Defining “Normal” and “Abnormal”
Ideas of “normal” and “abnormal” are largely shaped by social standards and can have profound social ramifications.
Analyze the challenges inherent in trying to define “normal” and “abnormal”
- What is considered “normal” changes with changing societal standards.
- Despite the challenges inherent in defining “normal,” it is still important to establish guidelines so as to be able to identify and help people who are suffering. This is the goal of the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM-5), a publication in the field of clinical psychology.
- The DSM-5 attempts to explicitly distinguish normality from abnormality based on specific symptoms.
- In very crude terms, society generally sees normality as good and abnormality as bad. Being labeled as “normal” or “abnormal” can have profound ramifications for an individual, such as exclusion or stigmatization by society.
- Stigma and discrimination can add to the suffering and disability of those who are diagnosed with (or perceived to have) a mental disorder.
- In order to reduce stigma, a recent move has been made toward the adoption of person-centered language: referring to people as “individuals with mental illness” rather than “mentally ill individuals” (e.g., a “person with bipolar disorder,” rather than a “bipolar person”).
- etiology: The establishment of a cause, origin, or reason for something.
- pathology: Any deviation from a healthy or normal condition; abnormality.
- social norms: Group-held beliefs about how members of that group should behave in a given situation.
- stressor: An environmental condition or influence that causes distress for an organism.
- stigma: The societal disapproval and judgment of a person or group of people because they do not fit their community’s social norms.
Challenges in Defining “Normal”
A psychological disorder is a condition characterized by abnormal thoughts, feelings, and behaviors. However, defining what is “normal” and “abnormal” is a subject of much debate. Definitions of normality vary widely by person, time, place, culture, and situation. “Normal” is, after all, a subjective perception, and also an amorphous one—it is often easier to describe what is not normal than what is normal.
In simple terms, however, society at large often perceives or labels “normal” as “good,” and “abnormal” as “bad.” Being labeled as “normal” or “abnormal” can therefore have profound ramifications for an individual, such as exclusion or stigmatization by society.
Although it is difficult to define “normal,” it is still important to establish guidelines in order to be able to identify and help people who are suffering. To this end, the fields of psychology and psychiatry have developed the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM-5), a standardized hierarchy of diagnostic criteria to help discriminate among normal and abnormal (i.e. “pathological”) behaviors and symptoms. The 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) lays out explicit and specific guidelines for identifying and categorizing symptoms and diagnoses.
Clinical Definitions of Abnormal: The DSM
The DSM is a central element of the debate around defining normality, and it continues to change and evolve. Currently, in the DSM-5 (the fifth edition), abnormal behavior is generally defined as behavior that violates a norm in society, is maladaptive, is rare given the context of the culture and environment, and is causing the person distress in their daily life. Specifically, the goal of the DSM-5 is to identify abnormal behavior that is indicative of some kind of psychological disorder. The DSM identifies the specific criteria used when diagnosing patients; it represents the industry standard for psychologists and psychiatrists, who often work together to diagnose and treat psychological disorders.
As the DSM has evolved over time, there have been a number of conflicts surrounding the categorization of abnormal versus normal mental functioning. Much of this difficulty comes from distinguishing between an expected stress reaction (a reaction to stressful life events that could be considered “normal”) and individual dysfunction (symptoms or stress reactions that are beyond what a “normal” or expected reaction might be). As a result, the DSM explicitly distinguishes mental disorders and non-disordered conditions. A non-disordered condition results from, or is perpetuated by, social stressors. To this end, the DSM requires that to meet the diagnostic criteria for a mental disorder, an individual’s symptoms “must not be merely an expectable and culturally sanctioned response to a particular event; for example, the death of a loved one. Whatever [the pattern of symptoms’] original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual.”
That said, if an individual’s response to a particular situation is causing significant impairment in more than one area of the individual’s life (such as work, home, school environment, or relationships), it may be considered abnormal or an indicator of a psychological disorder regardless of its etiology.
It is important to analyze the societal consequences of diagnosis because so many people experience mental illness at some point in their lives. According to the World Health Organization (WHO), more than a third of people globally meet the criteria for at least one diagnosable mental disorder at some point in their lives. Unfortunately, stigma and discrimination can add to their suffering and disability. This has led various social movements to work to increase societal awareness and understanding of mental illness and challenge social exclusion.
A stigma is the societal disapproval and judgment of a person or group of people because they do not fit their community’s social norms. In the context of mental illness, social stigma is characterized as prejudiced attitudes and discriminatory behavior directed toward individuals with mental illness as a result of the label they have been given. In the United States, people are often pressured to be “normal”—or at least perceived as such—in order to gain acceptance by society. Society tends to be uncomfortable with “abnormality”—so if someone does not conform to what is perceived as normal, they might be given a number of negative labels, such as “sick”, “crazy”, or “psycho.” These labels lead to discrimination, marginalization, and isolation of—even violence against—the individual.
In a related issue, self-stigmatization is when someone internalizes society’s negative perceptions of them or of people they think are like them: they begin to believe, or fear that others will believe, that the negative labels and perceptions are true.
Effects of Stigma and Self-Stigma
This internalization contributes to feelings of shame and usually leads to poorer treatment outcomes. Experience of stigma or self-stigma can also lead to the following:
- Refusal to receive treatment. An individual’s fear of stigmatization and alienation may lead them to refuse treatment altogether. Anxiety about others’ perceptions and the social consequences that come along with a label of mental illness often deter people from seeking help in any therapeutic, familial, social, or pharmacological context.
- Social isolation. An individual with mental illness may avoid social settings altogether; for example, an individual struggling with depression may choose not to see or speak with friends and family for fear of “bringing them down” or “being a burden.” This is especially dangerous in light of the knowledge that social connectedness is one of the key factors in recovery from mental illness.
- Distorted perception of the incidence of mental illness. Although approximately one in three people will experience mental illness at some point in their life, there are still many people who do not acknowledge mental illness as a public health concern. By causing people to not seek out treatment, society’s stigma of mental illness leads to fewer diagnoses and fewer people getting help. This means that mental illness seems far less common than it actually is.
Stigmas are usually deeply ingrained in society over many years and so cannot be eradicated instantly. But with the rising awareness that mental illness affects so many people in the United States and globally, more and more is being done to reduce the stigma associated with such illnesses.
For example, the field of psychology has recently moved toward using deliberate person-centered language—referring to people as individuals with mental illness rather than mentally ill individuals. In this way, the language emphasizes the individual’s humanity and defines them as a person first, rather than defining them by their illness.
For instance, referring to someone as “the anorexic girl” has a different impact than “the girl with anorexia.” In the first example, the individual is entirely defined by the disorder; in the second, anorexia is a characteristic, but not a defining one. The same goes for “the student with ADHD,” “the child with autism,” and “the mother with depression”—each of these is far less stigmatizing than “the ADHD student,” “the autistic child,” and “the depressed mother.”
Classifying Abnormal Behavior: The DSM
The DSM guides the diagnoses of psychological disorders; it has been revised many times and is both praised and criticized.
Evaluate the pros and cons of the DSM system of classifying mental disorders
- The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification manual used by mental health professionals in the United States.
- The DSM contains a hierarchy of diagnostic criteria for every mental-health disorder recognized by the American Psychiatric Association.
- The DSM has been revised multiple times since the initial writing of the DSM-I (including the DSM-II, DSM-III, DSM-III-Revised, DSM-IV, DSM-IV-TR, and DSM-5).
- Some of the strengths of the DSM are that it helps develop evidence-based treatments and it affords consistency among clinicians, insurance companies, and other healthcare providers.
- The DSM has been criticized for its lack of reliability and validity in its diagnoses; basing its diagnoses on superficial symptoms rather than underlying causes; its distinct cultural bias; and a conflict of interest related to its relationship with pharmaceutical companies.
- comorbidity: The presence of one or more disorders (or diseases) in addition to a primary disease or disorder.
- neurosis: A mental disorder, less severe than psychosis, marked by anxiety or fear.
- psychodynamic: Of an approach to psychology that emphasizes the systematic study of psychological forces that underlie human behavior, feelings, and emotions, as well as how these might relate to early experience.
- psychosis: A severe mental disorder, sometimes with physical damage to the brain, marked by a distorted view of reality.
What Is the DSM?
Although a number of classification systems have been developed over time for the diagnosis of mental disorders, the one that is used by most mental health professionals in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published most recently in its 5th edition (known as the “DSM-5”) by the American Psychiatric Association in 2013.
The DSM is the standard classification manual of mental disorders and contains a hierarchy of diagnostic criteria for every mental-health disorder recognized by the American Psychiatric Association. The DSM is used by psychiatrists and psychologists, doctors and nurses, and therapists and counselors. It is used for individual clinical diagnoses, but its codes and criteria are also used in the collection of data about the incidence of different disorders.
The DSM is often considered a “necessary evil”—it has many flaws, but it is also the only widely accepted method of diagnosing mental disorders.
History of the DSM
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. Research and changing cultural norms have contributed to the DSM’s evolution over time.
The first version of the DSM was created in response to the large-scale involvement of psychiatrists in the treatment, processing, and assessment of World War II soldiers. The DSM-I was 130 pages long and listed 106 mental disorders, many of which have since been abandoned.
The DSM-I and the DSM-II are clear reflections of the strongly psychodynamic slant the field of psychology had at the time of their publication. Symptoms were not specified in detail for specific disorders, and many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis. Sociological and biological knowledge was incorporated in a model that did not emphasize a clear boundary between normality and abnormality.
Around this time, a controversy emerged regarding the deletion of the concept of neurosis. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the American Psychological Association’s (APA’s) board of trustees unless “neurosis” was included in some capacity; a political compromise reinserted the term in parentheses after the word “disorder,” in some cases. The DSM-III included more than twice as many diagnoses (265) as the original DSM-1 and was nearly seven times its size (886 total pages).
In this version, a clinical significance criterion was added to almost half of all the categories. This criterion required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
A “text revision” of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The DSM-IV-TR was organized into a five-part axial system.
- Axis I: Clinical disorders, such as depression and anxiety.
- Axis II: Personality disorders and/or developmental disorders (such as intellectual disabilities, formerly called mental retardation).
- Axis III: Physical issues that may impact mental health, such as diabetes.
- Axis IV: Psychosocial stressors, such as occupational problems.
- Axis V: A global assessment of functioning score (GAF), which provides a score of the person’s overall functioning from 1 to 100.
Perhaps the most controversial version yet, the DSM-5 contains extensively revised diagnoses; it broadens diagnostic definitions in some cases while narrowing definitions in other cases. Notable changes include the change from autism and Asperger syndrome to a combined autism spectrum disorder; dropping the subtype classifications for variant forms of schizophrenia; dropping the “bereavement exclusion” for depressive disorders; a revised treatment and naming of gender -identity disorder to gender dysphoria; and changes to the criterion for post-traumatic stress disorder (PTSD). The DSM-5 has discarded the multiaxial system of diagnosis of the DSM-IV, listing all disorders on a single axis. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (the GAF) entirely. Although DSM-5 is longer than DSM-IV, the volume includes only 237 disorders, a decrease from the 297 disorders that were listed in DSM-IV.
Strengths of the DSM
One of the strengths of the DSM is its use in researching and developing evidence-based treatments. Researchers use the DSM diagnoses to conduct studies and trials on patients, and this research determines which treatment approaches provide the most effective results. As studies get published, mental-health service providers learn how to incorporate the most evidence-based treatments into their practice.
Consistency and Insurance Coverage
The DSM also provides a common language for physicians, social workers, nurses, psychologists, marriage and family therapists, and psychiatrists to communicate about mental illness. In addition to providing a common language among practitioners, hospitals, clinics, and insurance companies in the US also generally require a DSM diagnosis for all patients treated. Providers must often use the DSM in order to get coverage for their clients from insurance companies, which require certain DSM diagnoses for treatment.
Weaknesses of the DSM
Reliability and Validity Concerns
The revisions of the DSM from the 3rd edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. Many diagnoses are so similar that there is a high rate of comorbidity between disorders.
Diagnoses Based on Superficial Symptoms
The DSM is primarily concerned with the signs and symptoms of mental disorders, rather than their underlying causes. It claims to collect them together based on statistical or clinical patterns. Furthermore, diagnostic labels can be stigmatizing for patients by creating stereotypes about certain diagnoses.
Current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Common criticisms include both disappointment over the large number of documented non-Western mental disorders still left out and frustration that even those included are often misinterpreted or misrepresented.
Medicalization and Financial Conflicts of Interest
It has been alleged that the way the categories of the DSM are structured and the substantial expansion of the number of categories are representative of an increasing medicalization of human nature. This has been attributed by many to the expanding power and influence of pharmaceutical companies over the last several decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest.
Because the DSM is a system of labeling, it is often criticized for contributing to the creation of social stigma against those with mental illnesses. In the context of mental illness, social stigma is characterized as prejudiced attitudes and discriminating behavior directed toward individuals with mental illness as a result of the label they have been given. Stigma and discrimination can add to the suffering and disability of those who are diagnosed with a mental disorder.
Preventing Psychological Disorders
Focusing on the prevention of mental illness, rather than only on treating existing mental illness, has numerous health and economic benefits.
Give examples of primary, secondary, and tertiary approaches to preventing psychological disorders
- Prevention of mental illness has a number of benefits, ranging from improvements in individuals’ well-being to positive economic and social changes.
- Risk factors for mental illness include both genetic and environmental influences.
- Prevention efforts involve assessing risk factors for mental illness. There are three levels of prevention: primary, secondary, and tertiary.
- Primary prevention targets individuals who are at high risk for developing a disorder based on biological, social, or psychological risk factors (e.g., teaching emotion-regulation skills to teens).
- Secondary prevention seeks to diagnose and treat a disorder in its early stages (e.g., rape crisis counseling).
- Tertiary prevention targets individuals who already have a disorder by seeking to reduce or eliminate the negative impact of the disorder (e.g., Alcoholics Anonymous, or AA).
- predisposition: The state of being susceptible to something, especially to a disease or other health problem.
- stressor: An environmental condition or influence that causes distress for an organism.
- intervention: The action of interfering in a course of events.
- primary prevention: Efforts to avoid occurrence of disease either through eliminating disease agents or through increasing resistance to disease. Examples in the context of physical health include immunization against disease, maintaining a healthy diet and exercise regimen, and avoiding smoking.
Prevention of mental illness has a number of benefits, ranging from improvements in individuals’ well-being to positive economic and social changes. The 2004 report of the World Health Organization (WHO) Prevention of Mental Disorders stated that “prevention of these disorders is obviously one of the most effective ways to reduce the [disease] burden.” Similarly, the 2011 European Psychiatric Association (EPA) guidance on prevention of mental disorders states that “There is considerable evidence that various psychiatric conditions can be prevented through the implementation of effective evidence-based interventions.”
Risk factors for mental illness include both genetic and environmental influences. Environmental influences include early childhood relationships and experiences (such as abuse or neglect), poverty, the effects of race and racism, and major life stressors (such as a breakup, the loss of a job, or the death of a loved one). Other risk factors may include family history of mental illness (such as depression or anxiety ), temperament, and attitudes (e.g., pessimism).
Some mental disorders have a genetic link. Usually this link is a predisposition to developing the disorder, which means that while an individual may be more likely than other individuals to develop it, there is no guarantee that they will. Primary prevention (discussed below) can help reduce the likelihood that a genetically predisposed individual will develop a given disorder.
Three Levels of Prevention
Prevention falls into three levels: primary, secondary, and tertiary. Primary prevention targets individuals who are at a high risk for developing a disorder; secondary prevention targets those who are in the early stages of a disorder; and tertiary prevention targets individuals who already have a disorder by seeking to reduce or eliminate its negative impact.
Primary prevention includes methods to avoid the occurrence of a disorder or disease altogether. Most population-based health promotion efforts are of this type. This method targets individuals and groups who have a high risk of developing a mental illness based on biological, social, or psychological risk factors. Primary prevention programs might include teaching parents effective parenting skills, distributing condoms to students who are at high risk for STIs or teen pregnancy, or providing social support to children of divorce. Research has found such programs to be highly effective, and financially speaking the cost of implementing such primary prevention programs is often much lower than the ultimate cost of caring for individuals after they have been diagnosed with the disorder or disease.
Secondary prevention includes methods to diagnose and treat a disorder or disease in its early stages before it causes significant distress. This approach also aims to lower the rate of established cases. An example of a secondary prevention program is rape crisis counseling. After being raped, an individual may develop or be in the early stages of developing a number of disorders such as depression, anxiety, or post-traumatic stress disorder (PTSD). Early intervention through counseling can help minimize the progression of one or more of these mental health issues.
Tertiary prevention includes methods to reduce the negative impact of existing disorders or diseases by reducing complications and restoring lost function. These methods include interventions that prevent relapse, promote rehabilitation, and reduce the nature of the disorder. Examples of tertiary prevention programs include Alcoholics Anonymous (AA), diabetes control programs, and home visits to those who are chronically ill.