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What is normal?
Date: 6 June 2005
MIND MATTERS
By Professor Dr T. Maniam
Consider the following fictitious case history:
Mat is an 18 year-old student who is in love with his classmate. He worries because she does not seem to be showing any interest in him despite his efforts to capture her attention. He feels pangs of jealousy when she talks to other boys. In the canteen when he sees her sitting at a table with others – even in a mixed group of boys and girls – he loses his appetite. Some nights he lies awake thinking of her with unhappy thoughts.
He is distressed and unhappy but are Mat’s reactions normal? We will probably consider this as a normal experience. But suppose I added further details of what happened to Mat: he was unable to study, finds it difficult to concentrate and failed his monthly class exams. His friends say he is more irritable and has withdrawn from usual fun activities.
Now would you say Mat is going through a normal reaction? Probably not.
Popular opinion states that no one is normal – we all deviate from normal to a greater or lesser extent. Salvador Dali, the surrealist painter, once said that “The only difference between a (mentally ill man) and me is that I am not (mentally ill)*.” How do we differentiate normal unhappiness from depressive illness, or normal anxieties from an anxiety disorder? This is a vexing question that doctors often face. Abnormality is an elusive thing, so in clinical practice doctors use a number of guidelines to help them differentiate normality from illness.
Firstly, in illness the emotions and behavior must cause distress to the individual (or sometimes to others as well). The sufferer is disturbed and feels emotional pain that he finds difficult to bear. Now, not all people who have mental illness suffer distress. Manic disorder is an example. In this condition the subject may actually feel very well, enjoy himself or herself immensely, but yet at the same time be so ill as to disrupt their and other people’s lives. So using distress as the sole indicator of illness is not satisfactory.
Secondly, dysfunction may be an indicator of illness. This means that the subject’s daily functioning is affected. Their symptoms are such that they may not be able to work, study or perform household duties. In other words occupational functioning is affected. Students may show deterioration in their examination performance. Additionally there may be problems in social functioning whereby the subject is unable to mix around as before and may withdraw from social contact. Conversely he may uncharacteristically over-socialize, or act in socially inappropriate ways. However, we must be careful not to label as abnormal behaviors that are merely eccentric.
A third factor sometimes used to conclude whether a person is ill or otherwise is deviance. How much does a behavior deviate from normal? But the vexing question here is: normal from whose point of view? From the views of the majority (statistical norm)? But a simple, almost absurd, example shows that this not satisfactory at all. In a university class a majority of students may be wearing glasses, but who is “abnormal” here? What about normality from a religious viewpoint? But, then, whose religious viewpoint? Some behaviors may be acceptable in another religion or culture but not in ours, and even within our own culture there are many varieties of experiences and ways of doing things.
Fourthly, another way of determining abnormality is the danger (or ill effect) the particular symptom or behavior produces to the sufferer or to others. In Mat’s case a little loss of appetite may be acceptable. But if he continues to lose his appetite leading to significant loss of weight and consequently ill health then that symptom has become abnormal. Suppose Mat gets angry with the girl and confronts her and warns her not to talk to other boys. Now what do you think?
Finally, clinicians also look at how long these symptoms and behaviors have been occurring, that is, the duration. Feeling unhappy for a while is common and all of us at some time or other get unhappy thoughts and feelings, but if one becomes unhappy for a prolonged period of time, even long after whatever caused the unhappiness is past and done with then illness must be considered. To give another example: sadness and distress following the death of a loved one is normal. It usually passes after 3 to 6 months, though thoughts of the departed person may still bring sudden pangs of pain. However if the bereaved person continues to be severely distressed for years and his daily functioning is compromised then the doctor should consider that an illness has supervened following the loss of the loved person. Generally speaking depressive symptoms that last for more than 2 weeks need to be taken seriously unless they occur in the context of bereavement.
From the foregoing the reader will see that normality is a contentious issue. Philosophers often argue about it. Clinicians struggle with it. Psychiatrists are sometimes accused of labeling people as ill when they may not be. R.D. Laing railed against the diagnosis of schizophrenia claiming that the problem was with society. “Insanity,” he said, “is a perfectly rational way of adjusting to an insane world.” More recently Bentler has urged that we re-look at what we mean by mental illness, arguing that the “unusual” experiences people have, now being labeled as mental illness, might just be part of the spectrum of normal experiences. All this is heady stuff, but we must be careful that in pursuing these ideas we do not neglect the weight of evidence that points to the presence of illness and thereby unfairly deprive people of effective treatment. Doctors should, of course, be aware of the effects of labeling. Because mental illness is such a serious label special precautions are taken to avoid doing so. Most of the time, thankfully, we do not have problems in this regard. In my clinical experience I rarely see a person who is well being mistakenly brought for treatment. The problem is the other way around. People who are ill are not recognized to be ill. Sometimes the patient himself does not acknowledge he is ill. We call this lack of insight. Insight is the awareness of and capacity to recognize that one’s symptoms are not normal, and also being able to attribute correct reasons for the symptoms. Presence of insight helps a person seek treatment.
Even when recognized much time is often wasted in administering ineffective or unproven therapies. People often come very late for medical treatment when the illness has become chronic and more difficult to treat. Then the struggle begins. The general rule about recovery for any illness is the earlier the treatment the better the outcome.
* Original words in parentheses have been substituted for stylistic reasons.
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