The concept of normality: A psychopathological approach · 11:59pm Nov 18th, 2013
What is madness: be the prancing knight
or following him as a shield-bearer?
Of the two of us, who is the real insane one?
The one which, awoken, dreams nonstop?
The one which, even blindfolded,
sees the real and follows the dream
of a madman by witches witched?
~ Carlos Drummond de Andrade
Psychotic Syndromes
Humour Disorders
Anxiety, Dissociative and Somatoform Disorders
Personality Disorders
Eating Disorders
The concept of normality: A psychopathological approach
Organic Mental Disorders
The concept of health and normality in psychopathology is a question of great controversy. Obviously, when dealing with extreme cases, with prolonged and intense behavioral and mental alterations, the line-making that separates the normal and the pathological isn't so problematic. However, there are many borderlines, in which a clear categorization between behaviors and the form by which they experience facts cannot be so easily be classified. In these situations, the concept of normality in mental health gains a special kind of relevance. As a side note: this problem isn't only related with mental pathologies, but with all fields of medicine; take for example the question of outlining the normal and pathological levels of blood pressure or blood sugar. The concept of normality in psychopathology also implicates the very same definition of what is a mental illness. These themes have each their own analysis, depending which area of mental health one is judging by. For instance:
1) Forensic psychiatry
The determination of psychopathological abnormality can have important legal, criminal and ethical repercussions, being able to define the social, institutional and legal destiny of a person.
2) Psychiatric epidemiology
In this case, the definition of normality is both a problem and an object of work and research. The epidemiology can contribute a lot towards the discussion and the better understanding of the concept of normality in health-related problems.
3) Cultural psychiatry (ethnopsychiaty)
Here, the concept of normality is a topic of great researches and debates. In a general way, the concept of normality in psychopathology imposes the analysis of the sociocultural context; it demands the study of the relation between the supposedly-pathological phenomena and the social context in which said phenomena presents itself, receiving that or this cultural significance.
4) Mental health planning policies
In this area, one should establish normality criteria, especially in the sense of verifying the attendance demands of a determined population group, the needs of the services, which and how many services must be placed at said group disposition, etc.
5) Professional orientation and qualification
These are important in the definition of capacity and adequacy of an individual to exert a certain task, such as manipulating heavy machinery, dealing with firearms, driving vehicles, etc. As an example, the case of individuals with cognitive deficits who wish to drive vehicles and people with psychotic symptoms that wish to bear firearms or individuals with epileptic crisis that manipulate heavy machinery, etc.
6) Clinical practice
In the process of clinical evaluation and intervention, it is very important to determine if such phenomena are pathological or normal, if they are but a part of a existential moment of the individual or if it is frankly pathological.
Normality Criteria
There are several normality and abnormality criteria in medicine and psychopathology. The act of adopting one or other depends on, amongst other things, the philosophical, ideological and pragmatic options of the professional. The main normality criteria utilized in psychopathology are:
1) Normality as the absence of a disease
The first criterion for health that is often utilized is the "absence of symptoms, signs or of a disease". According an expressive formulation of René Leriche (1936): "health is living with the silence of the organs". Normal, in a pychopathological point of view, would be, then, the individual that simply doesn't bear a defined mental disorder. Such criterion is very faulty and precarious for, not only it is redundant, but it also based on a "negative definition", that is, normality is defined not by what it supposedly is, but by what it isn't.
2) Ideal normality
The normality, here, is taken as a certain "utopia". An arbitrarily, ideal norm that is supposedly "healthy" and "more evolved" is established. Such norm is, in fact, socially implemented and referenced. It depends, thus, on arbitrary sociocultural and ideological values and, at times, dogmatic and doctrinal. Examples of such concepts of normality are those based in the individual's adaptation to the moral and political norms of a certain society (such as McCarthyism in the USA and the pseudo-diagnosis of political dissidents as mentally ill by the old Soviet Union).
3) Statistical normality
The statistical normality identifies norm and frequency. It is a concept of normality that applies solemnly to quantitative phenomena, with a certain statistical distribution in the general population (such as weight, hight, blood pressure, hours of sleep, the quantity of anxious symptoms, etc.). The normal starts being what is most often observed. The individuals statistically located "outside" (or at the extreme) of a normal distribution curve are then considered abnormal or ill. Most often it is a faulty criterion in general and mental health, as not all that is frequent is necessarily "healthy" and not everything rare or infrequent is pathological. Take, for instance, phenomena as dental cavities, presbyopia, light anxious and depressive symptoms, alcohol intake. All these phenomena are very frequent but, evidently, they can't a priori be considered healthy or normal.
4) Normality as the well-being
The World Health Organization (WHO), in 1946, defined health as the complete physical, mental and social well-being, not only the absence of a disease. It is a concept that is often criticized for being too vast and imprecise, after all, well-being is something hard to define objectively. Not only that, but this complete physical, mental and social well-being is so utopic that very few people would fit in the "healthy" category.
5) Functional normality
Such concept is based in functional aspects, not necessarily quantitative. The phenomena is considered pathological at the moment it becomes dysfunctional and brings suffering to the individual or its social group.
6) Normality as a process
In this case, the dynamical aspects of the psychosocial, disrupting and structuring development in a long term are considered. With it, crisis and certain changes inherent to a particular age group are also considered. This concept is very useful in pediatric, hebiatric, hebeatric and geriatric psychiatry.
7) Subjective normality
Here, a greater emphasis is given to the subjective perception of the individual itself, regarding its state of health, taking into account his subjective experiences. The weak point of this criterion is that many people feel well, "very healthy and happy", such as individuals in a manic episode (who indeed present a grave mental disorder.
8) Normality as freedom
Some authors with an existential and phenomenological orientation propose to conceptualize mental illness as the loss of an existential freedom (for instance, Henri Ey). This way, mental health would be connected to the possibilities of treading, with varying levels of freedom, over the world and their own destiny (using the term loosely). Inside this "spirit", psychiatrist Cyro Martins (1981) affirms that mental health could be seen, up to a certain point, as the possibility of having "a sense of reality; a sense of humor; a poetic sense towards life", attributes that would allow the individual to make their suffering and limitations, inherent to the human condition, "relative". And thus, they would be able to enjoy the smallest amount of freedom and pleasure that existence offers.
As we could see, in a general way, we could conclude that the normality and diseased criteria in psychopathology vary considerably depending on the specific phenomena with which one would work with and, also, in accordance with the philosophical options of the professional. However, in some cases, one could utilize the association of various normality and diseased criteria according to the objective one has in mind. Either way, this is an area of psychopathology that demands a permanently critical and reflective position.
I'm going to ramble a bit and less-than-eloquently relay my thoughts that are placed above with a surpassed scholarly analysis to my own dribble.
Normal and mental illness have the same connotations to me now as good and evil do. Allow me to explain myself before people begin to think I equate mental illness to "evil". If anything, normal is far more evil than any illness. It plagues the mind, does it not? This obsession with normal, what isn't normal, how to be normal and how to avoid the abnormal or how to make something abnormal normal... normality is a cult following in itself. Just as many borderlines to good and evil as there are normal to illness I'd imagine.
Normal, in this person's opinion, should stop being used as a status and instead be used as a selective adjective to situations. "It is normal for X to happen." "To feel this way about X is normal." I fear that being normal is far more dangerous than being abnormal and not nearly as profitable. It's... something I cannot profoundly articulate because I have no experience in such a field. Normal carries such a strong connotation these days that it's either the biggest relief to know something is normal or a stressor to know something is not normal.
I don't rightly know what I'm trying to say, so take nothing here for any serious after thought. Just... would the world be a better place if everyone wasn't so worried about trying to hit this nigh undefinable thing? I absolutely understand the importance and relevance to normality, but now I realize I'm asking a very social creature, us, to not worry about a thing that defines us. Oi vey.
I have no idea what I'm saying, I just wanted to ramble on normality...
This was informative....I guess.
I ascribe to the theory that mental irregularities become a problem when they impede on the person's ability to function in society and lead a happy, satisfactory, and enjoyable life.
1519511
I think I grasped what you wanted to say, Cosmic. Something like "people nowadays are so focused on the thought of being normal that end up creating a "kool kidz gr00p" just for those who are normal, leaving those that are less normal than then out". Basically the social merits of "normality" (social in the sense of what is more common to the general population).
While it does bring a good point on the topic of how alienated our society currently is, I have to take a step back and state that, for medical purposes, the distinction between "normal" and "abnormal" is of great importance (bold'd, cursive'd and underline'd!!). Moreso in the psychopathological field (nope, I'm not biased towards psychiatry. Nu-uh.
). It dictates, as dear Whiteeyes stated, a mode of functionality. If a person is able to operate on a society. This is a constant debate in psychiatry which has been addressed in the DMS-V (it should be noted that I only save my semen for the ICD 
); especially when regarding to personality disorders.
Nowadays, we stop trying to "bend the patient in order to fit the mold" and we let the mold adapt to the patient. In a therapy session, we will address what the patient (and/or its relatives) claims, trying to see them as a whole instead of focusing on a particular disease just to prescribe-what-has-been-hardcoded-in-your-brain-as-the-optimal-drug-just-to-make-them-stop-talking-oh-my-god-I-still-have-30-more-patients-today-fuck-my-life.
With the DSM V; along with the changes on other chapters, we also have what we call "traits". One doesn't need to fit on, say, anti-social personality disorder criteria-per-criteria in order to receive treatment. If we observe some traits that are impeding this person to be well adjusted, we will focus our attention on said traits.
This also falls on the pitfall of "then what should be addressed?!" and the answer is: what is abnormal. Then we return to the first topic; on the concept of normalcy. In my slightly-but-not-really-all-that-educated opinion, normalcy should allow the individual to establish who he/she is, without taking away a little malleability from his/her personality away, as long as said person remains socially functional. This brings yet another discussion on the merits of social functionality
and the horrors of how capitalism is influencing psychiatry.I crossed this last part for comedic purposes. Social functionality, to me, relates to what anarchists like Mr. Chaz Bufe and Mrs. Emma Goldman call "positive freedom", or "the freedom to" (a shout out for my friend DarkInnocence for helping me get enlightened). Of course, on some pathologies, the patient still maintains his/her volition to; but I should just add that this freedom should come with:
)
A) The ability to make informed choices.
B) The ability to perceive the full consequences of such choices (basically, weigh pros and cons).
(Funnily enough, this anally ravages the concept of statistical normality without prior lubricant administration, as most people in this world will not fit the criteria; and now we're back to where your comment started.
Now, let's stop before I have to
fail trying todefine "logic" by a delusional person's point of view.1519798
I was expecting some kind of discussion, but thanks... I guess.
1524397
And you'd be correct. This is a very popular concept for normalcy in psychopathology and I do believe that it is the most used one. It is, however, not completely rid of pitfalls... I dislike the second part of it: "[...]and lead a happy, satisfactory, and enjoyable life". Take a type 1 bipolar in a manic phase, for instance: this person will feel great. Wonderful. Often, these patients present delusions with mythical content, believing themselves to be deities or filthy rich! No matter how happy they are, they aren't on their right minds.
It is very common for a bipolar in mania to sink the entire family in debts due to a delusion forcing him/her to believe that he/she is the richest person in the globe. Or, for instance, acquire several sexually-transmitted diseases, as they go out and make sweet tender love to everyone out there (in a case I was present when my teacher carried the interview, a bipolar man managed to have sex with 40 different people on the same day; I was left speechless).
And they feel happy by doing so. Hence why mania/euphoria is also colloquially called, much to Owlor's delight, pathological happiness.
In short: the first part of what you said is very correct (and a reason as to why I like this criterion a lot), the second makes me a little... reserved, shall we say, for the reasons presented above.
1525431 Except that such a person doesn't meet my criteria. Yes they are happy, but that's just an emotional state (which is still important). There is still the matter of being satisfactory, achievement of accomplishments as a factor of self worth. A lack of respect or satisfaction in ones own life would, in my belief, be motivation for a fugue or delusions of grandure symptoms, as well as fuel for depressive episodes. In addition, such a life would not be enjoyable, i.e. it would cause the person substantial problems; it does not matter that their state renders them unaware of it. In fact it makes it worse as they are rendered unable to work towards an enjoyable state of being.
As such a manic person would live a happy life, but would not have satisfaction or enjoyment.
1527346 Yes, I get what you're saying. How someone with mania would, although appearing happy and feeling happiness, wouldn't lead a... substantial life (completely oblivious to the fact, to boot). And that is completely true! Even though they would feel satisfaction, enjoyment and a gigantic feeling of self-worth, they would cause much pain and grief to everyone close to them. A manic state isn't solely emotional. It always, always carries delusions of grandeur with them, affecting the person's cognitive levels (so much that schizophrenia is a differential diagnosis).
Now, remember what delusions are? They have three core-characteristics, independent of the type (mystical, of ruin, of grandeur, etc.):
- It is irreducible to logic.
- It is not shared.
- It is unreal.
The patient will believe and live his/her life according to their delusion. In a manic state, grandeur and a little bit of paranoid (as they feel as if all their loved ones are trying to make them stop because they're either jealous or they want to steal their money) delusions will manifest. This really will make the person feel not only happiness, but every pleasant emotion and thoughts towards him/herself! The person literally becomes "The man/woman".
I do agree with you that these people aren't really normal (using the crude definition of it, I guess). But to say that they aren't happy and they do not feel satisfaction or enjoyment would be a big misunderstanding.
I also don't agree with the "lack of respect or satisfaction in ones own life would, in your belief, be a motivation for delusions of grandeur symptoms". Well, to put it simply, when we talk about bipolar disorders, there is much more genetic influence than environmental. Sure, there is environmental, but that only serves as a trigger for symptoms of an already-established condition, not a means for the condition to establish itself.
I do agree, however, with it being able to fuel depressive episodes (even psychotic episodes, depending on the person's vulnerability and the amount of stress they are experiencing) and fugue symptoms.
1529221 So bipolar disorder is mainly genetic? That's good to know, it's hard to keep track of which ones are environmental and which are genetic...especially as they seem to change their minds or make exceptions to the rules so often (at least from an outsider perspective).
1529369 Well, what can I say? New studies are made daily and we ought to change our views according to what evidence points us towards. Given that it is a correct study, that is.