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David Baxter PhD

Late Founder
Mental health: What's normal, what's not
Mayo Clinic

Deciding what's normal mental health and what's not is tricky. See how feelings, thoughts and behaviors are classified on the ever-evolving continuum of normalcy.

What's the difference between mental health and mental illness? Sometimes the answer is relatively clear. Sometimes it isn't.

People who hear voices in their heads may have schizophrenia, for instance. And those with grandiose ideas ? who believe they can run the United Nations, even though they have no applicable experience ? may have a form of bipolar disorder.

But more often the answer is less clear-cut. If you can't give a speech in public, does it mean you have a disease or simply a run-of-the-mill case of nerves? If you feel sad and discouraged, are you just experiencing a passing case of the blues, or is it full-fledged depression, for which you may need medication?

Just what is normal, anyway?

The role of culture and science in defining normalcy
Determining what's normal and what's not is tricky. Scientists, researchers and mental health experts have wrestled with the issue for hundreds of years, and even today the line between normal and abnormal is often blurred.

"There's a huge range of what's normal," says Donald E. Williams, Ph.D., a psychologist at Mayo Clinic, Rochester, Minn. "But there are also many types of mental disorders ? thoughts, feelings or behaviors that are abnormal."

What's normal is often determined by who's defining it. Normalcy is ambiguous and often rooted in value judgments particular to a certain culture or society. And even within cultures, concepts of normalcy may change over time, particularly if influenced by evolving societal values or expectations. New medical research and knowledge can also lead to changes in definitions of normalcy.

One thing that makes it so difficult to distinguish normal versus abnormal mental health is that you can't simply be tested for it. There's no MRI or blood test for obsessive-compulsive disorder, no ultrasound for depression, no X-ray for bipolar disorder. That's not to say mental disorders aren't biologically based, because they are linked to chemical changes within the brain, and scientists are beginning to map those changes visually. But there's no physiological diagnostic test for mental illness.

So how do you define mental illness?
Instead of using tests, mental health professionals define mental disorders through their signs, symptoms and the functional impairments they may cause.

Functional impairment is the inability to perform certain routine or basic daily tasks, such as bathing or going to work. Signs are what objective observers can document, such as agitation or rapid breathing. Symptoms are subjective, or what you feel, such as sadness or hopelessness.

In mental health, signs and symptoms commonly show up as:

  • Behaviors, such as repeated hand washing
  • Feelings, such as sadness
  • Thoughts, such as delusions that the television is controlling your mind
  • Physiological responses, such as sweating
Signs, symptoms and functional impairments are spelled out in detail in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a 2-inch thick volume that classifies and describes more than 300 types of mental disorders. The book, published by the American Psychiatric Association, is used by mental health professionals to diagnose everything from anorexia to voyeurism. The first edition of the diagnostic manual was published in 1952, and revisions have been made periodically since.

Why is it important to distinguish between normal and abnormal, to attach labels that could ultimately be stigmatizing? Why does a specific diagnosis matter? One reason is that the health insurance industry uses the diagnoses spelled out in the DSM to determine coverage and benefits and to reimburse mental health providers. But more important is that in order to get appropriate treatment, you must know what condition to treat ? and whether it should be treated.

How signs, symptoms and function are interpreted
How do mental health professionals determine whether the signs, symptoms and dysfunctions you're experiencing are normal or abnormal? Experts often use a combination of the following approaches:

  • Your own perceptions. How you perceive your own thoughts, behaviors and functioning can help determine what's normal for you. You may realize that you aren't coping well or that you aren't able to or don't care to do routine activities or the things you used to enjoy.

    If you have depression, the dishes may go unwashed for days, you may stop bathing, put off socializing, lose interest in hobbies or yell at your family more often. You may feel sad, hopeless or discouraged. You might recognize these behaviors and feelings as a deviation from the norm. You may notice that something's amiss.
  • Others' perceptions. Your own perceptions are subjective and may not give you an accurate assessment of your behavior, thoughts or functioning. Objective observers, on the other hand, might be able to do so.

    To you, your life may seem perfectly normal or typical. Yet to those around you, it may seem odd or abnormal. This is often the case with schizophrenia. If you have schizophrenia, you may have auditory hallucinations ? you'll hear voices and carry on conversations with them, believing it's a normal interaction with another person. To witnesses who observe this behavior, it may seem abnormal.

    "It's common that people have something wrong and not know it," Dr. Williams says. "That's true of both mental and physical disorders. People die of a heart attack who never even knew they had heart disease."
  • Cultural and ethnic norms. Many times what's normal behavior or thinking is defined by your culture. But that means what's normal within the bounds of one culture may be labeled abnormal within another.

    Conversing with voices only you can hear may be an indicator of schizophrenia in Western cultures. But these kinds of hallucinations may be a normal part of religious experience in other cultures.

    And something may be normal or acceptable within your own family that's considered abnormal and in need of changing outside of your home. For instance, the behavior of a child with attention-deficit/hyperactivity disorder may be unacceptable in a structured school environment, but be perceived as normal and acceptable in a less structured home environment, notes Jennifer Fisher, Ph.D., a psychologist at Mayo Clinic, Rochester, Minn.
  • Statistical values. Normal is often defined by what's statistically average. Most people fall in the middle ground, the average, while others fall to one extreme or the other.
Length, severity of symptoms also considered
In assessing someone's mental health, all four of these approaches are typically taken into consideration. Mental health experts may ask you how you feel, whether others have noticed a difference in your behavior or mood, and what your cultural background is. They also may ask you to fill out psychological questionnaires.

Other factors are also considered. Among them:

  • How long your symptoms have been going on
  • How severe the symptoms are
  • How upsetting the symptoms are to you
  • How the symptoms disrupt your life
It's normal to feel sad after a valued relationship ends. But if you feel intensely sad and upset for several weeks and you lose interest in daily activities, such as going to work, doing household chores, or visiting with friends, you may have depression. Similarly, if you get anxious before giving a presentation to a big client but forge ahead and manage the signs and symptoms, such as sweating or rapid breathing, you may just have a case of normal stage fright, and not social phobia (social anxiety disorder).

And if you cut someone off in traffic or yell at a store clerk, you may just be having a bad day or be a generally ornery person. But if you're abusive, violent, manipulative, exploitive or irresponsible, or if you disregard the law ? traits that are persistently maladaptive and inflexible, and cause functional impairment or distress ? you may have antisocial personality disorder, sometimes known as sociopathy.

Mental health as an evolving continuum
Despite these criteria, a precise definition of normal mental health remains elusive. The Diagnostic and Statistical Manual acknowledges the difficulty and resorts to defining mental disorders as behavioral or psychological syndromes or patterns that cause distress, disability in functioning, or a significantly increased risk of death, pain or disability. And that syndrome or pattern can't just be an expected and culturally accepted response to a particular event, such as grieving the death of a loved one.

The Surgeon General's 1999 report on mental health states that mental disorders are "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning."

By most accounts, mental health and mental illness don't have well-defined boundaries.

"I think of it more as a continuum than an absolute," Dr. Fisher says.

Not only is it a continuum, but it's an evolving continuum. In some ways, this is no different from the diagnosis or classification of physical disorders. For years, a blood pressure of 120/80 millimeters of mercury was considered normal, for instance. That changed overnight in May 2003. Now with that blood pressure measurement, you'd be diagnosed with the abnormal condition of prehypertension, at risk of life-threatening cardiovascular complications.

Just as with blood pressure, new medical information can lead to changes in the classification of mental disorders ? new ones will be added while existing ones will be removed, or the associated signs and symptoms will be modified as new opinions develop over time. Today, some mental health experts, for instance, are proposing that the premenstrual signs and symptoms many women experience every month be classified as a mental disorder ? premenstrual dysphoric disorder.

Revisions may also reflect evolving social and cultural attitudes. Homosexuality, for instance, used to be classified as a mental disorder but was removed from the Diagnostic and Statistical Manual in 1973.

To treat or not to treat: Therapy not always necessary
Even if you do have a diagnosable mental disorder, it may not pose a problem in your daily life to such an extent that it requires treatment.

"It can be abnormal but be OK," Dr. Fisher notes.

Consider spiders, for example. You may have a terrible fear of spiders, but if you never encounter spiders, or you can get someone else to handle them for you, that phobia may have little or no impact on your life. It doesn't impair your ability to go about your normal routine.

"Would we recommend therapy in a case like that?" Dr. Fisher asks. "No. The condition may be diagnosable but not require therapy. You're in need of therapy when something impairs your functioning."

Some critics even contend that too many characteristics or quirks are being pathologized ? labeled abnormal ? to make money. The pharmaceutical industry in particular has come under fire for bringing new drugs to market to treat recently labeled conditions that used to be chalked up to harmless eccentricity.

But there is a bit of good news amid the controversy.

"We have a lot of effective treatments for the things out there that are considered abnormal," Dr. Williams says. "Chances are, something is going to help you."


In mental health, signs and symptoms commonly show up as.......

These two terms puzzled me, until I looked them up. For anyone who is interested:

What is a Symptom?

Symptom: Any subjective evidence of disease. A symptom is a phenomenon that is experienced by an individual. Anxiety, lower back pain, and fatigue are all symptoms. They are sensations only the patient can perceive. In contrast, a sign is objective evidence of disease. A bloody nose is a sign. It is evident to the patient, doctor, nurse, and other observers.

What is a Sign?

Sign: Any objective evidence of disease. A sign can be detected by a person other than the affected individual. Gross blood in the stool is a sign of disease. It can be recognized by the patient, doctor, nurse, or others. In contrast, a symptom is, by its nature, subjective. Abdominal pain is a symptom. It is something only the patient can know.

It is very helpful to evaluate symptoms and signs in diagnosing the causes of health problems and in monitoring the status of diagnosed diseases. Moreover, assessment of symptoms and signs is important during treatment with medications in order to determine the effectiveness of treatment and the development of side effects

Source: Medicine-Net
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