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DefiningAbnormality

Page history last edited by PBworks 13 years, 11 months ago


Defining Psychological Abnormality

 

Statistical infrequency and deviation from ideal mental health

 

The concept of abnormality is very imprecise and difficult to define. Examples of abnormality can take many different forms and involve different features, so that what at first sight seem quite reasonable definitions turn out to be quite problematical.

 

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One criteria that has generally failed the test of time is deviation from statistical norms. This starts from the common sense point of view that many examples of abnormal behaviour, such as hallucinations and delusions are relatively infrequent. In statistical terms, instances of abnormality would lie at both extremes of a normal distribution, just like very high and very low marks in an A level examination. However, there are many criticisms of the idea that what is infrequent is necessarily abnormal. One criticism is that abnormality is usually seen as undesirable (e.g. needing treatment of some sort). However some rare traits are often highly desirable (such as getting a very high mark in the A level.). Whether they are desirable or not is often a matter of culture. In many cultures people with rare abilities, for example being able to hear voices of spirits are often highly valued, whereas most people in our society would see this as an abnormal trait.

 

Another definition that fails to deliver is deviation from ideal mental health. The assumption here is that anyone who does not possess the qualities to function normally in society is in one way or another abnormal. For example being able to go to work or school without too much anxiety is a requirement for normal functioning. Some one who suffers from a phobia and is unable to leave their house is therefore abnormal. The problem with this definition is that it begs the question of what is normal. We first of all have to define ideal mental health in order to decide if someone deviates from it. One attempt to do this was made by Marie Jahoda (1958). She surveyed that doctors, psychiatrists and others concerned with mental health and proposed six categories that were a condition of normality:

  • Positive self esteem and a strong sense of identity
  • Personal growth and development
  • Ability to cope with stressful situations (integration)
  • Autonomy and independence
  • Accurate perception of reality
  • Successful mastery of the environment, particularly relationships.

As well as the obvious point that it is extremely hard to assess the degree to which any one meets these criteria (it is not like measuring their IQ for example), there is the further problem that not everyone agrees with the list, particularly those that do not share ‘Western’ cultural values. For example, autonomy is not as not as highly valued in so-called ‘collectivist’ cultures, where there is a premium on cooperation rather than independence.

 

Abnormality as deviation from social norms

Perhaps the least satisfactory definition of abnormality from a psychological point of view is in terms of a deviation from social norms — though this has not prevented repressive regimes from using such criteria to stifle political dissent. For example in Stalinist Russia, psychiatrists were often called upon to hospitalise dissidents on the basis of them suffering a mental disorder.

The difficulties of establishing what is normal and abnormal are well illustrated by changing perspectives on homosexuality. This has been seen as abnormal behaviour, sometimes even as an illness.

 

Cultural relativism and abnormality

One of the main problems with the idea of defining abnormality as statistical infrequency, deviation from ideal mental health or deviation from social norms is the fact that none of these criteria copes well with cultural variations. The idea of cultural relativism suggests that beliefs about abnormality differ between cultures and sub-cultures. What may be considered as perfectly acceptable behaviour in one culture may be seen as abnormal in another. Researchers have only recently begun to consider the implications of multi-cultural experiences on health and illness (including physical health).

Western culture makes a number of assumptions about psychological states, for example that:

  • Physical and psychological components of a disorder are separate and the emotional aspects are normally given primacy.
  • Mental illness is caused by psychological conditions and might be treated by psychological processes.
  • An individual self exists which is experienced as whole, continuous over time, distinct and unique.

Cultural variations in the experience of mental disorders

One of the reasons that definitions of abnormality vary considerably from culture to culture is that there are differences in the way that people experience mental disorders. For instance, cultures outside the West do not necessarily conceive of internal emotional experiences as separate from bodily experiences and may focus more on physical ailments than psychological distress. Thus a Chinese person may complain of a stomach-ache rather than depression.

Some groups and sub-cultures value showing their emotions, whereas others emphasise containment. For example, the British are expected to avoid displays of emotion and to ‘keep a stiff upper lip’.

Some cultures emphasise the religious or spiritual aspects of mental illness. For example, an Afro-Caribbean person might seek a religious solution to a psychological problem. Some cultures treat religiously induced trance-like states as acceptable spiritual experiences, while others may see the same behaviour as a symptom of mental illness. It may be seen as a sign of weakness to ask for help from a mental health practitioner. Others, such as Asian culture, believe that problems should be dealt within the family and it would be disrespectful to discuss personal and family problems with a stranger.

Many cultures have a much more fluid view of the self and of reality. For example, an American Indian who hears the voice of a recently deceased relative calling from the afterworld would view this as a perfectly normal experience, whereas a European person may see this as a hallucination.

Cultural bias in diagnosis

Within attempts to define and classify abnormality, cultural biases exist. For example, Puerto Ricans have a unique way of reacting to stressful situations which includes symptoms such as heart palpitations, faintness and seizure-like episodes. These are often misdiagnosed as signs of severe mental disturbance due to a lack of knowledge of the culture (Guaraccia et al., 1990). In Britain and the USA, black males are more likely to be treated as criminals and sent to prison rather than be diagnosed as mentally ill. If they show symptoms of alcohol and drug abuse, they are more likely to be diagnosed as psychotic than are white males.

Cultural differences must not be confused with effects that are due to poverty or poor education.

Are disorders the product of cultures?

Definitions of mental disorders are also influenced by the fact that there are some disorders that are highly specific to particular cultures. The values and stresses of modern Western life have created more and different disorders that did not exist before. People might consider going to a therapist because they have a vague sense of lack of fulfilment and consider this to be pathological.

Even with disorders that are considered to be universal (e.g. depression, schizophrenia, manic-depression, certain types of anxiety disorder and dementia), there are cultural differences in the way that symptoms are expressed.

Eating disorders mainly exist in Westernised, middle-class communities. In Catholic and Islamic cultures, where suicide is considered to be a sin, there are relatively low suicide rates whereas in Japan suicide is considered an honourable response to perceived shame. Helzer and colleagues (1990) found very marked differences in rates of alcoholism between cultures, especially among men. The rates ranged from 43% in Korean men to 13% in Chinese men. Another example is Koro, a panic state deriving from the fear that the genitals will retract into the abdomen. This is common in Asian countries, but almost unheard of in the West. Also common outside the West are various forms of possession by spirits. These disorders are not represented in DSM and similar classifications.

The conclusion from studies of cultural differences is that expression of symptoms and help-seeking behaviour vary greatly between cultures. Research has shown significant differences in the extent to which ethnic groups use mental health services.

 

Abnormality as ‘failing to function adequately’

A more promising approach to defining abnormality recognises that a number of criteria might contribute towards abnormality. This is known as the ‘failing to function adequately’. Rosenham & Seligman (1989) offered one list of such criteria. For them, abnormality was indicated when it could be seen to involve the following:

  • Suffering
  • Maladaptiveness
  • Vividness and unconventionality
  • Unpredictability and loss of control
  • Irrationality and incomprehensibility
  • Observer discomfort
  • Violation of moral and ideal standards

It is suggested that the more of these features that are in evidence, the more likely is the behaviour to be defined as abnormal. However, this approach to defining abnormality has also been criticised. Firstly, it is suggested that depends too heavily on subjective assessments, and secondly, it does not sufficiently differentiate abnormal behaviour from behaviour that is non-conformist, unconventional or just plain eccentric.

 

Labelling and defining abnormality

The subjective nature of psychiatric diagnosis was vividly demonstrated in an experiment carried out by Rosenhan (1973). In this study eight psychiatrically normal individuals presented themselves as ‘patients’ at a hospital complaining of hearing voices. Most were diagnosed as suffering from a serious mental disorder (schizophrenia). Once admitted they behaved normally, but this ‘normal’ behaviour was interpreted as abnormal by staff (e.g. pacing a corridor out of boredom was interpreted as ‘anxiety’). In one case it took 52 days for the staff to become convinced that the ‘pseudopatient’ was well enough to be discharged.

If we are to accept Rosenhan’s conclusion, then it would seem that the whole task of distinguishing normal from abnormal behaviour is flawed. However, there are some limitations to the study. For example, the conditions in the experiment were very unusual. Also, it does not logically lead to the conclusion that psychiatrists do not know the difference between mentally ill and mentally healthy individuals. In the view of the information presented to them, and the context, was it not reasonable to expect them to attempt a psychiatric diagnosis? Changes in the approach to psychiatric care also make it highly unlikely that what Rosenham found could happen today. Hospitalised patients have much more interaction with carers (primarily psychiatric nurses), receive counselling and are actively encouraged to become involved in their own treatment. However, the study did make a powerful statement about the dangers of labelling someone with a psychiatric diagnosis (see below): once labelled, it is very difficult to escape the label.

We tend to think of them as ‘having’ the disorder, and may even give the disorder a life of its own, treating it as an object (reification), rather than a provisional, and convenient shorthand description. This is illustrated by the practice of calling someone who has been diagnosed as having the symptoms of schizophrenia a ‘schizophrenic’. The label may become permanent, with potentially serious consequences for the individual.

 

 

References

 

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