A lot of hard work has gone into bringing 21st century psychiatry and mental health into the modern age.  Some of our language, however, still lingers behind.  While some folks might view a concerted effort to change some of our terms as mere "political correctness," words matter and can carry implications that we don't really want. Four terms in particular that deserve our scrutiny and, in the opinion of many in our field, a replacement include the following.


Why it doesn’t work:  This word used to be invoked when behavioral symptoms were found to be the product of a known and observable medical illness.  Depressive symptoms that are driven by something like an underactive thyroid is a good example, and doctors have traditionally been taught to "rule out the organic" before concluding that a psychiatric illness is to blame.  The problem is it implies that, in the absence of such findings, the symptoms are therefore NOT organic which is a short hop to stating that they are not real.  At this point, there is overwhelming evidence that all psychiatric disorders are true brain based conditions.  How could it be otherwise?

Possible ReplacementNonpsychiatric.  Use it in a sentence. “The lab testing shows evidence of hypothyroidism so it is quite possible than some of your depressive symptoms are nonpsychiatric in origin.”


Why it doesn’t work:  When doctors couldn’t find good explanations for symptoms such as pain or neurological symptoms, they could quickly be chalked up as being functional, which again implied that they weren’t real and that they were serving some specific purpose, like feeding some unconscious need to be sick or disabled.  While it’s true that things like anxiety can manifest itself in many ways, the “function” is often difficult to determine and speculative.  In many cases, additional medical workup reveals other explanations that would otherwise have been missed.

Possible ReplacementUnexplained.  Or, if a more precise hypothesis is being proposed, use that more specific term (such as malingering if there is suspicion that a person is purposely making up symptoms to achieve a specific aim).   Use it in a sentence.  “The patient has unexplained abdominal pain each morning before school.  Please evaluate for Separation Anxiety Disorder.”


Why it doesn’t work:  The expression “acting out” is actually an older Freudian term that refers to the defense mechanism of turning an unconscious inner conflict into an outward behavior.  The term has been usurped to designate any type of disruptive or externalizing behavior.  The true meaning of acting out, however, suggests a specific cause of the behavior that most people don't actually mean, let alone can identify. 

Possible Replacement:  Disruptive or Acting Up.  Use it in a sentence.  “This child has struggled with a lot of disruptive behavior at school.”


Why it doesn’t work:  This one might surprise people as it seems on the surface like a wonderful term to encompass all the potential sources of behavior and behavioral problems.  Indeed, many psychiatrists and other mental health professionals continue to love the term and use it liberally as a convenient way to describe (and remember) lots of potential causes for emotional behavioral problems.  Genetic effects might be seen as a "bio" cause, early trauma a "psycho" cause, and poverty a "social" cause, for example, that all contribute to a disorder or syndrome.

These specific causes may be quite valid, but the categories themselves collapse under scrutiny. The term once again implies some sort of division between biological and psychological factors that can’t really exist. We know now, for example, that traumatic experiences can result in physical changes to a person’s DNA that can alter a child's behavior and evoke increased chaos in the home environment that further exacerbates the problem. What category does this process belong to? 

Possible ReplacementComprehensive or Mutually Interacting Factors.  Use it in a sentence.  “In my view, this child’s difficulties are the result of a number of mutually interacting factors that require a comprehensive intervention strategy.” 

It is not easy to change one's vocabulary but, in my view, worth the effort to remove words that convey implications that are outdated and in many cases, just wrong. 

David Rettew is  a child psychiatrist and author of Child Temperament: New Thinking About the Boundary Between Traits and Illness.  You can follow him on Twitter @PediPsych and like PediPsych on Facebook

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