Final lecture notes: HOW DO WE DETERMINE WHO’S NORMAL? What constitutes normal behavior? Context, of course. Determining normal behaviors depends in part on particular place/time. While there are some constants, for the most part behavioral norms/socialnorms are always shifting. Social norms: help us distinguish who is “included” and who is “an outsider.”Who is behaving appropriately? Who isn’t – and what do we do about it? How do we really decide what’s normal behavior, or what’s seen as weird, deviant, or a sickness? Excerpted from an article by a young psychiatrist, just beginning his medical career: I’ve been thinking a good deal about normality lately. It’s a concern in the medical world. The complaint is that doctors are abusing the privilege to define normal. Ordinary sadness, critics say, has been labeled depression. “Boyishness” (or being very active), wanting to run and jump. Is this “normal” behavior .. or is it ADHD?Has a diagnosis of social phobia replaced ordinary shyness?There are plenty of books that document this transition. Just a few:The Loss of Sadness: How Psychiatry Transformed Normal Sadness into Depressive Disorder.Shyness: How Normal Behavior Became a Sickness.Back to Normal: Why Ordinary Childhood Behavior Is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum DisorderThe Last Normal Child.delves deeply into the factors that drive the epidemic of children’s psychiatric disorders and medication use today, questioning why these medications are being sought, and why Americans use more of these drugs with children than is used in any other country in the world.These books and more challenge what critics refer to as psychiatry’s narrowing of the normal.According to the young psychiatrist: The fate of normality is very much in the balance. As the number of mental disorders has increased over the years … some people talk in terms of a PSYCHIATRIC POWER GRAB.Have the mental health professionals taken over? The pharmaceutical companies?Have they become the new arbiters of defining who or what is normal?Which leads to another complaint … that we in the United States are overmedicated. That we’ve narrowed healthy behavior so dramatically that our “quirks” and eccentricities have become problems that we need to fix. And in many cases, that we expect drugs to fix. Some of the harshest CRITICS complain that often doctors medicate patients who meet no diagnosis at all.
They call it COSMETIC PSYCHOPHARMACOLOGY. Which is a fancy way of saying trying to “fix” someone who at one time would have been described as perfectly normal – say someone who is insecure, lacking confidence. Less than ideal, perhaps … but abnormal? Today … there’s therapy for that. There are drugs for that. So many behaviors that used to fall within the realm of normal now have LABELS that we’ve all become familiar with. EXAMPLE: A wife complains that her husband lacks empathy. Does he have Asperger’s syndrome? (Which actually is no longer called Asperger’s. Now we would say he’s on the Autism spectrum)Or perhaps he’s a guy who just doesn’t get it? Doesn’t see human interactions in the same way that more socially aware people do.His wife might say that he just doesn’t recognize social cues the way that most women do. Of course, this isn’t all bad.
Labels are important.
Diagnoses can bring relief. Parents who once might have considered their child slow, or not very bright, may be comforted by a diagnosis of dyslexia. And really … wouldn’t we rather have the label of dyslexia than the accusation that a child is stupid. Or lazy? According to the latest Diagnostic and Statistical Manual– the “psychiatric bible” – the DSM-5 … it’s likely that almost 50% of Americans will have a diagnosable mental illness in their lifetime. We could say … the latest version of the DSM makes it even “easier” to get a diagnosis. *****If we think of having a diagnosable mental illness as being under a tent, the tent seems pretty big. Huge, in fact. How did it happen that half of us will develop a mental illness? 1. Has this always been true, and we just didn’t realize how sick we were—we didn’t realize we were under the tent? 2. Or are we really mentally less healthy than we were a generation ago? 3. OR perhaps this is due to a third explanation … that we are labeling as mental illness, psychological states that were previously considered normal, albeit unusual, making the tent bigger. The answer appears to be all three.FIRST: we’ve gotten better not only at detecting mental illness but doing so earlier in the course of the illness. Better/earlier detection results in better treatment options. SECOND: some studies suggest that we’re not just diagnosing better .. but that we really are getting “sicker.” They point to comparative studies over time. But fundamentally flawed – maybe people didn’t admit to how they felt, didn’t seek treatment. But … THIRD: There’s another explanation for the higher rate of mental illness. One that implies CULTURAL SHIFTS.
What was once considered psychologically healthy (or at least not unhealthy)may now constitute a diagnosable mental illness. “Normal” behavior now seen as pathological. Thus, the actual definition of mental illness has broadened, creating a bigger tent with more people under it. This explanation strongly suggests that we, as a culture, are more willing to see mental illness in ourselves and in others.Whatever the cause we do know …That each edition of the DSMhas increased the overall number of disorders. And remember, the DSM is the book that defines mental illness. DSM-I – 1952 = 106DSM-III – 1980 = 265DSM-IV= 297 The people who created the DSM-5 were determined to not add any disorders .. but they did categorize them differently (265 – but that doesn’t count sub-categories) One example of a disorder included in the latest edition is called “caffeine intoxication.”This is characterized by at least 5 symptoms experienced after consuming the equivalent of 2 or 3 cups of coffee. These might include: restlessness, gastrointestinal problems, difficulty sleeping, nervousness, and rapid heartbeat. To meet the diagnosis, the symptoms must impair functioning in some way. A Time Magazine article a few years ago cried out: “Caffeine Withdrawal is Now a Mental Disorder.” Sub-titled: Does it really belong in a guide devoted to mental disorders?According to one critic: “It’s hard to believe that an episode of too much coffee or Red Bull constitutes a mental disorder. But guess what – it does! With disorders like this in the DSM, he continued, it’s no wonder that half of Americans will have a diagnosable disorder in their lifetimes. The wonder is why more Americans won’t! TheDSMcontinues to nibble at the edges of “normal” by reclassifying patterns of thoughts, feelings or behaviors that were previously considered normal (albeit perhaps weird or odd). At the same time, it has lowered the threshold of what it takes to be diagnosed with a given disorder. For instance: the criteria for “generalized anxiety disorder,” something that involves excessive and persistent worrying.A previous version of the DSM required 3 out of 6 symptoms for diagnosis, where now only one symptom is needed.Formerly the symptoms needed to last for 6 months .. now they only need to persist for 3 months. So, if you are excessively worried for three months about your finances or your health or that of a family member (to the point where you can’t control the worries), you could be diagnosed with this disorder, whereas in the past you wouldn’t have been. One result of a bigger mental illness tent is that there are fewer people actually standingoutsidethe tent. If we continue in this direction – if it takes fewer symptoms or less severity to meet the criteria for diagnosis – increasing #s of people will qualify. There are, and probably will continue to be, fewer and fewer people who will live their
lives in relatively good mental health according to theDSM.The normal trials and tribulations of life—the periods of sadness, or worry, of anxiety, or grief, or difficulty sleeping, or drinking too much caffeine or having caffeine withdrawal headaches—have been pathologized. More “normal” thoughts, feelings, and actions now merit a diagnosis. Providing a bigger tent for mental illness leaves us with an increasingly restricted definition of mental health and can make us all more likely to see mental illness when perhaps it’s just normal human struggle. We can become so used to seeing psychopathology that we think—erroneously—that being odd or having difficulties must be an expression of mental illness – rather than just an accepted part of life.What else is going in our culture that allows for this expanding definition of mental illness? Insurance. Pharmaceutical companies. Increased work demands. Instant gratification.