Defining Abnormality

When you think of people who are suffering from mental illness, what images come to mind?  An angry, violent man screaming in a mental ward?  A hysterical woman crying in a therapist's office?   A person rambling on the street, who you might cross to the other side to avoid?

There is a long history of fear and misunderstanding around mental illness.  Labeling someone as "crazy" or "insane" is not usually a compliment.  Some have argued that labeling people as "mentally ill" does more harm than good.  We all have different minds, and perhaps our different ways of thinking and feeling ought to be respected, rather than feared.

On the other hand, it is undeniable that mental pain and suffering is a real experience.  If we can find a way to identify and treat people who are suffering from mental illness, than surely this would improve the lives of many people.  In order to do so, we first need to decide who is mentally normal, and who is mentally abnormal.  As you will see, this is far easier said than done, and continues to be a source of controversy within the field of Psychology.
Think Critically

Read a short description of six people below.  For each person, consider the following:

  • Is this person "normal" or "abnormal"?  Explain why

  • Do you think this person is in need of psychological intervention, like going to see a therapist or being prescribed psychiatric medication?  Why or why not?

  • Do you think that everyone would agree to your answers to the two questions above?  What could be a reason why someone else might think differently?

A. Mark is a 21-year old university student. He was raised in a religious Christian family, but has developed deep hostility and anger to his parents.  For the past two years, he has rebelled against his Christian family and worshiped Satan. He conducts rituals that involve killing small animals (like rats), sprinkling their blood on an altar, and chanting in praise of Satan.

B. Jerry is a 14-year high school student.  He has always felt “different” from other boys and has always spent more time with girls.  Recently, he has started to feel sexual attraction towards boys in his class. He has also begun to feel uncomfortable with his body, especially his penis.  He likes dressing up in girls’ clothes when nobody else is around.

C. Sarah is a 59-year old former housewife.  Nine months ago, her husband passed away from cancer.  Ever since the death, Sarah is been unable to feel any joy or happiness.  She rarely leaves the house, and frequently cries uncontrollably.

D.  Joy is a 32-old former model.  Ever since she turned 30, she has been extremely worried about aging.  She spends a great deal of time reading beauty magazines and anti-aging blogs, and has already had several cosmetic procedures in her attempts to look more youthful.

E.  Jack is a 45-year old construction worker.  He is clinically obese, but can’t seem to stop eating fast food and unhealthy snacks.  He has tried dieting several times, but always gives up after a few weeks and quickly gains all the weight back (and more).  Jack’s doctor warns him that if he doesn’t change his diet soon, he will likely have a heart attack.

F.  Jane is a 15-year old high school student whose behavior and dress is very different from other girls.  She dresses all in black, with studded boots and bracelets, and listens to dark goth and metal music. She has no friends at school, but doesn’t seem to mind.  She hangs out with older boys from other schools, and has recently started experimenting with illegal recreational drugs.
What is abnormal?

Did you find the above activity challenging?  Do you think that everyone would agree with your answers?  It should become apparent that your own beliefs and values play a role in deciding who is normal.  For instance, someone who is a religious Christian (or an animal rights activist!) might view Mark's behavior as abnormal, while an atheist might argue that worshiping Satan is just another form of religion, perhaps no better or worse than worshiping any other deity.

​So is there any fair, objective way to decide who is really abnormal, after all?  Here are three criterion that have been proposed as objective ways of defining abnormality.

A.  Statistical deviation from the norm

Perhaps the simplest and most objective way of defining abnormality, this criteria relies on simple Statistics.  If a person's behavior is similar to the majority of the population, that person is normal.  If, on the other hand, a person's behavior is very deviant and unusual, than that person is abnormal.  

Imagine a bell curve in which most people, who share common patterns of behavior, form the middle of the bell curve, representing normality.  On the other hand, people who act very differently lie on the extreme ends of the bell curve, representing abnormality.

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B.  Social norms criteria

Social norms are the "rules" of a society.  They can be written rules (like laws), or unwritten rules, like good manners.  For example, think of the "rules" for using the toilet.  For starters, no matter how urgent the situation may be, we are all expected to relieve ourselves only in bathrooms - doing so on a public street or park is a definitive no-no.  If it is a public bathroom, there will be a separate area for males and females, and we are expected to use the "correct" area.  There are also norms for how to clean ourselves afterwards - depending on the country, either using toilet paper, a spray hose, or a bucket of water - and how to dispose of any soiled toiled paper or tissue afterwards.

According to the social norms criteria of abnormality, therefore, anyone who follows social norms is "normal", while repeatedly violating social norms is "abnormal".  Abnormal behavior is simply behavior that goes against the rules that society has established for what is normal and acceptable.  And indeed, if you saw someone relieving them self in public, in clear view of others, you would probably question that person's mental health.


C.  Rosenhaun & Seligman's criteria for abnormality - MIS VOUV

In contrast to the two approaches above, which are simple and seemingly objective ways of defining normality and abnormality, Rosenhaun & Seligman's view of abnormality is more complex and nuanced.  They argued that there are seven criteria that characterize abnormal behavior, which are as follows:


  • Maladaptiveness - Behavior which makes life more difficult

  • Irrationality - The person is unable to communicate in a rational manner that is understood by others

  • Suffering -  The behavior causes suffering

  • Vividness / unconventionality - The person experiences reality in a unconventional way

  • Observer discomfort - The behavior makes other people uncomfortable

  • Unpredictability - The person's behavior is erratic and difficult to predict

  • Violation of moral standards - The behavior violates accepted standards for right and wrong

Try it Out

1.  Choose one of the criterion above (either statistical deviation, social norms, or MISVOUV)

2.  Apply that criterion to the six people described in the earlier activity.  According to your chosen criteria, is that person normal or abnormal?

3.  Do you think that your chosen criteria is reliable - in other words, would all observers, using the same criteria, reach the same decision about whether the person is normal?

4.  Do you think that your chosen criteria is valid - in other words, does it give the "right" answer about who is normal and who is abnormal?  Explain why
Difficulty in defining normal

As you may have realized, all the criterion discussed so far have some obvious shortcomings in defining normal and abnormal behavior.

The statistical deviation from the norm criteria is simple, reliable, and seemingly objective - it is based on statistics, not on values or beliefs.  However, it is far from adequate, because not all statistically unusual behavior is considered undesirable or problematic.  Take, for instance, a dedicated Mathematician, who spends most of her waking hours alone, working on a difficult proof that has yet to be solved.  This is clearly very unusual behavior, but few would consider it necessarily problematic.  The Mathematician may find her work engrossing and highly rewarding, and might someday be awarded the Nobel prize for her efforts - clearly not something to be discouraged!

The social norms criteria, much like statistics-based definitions, is also simple and reliable.  Most of us would agree on whether behavior has violated social norms or not.  However, social norms vary a great deal between one country and the next, and also evolve over time.  In some countries, for instance, eating pork or beef is a very serious violation of social norms.  However, it doesn't seem quite right to call such behavior "abnormal", especially when someone could simply hop on a plane, visit a different country, and find that behavior to be common

On the other hand, Rosenhaun and Seligman's MIS VOUV criteria seems to be a more nuanced, complex, and realistic way of understanding abnormality.  It perhaps is more accurate in reflecting the experiences of many people who suffer from mental abnormalities, and who often find their behavior to be maladaptive, a cause of suffering, and so forth.  However, this criteria also suffers from shortcomings. 

  • The criteria is more subjective than the others, as two people may come to different conclusions. 

  • It is not clear how many of the seven items must be met for a behavior to be considered abnormal. 

  • Many of the items are clearly related to social norms and judgments, which vary across time and place.  In some countries, for instance, homosexuality is illegal and subject to long prison sentences, or even death.  In such places, a gay person would meet many of the items - the behavior is maladaptive, linked to suffering, violates moral standards, and would cause observer discomfort - even though many people in more liberal countries would strongly reject the idea that there is anything abnormal with homosexuality


The Medical Model 

In the last 50 years, the field of Psychology has mostly settled on the medical model as a way of understanding abnormal behavior.  Most of what you have heard about different mental disorders - like depression, schizophrenia, and so forth -  is based on the assumptions of the medical model.   To better understand what the medical model suggests about abnormal behavior, watch the video below

As you watch the video below, consider the following:

  • According to the video, what is depression?

  • What are some of the symptoms of depression?

  • How should we behave towards someone who is depressed?
According to the medical model - as seen in the video above - the cause of abnormal behavior is a mental disorder, which includes depression, anxiety, eating disorders, and so forth.  Mental disorders are diseases, just like any other disease, except that they exist in the brain.  As the narrator in the video says, "Just because you can't see it, doesn't mean it isn't real".

The medical model was established with the publication of the first edition of the Diagnostics and Statistical Manual (DSMin 1952.  The DSM is a guide to all of the psychological disorders that are currently known within the scientific community.  The DSM lists the symptoms and behaviors associated with each disorder, and is used by psychiatrists to identify which disorder a person may be suffering from.  Every so often, a new version of the DSM is released, reflecting the latest scientific consensus about mental disorders.  The latest edition, the DSM V, was published in 2013, and gives information about 300 mental disorders.

The basic assumptions of the medical model include the following:

  • Abnormal behavior is a symptom of a mental disorder

  • Mental disorders are related to biological abnormalities in the brain.  For instance, depression is thought to be related to a lack of serotonin.  Mental disorders are often thought of as a "chemical imbalance" in the brain

  • Mental disorders are no different than other diseases.  Just as your heart or liver can carry a disease, so can your brain

  • Mental illness can be treated by correcting the biological abnormalities that caused the disorder.  For example, antidepressant drugs increase levels of serotonin in the brain, thereby treating depression

  • Normal behavior is simply the absence of any problems in the brain 


Evaluating the medical model

Most people agree that the medical model is a significant improvement in addressing abnormal behavior.  Before the medical model, people who behaved abnormally were often imprisoned, accused of being witches or possessed by evil spirits, or simply excluded from their communities.  Here are some of the strengths of the medical model:

  • Removes blame.  If someone was suffering from a broken leg, you wouldn't blame them for not being able to run very fast.  Similarly, the idea that mental disorders are real, biological illnesses, just like any other illness, removes much of the blame from the patient.  Rather than being angry at a depressed person who refuses to get out of bed, or asking them to just "try to be happy for once", understanding that depression is a disease leads to more understanding and less finger-pointing

  • Enables research into causes and treatments.  Once psychological disorders are understood as real illnesses - rather than just character flaws - scientists can begin studying the causes of these disorders, and most importantly, how they can be treated.  In fact, for some disorders, we now have some pretty good treatments - although, for other disorders, much work remains to be done.  Hopefully, with enough research, we will someday find effective and safe treatments for all mental disorders

On the other hand, there are some pretty strong criticisms and limitations of the medical model.  Watch the video below, in which Thomas Szas, one of the strongest critics of the medical model, explains why he thinks mental illness simply does not exist

Watch the video below of Thomas Szas, and consider the following:

  • What are some limitations of the medical model of abnormality?

  • Why does Thomas Sasz consider mental illness to be a "myth"?
​Some limitations of the medical model, as discussed by Thomas Sasz, include the following:

  • Uncertainty about which disorders are "real".    A controversial example is the huge increase in the number of children (mainly boys) who have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) in the United States.  Such a diagnosis is usually given to boys who display behavioral problems and lack of concentration in class.  Some argue that ADHD is a real mental disorder, while others think that the real problem lies in the school system itself, which expects young children to sit still and follow instructions obediently for long hours every day.  In fact, with every new edition of the DSM, there are arguments over which disorders are real mental illnesses, and which should be eliminated.

  •  No way to objectively diagnose mental disorders.  For most mental disorders, there is no way to objectively test who has the disorder, and who doesn't.  For example, there is no blood test or X-ray that can determine if someone is depressed or not.  This makes the process of diagnosis rather subjective and unreliable, and raises questions over what behavior should be considered abnormal.  For instance, what some people might consider a normal period of sadness, others might consider clinical depression.

  • Diagnosis can lead to stigmatization.  Calling someone "mentally ill" is not usually meant as a compliment.  Being labeled with a mental disorder can cause employers, family, friends or romantic partners to perceive you differently.  This is particularly worrisome in the diagnosis of children, who may face stigmatization by their peers, family and teachers, and who are often forced to take psychiatric medication, which may have serious side effects
Checklist

  • ​I can explain three different ways of defining abnormal and abnormal behavior:  statistical deviation from the norm, violation of social norms, and Rosenhaun & Seligman's criteria 

  • I can discuss limitations of each of the above criteria in defining abnormality

  • I can explain the medical model of psychiatry, including the assumptions on which the model is based, and the role of the DSM in defining what is abnormal

  • I can evaluate the strengths and limitations of the medical model of psychiatry
Quiz Yourself!


1.  In 2018, a 71-year old Frenchman named Jacques Savin attempted to cross the Atlantic Ocean in a barrel.  According to which criteria would this be considered abnormal behavior?

(a) Statistical deviation

(b) Violation of social norms

(c) Rosenhaun & Seligman's criteria

(d) the Medical Model


2.  Which of the following items is NOT one of Rosenhaun and Seligman's criteria?

(a) Unpredictability

b) Maladaptiveness

(c) Irrationality

(d) Harmfulness to others


3.  What is a limitation of BOTH the violation of social norms criteria and Rosenhaun & Seligman's criteria?

(a) Rare and unusual behavior is not necessarily problematic or cause for concern

(b) Social norms and moral standards vary across time and place

(c) It is not clear how many of the seven criteria must be met for a behavior to count as abnormal

(d) The reliability of the criteria is low


4.   Which of the following is NOT considered a strength of the medical model of abnormality?

(a) Diagnosis does not require invasive medical procedures

(b) Removes a sense of personal blame from patients

(c) Helps guide research into the causes of mental disorders

(d) Helps guide research into the treatment of mental disorders


5.  Thomas Sasz would likely agree with all the following statements, except for which one:

(a) Addressing the mental health needs of children can help them achieve their potential

(b) A disease is a biological abnormality, not a behavior

(c) It is unethical to force children to take psychiatric medication

(d) Labeling people with a mental disorder is often an attempt to control them
Answers

​1 - A, 2 - D, 3 - B, 4 - A, 5 - A