Concept of normality in psychiatry

Concept of Normality in
Psychiatry
Presenter- Dr. Sakshi Bhardwaj
MD Psychiatry
PGIMS, Rohtak

Flow of seminar
0 Introduction
0 Why should the clinician care about clarifying the
normal–disordered boundary?
0 Historical concepts
0 Perspectives of Normality
0 Models of mental health
0 Effect of psychiatric classification
0 Conclusion

Introduction
• Concept of normality is central in medical sciences.
• Etiology, prevalence figures, diagnosis, and treatment
all rely on ability to identify individual’s behavior
abnormal which require diagnosis and treatment.

What is Normality
0 Normality has been defined as patterns of behavior or
personality traits that are typical or that conform to some
standard of proper and acceptable ways of behaving.

Normality=Mental health=Absence of
disease ????????????????

Definition of Mental Health
A state of well being in which the individual realizes his
or her own abilities, can cope with the normal stresses of
life, can work productively and is able to make a
contribution to his or her community.
WHO definition
 It is not merely the absence of mental disorder.

Positive
Mental
Health
“Average" is not
healthy
Geography,
culture, and the
historical
moment
Contamination by
values
Trait or state

0 “Mental illness” is defined as-
A substantial disorder of thinking, mood, perception,
orientation or memory that grossly impairs judgment,
behaviour, capacity to recognise reality or ability to meet
the ordinary demands of life, mental conditions
associated with the abuse of alcohol and drugs, but does
not include mental retardation which is a condition of
arrested or incomplete development of mind of a person,
specially characterised by subnormality of intelligence.
Mental Health Care Act,2017

Why should the clinician care about clarifying the
normal–disordered boundary?
0 Negative mental states…sadness, despair, anxiety, fear,
agitation, and anger can be normal responses to life’s
vicissitudes.
0 Mental health professionals are routinely consulted.
0 Becomes duty of the clinician to differentiate normal
from abnormal.
Wakefield et al,2013

0 Overlap between the symptoms of normal suffering
and of mental disorders, lead to false-positive
diagnoses of normal suffering as mental disorder.
0 This distinction ensure appropriate treatment for those
people who need it and protect people without a
mental disorder from receiving aggressive treatment
and stigma.

 It sounds easy to differentiate but consider “one flew
over the cukoos nest” and “Rosenhan’s study”.
 They demonstrate how difficult it is to prove your
normality.
 Rosenhan argued that psychiatry could not even
distinguish between those who were normal and those
who were insane.

4 ways to
comprehend
normality
Adjustment/
Maladjustment
Social context
Wellbeing/
Discomfort
Subjective
experience
Statistics normal/
abnormal
Health/Illness
Scientific
principles
Jaramillo et al, 2015

Adjustment/Maladjustment-
 According to the adjustment criterion of mental health,
who adjusts to the dominant rules, does not show
serious problems and does not give serious problems
to others is considered normal.
 Considered as socially adjusted.

 On the contrary, those people who-
 Deviate totally or partly from the established social
norms, set by the community
 Generating disruptive behavior
 Do not conform to that is expected by most
 Considered as maladjusted/ lacking mental health and
require professional intervention.

Health/illness –
 Determined by biological factors under the medical
model.
 Most physicians equate normality with health and view
health as an almost universal phenomenon.
 As a result, behavior is assumed to be within normal
limits when no manifest psychopathology is present.

Statistics normality/ statistics abnormality
 Statistical notion suggests that the behaviors that
frequently occur in a population are normal, while
infrequent behaviors are abnormal.
(Rogers & Pilgrim, 2010)

Wellbeing/discomfort-
 Related with the assessment that subjects make about
their own life experiences.
0 Welfare allows the subject to give a subjective
experience of intrapersonal, interpersonal, social and
environmental integration.
0 Discomfort indicates a rupture of the subject with
himself, with others or with some aspect of family life
(work, family, social, environmental) that causes
suffering or displeasure.

Historical Concepts
0 There has been an assumption that mental health could
be defined as the-
 Antonym of mental illness.
 Absence of psychopathology and
 Synonymous with normal.

0 Adolphe quetelet
 Published the first book
on normality in 1835.
 Rather than focus on pathology,
he tried “to approach what is good and
beautiful”.
 His goal was the statistical analysis
of healthy humans.

0 After World War II, In1941 John clausen and his
coworkers were commissioned to assess mental health
for the draft board.
 They focused on the absence of psychosomatic
symptoms.
0 Many post war psychiatrists agreed with Freud, who
had dismissed mental health as “an ideal fiction.”

0 In the late 1950s –
 “There is no general definition of normality and
mental health from either a statistical or a clinical
viewpoint.”
Fritz Redlich,1957
 “Mental health is an invincibly obscure concept.”
Aubrey Lewis,1958

0 Mentally healthy individuals should be-
(1) In touch with their own identity and feelings.
(2) Oriented toward the future
(3) Their psyches should be integrated and should
provide them resistance to stress.
Marie Jahoda,1958

(4) They should possess autonomy and should recognize what
suits their needs.
(5) They should perceive reality without distortion and should
possess empathy.
(6) They should be masters of their environment-able to work,
to love, to play, and to be efficient in problem solving.

0 Menninger psychotherapy project- 1954
 Quantitative longitudinal study, 42 patients
 Goal was to study what happened in the course of treatment
and changes in the patient.
 Devised Health-Sickness Rating Scale [HSRS] to assess
psychological functioning on a scale of 0 to 100.
 A score of 95 to 100 reflected “an ideal state of complete
functioning integration, of resiliency in the face of stress, of
happiness and social effectiveness.”

 In 1976, HSRS was revised and named as the Global
Assessment Scale (GAS) which was further modified
to Global Assessment of Functioning (GAF).
 By 1978 The Report to the President by the
President's Commission on Mental Health introduced
the importance of defining mental health clearly.

Perspectives of Normality
0 Mainly two broad categories:
 Functional perspectives of normality
 Psychoanalytic theories of normality

Functional perspectives of normality
0 Described by Daniel Offer and Melvin Sabshin
0 Four functional perspectives.
0 Each perspective is unique and has its own definition
and description.
0 The perspectives complement each other.
0 They represent the totality of the behavioral science
and social science approaches to the subject.

Four functional perspectives are as follow-
0 Normality as health
0 Normality as utopia
0 Normality as Average
0 Normality as process

Normality as utopia
0 Conceives normality as the harmonious blending of the
diverse elements of the mental apparatus that lead to
optimal functioning.
0 This approach can be traced back to Sigmund Freud,
who stated that, “A normal ego is like normality in
general, an ideal fiction.”

Normality as Average
0 Is based on a mathematical principle of the bell-shaped
curve.
0 This approach considers the middle range normal and
both extremes deviant.
0 Variability is described only within the context of
groups, not within the context of the individual.

Normality as process
0 States that normal behavior is the end result of
interacting systems.
0 This perspective stresses changes or processes rather
than a cross-sectional definition of normality.
0 A typical example is Erik Erikson's conceptualization
of personality development and the developmental
stages essential in attaining of mature adult
functioning.

Psychoanalytic theories of personality
0 Heinz Hartmann-
 Conceptualized normality by describing the “autonomous
functions of the ego”.
 These are present since birth that develop independently of
intrapsychic conflict between drives and defenses.
 These functions include perception, learning, intelligence,
intuition, language, thinking, comprehension, and motility.

0 Melanie Klein
 Normality is characterized by
strength of character, the capacity
to deal with conflicting emotions,
the ability to experience pleasure
without conflict, and the ability to
love.

0 Karl Jaspers
 Described a “personal world”- the way a person thinks or
feels ”that could be either normal or abnormal”.
 The personal world is abnormal when:
1. It springs from a condition that is recognized
universally as abnormal, such as schizophrenia.
2. It separates the person from others emotionally.
3. It does not provide the person with a sense of
“spiritual and material” security.

0 Erik Erikson-
 Normality is the ability to master the periods of life.
 Trust vs. Mistrust
 Autonomy vs. Shame and doubt
 Initiative vs. Guilt
 Industry vs. Inferiority
 Identity vs. Role confusion
 Intimacy vs. Isolation
 Generativity vs. Stagnation
 Ego integrity vs. Despair

0 Karl Menninger-
 Normality is the ability to adjust to the external world
and to master the task of acculturation.
 Acculturation explains the process of cultural change
and psychological change that results following that.

0 Alfred Adler-
 The person's capacity to develop social feeling and to
be productive is related to mental health; the ability to
work heightens self-esteem and makes one capable of
adaptation.
0 Otto Rank-
 Normality is the capacity to live without fear, guilt, or
anxiety and to take responsibility for one's own
actions.

1,2
• Mental health as above normal
• Mental health as positive psychology
3,4
• Mental health as maturity
• Mental health as socioemotional
intelligence
5,6
• Mental health as subjective well-being
• Mental health as resilience
Models of Mental Health

Model B: Mental Health As Positive Psychology
0 Psychologists approached mental health differently from
psychiatry which led to the second model.
0 They focus at continua (traits) rather than categories.
0 The medical goal of using medication to remove pathology is
different from the psychologists' goal of fostering joy,
enthusiasm, curiosity, and love for others in an educative
model.
0 Positive psychology give insights to learn how to build the
qualities that help individuals and communities to survive and
to flourish.

0 According to Seligman-
 At the individual level, it is about positive individual traits.
 The capacity for love and vocation
 Courage
 Interpersonal skill
 Perseverance, forgiveness, originality, future mindedness
 Spirituality, high talent, and wisdom.
 Positive psychology tries to adapt what is best scientific method
to the unique problems that human behavior presents.

0 The concept of optimism is important to positive mental
health that asserts that-
 Good things last forever and are pervasive while bad things
are limited and unlikely to happen again.
 Longitudinal studies reveal that it improves physical health
and wards off depression.
0 Positive psychology have divided positive mental health into
four components: talents, enablers, strengths, and outcomes.

0 Talents - Inborn and genetic, not much effected by
intervention (e.g., high IQ or being an easy baby).
0 Enablers- reflect benign social conditions, interventions,
and environmental good luck (e.g., a strong family, a
good school system); enablers can be modified to
enhance strengths.
0 Strengths- are character traits such as curiosity and
openness that reflect facets of mental health that are
amenable to change.
0 Outcomes- reflect dependent variables (improved GAF,
social relationships, and subjective well-being) that can
be used to provide evidence for the predictive validity.

Model C: Mental Health as Maturity
0 The adult mental health reflects a continuing process of
maturational unfolding.
0 Therefore, the assessment of positive mental health
requires almost a lifetime.
0 The association of mental health to maturity is probably
mediated not only by progressive brain myelination into
the sixth decade but also by the evolution of emotional and
social intelligence through experience.

0 In Erikson's model the adult social radius expanded
over time through the mastery of certain tasks such as:-
 Identity versus Identity Diffusion
 Intimacy versus Isolation
 Generativity versus Stagnation and
 Integrity versus Despair.
0 Vaillant has added two more tasks-career
consolidation and keeper of the meaning to Erikson's
four.
0 The mastery of such tasks appears relatively
independent of education, gender, social class, and
culture.

A schematic model of the expanding social radius
of maturing individuals during adulthood.

IDENTITY
0 It requires mastering the last task of childhood: sustained
separation from social, residential, economic, and
ideological dependence on family of origin.
0 Such separation derives as much from the identification
and internalization of important adolescent friends and
nonfamily mentors as it does from simple biological
maturation.
0 For example, our accents become relatively fixed by age
16 years and reflect those of our adolescent peer group
rather than the accents of our parents.

Intimacy
0 Intimacy permits young adults to become reciprocally
involved with a partner.
0 The relationship may be with a person of the same gender;
sometimes completely asexual and sometimes, as in
religious orders, the interdependence is with a community.
0 The mastery of intimacy may take very different forms in
different cultures and epochs.

Career consolidation
0 It is usually mastered together or follows the mastery of
intimacy.
0 It permits adults to find a career as valuable as they once
found play.
0 There are four crucial developmental criteria that transform a
"job or hobby into a "career: " Contentment, compensation,
competence and commitment.
0 Schizophrenics, individuals with severe personality disorder
often manifest a lifelong inability to achieve intimacy or
sustained, gratifying employment.

Generativity
0 The demonstration of a clear capacity to care for and guide
the next generation.
0 It can be serving as a consultant, guide, mentor, or coach to
young adults in the society.
0 It reflects the capacity to give the self; finally completed
through mastery of the first three tasks of adult development.
0 It’s mastery is strongly correlated with successful adaptation
to old age.

Keeper of the meaning
0 The penultimate life task is to become a keeper of the
meaning.
0 Like grandparenthood, this task involves passing on
the traditions of the past to the future.
0 The focus of a keeper of the meaning is with
conservation and preservation of the collective
products of mankind—the culture in which one lives
and its institutions—rather than with just the
development of its children.

Integrity
0 Finally, in old age it is common to feel that some life
exists after death and that one is part of something greater
than one’s self.
0 The task of achieving some sense of peace and unity with
respect both to life and to the whole world.

Model D: Mental Health As Socioemotional
Intelligence
0 Aristotle defined socioemotional
intelligence as follows:-
“Anyone can become angry—that is easy.
But to be angry with the right person, to
the right degree, at the right time, for the
right purpose, and in the right way—
that is not easy.”

Primary
emotions
Anger
Fear
Excitement
Interest
Surprise
Disgust
Sadness

0 Empathic children are more popular than their peers.
0 They acknowledges what kind of behavior
is expected, being able to wait, and knowing
how to get on with other children.
0 The more one is skilled in empathy,
the more one will be valued by others, and
so the greater will be social supports,
self-esteem, and intimate relationships.

0 Social and emotional intelligence can be defined by the
following criteria:
 Accurate conscious perception and monitoring of one's
emotions.
 Modification of emotions so that their expression is
appropriate.
 Accurate recognition of and response to emotions in others.
 Skill in negotiating close relationships with others.
 Capacity for focusing emotions (motivation) toward a desired
goal.

Model E: Mental Health As Subjective
Well-being
0 It is not just the absence misery, but the presence of
positive contentment.
0 Subjective happiness can have maladaptive as well as
adaptive facets.
0 Happiness that comes from joy or from unselfish love, self-
control and self-efficacy, play and “flow” (deep but
effortless involvement) reflects health.

0 Illusory happiness is seen in the character structure
associated with bipolar and dissociative disorders.
0 Examples of maladaptive “happiness” can be the
excitement of risk taking, from being “high” on drugs
and from “turning-on” to any unmodulated but
gratifying primitive need like binge eating, tantrums,
promiscuity, and revenge.

Model F: Mental Health As Resilience
0 In 1856, Claude Bernard, a French physiologist imporved
the understanding of positive health when he wrote-
“We shall never have a science of medicine as long as
we separate the explanation of the pathological from the
explanation of normal, vital phenomena.”
0 It is not stress that kills us, but healthy mastery of stress that
permits us to survive.

0 In 1925, Adolf Meyer, asserted that there were no mental
diseases, there were only characteristic reaction patterns to
stress.
0 Meyer's point was that although adaptive mental “reaction
patterns” like denial, phobias, and even projections can
appear to reflect illness, they are in fact be “normal, vital
phenomena” related to healing.
0 Involuntary coping mechanisms heal by distorting mental
processes.
0 Mental illness are the outward manifestations of homeostatic
struggles to adapt to life.

0 Three broad classes of coping mechanisms that humans use
to overcome stressful situations:-
0 First, individual elicits help from appropriate others or
consciously seeking social support.
0 Second, there are conscious cognitive strategies that
individuals intentionally use to master stress.
0 Third, there are adaptive involuntary coping mechanisms
(often called “defense mechanisms”) that distort our
perception of internal and external reality in order to reduce
subjective distress, anxiety, and depression.

Effect of DSM classification
Transforming normality into pathology??

0 Revisions in DSM classification system were accompanied by a
continuous increase in the number of mental disorders.
0 Allen Francis, Professor of Psychiatry at Duke University,
argued that lowering the threshold for psychiatric diagnoses
would lead to an undue increase in the number of persons
labelled in such a way, with corresponding consequences not
only to them but also to the health care system itself.
Wulf Rossler,2013

0 The first two editions of DSM used vague definitions
of disorders.
0 Neither clinicians nor researchers could make reliable
use of these definitions, causing their classifications to
be idiosyncratic and vary widely across individual
psychiatrists.
0 DSM III- “Diagnostic Psychiatry”
 Several hundred specific definitions of various types of
mental illnesses were listed that relied on the
characteristic symptoms of each entity.

0 The subsequent editions of the DSM have all included a
heavy symptom based pathology diagnosis system.
0 DSM treat both the natural stress process and individual
pathology as mental disorders.
0 DSM IV definition of mental disorder makes the appropriate
distinction between mental disorders and non disordered
conditions that result from and are maintained by social
stressors.

0 According to the DSM-IV, Mental disorders “must not be
merely an expectable and culturally sanctioned response to
a particular event, for example, the death of a loved one.
0 This definition limits mental disorders to conditions that
are dysfunctions in the person and excludes conditions that
are proportionate responses to social stressors.
Allan V. Horwitz,2007

0 DSM-5 - In Section 2, mental disorders are grouped
into 22 diagnostic categories.
 Polythetic criteria
 Primarily relies on a categorical approach to diagnosis.
 Clearly states that every diagnostic criteria set must
satisfy the requirements set by the definition of mental
disorder to validly identify disorders.
 Absence of multiaxial system
Meghan et al,2015

 DSM-5 obscures the already fuzzy boundary and will
lead to over diagnosis and mistreatment.
 Disruptive mood dysregulation disorder (DMDD)
diagnosis requires multiple temper outbursts each
week for a year inconsistent with developmental level
and disproportional to environmental provocations; the
diagnosis also requires a generally irritable mood
between outbursts.
 Pathologize difficult children as they often present
with chronic irritability and disruptive tantrums.

0 Bereaved individuals manifesting five general-distress
depressive symptoms for two weeks after a loss are
classifiable as having MDD which will be treated with
antidepressants.
0 For diagnosis of mild neurocognitive disorder, requires
only modest cognitive decline that does not interfere
with everyday activities.
 Almost all individuals as they age will fulfill this
criteria and will now be misdiagnosed as Minor
neurocognitive disorder.
Wakefield,2015

0 For Binge eating disorder, diagnosis requires rapidly
eating more than is comfortable or usual, accompanied
by a sense of loss of control and other negative
feelings such as shame, distress, or self-disgust, at least
once a week for three months.
 This low frequency/duration threshold makes the
people who overeat on the weekends for a few months
as diagnosable.

 Homosexuality, at one time, was considered to be
mentally disordered.
 2009- illegal and punishment(fine or imprisonment)
 2012 – Ministry of Home Affairs proposed the
decriminalisation of homosexual activity.
 6 sept 2018- supreme court of India decriminalised
homosexuality by declaring sec 377 of IPC.
 Considered as a normal and positive variant of human
sexuality.

Conclusion
0 The concept of normality is a hybrid of social values and
statistical calculations, and mix of interpretations about
expected and ideal behaviour.
0 Distress and mental disorder are not different points on the
same continuum, with distress being a less serious version
of disorder, both are considered as different continua.

0 Since the development of the DSM-III in 1980, the
mental health professions, policy makers, advocacy
groups, and the media have conflated these two
separate phenomena into a single entity, calling both
“mental disorders.”
 It also have influence on insurance coverage and
eligibility of disability and services.
 DSM 5 reflects the trend driven by pharmaceutical
industry’s attempts to reduce the differences in
behavior into easily categorised mental illness that
require treatment with psychiatric drugs.

Concept of normality in psychiatry

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