Normality

Image credit: UsienThis lesson looks at the learning objective: Examine the concepts of normality and abnormality. This is usually how I start the unit on abnormal psychology. Below you will find a series of activities and then some notes for students. Below you will also find links to CAS.

Personally, I feel that this is one of the most important parts of this unit. It is a chance for us to help students develop a sense of empathy for those with mental illness. What the IB Learning Profile calls "caring." Understanding the debates about what is normal and what is abnormal is essential in understanding many of the controversies that are linked to psychiatric diagnosis.

Task 1: Thinking about abnormality

I start with this activity: Abnormality definitions

Then I have students watch the following film: John's Not Mad

We finish our activities by introducing two more terms: distress and dysfunction. Then we do this activity: Rating abnormal behaviour

Then we move on to note-taking.

Notes: Definitions of abnormal behaviour

The DSM-IV defined abnormal behaviour as "A clinically significant behaviour or psychological syndrome or pattern that occurs in an individual and that is associate with present distress or disability - i.e., impairment in one or more important areas of functioning - or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom."

What problems do you notice with this "official" definition of abnormal behaviour?

There a few problems. What is meant by a "clinically significant behaviour?" There is also the problems of "distress" and "disability." This information would be obtained by a psychiatrist only by self-reported data. Therefore, it is difficult to measure the actual level of distress or disability. Finally, there is the question of how one measures "risk." Although conceptually the definition makes a lot of sense, practically it is difficult to measure and those objectively determine one's level of abnormality.

1. Conceptual definitions

This can be a statistical deviation from the norm, deviation from social or cultural norm, or deviation from the concept of ideal mental health.

Statistical deviation puts all of our behaviours on a bell curve. Those behaviours that are least common are those that should be considered "abnormal behaviour." Mental retardation, for example, fits this definition. However, many unusual behaviours are actually desirable - for example, high intelligence or athletic ability.

In addition, it may be "normality" that is the endangered species. The NIMH estimates that, in any given year, 25 percent of the US population (that’s almost 60 million people) has a diagnosable mental disorder. A prospective study found that, by age thirty-two, 50 percent of the general population had qualified for an anxiety disorder, 40 percent for depression, and 30 percent for alcohol abuse or dependence.

Social deviation is when an individual somehow violates or rejects the norms of his/her society. Often social deviation is based on community norms for morality. In the past, homosexuality was considered a mental illness as a result of this approach. But this approach has many limitations. Societies change over time. In addition, this is a local approach to defining mental illness and cannot be universally applied. Finally, who is it that decides that a behaviour is "socially deviant?" This method of determining what is abnormal behaviour has been criticized as leading to an abuse of individual rights.

Finally, there is the definition that is based on deviation from optimal health norms. Jahoda suggested that we could define psychological well being in order to recognize mental illness. The key features would be: self-acceptance, potential for growth and development; autonomy; accurate perception of reality; environmental competence; and positive interpersonal relationships.

Although this method appears to be more objective than the first two, it also is problematic. First, how does one measure a client's "potential for growth and development" or "self-acceptance?" The theory also is very Western and individualistic in nature. Autonomy is very much a value of individualistic societies which focus on freedom, uniqueness and independence. Finally, mental health is on a continuum - that is, each and every one of us move between very positive mental health and negative mental health. Therefore, modern psychology tends to focus on the extent and duration of symptoms in order to determine whether the behaviour is actually a "disorder." Using Jahoda's mental health criteria, we may all end up being a bit mentally ill.

2. Practical definitions

Practical definitions are based on what can be observed, rather than variance from a norm.  Often these definitions are based on one's able to "function" in society. This is why abnormal psychology is also referred to as the psychology of dysfunctional behaviour. Dysfunction refers to the disruption in one's ability to work and/or to conduct satisfying relations with people. A great part of this dysfunction is the distress that the individual experiences as a result of his/her abnormality.

However, in some situations what may seem to be dysfunctional behaviour may be functional. Many bipolar artists have been able to create an incredible range of fantastic pieces of art. People with narcissism become actors or CEOs. And not all mental disorders are accompanied by distress. In addition, we can experience distress that is not a disorder.  Losing a loved one leads to grief, but this is seen as a normal and healthy part of coping with loss.

Rosenhan & Seligman suggested that certain elements jointly determine abnormality. When they co-occur, they are symptomatic of abnormality: suffering, maladaptiveness, irrationality, unpredictability, unconventionality, observer discomfort, violation of moral standards. This list, which focuses on negative behaviours rather than positive ones, has the same limitations as the "Optimal Mental Health Criteria" proposed by Jahoda.

So, many practitioners focus on "symptoms" that help them to identify mental illness and decide whether one's behaviour is "abnormal" and/or "dysfunctional" or not.

Taking a break

Watch this short video on diagnosing Bipolar disorder.

1.  Why does it take so long to diagnose bipolar disorder II?

2.  Why is it easier to diagnose bipolar disorder I?

The question of symptoms: the DSM

The DSM, or the Diagnostic and Statistics Manual of Mental Disorders, is used by American psychologists in order to assist in the diagnosis of patients. The DSM works by having psychiatrists go through five "axes" in order to consider all the factors that may be contributing to an individual's behaviour.

Axis 1:  The psychiatrist must decide whether the client is showing symptoms of one or more disorders.

Axis 2:  The next step is to look to see at the patient's personality and intellectual abilities. These factors may be masked by  acute symptoms.

Axis 3: Then the psychiatrist needs to look at medical or neurological conditions that may influence the psychological problem - or how the disorder may be treated.

Axis 4: Social factors are also important.  Axis 4 identifies recent stressors - a death of a loved one, divorce, losing a job - that may affect diagnosis, treatment or prognosis.

Axis 5: Identifies the patient's level of function on a scale of 0 - 100.  This is known as the Global Assessment of Functioning (GAF).

Watch this video on how the DSM is supposed to be used.

So, what are the problems with using symptoms as a way of determining whether behaviour is actually "abnormal?"

1.  Mental health is on a continuum. A snapshot of an individual may reveal behaviour that could be labeled as abnormal, even though it is not typical for the individual.

2. When someone is feeling distressed, the client is in the "sick-role."  Because an individual is concerned about his or her symptoms, the doctor may find a disorder, even if there may not be one.

3.  There are rarely pathognomonic symptoms - that is, symptoms that specifically indicate a single disorder.  Often a symptom may be a potential indication of severl different disorders.

4.  Finally, symptomology is not universal.  It appears that different cultures show different symptoms for different disorders.  This is one of the great criticisms of the DSM - that it it is too Amerocentric and does not consider cultural variations.

The great debate: universal or cultural?

Culture seems to play a major role in how we manifest our symptoms as well as what treatments are most appropriate.  Watch this short video by Ethan Watters on trauma.

One of the problems of discussing what is "abnormal behaviour" is that cultures explain distress, dysfunction and pain very differently.

At the same time, sometimes "culture bound syndromes" - or mental illness which appears within a culture - may appear to be unique, but actually have parallels in other cultures.  Read this short article on Hikikomori. The article makes it sound like this is a "Japanese illness."  Is it possible that this disorder exists in our own countries?  If someone is spending a lot of time on the Internet or gaming, how do we know whether they may have a version of "Hikikomori?"

For more on this disorder, watch this BBC special.

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