How We Talk About Mental Illness: Definitions vs. Connotations

Recent discussions in the blogosphere have got me thinking about the different ways that different people may use the same words. When it comes to mental health conditions, there are technical medical/psychiatric/psychological definitions of terms, but those aren’t necessarily the definitions that people are using in casual conversations. Then there are connotations to words that can vary widely among people.

This means that you might be having a conversation with someone and using the same words but having very different ideas about what those words mean.

This post looks at some technical definitions of terms that are commonly used in relation to mental illness. These primarily come from Merriam-Webster’s medical dictionary and the American Psychological Association’s Dictionary of Psychology. Before you yawn too loudly, I’m curious how many of them fit with the way in which you interpret these terms.

Being sick

While “mental illness” is the most commonly used way of referring to mental health conditions, not everyone is a fan of that term (you can read more about that in the post Is It Helpful to Talk Around Mental Illness?). So let’s look at different ways we might talk about being sick.

Illness

The Merriam-Webster Dictionary defines illness as “an unhealthy condition of body or mind.” It defines mental illness as:

“any of a broad range of medical conditions… that are marked primarily by sufficient disorganization of personality, mind, or emotions to impair normal psychological functioning and cause marked distress or disability and that are typically associated with a disruption in normal thinking, feeling, mood, behavior, interpersonal interactions, or daily functioning.”

Sometimes, people in the medical world will use the term illness to refer to an individual’s experience of a health problem rather than the physiological problem itself. A CMAJ editorial calls bullshit on the supposed distinction that “The disease is what has gone awry with the patient’s body; the illness is the person’s reaction to or experience of that disease.” The problem with that is that it’s easy to add connotations of “it’s all in your head.”

Disorder

Merriam-Webster defines disorder as “an abnormal physical or mental condition.”

The APA Dictionary has a definition for “mental disorder,” and lists “mental illness” as a synonym:

“any condition characterized by cognitive and emotional disturbances, abnormal behaviors, impaired functioning, or any combination of these. Such disorders cannot be accounted for solely by environmental circumstances and may involve physiological, genetic, chemical, social, and other factors.”

Disease

Merriam-Webster defines disease as:

“an impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors…, to specific infective agents…, to inherent defects of the organism (as genetic anomalies), or to combinations of these factors.”

The APA Dictionary defines disease as:

“a definite pathological process with organic origins, marked by a characteristic set of symptoms that may affect the entire body or a part of the body and that impairs functioning.”

Disease is about the physical process. Infectious diseases might be the first thing that comes to mind when you hear the word disease, but there are many different kinds of diseases. Disease may be acute or chronic (which we’ll define later in this post).

Subclinical

In psychiatry, the term subclinical is sometimes used to refer to symptoms that don’t meet the full DSM criteria for a diagnosis. For example, “Subclinical depression is a condition in which a person has depressive symptoms but does not meet the criteria for a depressive disorder” (source).

Sometimes, the term subclinical psychopathy is used to refer to people who have some psychopathic characteristics but don’t meet the criteria in Hare’s Psychopathy Checklist. The dark triad of personality includes subclinical narcissism, which refers to narcissistic traits that don’t meet the full criteria for narcissistic personality disorder.

Getting better

There seems to be a lot of variability in the ways that people interpret words related to getting better. I think sometimes that leads to people using the same words but talking about quite different things.

Response

The term response is often used in clinical trials of psychiatric medications. Each individual study defines precisely what they mean by response, but it commonly refers to a 50% reduction in score on a symptom rating scale (source). Let’s say I was studying the effects of antidepressant X given over 8 weeks. I might define response as having a 50% reduction in score on the HAM-D rating scale at the end of week 8 compared to scores at week 0. Based on that definition, I could compare response rates in participants getting drug X vs. placebo.

Response is a useful concept in a research context, but in the real world, psychiatrists shouldn’t just be aiming for response. They should be trying for remission, because you deserve more than 50% better.

Remission

Merriam-Webster says remission is “a state or period during which the symptoms of a disease are abated.”

The APA Dictionary defines remission as “a reduction or significant abatement in symptoms of a disease or disorder, or the period during which this occurs. Remission of symptoms does not necessarily indicate that a disease or disorder is cured.”

In psychiatry, remission is used to refer to the absence or near-absence of symptoms; it does not refer to a cure. For research purposes, this is defined precisely in terms of cutoff scores on symptom rating scales. Most studies use response rather than remission as an endpoint, in part because it takes longer to get 95-100% better than it takes to get to 50% better. A notable exception was the STAR*D study, a large study that looked at remission as an endpoint. You can find definitions here for remission in depression, bipolar, and schizophrenia.

Recovery

The APA Dictionary uses a generic definition for recovery rather than referring to the recovery model: “consistent progress in the measurable return of abilities, skills, and functions following illness or injury.”

Recovery has a different definition in the context of the recovery model. This is sometimes referred to as personal recovery or psychosocial recovery. This definition from Anthony (1993) is commonly used:

“Recovery is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”

The recovery model version of recovery seems to be referred to more commonly than the generic version. However, I think a lot of people use the term recovery without really being sure of what they’re talking about. I think it often gets confused with the term remission, but psychosocial recovery and remission are actually very different things.

Getting sicker vs. staying the same

Stable

If you’re not getting sicker or getting better, then you might be described as being stable. Merriam-Webster defines stable as “not changing or fluctuating.” Someone might be stable and well, or stable and quite unwell. You might hear on the news that someone is in hospital “in serious but stable condition,” meaning they’re sick, but they’re not having major fluctuations.

Stable may seem to have connotations of doing well, but it actually just means not getting significantly better or worse. Significant is subjective and relative. For someone with ongoing symptoms, stable might look like staying out of hospital. For someone else, stable might look like sustained full remission.

Decompensation

If you’re not stable, and instead you’re getting sicker, you might be decompensating.

Merriam-Webster defines decompensation in a medical sense as “loss of physiological compensation or psychological balance.”

The APA Dictionary takes a psychoanalytic perspective and defines decompensation as “a breakdown in an individual’s defense mechanisms, resulting in progressive loss of normal functioning or worsening of psychiatric symptoms.”

The APA definition, minus the psychoanalytical bit about defense mechanisms, is how I’ve always heard it used.

Course over time

Chronic vs acute

Merriam-Webster offers 3 ways that the term chronic is used medically:

• 1a: “marked by long duration, by frequent recurrence over a long time, and often by slowly progressing seriousness : not acute”
• 1b: “suffering from a disease or ailment of long duration or frequent recurrence”
• 2: “having a slow progressive course of indefinite duration —used especially of degenerative invasive diseases, some infections, psychoses, and inflammations”

The APA Dictionary defines chronic as “denoting conditions or symptoms that persist or progress over a long period of time and are resistant to cure.”

It defines acute as “denoting conditions or symptoms of sudden onset, short duration, and often great intensity.” One might have a chronic condition like bipolar disorder with acute episodes of mania, for example.

Episodic

The APA Dictionary defines episodic as “any disorder characterized by the appearance of symptoms in discrete, often brief, periods or episodes.”

Mood disorders are often episodic, with discrete depressive, hypomanic, and/or manic episodes.

High-functioning

High-functioning isn’t a psychiatric or psychological term, so it doesn’t have a precisely defined meaning. As a result, it ends up meaning whatever a given person using it wants it to mean. I don’t find that particularly useful for much of anything.

High-functioning autism tends to be used somewhat more precisely to refer to autistic people who don’t have an intellectual disability. However, it’s a bit absurd to assume that just because someone doesn’t have an intellectual disability, they’re high-functioning in a practical sense.

In my opinion, if a health care provider tells you that you’re high-functioning, they’re pretty much pulling that out of their ass.

Connotations

We often have our own definitions of words or connotations that we associate with them that have nothing to do with the dictionary. That can become a problem if we think we’re talking about the same thing as someone else but we’re actually not at all.

A number of the words that are defined in this post are considered stigmatizing by some people/organizations. Yet there’s nothing inherently bad about any of these dictionary definitions. So, is the problem with the words themselves, or the idiosyncratic interpretations?

It’s probably pretty difficult to turn connotations off in our heads, but maybe it’s worth keeping in mind that the connotations in our own heads may be very different than the connotations in other people’s heads.

So, do your definitions/connotations for these words differ much from those I’ve referred to here?