MENTAL HEALTH NORMALITY, MENTAL HEALTH AND MENTAL ILLNESS
Normality Generally psychologists agree that normality refers to patterns of behaviour or personality traits that are typical. Sometimes it is very easy to distinguish what is normal and what is abnormal. At other times it is harder to make this decision.
Look at the following behaviours and decide which are normal and which are abnormal. Being scared of hairy spiders Enjoying sky diving Wearing black makeup and clothing Changing your plans because of a horoscope prediction Walking arm in arm down the street with a friend of the same sex Having a belly button that sticks out Being in love with someone you have never met Achieving an extremely high score on an IQ intelligence test Preferring to live alone, isolated from others Being able to provide help to someone in need of it, but choosing not to.
Normality and abnormality • There are six different approaches that have been proposed for describing normality and abnormality: • Socio-cultural approach • Functional approach • Historical approach • Situational approach • Medical approach • Statistical approach
Socio-cultural approach Thoughts feelings and behaviour that are appropriate or acceptable in a particular society or culture are viewed as normal and those that are inappropriate or unacceptable are considered abnormal. The socio-cultural approach considers whether behaviour is typical according to the cultural values and beliefs of a particular society- whether the behaviour fits in with the norms of that society. Eg. In some cultures crying and wailing at the funeral of a stranger is expected and considered normal, whereas in other cultures that is considered abnormal.
Functional approach Thoughts, feelings and behaviour are viewed as normal if the individual is able to cope with living independently in society, but considered abnormal if the individual is unable to function effectively in society. The functional approach defines normality by the level of one’s ability to interact and involve oneself in society. Eg. Being able to feed and clothe yourself, find a job, make friends and so on is normal, but being so unhappy and lethargic that you cannot get out of bed, cannot eat properly and cannot find a job is abnormal.
Historical approach What is considered normal and abnormal in a particular society or culture depends on the era, or period of time, when the judgment is made. The historical approach to defining normality depends on the period of time, century or era in which the judgment is made. Eg. Prior to the 20th century, if a parent severely smacked their child for misbehaving, few people would have considered this to be abnormal, but in western societies and cultures today, such behaviour would be considered abnormal and perhaps even illegal.
Situational approach Within a society or culture, thoughts, feelings and behaviour that may be considered normal in one situation may be considered abnormal in another. The situational approach refers to the social situation, behavioural setting or general circumstances in which the behaviour occurs. Eg. If you were to come to school wearing pyjamas most of your friends would think that was abnormal, however it is considered normal to wear pyjamas to bed.
Medical approach Abnormal thoughts, feelings or behaviour are viewed as having an underlying biological cause and can usually be diagnosed and treated. According to the medical approach an individual is considered normal if they are physically healthy while abnormality is determined by having an illness that has an underlying physical cause. Eg. Someone who is colour-blind would not be considered as normal. Neither would someone with a common cold.
Statistical approach The statistical approach is based on the idea that any behaviour or characteristic in a large group of individuals is distributed in a particular way; that is, in a normal distribution. The statistical approach defines normality based on the experiences and behaviours of the statistical majority. Generally if a large majority of people, called the ‘statistical average’, think, feel or act in a certain way, it is considered normal. Eg. It is normal to laugh when tickled because most people do but to laugh when someone dies would be abnormal because not many people would do this.
Approaches to defining normality and abnormality Psychologists acknowledge that none of these approaches is entirely satisfactory on its own. However, each approach has contributed to the understanding of normality or abnormality. Normality is often defined as a pattern of thoughts, feelings or behaviour that conform to a usual, typical or expected standard. These standards, however, may depend upon many different factors. In one form or another, each of the six approaches has influenced the way normal and abnormal thoughts, feelings and behaviour are viewed and studied.
Approaches to defining normality and abnormality Identifying the meaning of abnormality in relation to mental processes and behaviour is of greater concern to psychologists because of the implications when diagnosing and treating mental health problems. Abnormality may be defined as a pattern of thoughts, feelings or behaviour that are deviant, distressing and dysfunctional.
Deviant, distressing and dysfunctional. • Thoughts feelings and behaviour are considered: • Deviant when they differ or vary so markedly from social or cultural norms ‘governing’ behaviour that they can reasonably (or legally) be considered inappropriate or unacceptable • Distressing when they are unpleasant and upsetting to the person experiencing them and/or others around them • Dysfunctional if they are interfere with the person’s ability to carry out their usual daily activities in an effective way.
Health and illness According to the world health organisation (WHO) health is a state of complete physical, mental and social wellbeing and not merely the absence of illness or disease. Physical, mental and social wellbeing are all equally important to the overall health of any individual. Illness refers to a person’s subjective experience of feeling unwell in relation to one or more aspects of their health including the way they think about their physical, mental and social health.
Health and illness Physical wellbeing primarily involves the body and such activities as exercising regularly, eating well, being well rested, and maintaining a body weight that is biologically appropriate for the individual. Mental wellbeing primarily involves the mind and such activities as expressing feelings calmly even when angry or sad and rational thinking. Social wellbeing primarily involves personal relationships and interactions with others and such activities as getting along with family, friends and acquaintances, giving and receiving social support when needed and making and keeping friends.
Differentiating physical health from physical illness Physical health refers to the body’s ability to function efficiently and effectively in work and leisure activities, to be in good condition, to resist disease and to cope in threatening or emergency situations. (Temperature, heart rate, blood pressure, cholesterol, breathing etc) Physical illness refers to our subjective experience of a disease or physical health problem that interferes with the normal functioning of our body and adversely impacts on our ability to function effectively in everyday life.
Differentiating mental health from mental illness Mental health and mental illness primarily involve the mind whereas physical health and physical illness primarily involve the body. Mental health is the capacity of an individual to interact with others and the environment in ways that promote subjective wellbeing, optimal development throughout the lifespan and effective use of a person’s cognitive, emotional and social abilities. Characteristics of good mental health include being able to establish and maintain positive social relationships and to cope effectively with problems and issues that arise in everyday life.
Differentiating mental health from mental illness • Mental health is not something that we either have or do not have. • Therefore, mental health is often represented as being on a continuum, ranging from: • mentally healthy, when we are functioning well and coping with the normal stressors of life • through to a mental heath problem • through to a mental illness that may be serious or prolonged.
Mental illness describes a psychological dysfunction that usually involves impairment in the ability to cope with everyday life, distress, and thoughts, feelings and/or behaviour that are atypical of the person and may also be inappropriate within their culture. Dysfunction means that the person does not think, feel and/or behave as they normally do and it affects their ability to cope effectively with everyday life experiences. When a person experiences distress they are very upset, anxious and/or unhappy. Impairment in the ability to cope with everyday life is another characteristic of mental illness. If a person is unable to do the things they normally do on a daily basis because of their mental state, they are considered to have impaired functioning. Atypical means that the person responds in a way(s) that is not normal, or ‘typical’ for them.
The biopsychosocial framework The biopsychosocial framework is an approach to describing and explaining how biological, psychological and social factors combine and interact to influence a person’s physical and mental health. This framework is based on specific factors from each domain which combine and interact to influence our wellbeing.
The biopsychosocial framework Biological factors- involve physiologically based or determined influences, often not under our control, such as the genes we inherit and our neurochemistry. Psychological factors involve all those influences associated with mental processes such as how we think; learn; make decisions; solve problems; perceive our internal and external environments; manage emotions and deal with stress. Social factors are described broadly to include such factors as our skills in interacting with others, the range and quality of our interpersonal relationships, the amount and type of support available when needed as well as socio-cultural factors.
The biopsychosocial framework This framework represents a holistic view of health meaning that it looks not only at the internal aspects of the individual but also the external circumstances. It views each of the three domains as equally important for both physical and mental health. Eg. A personality disorder might best be explained by the combined influence of an individual’s inheritance of certain genes and impaired functioning of part of the brain that controls impulsive behaviour (biological) poor self image and an intense fear of abandonment (psychological) and their strict upbringing and lack of skills required to develop and maintain social relationships (social).
Pic pg 555 Biopsychosocial model
Classifying mental disorders Clinical psychologists, psychiatrists and other mental health professionals classify mental health problems and disorders in different categories according to characteristic patterns of thoughts, feelings and behaviour. Classification is the organisation of items into groups on the basis of their common properties. Often the groups into which items are organised through classification are referred to as categories or classes. Classification makes it easier to identify and understand relationships between different groups.
Categorical approaches to classifying mental disorders To help provide guidelines and a standard for classification of mental illnesses, categorical approaches of defining mental disorders have been developed. Categorical approaches involve grouping psychological problems into broad categories, or groups, with common symptoms. This is a yes-no approach to classification. Categorical approaches classify a person’s symptoms in terms of which specific category of mental disorder they best fit or ‘belong’ to. The focus is on diagnosing whether the person has or does not have a disorder.
Categorical approaches A system of classifying mental conditions and disorders that uses a categorical approachorganises and describes mental conditions and disorders in terms of different categories and subcategories, each with symptoms and characteristics that are typical of specific mental conditions and disorders. A key principle of the categorical approach is that a mental disorder can be diagnosed from specific symptoms reported and/or presented by a client during a mental health assessment. These symptoms fit into a specific category which then represent the disorder that the person is suffering from.
Categorical approaches This means that there are clear boundaries around each disorder and that disorders do not overlap. Eg. The pattern of thoughts, feelings and behaviour classified as OCD is clearly different from the pattern for antisocial personality disorder. Another principle of the categorical approach is the ‘all or nothing’ principle which means that an individual either has a diagnosable mental disorder or does not have a disorder. Categorical approaches therefore view mental illness in the same way as something like pregnancy; you are either pregnant or you are not pregnant.
Categorical approaches Another underlying principle of this approach is that the system needs to be both valid and reliable. Validity means that the classification system actually organises mental disorders into discrete and distinct disorders which enables accurate diagnosis of the disorder. Reliability means that the classification system produces the same diagnosis each time it is used in the same situation. Inter-rater reliability indicates the degree to which different mental health professionals diagnose the same client with the same mental disorder.
Categorical approaches to classifying mental disorders Two examples of categorical approaches to classifying mental disorders are those provided by the Diagnostic and Statistical Manual of Mental Disorders, Edition IV, Text revision (DSM-1V-TR) and the International Classification of Diseases, Edition 10 (ICD-10)
DSM-IV-TR The DSM-IV-TR is a categorical system for diagnosing and classifying mental disorders based on symptoms that are precisely described for each disorder. Since it was first published in 1952 it has been revised 5 times. There are 365 mental disorders described in the DSM-IV-TR. They are grouped in 16 major categories and there is one additional section, ‘Other conditions that may be a focus of clinical attention’. It lists known causes of these disorders; provides statistics in terms of gender, age of onset and prognosis; and also provides information about some research concerning optimal treatment approaches.
DSM-IV-TR Each disorder has a diagnostic criteria- this indicates the symptoms that are characteristic of the disorder and therefore enable assessment of the presence of the disorder. Inclusion criteria- are used to identify the symptoms that must be present in order for the disorder to be diagnosed. Exclusion criteria- identify the symptoms, conditions or circumstances that must not be present in order for the disorder to be diagnosed.
DSM-IV-TR- separation anxiety Inclusion- the presence of at least 3 of the 8 symptoms, the symptoms must have been present for the last four weeks, the symptoms develop before the age of 18 years, and the symptoms cause distress or impairment. Exclusion- separation anxiety is not diagnosed if the symptoms can be explained by the presence of another mental disorder.
DSM-IV-TR • The DSM-IV-TR also includes information on: • The typical course of each disorder • The age at which the person is most likely to develop the disorder • The degree of impairment • How common the disorder is • Whether it is likely to affect others in the family • The relationship of the disorder to gender, age and culture
DSM-IV-TR- nightmare disorder • The DSM-IV-TR also includes information on: • The typical course of each disorder (the child usually grows out of it) • The age at which the person is most likely to develop the disorder (3-6 years old) • The degree of impairment (sleepless nights and sleep deprivation) • How common the disorder is (11-50% of children experience this disorder) • Whether it is likely to affect others in the family (will affect parents) • The relationship of the disorder to gender, age and culture (females report nightmares more often than men)
DSM-IV-TR When making a diagnosis using the DSM-IV-TR, information in relation to five different axes must be considered in order to completely evaluate an individual’s mental condition. This is why diagnosis in this system is called a multiaxial system. Together the five axes are intended to provide comprehensive and useful information when planning treatment.
DSM-IV-TR- axis I Axis I describes all the mental disorders in the DSM (except for those in axis II). This axis is used to identify the persons current mental condition and relevant disorders the person may be suffering from.
DSM-IV-TR- axis II Axis II describes only two categories of mental disorders: personality disorders and mental retardation. A personality disorder involves a pattern of inflexible and maladaptive ways of thinking, feeling and behaving that are often socially unacceptable and have been evident over a long period of time. A person with an intellectual disability has a significantly below average level of intellectual functioning and usually has difficulty in coping independently with everyday life activities.
DSM-IV-TR- axis III Axis III provides information about medical conditions that may be related to each of the mental disorders in axis I or II. These conditions may give information that is potentially relevant to understanding and planning treatment for the individual.
DSM-IV-TR- axis IV Axis IV provides information about potential stressors in an individual’s life that may be relevant to their disorder, and is used to identify current and recent stressors impacting on their thoughts, feelings and behaviour and which need to be considered when devising a treatment program. Eg. If a person had lost their job this may be a consideration in diagnosis and treatment.
DSM-IV-TR- axis V Axis V is used to assess an individual’s overall level of psychological, social and occupational functioning. This is achieved using the descriptions in the Global Assessment of Functioning (GAF) scale provided in the DSM. This information is obtained during a ‘clinical interview’ and provides an overall numerical rating on a 100-point scale on which ‘1’ indicates severe impairment and ‘100’ refers to superior functioning.
Global Assessment of Functioning Table 11.4
ICD-10 The International Classification of Diseases and Related Health Problems (ICD) is a categorical system for diagnosing and classifying diseases and mental disorders based on recognizable symptoms that are precisely described for each disease and disorder. The ICD-10 consists of 21 chapters covering the whole of medical practice; that is, all physical and mental conditions and disorders.
ICD-10 Like the DSM-IV-TR, diagnosis of a mental disorder consists of identifying the disorder(s) that best matches or reflects the symptoms presented by an individual. Diagnostic guidelines are also provided for each disorder. Diagnostic guidelines identify the symptoms that are characteristic of the disorder and therefore indicate the presence of the disorder.
DSM-IV-TR & ICD-10 Although the ICD is used in the same way as the DSM and helps a mental health professional decide whether or not a person can be diagnosed with a mental disorder, the ICD is a less detailed categorical system that the DSM. The ICD provides a detailed description and diagnostic guidelines for each disorder, but it typically does not provide information about the course, prognosis and prevalence of each disorder as the DSM does.
Strengths of categorical approaches Both diagnostic tools are based on ongoing scientific research and regularly revised on the basis of the research findings. They are comprehensive in terms of the number of disorders included and the detail provided for these disorders. Useful in educating mental health professionals and the community about mental disorders. Assists mental health professionals in the diagnosis of disorders and devising a treatment plan. User-friendly and provides a common language.
Limitations of categorical approaches Low inter-rater reliability as different professionals often reach different conclusions about the diagnosis. 70% agree on the diagnosis while 30% disagree. At times the overlap in symptoms can lead to ‘fuzzy’ categories and uncertainty about the disorder and diagnosis leading to misdiagnosis. Valuable clinical information can be lost. That is, whenever we use categories the uniqueness of the person is overlooked.
Limitations of categorical approaches • Classifying in this way often involves labeling which can lead to many issues one of which is stigma. • Stigma is a sign of social unacceptability or undesirability, often involving shame or disgrace. This can influence the way the person feels above themselves and they way they are viewed by others.
Dimensional approaches Dimensional approaches are an alternative to the categorical approach. Dimensional approaches assume that normality and abnormality are end points on the same continuum with no clear dividing line between them. A dimensional approach quantifies a person’s symptoms or other characteristics of interests and represents them with numerical values on one or more scales or continuums, rather than assigning them to a mental disorder category. Classification is therefore accomplished by assessing a person on relevant dimensions and giving them a score on each of these dimensions.