time. See The Professor and the Madman (1998) by Simon Winchester—or the 2019 Mel Gibson/Sean Penn movie with the same title.]
The term “mental illness” was introduced, in part, to create a parallel to physical illness and thereby promote more compassionate views of what had been referred to by frightening and stigmatizing earlier designations such as “deranged,” “mad,” “crazy,” and “insane.” The idea of “illness” suggests a no-fault condition that is not an intrinsic part of the person, but an affliction that comes unwanted and undeserved. It conveys, furthermore, that, as illnesses, such conditions warrant compassion and acceptance and that afflicted individuals should be treated humanely and professionally, as we would do for people with physical illnesses. Very importantly, the term also suggests that these “illnesses” can be identified and treated, just as physical illnesses can be.
One controversial aspect of the term “mental illness” is that it implies that these conditions are medical ones like other “illnesses.” The Psychiatry.org website, in fact, states that “[mental illness] is a medical problem, just like heart disease or diabetes.” However, definitive evidence is lacking for specific medical causes for most identified mental illnesses. In addition, the term “illness” includes the (increasingly disputed) implication that these problems need to be addressed by medical professionals (i.e., M.D.’s), treated in medical facilities (i.e., hospitals), and ameliorated by medical means (e.g., medication). Although current use of term “mental illness” includes a spectrum of problems treated by variety of medical and non-medical practitioners with medical and non-medical interventions within and outside medical settings, there is still a tendency to associate the term with more severe conditions that may require medication and hospitalization. Consequently, concern has been expressed that the term “mental illness” may still conjure up stigmatizing images of grim mental hospitals and One Flew Over the Cuckoo’s Nest.
Mental disorder: In addition to its association with severe conditions, “mental illness” has historically been used somewhat generically, without clearly distinguishing the many different forms and degrees of mental illness we now recognize.
Cue the publication of a more comprehensive diagnostic system by the American Psychiatric Association (APA), the Diagnostic and Statistical Manual of Mental Disorders (DSM). A basic tenet of that work is that “mental disorder” is not a general or uniform condition. Instead, there are specific disorders, with varied patterns of symptoms, onset, course, and severity. Beginning with its first edition in 1952, the DSM has attempted to identify and define more precisely the diagnostic criteria for the wide range of mental health conditions observed in clinical practice. A companion idea is that the different disorders may have different causes and require different forms of treatment. DSM does not suggest that “medical” treatment is always warranted.
In terms of what is meant by a “mental disorder,” the DSM attempts a detailed definition of the term. Considerations of space do not permit me to go into all the many elements of that definition. But central elements are that mental disorders involve “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior” that is “usually associated with significant distress or disability.” Both stated elements must be present. There must be impairment or disturbance in thinking, emotion, and behavior AND those disturbances must create distress and/or disability (i.e., poor functioning). Furthermore, they must be present to a “significant” or “clinically significant” degree. Although “significant” remains an inexact and somewhat subjective descriptor, the idea is that milder disturbances in feeling, thinking, or behavior that do not lead to “meaningful” life disruptions should not be counted as mental disorders. Individuals can be sad or stressed or anxious as part of the ordinary challenges of life but not to an impairing level, in which case, they would not be seen as having a mental disorder.
Beyond the conceptual definition of “mental disorder,” there is an operational definition resulting from the adoption of DSM as the main diagnostic authority in the United States (other countries use different manuals). Operationally, a mental disorder is one that is described and meets the criteria of a specific disorder in DSM. Some have suggested, only partly in jest, that an applicable definition of mental disorder is “what’s in DSM.” In other words, when we say someone has a “mental disorder,” we basically mean that that person has a condition that meets the criteria for one or more of the disorders included in DSM. It is probably important to mention here that DSM has had many revisions, and what it includes as a mental disorder and the criteria it uses for specific disorders have changed over time, adding some uncertainty to even this operational definition.
It is even more important to recognize that there are many troublesome psychological phenomena that are NOT mental disorders, however socially unacceptable they may be and however much we may wish to conceptualize them as products of mental dysfunction. Hatred is NOT a mental disorder. Prejudice and bigotry are NOT mental disorders. Bullying and abuse are NOT mental disorders.
Mental health condition: To some, “disorder” has a pejorative, judgmental overtone of something fundamentally wrong with the person. Many are not comfortable with the designation of people, especially themselves, as “disordered.” Moreover, there is concern that a focus on diagnosable “disorders” does not address the many struggles for which mental health assistance is appropriate and helpful.
The term “mental health condition” is meant to avoid the “disorder” label and to be a broader umbrella than the previous terms. It is, by the way, the term preferred by Mental Health Connecticut. “Mental health conditions” include both diagnosable mental disorders/illnesses AND other psychological and behavioral difficulties that involve distress and dysfunction but do not reach the level of a DSM disorder. As suggested previously, we can be troubled by work stresses, saddened by losses in personal relationships, frustrated by the demands of parenting, or challenged by physical illness or impairments. And, even though our problematic thoughts and feelings and behaviors may not reach the threshold for a diagnosis, our psychological functioning is likely less than optimal, and our anxiety, sadness, anger, discouragement, loss of self-esteem, etc. qualify as “mental health conditions” that need to be acknowledged and addressed.
Behavioral health problem: This is a term with which I struggle a bit, as it seems to be used in a variety of different ways. Often the term is utilized as simply another way to refer to all the same kinds of disruptions of functioning and life enjoyment encompassed by the previous terms but used as a way to avoid some of the stigma that still attaches to the “mental” designator in the previous labels. Other times, however, the term is used more narrowly to refer specifically to difficulties that involve harmful actions rather than problematic thoughts and emotions—substance abuse and other addictions, for example. Thoughts and emotions may play a role in such difficulties, of course, but the problems are seen as more involving what people do. Thus, they are “behavioral health problems.” Relationship problems—difficulties in how people relate to and communicate with others–may fall under this umbrella as well. Still another use of the term is to refer specifically to behaviors that have harmful physical effects—overeating, lack of exercise, smoking, and other problematic health habits—and to ways to improve physical health through behavior change.
I now return to my opening disclaimer concerning limitations of my attempts at clarification. There are, of course, other terms in use that I have not included, as well as modifiers like “psychological” and “psychiatric.” My explanations, furthermore, do not capture all of the history or rationales or nuances of psychiatric terminology. Also, as mentioned earlier, I have no doubt that there are some who will disagree with aspects of my characterizations of the specific terms considered here. I hope, however, that my goal of “some” clarification has been achieved.
Otto Wahl, Ph.D.
MHCT Development Committee Member
