In addition, Kleinman studied neurasthenia at a psychiatric hospital in China. His aim was to investigate if neurasthenia in China is similar to depression in DSM-III. Kleinman interviewed 100 patients diagnosed with neurasthenia using structured interviews based on DSM-III diagnostic criteria. He found that 87% of patients could be classified as suffering from depression; 90% complained of headaches, 78% of insomnia, 73% of dizziness and 48% of various pains. Depressed mood was only given as the main complaint in 9%. Therefore, he concluded that neurasthenia is a specific Chinese way of expressing depression in somatic ways since the majority of the patients only presented physical symptoms.
Kleinman study does not establish cause and effect relationship and there are many confounding variables. However, using structured interviews for depression he achieved to provide evidence that culture plays a major role in the expression of a disease (emic approach). Hence, he showed that again it is very difficult to define abnormality because it is culturally affected.
Researchers have also tried to define abnormality as the deviation from social norms. Social norms constitute informal or formal rules of how individuals are expected to behave in any given situation. When people violate such social rules, other people have a tendency to assume that there is something wrong with them. However, there are also many limitations regarding this definition of abnormality. First of all, social norms vary across cultures and social norms. For instance, some African tribes revere their members who claim to hear voices; in Western society this may well be viewed as a symptom of schizophrenia or other mental abnormality. Social norms vary across history too. For example, homosexuality was seen as abnormal in Britain around 1900 where the well-known Oscar Wilde was imprisoned for homosexuality. Homosexuality was classified as abnormal in the American Diagnostic and Statistical Manual DSM-II. In later versions of the manual, homosexuality in itself was not seen as abnormal. Finally, what is considered socially accepted has been established by groups with social power, which allows serious abuse of individual rights. For example, political dissidents could be considered “abnormal” and sent to hospitals for treatment as occurred in the former Soviet Union.
A study which shows that social factors play an important role in the definition of abnormality and make the distinction of abnormality from normality much harder is the one by Brown and Harris in 1978. They aimed to investigate the link between depression and both current and past life events in the lives of sufferers, and they mainly focused on working-class women. They created a complex interview called the life events and difficulties scale (LEDS). A group of 539 women in Camberwell, London were interviewed using LEDS aimed to uncover stressful events in the previous years as well as childhood events. Events were rated by a many blind researchers. They found that both recent high levels of stress and having suffered a stressful childhood event left people particularly vulnerable to depression. In the previous year, 37 of them (8 per cent of the total) had become clinically depressed. Of these, 33 (almost 90 per cent) had suffered an adverse life event. Three of the four factors that had the strongest associations with depression involved recent levels of stress. These were: lack of an intimate relationship, lack of paid employment, and the presence of three of more children in the home. However, childhood events were also important, especially the death of the mother before the age of 11.
The study by Brown and Harris does not establish cause and effect relationship (correlation) and it is mainly a qualitative research. In other words it examines the meaning of participants’ actions and words. In addition, the sample is non-representative since it is a purposive sampling, and therefore it is difficult to generalize. On the other hand, theoretical generalizations can be made and new theories can emerge that potentially can be generalized. Moreover, a significant problem of this study is memory distortions. Probably, some participants do not remember well some events from their childhood. However, a sophisticated scale was used and blind researchers rated the events and therefore biases regarding the results were eliminated. Finally, Brown and Harris’s had an important effect. The finding that most people did not get depressed because there was something wrong with their personality, but because there was something wrong in their lives, transformed how depression was seen by general practitioners and psychiatrists in Britain.
Regarding the definition of abnormality the humanistic psychologist Marie Jahoda took a different approach in that instead of defining what is abnormal, she tried to define what is normal. Jahoda, based on literature review, she identified six components of ideal mental health, and deviation from these would mean that the individual is abnormal. These are positive attitude towards self, growth development and self-actualisation, integration and ability to resist stress, personal autonomy, accurate perception of reality, and environmental mastery.
The concept of ideal mental health is a refreshing approach because it focuses on the positive aspects of life rather than the negative ones, but the six criteria appear quite demanding and most people are likely to fall short on at least one of them. It is also necessary to say that Jahoda’s ideas are based on western individualistic societies. In collectivistic societies people’s future is planned for them by elders and it would seem “abnormal” to pursue one’s own individualistic goals.
Another definition of abnormality is the failure to function adequately. Maladaptive behaviors may be thought of as those that cause difficulties or are counterproductive for the individual or for others. If an individual’s abnormal behavior, mood, or thinking adversely affects their well-being, then help is needed. On a more extreme level, if an individual’s abnormal behavior becomes a danger to their own safety, then they may be defined as abnormal and institutionalised.
However, failure to function adequately may not be recognized by those who are in a psychotic state, so the definition may have to be applied by others. In addition, difficulties in functioning may be the result of social rejection and ‘adequate’ functioning is to some extent a social judgment which may be based more on threats perceived by the majority in society than actual threats or a genuine concern to help. Cultural factors also play a role. It is possible that the inability to cope with the demands of daily living may be the cause of mental disorder. This might be the reason why immigrants and ethnic minorities in western countries show higher incidence of mental disorders.
Another study that shows the difficulty between abnormality and normality is the one By Rosenhan et al. Rosenhan and a group of colleagues (1973) tested the validity of psychiatric diagnosis (the DSM-II). The study is considered an important and influential criticism of psychiatric diagnosis. Rosenhan's study was done in two parts. The first part involved the use of healthy associates (including a housewife, a painter and a student) or "pseudopatients" who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in various locations in the United States. All but one were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had not experienced any more hallucinations. Hospital staff failed to detect a single pseudopatient. It took between 7 and 52 days for the pseudopatients to be released, with an average of 19 days. This time was used by them to conduct a participant observation of life in the hospital, which involved taking notes. Their writing was seen by the staff as a symptom of their illness. Only the real patients expressed some concern about the pseudopatients. All were forced to admit to having a mental illness and agree to take antipsychotic drugs as a condition of their release. The second part involved asking staff at a psychiatric hospital to detect non-existent "fake" patients during a 3 month period. No fake patients were sent, yet 41 real patients were judged with great confidence to be pseudo by at least one member of staff. The staff falsely identified large numbers of ordinary patients as impostors. The study concluded, "It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and labeling in psychiatric institutions. Therefore, this study is a very strong evidence that is very difficult to distinguish normal from abnormal.
This study had an enormous impact in psychiatry. It sparked off a discussion and revision of diagnostic procedures as well as discussion of the consequences of diagnosis for patients. The development of diagnostic manuals has increased validity and reliability.
The method used raises ethical issues but it was justified since the results provided evidence of problems in diagnosis which could benefit others. There is strong deception and there were also serious ethical issues in the follow-up study since the staff thought that impostors would present, but they were real patients and may have not received the treatment they needed.
In conclusion, it is extremely difficult to precisely explain what an abnormal behavior is. However, there are diagnostic symptoms available to mental health practitioners that allow them to deal with the exceptions and problems of the definitions of abnormal behavior mentioned above.
by
anastasia26 (student)
