How We Think About Mental Health Disorders (Part 1): "Normal" vs. "Abnormal"
A seemingly never-ending debate within psychology, and outside of the field as well, is how to go about diagnosing people with mental health disorders. It is a very controversial topic, with people suggesting that some things are overdiagnosed (e.g., ADHD), some are hard to distinguish (e.g., anxiety and depression), and so on. One argument that seems to crop up fairly often, and that is seemingly of the most interest for those not in the field of psychology, is how we distinguish between "normal" and "abnormal." This is especially important for some people who feel that psychology has a tendency to pathologize "normal" behaviors, like tantrums in kids. Here, I want to help clarify some of what goes into thinking about diagnoses, with a focus on showing how we do not pathologize "normal" behavior.
Disclaimer: These posts are not intended to help anyone make a diagnosis, either within themselves or in other people. Instead, these posts are simply meant to demonstrate how psychology thinks about behaviors and thought processes. Many aspects of diagnosis will be simplified for the sake of communication. If you are concerned someone may meet criteria for a disorder, please meet with a qualified therapist in a professional setting.
As you've no doubt noticed by now, I keep talking about "normal" behavior in quotes. The reason is that there is no clearly defined set of normal behavior, which means that "normal" has an unclear meaning. For anyone who is familiar with statistics, you can think about the normal bell curve:
In a normal bell curve, we consider anything in the middle area to be average or "normal." That's roughly 68% of whatever we're talking about, but you can see that there is room for quite a bit of variability within there (i.e., 85 and 115 are both "normal," but are still fairly different from each other). Behavior is the same way, with a lot of different behaviors falling with the "normal" range even though they can all be very different.
"Normal" may be hard to define, but it's a little easier when we think about "abnormal." In fact, you'll find that psychology classes dealing with the basics of diagnostics are often called "Abnormal Psychology." It can be hard to say when a behavior is "normal" because there are so many "normal" behaviors, but look back up at the bell curve. For abnormal, depending on what is being talked about, we are often most interested in the outer areas, so roughly 4.4% of the total. (The roughly 27% of behaviors in-between the average and more extreme ranges is often considered "borderline," or "at-risk" but not currently at a level that warrants diagnosis). That 4.4% is much smaller, and as a result it's easier to discuss and identify.
Again, we are simplifying the situation here. When dealing with people, these percentages are never consistent or absolute. Instead, just think of this as the gist.
Thinking in extremes
So now that we have gone over the general idea of "normal" vs. "abnormal," let's see how that applies to some actual situations in psychology. Mood is probably the easiest to discuss, so consider a "normal" happy person. A "normal" level of happiness can vary a lot, but most people fall within the "normal range." But what if someone is too happy? Extreme highs can lead to a manic-like mood. In the other extreme, with someone too low on happiness, there can be extreme sadness/depression. (Mania and depression are more complicated than that, but for now it works to make the point).
In psychology, we're often dealing with these extremes. The behaviors/moods/etc. themselves are often "normal," but within certain limits. We generally do not try to claim that "all instances of behavior X are diagnose-able." Instead, we consider the severity of the behavior, or the intensity of the mood.
For example, tantrums in children are normal (during certain ages). The frequency and severity of tantrums can vary quite a bit while still being "normal," but it's possible for them to fall into the extremes. Tantrums that happen very often, and/or at high intensities, begin to fall within the "abnormal" range and may warrant a diagnosis like intermittent explosive disorder (IED). Therefore, something like IED is only meant to apply to the most extreme cases; we're not trying to say "any kid who throws a tantrum has IED."
The same idea applies for a lot of different behaviors/moods. Happiness is normal, but mania is problematic. Sadness is normal, but depression can be crippling. Misbehavior is normal in children, but frequent destruction of property should be taken seriously. Grieving after the loss of a loved one is normal, but not being able to perform your daily tasks for a long period of time isn't healthy.
Comparison to medicine
To help make the situation a little more clear, I want to make a comparison to diagnosis of medical conditions. In medicine, there is often a similar process of identifying extremes that fall outside the normal/healthy range. For example, having an itch after a mosquito bite is normal, but having a rash and swelling on large portions of the body is not. Pain when poked with something sharp is normal, but high levels of pain at the gentlest touch is not. The same identification of extremes applies.
It's true that in psychology we often talk about behaviors that are generally "normal." The difference, which can be hard to tell from simply reading something like the DSM, is the degree of frequency and severity. Because we discuss behaviors that are "normal" in most cases, that is probably why many students who take a class like Abnormal Psychology begin to see diagnoses in themselves and those around them. We all engage in many of the behaviors that are involved in the diagnosis of mental health disorders, but the majority of us fall within the "normal range." It's with in-depth education and training that clinicians can become familiar with what falls outside of that range and warrants treatment.
Hopefully this helps clarify how psychologists think of mental health disorders. And with that, hopefully it's easier to see how overdiagnosing (especially by those not specialized in psychology) can sometimes happen.
"But how do you decide when a behavior has reached the level of being abnormal?" Great question! As I mentioned above, just looking at percentages isn't enough, and we need some way to assess frequency and severity. How we should do that is another debate within the field, but I want to save that for another post.
Until then, do you have thoughts about this topic? Are there questions related to the diagnosis of mental health conditions that you have? Let me know in the comments!