Mental Health. Part 2: What the “Normality Level” is

In the first part of the series, we analyzed the traditional and new definition of mental health and its components based on insights from the Mental Health Discussion Group of the Founders club startup studio. Today we will focus on the concept of "normality" in the context of modern society and define mental disorders.

Understanding where the boundary between normality and disorder lies is a fundamental conceptual challenge in psychiatry. The understanding of what "normality" is was presented by American psychotherapists in a study that shows attempts to illuminate the boundary between normal behavior and disorder.

In the light of this study, we will focus on the problem of how to distinguish normal human suffering from psychopathology, which the authors refer to as the boundary between normality and disorder.

In the first part of the cycle, we already discussed that it is absolutely normal to experience a range of negative mental states, such as sadness, despair, anxiety, fear, excitement and anger, and they are not deviations, but a normal reaction to the vicissitudes of life.

But why is it important for us to understand the boundary between normality and disorder? When does the normal response to the hardships of life become destructive?

From a psychotherapeutic perspective, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) includes a section on diagnoses such as "Other conditions that may be the subject of clinical attention".

These conditions require closer attention, because the decision on how a suffering person reacts to difficult circumstances or experiences pathological psychological processes often has a great influence on what the doctor’s conclusion will be and the subsequent treatment.

It is easy to end up with a false positive diagnosis of normal suffering as a mental disorder. How can these conditions be better differentiated in order to provide appropriate treatment to those who need it and to protect people without mental disorders from unnecessary or overly aggressive treatment and social stigma?

For example, the loss of a loved one causes sadness, loss of interest in daily routine, loss of appetite, trouble concentrating, and trouble sleeping. These symptoms are also part of the defining symptoms of major depressive disorder (MDD). Is a person's reaction to loss a normal grief reaction, or is it better thought of as MDD? Making the wrong decision in either direction can either over treat someone who is experiencing normal grief or deprive the person with MDD of needed treatment.

The challenge in today's psychotherapy is to distinguish mental disorders such as major depressive disorder and generalized anxiety disorder from normal social distress and suffering, which can closely resemble a mental disorder in symptoms. 

The authors of the study emphasize that the diagnostic criteria must meet the requirements established by the definition of a mental disorder.

The definition of a mental disorder is as follows:

A mental disorder is a syndrome characterized by a clinically significant impairment in a person's cognition, emotion regulation, or behavior that reflects dysfunction of the psychological, biological, or developmental processes that underlie mental functioning.

This means such a disorder in psychological functioning that leads to dysfunction of a person. It is important to note that reactions to a common stressor, loss, such as the death of a loved one, are not a mental disorder if the reactions are not associated with dysfunction.

Another study argues that understanding the disorder requires two components:

1) scientific one: the symptoms represent an internal dysfunction, that is, the inability of any psychological mechanism to perform its biologically given function, i.e. impaired mental functioning and

2) a value judgment that a dysfunction causes harm to a person—usually in the form of distress or impairment.

While the concept of a mental disorder is fundamental to mental health theory and practice, there is currently no analysis of the concept that has been agreed upon and experts emphasize that the only way to understand what is and is not a disorder is by direct reference to the very definition of a mental disorder. 

The need to differentiate between normality and disorder is inevitable. This could be done by resorting to some technical method to determine what is and is not a disorder. Without  prior understanding of what we are trying to measure, no technical procedure will tell us what is normal and what is not. For example, both normal and disordered psychological processes are rooted in brain activity, so brain differences alone do not indicate whether a condition is pathological.

Also, in support of the importance of understanding the definition of mental health, let's take the example of "abnormal children" in another study: Parents' constructions of normality and pathology in child mental health assessments.

Central to the modern understanding of child psychiatry is the concept of the “normal” child. When judged to be outside the cultural and socially conditioned parameters of "normality", children are labeled as "abnormal"— for example, in the context of mental health, when this may warrant a psychiatric diagnosis. However, judgments about the "normality" of a child are further complicated by the circle of people who may be interested in this construction, including parents, guardians and specialists.

The study assessed children's mental health to examine how parents express concerns about their children's development. Parents did this in terms of "abnormal/normal", often contrasting the child with other "typical" children and/or contrasting the behavior of the same child in different settings or contexts.

The study concludes that, given the growing mental health crisis in children, initial assessments play a critical clinical role in determining diagnosis and stigmatization, and therefore understanding the definition of both mental health and disorder is critical.