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OF mental health care and mentally ill

Abnormal versus Normal Behavior

A major question that has plagued the field of abnormal behavior is, what are the criteria for abnormal behavior (or psychopathology, mental illness, or a similar term)? Perhaps a clue to the answer can be seen in the medical profession, that can diagnose physical illness or disease fairly accurately.

In the history of developing successful diagnostic procedures in medicine, a primary prerequisite has been a fairly precise knowledge of what constitutes normal anatomy and physiological functioning. In other words, before physicians can diagnose illness or disease, they must know the population parameters of ‘‘normal’’ biological functioning. The fact that an understanding of normal behavior is a prerequisite to identify and investigate abnormal behavior seems to have been all but ignored in developing classification systems for abnormal behavior. A classification scheme of normal behavior must be developed, and normative data must be obtained before one can empirically establish what constitutes deviant, abnormal, or unusual behavior. Adams et al. developed such a preliminary scheme for classifying normal behavior.

The taxonomy is based on the assumption that various types of observable responses (behavior) can be grouped into categories that represent fairly homogeneous independent response systems. In this sense, it is similar to normal physiological systems or the taxonomy used by biologists, with such categories as the cardiovascular, gastrointestinal, nervous, and musculoskeletal. Although it can be argued that the response systems proposed by Adams et al. are not independent of each other and that they interact, resulting in somewhat arbitrary divisions, note that the taxonomies of biological functioning and anatomy are also interrelated. Studying the interrelationships of biological systems, as well as the systems themselves, has proved useful to biological scientists and should provide similar knowledge to psychological scientists, so that they too can attempt to organize behavior into subsystems of responses. Because the psychological response system of Adams et al. is based on units of behavior or responses, some professionals may assume that it is a classification system based on the theoretical position of behaviorism. This was not the aim of this scheme, and the assumption that the primitive units of observation in psychology are responses or response patterns does not imply a behavioral orientation. Most mental health professionals, including humanists, behaviorists, psychodynamic theorists, and those who are biologically oriented, would agree that the study of human beings begins with the observation of their behavior. The implications and explanations of that observed behavior constitute the various theoretical orientations. It is imperative that an adequate classification system precede the development of these theories. Although the temporal order is often confused in actual practice, the sequence of the development of a science involves classification, then measurement, and then theories as a basic prerequisite for knowledge.

Once there is some idea of the parameters of normal behavior and the way it varies as a function of age, sex, cultural groups, and similar features, then the question of what constitutes abnormal behavior can be more appropriately addressed. Essentially, psychopathology can be defined by two methods: the class model and the multivariate, dimensional, or quantitative model. The multivariate model assumes that all behavior can be placed on a continuum; one example would be intelligence. When some behaviors, such as depression and anxiety, become so exaggerated that their intensity is exhibited by only a small fraction of the population, then psychopathology may be demarcated. In this sense, a disorder such as depression or anxiety is diagnosed in the same way as hypertension in medical classification. When these responses reach a certain frequency, intensity, and duration, they are labeled pathological. Note that to use this criterion, it is necessary to have the population parameters or, in less suitable situations, clinical knowledge of the attribute and to make some judgment about where the limits should be, a judgment that is somewhat arbitrary. Selecting the appropriate limits can be aided by knowledge of the consequences of the extremes of behavior. It is also necessary to know the environmental aspects and other related circumstances of these behaviors (stimulus parameters) to make such a decision. The loss of a loved one, for example, is typically assessed with an increase in depression of high intensity, but of limited duration. Epidemiological inquiry and the notion of prevalence are the key concepts in this approach, although it is important to keep in mind Costello’s warning that merely because behavior patterns are frequent does not mean that they are normal or acceptable. For example, posttraumatic stress disorder is a frequent, albeit arguably ‘‘abnormal,’’ response to traumatic events. The dimensional approach to classification is the essence of this method, which assumes that a particular aberrant response is dimensional (i.e., everyone has the characteristic to some degree). In addition, establishing that a particular behavioral pattern is deviant or statistically rare is only the first step in developing a classification scheme for psychopathology. The second step is to demonstrate that these behavior patterns are clinically significant and cause objective or subjective distress to the individual or to others. Two general criteria can be used in arriving at this decision. The first has been called the criterion of labeled deviance. Under this criterion, deviant behavior or psychopathology is defined by behavior patterns that violate social norms. This criterion varies as a function of local conventions and changes from society to society, from time to time, and even from place to place. An example of this relativity is homosexuality.

In DSM-I and DSMII, homosexuality was considered a form of mental illness. In DSM-III-R and IV, however, it is not. For example, homosexuality is barely referenced at all in DSM-III-R and IV, where ‘‘persistent and marked distress about sexual orientation’’ is cited as an example under the category ‘‘sexual disorders not otherwise specified.’’ The second criterion is the criterion of adjustment. This criterion is based on how well individuals cope with their environments and is, within limits, independent of culture, because it is keyed only to the satisfaction of one’s biological and/or social needs and one’s ability to survive. These two criteria can conflict with each other; for instance, hardworking executives may meet all the deviance criteria of normality but would qualify as abnormal in terms of the adjustment criterion if their hard work has caused a potentially lifethreatening stress disorder. Another case would be a young man whose draft resistance during the war in Vietnam qualified him as deviant in terms of social norms but who, alive and well in Canada, is normal by the adjustment criterion. Therefore, it is obvious that what is perceived as normal behavior may depend on which criterion is used, and it should be clear that these criteria differ. However, it is also apparent that when an individual satisfies both criteria, the label of psychopathology is greatly enhanced. The validity of these judgments of abnormality must be established by research efforts. Another approach to classification is the class or qualitative difference model, which assumes that some psychopathological disorders do not occur in the normal population. For example, some disease processes (e.g., cancer or syphilis) do not vary in degree in all people, even in a mild form. Such diseases are either present or absent. Because it is difficult to conceive of any response— even a loosening of associations—that does not occur at some time to some extent in most people, the classification categories and subcategories in psychopathology must refer to a constellation of responses that are functionally related, so that they have simultaneous and/or consecutive variation within a given subset of the population. Even though each response may occur in some form in the normal population, these responses do not covary in the same manner as in the deviant subset, or they may be independent of one another. Note that this type of classification scheme requires careful determination of the relationship of the constellation of responses. A good example is schizophrenia. Earlier definitions of schizophrenia required that the individual exhibit the fundamental symptoms of altered associations, altered affect, ambivalence, and autism. At one time or another, all of us have demonstrated any or all of these responses to some degree. However, it is doubtful that the four symptoms covary together in the normal population, and this covariation permits us to use the label of schizophrenia and to assume that it does not occur in the normal population.

According to this approach, if it is assumed that there is such a phenomenon known as schizophrenia that does not occur in the normal population, then such a phenomenon needs to be demonstrated or verified before it can be used as a classificatory concept. This prerequisite is often neglected, and the hypothesis that there is a pathological condition known as schizophrenia is transformed into the fact that an entity known as schizophrenia exists. This is known as the process of reification. The question as to whether there is such a phenomenon as schizophrenia has received scant attention, and as a number of theorists have noted, the phenomenon of schizophrenia may well be a figment of psychologists’ and psychiatrists’ imaginations. Carson  has been particularly critical of the DSM-IV and its tendency toward an Aristotelian mode of thought. Further, there are even those who feel that it is unimportant whether such entities exist. Kendell  found the ‘‘truth value’’ of classificatory schemata irrelevant and emphasized instead their heuristic value. He stated that ‘‘diagnostic terms are no more than convenient labels for arbitrary groupings of clinical phenomena’’ and that these are ‘‘concepts justified only by their usefulness’’. The point is that deviant behavior should be assumed dimensional, something we all have to some degree—like blood pressure—unless otherwise demonstrated. To verify that a disorder is categorical (i.e., limited to some people but not others), it must be demonstrated by research evidence.

In a recent development, Meehl and his colleagues described taxometric procedures that can determine if a classification category is typological (i.e., class or latent class, taxonic) or dimensional/continuous. The procedure is too complicated to describe in detail here, but it is obviously a method that should resolve many classification controversies in the argument about whether a disorder is a category or a dimensional variable. This procedure has the potential to revolutionize classification if it is used. In summary, adequate knowledge of normal behavior and behavioral norms are necessary prerequisites for establishing a reliable and valid classification system for psychopathology. Then, either the class or quantitative methods can be used to establish categories of psychopathology.

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