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FINALLECTURE-NOTES.docxFinal lecture notes:
HOW DO WE DETERMINE WHO’S NORMAL? What constitutes normal behavior?
Context, of course. Determining normal behaviors depends in part on particular
place/time. While there are some constants, for the most part behavioral norms/social
norms are always shifting.
Social norms: help us distinguish who is “included” and who is “an outsider.”
Who is behaving appropriately? Who isn’t – and what do we do about it?
How do we really decide what’s normal behavior, or what’s seen as weird, deviant, or a sickness?
Excerpted from an article by a young psychiatrist, just beginning his medical career:
I’ve been thinking a good deal about normality lately. It’s a concern in the medical world. The complaint is that doctors are abusing the privilege to define normal. Ordinary sadness, critics say, has been labeled depression.
“Boyishness” (or being very active), wanting to run and jump. Is this “normal” behavior .. or is it ADHD?
Has a diagnosis of social phobia replaced ordinary shyness?
There are plenty of books that document this transition. Just a few:
The Loss of Sadness: How Psychiatry Transformed Normal Sadness into Depressive Disorder.
Shyness: How Normal Behavior Became a Sickness.
Back to Normal: Why Ordinary Childhood Behavior Is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder
The Last Normal Child.
delves deeply into the factors that drive the epidemic of children's psychiatric disorders and medication use today, questioning why these medications are being sought, and why Americans use more of these drugs with children than is used in any other country in the world.
These books and more challenge what critics refer to as psychiatry’s narrowing of the normal.
According to the young psychiatrist: The fate of normality is very much in the balance.
As the number of mental disorders has increased over the years … some people talk in terms of a PSYCHIATRIC POWER GRAB.
Have the mental health professionals taken over? The pharmaceutical companies?
Have they become the new arbiters of defining who or what is normal?
Which leads to another complaint … that we in the United States are overmedicated.
That we’ve narrowed healthy behavior so dramatically that our “quirks” and eccentricities have become problems that we need to fix. And in many cases, that we expect drugs to fix.
Some of the harshest CRITICS complain that often doctors medicate patients who meet no diagnosis at all. They call it COSMETIC PSYCHOPHARMACOLOGY.
Which is a fancy way of saying trying to “fix” someone who at one time would have been described as perfectly normal – say someone who is insecure, lacking confidence. Less than ideal, perhaps … but abnormal?
Today … there’s therapy for that. There are drugs for that.
So many behaviors that used to fall within the realm of normal now have LABELS that we’ve all become familiar with.
EXAMPLE: A wife complains that her husband lacks empathy. Does he have Asperger’s syndrome? (Which actually is no longer called Asperger’s. Now we would say he’s on the Autism spectrum)
Or perhaps he’s a guy who just doesn’t get it? Doesn’t see human interactions in the same way that more socially aware people do.
His wife might say that he just doesn’t recognize social cues the way that
most women do.
Of course, this isn’t all bad. Labels are important. Diagnoses can bring relief.
Parents who once might have considered their child slow, or not very bright, may be comforted by a diagnosis of dyslexia. And really … wouldn’t we rather have the label of dyslexia than the accusation that a child is stupid. Or lazy?
According to the latest Diagnostic and Statistical Manual – the “psychiatric bible” – the DSM-5 … it’s likely that almost 50% of Americans will have a diagnosable mental illness in their lifetime.
We could say … the latest version of the DSM makes it even “easier” to get a diagnosis.
*****
If we think of having a diagnosable mental illness as being under a tent, the tent seems pretty big. Huge, in fact.
How did it happen that half of us will develop a mental illness?
1. Has this always been true, and we just didn’t realize how sick we were—we didn’t realize we were under the tent?
2. Or are we really mentally less healthy than we were a generation ago?
3. OR perhaps this is due to a third explanation … that we are labeling as mental illness, psychological states that were previously considered normal, albeit unusual, making the tent bigger.
The answer appears to be all three.
FIRST: we’ve gotten better not only at detecting mental illness but doing so earlier in the course of the illness. Better/earlier detection results in better treatment options.
SECOND: some studies suggest that we’re not just diagnosing better .. but that we really are getting “sicker.” They point to comparative studies over time. But fundamentally flawed – maybe people didn’t admit to how they felt, didn’t seek treatment.
But … THIRD: There’s another explanation for the higher rate of mental illness. One that implies CULTURAL SHIFTS.
What was once considered psychologically healthy (or at least not unhealthy)
may now constitute a diagnosable mental illness. “Normal” behavior now seen
as pathological.
Thus, the actual definition of mental illness has broadened, creating a bigger tent with more people under it. This explanation strongly suggests that we, as a culture, are more willing to see mental illness in ourselves and in others.
Whatever the cause we do know …
That each edition of the DSM has increased the overall number of disorders. And
remember, the DSM is the book that defines mental illness.
DSM-I – 1952 = 106
DSM-III – 1980 = 265
DSM-IV = 297
The people who created the DSM-5 were determined to not add any disorders .. but they did categorize them differently
(265 – but that doesn’t count sub-categories)
One example of a disorder included in the latest edition is called “caffeine intoxication.”
This is characterized by at least 5 symptoms experienced after consuming the equivalent of 2 or 3 cups of coffee. These might include: restlessness, gastrointestinal problems, difficulty sleeping, nervousness, and rapid heartbeat.
To meet the diagnosis, the symptoms must impair functioning in some way.
A Time Magazine article a few years ago cried out: “Caffeine Withdrawal is Now a Mental Disorder.”
Sub-titled: Does it really belong in a guide devoted to mental disorders?
According to one critic: “It’s hard to believe that an episode of too much coffee or Red Bull constitutes a mental disorder. But guess what – it does! With disorders like this in the DSM, he continued, it’s no wonder that half of Americans will have a diagnosable disorder in their lifetimes. The wonder is why more Americans won’t!
The DSM continues to nibble at the edges of “normal” by reclassifying patterns of thoughts, feelings or behaviors that were previously considered normal (albeit perhaps weird or odd).
At the same time, it has lowered the threshold of what it takes to be diagnosed with a given disorder.
For instance: the criteria for “generalized anxiety disorder,” something that involves excessive and persistent worrying.
A previous version of the DSM required 3 out of 6 symptoms for diagnosis, where now only one symptom is needed.
Formerly the symptoms needed to last for 6 months .. now they only need to persist for 3 months.
So, if you are excessively worried for three months about your finances or your health or that of a family member (to the point where you can’t control the worries), you could be diagnosed with this disorder, whereas in the past you wouldn’t have been.
One result of a bigger mental illness tent is that there are fewer people actually standing outside the tent. If we continue in this direction – if it takes fewer symptoms or less severity to meet the criteria for diagnosis – increasing #s of people will qualify.
There are, and probably will continue to be, fewer and fewer people who will live their lives in relatively good mental health according to the DSM.
The normal trials and tribulations of life—the periods of sadness, or worry, of anxiety, or grief, or difficulty sleeping, or drinking too much caffeine or having caffeine withdrawal headaches—have been pathologized.
More “normal” thoughts, feelings, and actions now merit a diagnosis. Providing a bigger tent for mental illness leaves us with an increasingly restricted definition of mental health and can make us all more likely to see mental illness when perhaps it’s just normal human struggle.
We can become so used to seeing psychopathology that we think—erroneously—that being odd or having difficulties must be an expression of mental illness – rather than just an accepted part of life.
What else is going in our culture that allows for this expanding definition of mental illness?
Insurance. Pharmaceutical companies. Increased work demands. Instant gratification.
>INSURANCE:
In order for medical care to be reimbursed by insurance, there has to be a diagnosis. It has to be a real, legitimate illness.
>PHARMACEUTICAL COMPANIES:
Pharmaceutical companies search for ever-wider markets for their products. When more people are diagnosed with a given disorder (perhaps because of less stringent criteria), or a new diagnosis is created, it widens the market for their drugs.
In fact, the DSM-5 and the pharmaceutical industry have a significant number of connections: One study found that 70 percent of DSM-5 task-force members have financial ties to the pharmaceutical industry.
>INSTANT GRATIFICATION:
online shopping, downloaded entertainment, and the immediate access to the world available through the Internet, if we have problems, we want a quick fix.
If a medication will help lessen uncomfortable thoughts or feelings or maladaptive behavior, we are receptive to medication.
“Like fast food, recent medication-centered practice comes from the most aggressively consumerist society (USA), feeds on people’s desire for instant satisfaction and a ‘quick fix,’ fits into a busy life-style.” But if we’re going to take a medication, we need to have a problem that is being treated—at least to get those doctors’ visits reimbursed by the insurance company.
>ELIGIBILITY FOR FINANCIAL/OTHER HELP FROM THE GOVERNMENT:
Certain diagnoses make the sufferer eligible for government services or programs or supplementary educational services.
People who feel they or their loved ones could benefit from those services may advocate for a widening in definition that would enable more people to be diagnosed and thus eligible for those services.
>Finally, perhaps there’s another reason: as our lives take on an even more frantic pace and our workload becomes ever greater, perhaps we’re relieved to put a label to the anxiety, the fatigue, the worry, or other suffering that we might feel. But .. many people ask, is labeling half of us with a mental disorder the best way to do it?
Regardless of how we personally feel about all of this … as a society we’re definitely moving in the direction of the “medicalization of deviance.”
And this constitutes a paradigm shift.
A SHIFT toward understanding behaviors as a matter of health,
Understanding behaviors as due to underlying sickness.
Finding the causes of deviance within the individual rather than in the social structure. And treating deviant behavior through medical intervention.
Wayward Americans:
A class not devoted solely to mental illness – but one that encourages us to think
about how we are all seen – or may have been seen in previous years – as “normal.”
Social norms.
Socially acceptable, culturally acceptable behavior.
In order to examine these behaviors, we realize that CONTEXT is vitally important.
Time & place
We’ve talked about cognitive abilities – in terms of intelligence
and what happened to some people (historically) who didn’t “measure up.”
The Supreme Court decision Buck v. Bell said ok to sterilize people who it seemed wouldn’t contribute to the collective gene pool.
In THE YELLOW WALLPAPER Charlotte Perkins Gilman’s character suffered from
post-partum depression – just as she did in real life.
Given that Perkins Gilman was a member of “elite” society and could afford the best care at that time – she went to a sanitarium for about 6 weeks and said afterward that she nearly lost her mind.
Today post-partum depression is widely recognized, usually short-lived and treatable. Women are encouraged to seek help and far-less stigmatized than
they were previously.
Postpartum depression hadn’t been created yet. Perkins Gilman was instead
diagnosed with neurasthenia. While she was forced to lie in bed and try to
reduce any mental clutter, well-to-do men were sent west to live the outdoor life.
We talked about mental retardation, feeble-mindedness – some cases deemed serious enough to warrant sterilization.
Of course, the diagnosis often masked what was really going on … in some
cases young women who became pregnant after being raped were targeted.
One of your readings had to do with whether or not trained professionals could recognize insanity. In a therapeutic setting – a psychiatric institution.
This particular research study determined that they couldn’t.
That’s not to say that there haven’t been many people whose behavior clearly indicated that they are seriously mentally ill.
Previously many of them would have been institutionalized.
But we learned that the vast majority of the large psychiatric institutions have closed. Patients were sent back into the community – ideally with access to medication and therapy.
Some did receive it. Many didn’t.
One recent article proclaimed: “How the Loss of U.S. Psychiatric Hospitals Led to a Mental Health Crisis”
“State hospitals began to realize that individuals who were there probably could do well in the community … It was well intended, but what many believe happened over the past 50 years is that there’s been such an evaporation of psychiatric therapeutic spaces that now we lack a sufficient number of psychiatric beds.”
While the deinstitutionalization movement helped many people receive appropriate care outside of large health centers, a significant # of people who could benefit from inpatient care can’t get it.
Neuroscientists tell us … it’s all in our head. Literally. Our brains determine our actions.
Science has made huge strides in understanding the human brain and how it functions.
Neurotransmitters are responsible for our moods and our general mental state.
Severe mental illnesses, such as Schizophrenia and Bipolar Disorder, are diseases of the brain.
Lesions or damage to the frontal lobes and to other parts of the brain can cause impulsive behaviors.
What about addiction? Is it a disease? Learned behavior? A habit one can break? A lack of social connections?
In fact the staggering statistics regarding opioid addiction raise questions not just about what causes this but “who” caused this?
According to many, big pharma bears a great deal of responsibility for fostering this dependence on pain-killers … and the cheaper non-prescribed alternatives.
A just-released study determined that:
Aggressive direct marketing to doctors by pharmaceutical companies is tied to fostering the ongoing epidemic of opioid abuse in the United States.
A county-by-county analysis showed that opioid use increased in places where drug makers focused their marketing efforts. "The counties that had the most opioid product marketing from pharmaceutical companies were the counties that subsequently one year later had more opioid prescribing and had more opioid overdose deaths.”
In the meantime, the U.S. opioid addiction crisis continues. Abuse of the drugs led to nearly 50,000 overdose deaths in 2017, according to the U.S. Centers for Disease Control and Prevention.
Americans now are more likely to die from an opioid overdose than from a car or motorcycle crash, a fall, drowning, or choking on food, the recent study concluded.
Heroin and fentanyl today are much more commonly involved in U.S. overdose deaths than prescription opioids … however, prescription opioids are still involved in about one-third of opioid overdose deaths, and they're commonly the first opioids people encounter before they start having a problem with addiction
All of this knowledge raises disturbing questions. Does any of this mean that we are not responsible for our behavior? Does it mean that we have no “free will” because “my brain made me do it?” It it’s true that my brain made me do it then, as a result, anything I do is a result of the way my brain works. In other words, I didn’t choose to steal that item, my brain did?
What about criminal behavior?
Sometimes peoples’ behavior is so egregious that they’re seen as just plain evil.
We debate whether violent psychopaths, for example, are morally responsible for their actions. Can they be held responsible if they’re mentally ill?
Emile Durkheim told us that crime is a necessary component of a healthy society.
Isn’t that more of a philosophical debate? That crime helps us to create, to recognize social norms.
But that’s in the abstract
What about violent crime? And the idea that neuroscientists are telling us everything stems from the brain. And maybe people just can’t help bringing automatic rifles into public places and killing scores of men/women and children.
Maybe violent behavior is due to a brain abnormality, something inside of us that we
can’t control.
And I get it that someone could have a mental illness that makes them do that. I honestly can’t believe that Andrea Yates, the woman in Texas who in 2001 killed her five children, wasn’t suffering from postpartum depression with psychosis – which is what she was diagnosed with. And that possibly if she had received sufficient mental health care with follow up support – wouldn’t have done something so horrible.
I get that crime is “normal.” And while we have compassion for anyone who has been the victim of a violent crime .. we can at the same time believe that there are some people who suffer from a severe mental illness that’s responsible for their violent behavior (though most mentally ill do not commit crimes).
But what about when we’re personally affected? Or our close friends or family?
Do we care that crime is “normal?”
Do we care that the perpetrator “couldn’t help himself/herself?”
And therein lies the rub! Does this make us all hypocrites? Perhaps.
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