Atypical Development – Diagnosis and Classification

How do we define normal? Normality and abnormality is based upon subjective judgement. Views of abnormality differ between individuals and cultures. When does somebody stop being merely eccentric and become mentally ill? Judging mental illness is difficult because it relies upon sound judgement and extensive research into cultural variations in behaviour patterns. We should also consider that psychology deals with individuals and everyone is different. If it is so difficult to define ‘normal’ and ‘abnormal’ then how can it be classified and diagnosed objectively? Abnormal is defined as a deviation from what is normal or usual. What is considered normal? Normal is considered as acting within a previously measured standard. How is the standard measured? There are different ways to define ‘normal/abnormal’ and there are different definitions that help us along the way, Deviation from statistical norms, social norms, ideal mental health and failure to function adequately.
Deviation from statistical norms describes a method that uses the population to gather its evidence. This technique analyses data collected from a varied range of people and highlights rare, un-typical behaviour, which is then labelled abnormal. For behaviour to be labelled normal from a statistical point of view, it needs to be average behaviour performed by the population in question. This is why labelling behaviours between cultures and places is challenging, as they have different standards and morals. It is assumed that personality traits and behaviour can be placed into normal distribution patterns with most people not straying far from average. For example; intelligence (IQ) can be plotted on a normal distribution curve which would show there are very few remarkably high or low scores. IQ is a good example of this ‘abnormality’ not necessarily being bad. ‘Normal’ IQ is around 100 on the distribution curve. However, Albert Einstein (IQ 160) and Sir Isaac Newton (IQ 190) have a high IQ which is regarded as a good thing. “Being a genius is very rare, is usually regarded as highly desirable, and few, if any, would see it as a psychological disorder” (Haralambas 2002). While this seems a good way to measure an ‘abnormality’, there are some things that are not taken into account. It disregards the desirability of a behaviour, for example IQ. Behaviours are more likely to be considered abnormal if they are undesirable. It also fails to identify how far an individual must deviate before being labelled abnormal. Another criticism is that within all societies there are large numbers of people who display undesirable behaviour, if all those people were placed into one category then over 50% of the population would have to be included, this would then make them ‘normal’ in a statistical sense. One last criticism of the statistical approach is that it does not consider the influence of an individual’s behaviour on others.
Deviation from social norms is when a person does not act as society deems acceptable. Every society has a set of rules based upon moral standards, some are clear-cut and to ignore those means you are breaking the law, e.g. stealing. Other rules are social, wearing the correct clothes for the occasion. This approach suggests you can label ‘normal’ or ‘abnormal’ using certain standards of social behaviour. Some behaviour is not only acceptable in society, but expected in particular circumstances. Most people are aware of these ‘rules’ and conform their behaviour accordingly. Individuals who do not conform are seen as ‘abnormal’ or mentally ill. This approach takes into consideration the impact of an individual’s behaviour upon others. Like other definitions, this one is bound by culture and society. An example of this would be sitting quietly in a library, or showing grief at a funeral. According to this, ‘abnormality’ is a deviation away from the pattern of desirable behaviour. An individual with schizophrenia may laugh at a funeral which would be considered emotionally inappropriate and unacceptable. Someone who shows a lack of conscience or behaves aggressively is considered to have anti-social tendencies. This person would have little or no guilt and would be unrepentant for shouting in a library for instance. Another example would be Mormons who believe in polygamy, in our society that would be unacceptable. This shows how some ‘abnormalities’ are nothing more than cultural differences. Again, there are limitations to this definition, particularly since the social rules we should follow are usually culturally relevant. Social norms vary within societies and standards change. For example, in our society homosexuality was illegal, now it is no longer considered wrong. We need to consider differences between countries and cultures when relating findings of any research to different social groups, one social group norm cannot be used to classify other group behaviours. Social deviance is not always a bad thing, during the 1890’s the suffragettes were considered at the time, socially deviant in fighting for their right to vote, but they weren’t abnormal.
Deviation from ideal mental health describes people who do not fit into the criteria of ideal health as laid out by Jahoda in 1958. Jahoda proposed six categories that highlighted ideal mental health, anyone who does not achieve the majority of these criteria would be considered ‘abnormal’. The criteria are,
Positive self attitude,
Self actualisation of personal potential,
Resistance to stress,
Personal autonomy,
Accurate perception of reality, and finally
Environmental mastery.
This approach looks to the positive psychology instead of looking for the problems. Jahoda looks to “identify characteristics that people need in order to be mentally or psychologically healthy rather than identifying the problems”. (Eysenck 2008). An example of this approach would be an individual suffering from agoraphobia. Going outside without anxiety is a requirement for normal functioning. Someone who cannot do this is classified as ‘abnormal’. However, Jahoda’s characteristics of mental health can be classed as too idealistic, it is more common for people to fall short of some of these characteristics than to fulfil all six.
Failure to function adequately is considered a person unable to live a normal life. According to this definition, each human being should achieve some sense of personal well-being and make some contribution to society. Recognition of not functioning properly could act as a standard of abnormality. Rosenhan and Seligman suggested a suitable approach to defining mental abnormality may be to “identify a set of seven abnormal characteristics, each of them on their own may not be sufficient to cause a problem, however when several are present, then they are more symptomatic of abnormality” (Eysenck 2008). The seven characteristics used to label a person normal or abnormal are:
1) Suffering, experience of personal distress, sometimes taking the form of intense anxiety, depression or loss of appetite.
2) Maladaptiveness, prevents good relationships and achieving life goals.
3) Vividness and unconventional behaviour, very different behaviour from other people.
4) Unpredictability and loss of control, variable, uncontrolled and inappropriate behaviour (most people can lose control in severe circumstances).
5) Irrationality and incomprehensibility, it is not clear why a person would act that way.
6) Observer discomfort, watching abnormal behaviour, or the breaking of society’s rules often causes discomfort. But this may also be because of cultural differences rather then abnormality.
7) Violation of moral and ideal standards, behaviour that is against the moral standards of society, (these standards may be outdated).
This approach to defining abnormality has also been criticised. Firstly, it is suggested that it depends too heavily on subjective assessments; secondly, it does not sufficiently differentiate abnormal behaviour from behaviour that is non-conformist, unconventional or eccentric. Most judgements are subjective (may cause discomfort for one person, but not others). Some of the seven characteristics are unreliable; personal distress is not absolute proof of abnormality, not all mental disorders are accompanied by distress, and many of the characteristics apply to non-conformists as well. All this makes abnormality harder to diagnose.
Psychologists often disagree about the causes of abnormality or the best way to treat them. As a result, four different models of abnormality were devised to cover all the different theories. All of these models try to reduce the ‘illness’ to a particular point, biological is a medical complaint, psychodynamic is all about learned behaviour and socio-cultural is when a group of people are more, or less vulnerable to psychological disorders as a result of their culture, position in society, or social group.
The biological model regards abnormality of mental functioning as an illness or disease. Mental disorders are thought to be related to physical malfunctioning or chemical imbalance in the brain. Some disorders are thought to have an organic basis, such as brain tumour, or poisoning due to alcohol or drug abuse. Mental disorders which do not have a clear organic cause are often referred to as functional disorders, although they are still thought to be physical in origin, symptoms occur as a consequence of chemical changes in the brain, this may be due to a genetic defect or to life stressors. In 1987 Weissman conducted a study into identical twins compared with fraternal twins to try to justify this biological assumption. Most of these studies show a positive correlation when each identical twin is studied to see whether they, at some point will become mentally ill. Most studies show if one identical twin becomes mentally ill, the other has a higher chance of doing the same. Whereas with fraternal twins this is not so much the case. An identical twin is around five times more likely to become ill if the other twin does than if they were fraternal twins. One of the main strengths of this model is that a medical diagnosis of mental illness can reduce the factor of blame that would usually be placed on the family and the sufferer; no-one is responsible for the illness. This is regarded as more human because there are no feelings of guilt linked to the diagnosis. This model is also criticised for the use of drug therapy in many treatment plans. Drug therapy is said to be too heavily relied upon and is too often assumed to be the cure for the problem. This does not take into account that chemical imbalances may be a symptom of the illness, not a cause. Therefore the symptom is being treated and is unlikely to be seen, however the underlying problem will remain. This is apparent when patients cease drug treatment and symptoms soon reoccur. It has also been said that this approach is reductionism. It tries to explain phenomenon such as psychological disturbances in a simple form, reducing the problem to an abnormal behaviour of brain cells. This oversimplifies the matter, there is likely to be a number of different factors that will cause and treat psychological abnormalities, and these are not all considered by the biological model.
Freud developed the concept of the psychodynamic approach; the idea behind this was to use ‘talking therapy’ to bring past memories from the unconscious to the conscious. The unconscious is when you do, or think something without being aware that you are doing it. Along with the idea of the unconscious Freud also developed the concept of the ID, the Ego and the Superego. The id is described as an impulsive, selfish side to our personality which is ruled by a pleasure principle, the superego is the moral part of our personality which recognises right from wrong; and our ego is the part of our mind which mediates between the two. He believed that there were two main causes of abnormality. One was childhood traumas and the idea that a bad memory from our childhood is so traumatic that it buries itself in our subconscious. This is what is believed to cause problems later in our adult life. The second cause was the concept that our mind has not learned to rationalise our id and our superego and that our ego is undergoing unconscious conflict which causes us anxiety. The behavioural model emphasises individual differences: we are all subject to our own unique learning experiences, which means that the gap between ‘normal’ and ‘abnormal’ is reduced. Capsi et al (1996) showed that undisciplined three year olds were more likely to have anti-social personality disorder when they reached twenty-one. In 1993 psychologist John Briere conducted research into the field of traumatic stress studies. He has written a number of articles and books on the lingering effects of child sexual abuse and treatment of adults sexually abused in early childhood. He took a sample of 450 adults reporting sexual abuse in their childhood. A total of 267 identified some period in their lives when they had no memory of the abuse they suffered. Many of the victims’ feared death as a result of telling a third party about the abuse. “In contrast, abuse characteristics more likely to produce psychological conflict (e.g., enjoyment of the abuse, acceptance of bribes, feelings of guilt or shame) were not associated with abuse-related amnesia.” (Briere, J, & Conte, J. 1993). The results of this study seem to support Freud’s initial ‘seduction hypotheses. There are both advantages and disadvantages to using this model to define abnormality. It consists of talking therapy, which is non-invasive, no drugs need to be used to treat the underlying cause, this is opposed to the biological method that consists of drug treatments and physical procedures. Another advantage of the psychodynamic model is that it is the first model which focuses on the importance of childhood. In the days of Freud it was thought that children should be seen and not heard, however after Freud’s theory the importance of a child’s first five years of childhood was recognised. There is no culture barrier as you are focusing solely on a single person. This gives power to the patient as they have all the answers. However whilst being very positive in its approach, there are limitations, it is very subjective, which means the patient is totally reliant on the interpretation by the professional. The treatment is long, expensive and is not always proven to be effective. Also, bringing a persons past to the consciousness may cause more problems, making this model psychologically invasive to the patient.
The socio-cultural model states that people are social and cultural beings. They are members of families, groups, clubs and society. From this point of view, the behaviour of these people is shaped by their position in society, family relationships and job status. There has been an increase in people with eating disorders; one explanation of this could be society’s view of the ‘perfect’ figure. As cultures change so do attitudes and mental illnesses. A good example of this is, women are twice as likely to be diagnosed with depression or similar anxiety based illnesses. One explanation could be their social role. With low paid jobs, they are sometimes totally dependent on their husband and are more likely to live in poverty (Haralambas & Holborn, 2000). The downfall to this approach is it tends to focus solely on the individual, basically ignoring cultural or social influences on an individual’s behaviour. People have also argued that this model does not look into why certain people develop psychological problems. This does explain why certain groups of people are more susceptible to certain mental illnesses. This suggests that changes in culture and society are needed to improve a person’s recovery from mental illness. However this would be extremely hard to implement. This model is an add-on to the other models, it looks at questions and answers them in a way the other models could not.
Doctors use two systems to help diagnose a mentally ill patient, DSM – diagnostic and statistical manual of mental disorders and ICD, International classification of diseases. To make a diagnosis, both systems need to identify specific symptoms which are listed; all or some of these symptoms must be present for a specific length of time. They are in relation to age, gender and the absence of other specified conditions and personal circumstances. Emil Kraepelin was the first person to observe people who seemed to act ‘abnormally’, the DSM and ICD stem from his work in 1883. DSM is widely used in the United States of America; ICD is produced by the World Health Organisation and is mainly used in Europe. In a study carried out in Britain, Copeland found that attributes such as age and location were likely to affect diagnosis. Older Glaswegian trained clinicians were more likely to perceive higher rates of abnormal behaviour than younger clinicians trained in London. (Copeland, J. et al (1971). This shows us that there are several problems within the classification system. Depending on where your doctor trained is a factor in how you are diagnosed. There is disagreement however, as to whether the DSM and the ICD are objective methods of diagnosis. Most notably, clinicians rarely agree on the same diagnosis, categories of symptoms overlap, and patients tend not to fit the criteria. Ethically, classification systems have been criticised because of their ability to create and attach stigma to the diagnosed (labelled) patient. A further concern regarding classification systems is one of the ethical consequences of diagnosis. Some psychologists argue that by diagnosing a patient, clinicians are applying a label, which effectively produces the disordered behaviour. In Rosenhan’s famous experiment, Being sane in insane places (1973), eight psychologically healthy people were sent to various psychiatric hospitals complaining of hearing a voice saying hollow, bump and thud. Most of the eight were admitted there and then with a diagnosis of schizophrenia. After admission each person told the doctors that the voices had stopped and they felt themselves again. Psychiatrists and nurses watching the patients noted behaviour such as note taking or pacing the corridor as signs of pathological behaviour and nervousness. Most of the people were released ‘in remission’ of their schizophrenia. The shortest stay was seven days, the longest being fifty-two. That person now will always be seen in terms of their label by doctors and psychiatrists. (Rosenhan, D. L.� 1973 in Bilton et al p608 2002). The process of labelling certainly has a huge effect on the patient. As well as being difficult to remove, it sanctions others to view the person as mentally ill; this affects how they get treated, both medically and socially. However diagnosis and the correct label can also get the right help and support. In conclusion it is apparent that to define abnormality is exceedingly difficult to achieve with a clear definition that captures all the essential features, because of the ever changing complexities that surround abnormal psychology, no one approach is entirely correct. You need the triangulation of ALL approaches to make a positive diagnosis; mental health is too fragile for guess work and subjective thinking.

Atypical diagnosis and classification bibliography

Briere, J., & Conte, J. (1993). Self-reported amnesia for abuse in adults molested as children, Journal of Traumatic Stress, 6, 21-31, Springer Netherlands
Eysenck, M, (2008) AS Level psychology 4th edition, Psychology press
Haralambas, M, Rice, D, (ed) (2002) Psychology in focus A Level, Causeway press LTD
Haralambos, M, and Holborn, M, (2000), Sociology: themes and perspectives (5th edition), London, Harper Collins
Rosenhan, D. Seligman, M. (1995) Abnormal Psychology, Norton USA