Is this Behavior Normal or Does It Suggests the Presence of an Illness?

When Does a Behavior Indicate Illness?

Posted Jul 12, 2010

In our book Demystifying Psychiatry, we define psychiatry as "the medical specialty that deals with disorders of the human mind and behavior." Some psychiatric patients have thoughts, feelings, or behaviors that most people would consider outside the boundaries of normal. For example, a person with schizophrenia may respond to voices commanding him to hurt someone, a depressed person may become convinced that he is evil and should commit suicide, or a 5'6" tall lady with anorexia nervosa may truly believe that she is overweight at 80 pounds.

Many patients have milder, yet very disabling, symptoms. For example, a patient with coronary artery disease may become depressed and exhibit symptoms of sadness, low motivation, diminished interest, decreased ability to concentrate, and feelings of low self esteem. Such depressive symptoms may be partially, and sometimes fully, responsible for a person not being able to return to her job, hobbies, and interactions with family and friends. Depressions in the context of heart disease are associated with increased risk of new heart attacks and increased risk of death.

The examples we just described involve people with either severe or moderately severe psychiatric illnesses that are associated with substantial disabilities. In both cases, medical treatments are likely to be helpful.

However, some individuals seek the advice of psychiatrists about issues that may be annoying but not truly disabling. For example, a shy person might wish to become more outgoing and interact more comfortably with colleagues and friends. Another example might involve a person who is annoyed about her need to check and re-check several times that the lights are turned off in the garage. Such behaviors may be inconvenient, but they don't interfere with a person's ability to adequately function. Are these behaviors within the realm of "normal" personality or are they symptoms of very mild illness?

Deciding whether a condition is a variant of normal or indicative of an illness is not unique to psychiatrists. Internists confront these issues all the time. For instance, at what point does a blood pressure reading truly represent hypertension or a blood sugar level indicate diabetes? This is a considerable problem when traits are distributed in the population along a "bell-shaped curve" (called a "normal" distribution in statistical terms). This means that most people have an "average" amount of a trait, but some people deviate significantly from average. Current data suggest that a number of behavioral traits (for example, social interactiveness and perhaps compulsive behaviors) are distributed like this. In these cases, illnesses, including disorders such as autism or obsessive-compulsive disorder, may reflect the far ends of the normal distribution, and the demarcation between "normal" and "ill" sometimes may be arbitrary and indistinct. This concept that the extremely "abnormal" behaviors that define certain illnesses are on a continuum with related "normal" behaviors has substantial implications for understanding how genes contribute to certain disorders. This concept also has implications about treatment decisions.

We would argue for a broad acceptance of what behaviors should be considered "normal." Some people are "harm avoidant" and feel most comfortable when life is routine and predictable. Others are bored unless they are involved in risky and exciting tasks ("novelty-seeking"). Similarly, some persons want to please those around them ("reward dependent"), while others could care less what people think about them. Some of us are a bit shy; some are a bit obsessive. Consider your friends, family, and people you know at work and you will probably agree that personalities are varied and that "normal" encompasses a broad range of behaviors. In fact, humans probably have survived as a species because individuals react and adapt differently to a variety of challenges.

So, how should a psychiatrist evaluate whether a person's concerns represent symptoms of a mild illness or are part of his or her "normal" personality? Should a doctor only treat behaviors that lead to significant disability or should a doctor, if requested, do everything possible to assist a person in modifying a part of his or her personality that the individual considers bothersome even though the behavior does not lead to significant disability? How should we define disability? If being shy negatively affects a person's ability to get certain types of work, does that make it a disability?

Currently, medications and therapies are available that can help a person be less shy or less obsessive. Should we treat these "traits" if medications or therapy might help?

There are two issues here. First, when does a "personality trait" become an "illness"? Second, should health care providers use medications or therapy to "treat" personality traits even if they are not indicative of an illness? Certainly, plastic surgeons perform cosmetic surgery. Is it appropriate for psychiatrists to perform cosmetic psychopharmacology?

We suspect that there will be a variety of opinions concerning these questions. Matters become even more complicated when factoring in that third party payers (medical insurance companies) may cover treatments for "illnesses" but may not pay for cosmetic treatments of "personality traits."

One final thought: Has the pharmaceutical industry contributed to the creation of "illnesses" from behaviors that arise from normal variations of personality? More on this topic in our next post.

This post was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.