It is often overlooked. How do clinicians diagnose mental illness without knowing what it is to be normal? This is not a trivial question. Defining normalcy is a central issue in the training of psychologists. Researchers focus on symptoms that reliably differentiates normal from abnormal functioning. It is the path of least resistance to dwell on symptoms, since through the use of informants, the researcher may obtain some degree of objectivity. What is overlooked, for the sake of objectivity, is what normality actually feels like to those who experience this state. Unfortunately, the feeling of being in a normal state of mind is hopelessly subjective.
People who are labeled as mentally ill often comment that they just want to be “normal like everyone else.” Like looking over the fence into the neighbor’s yard, people imagine the thoughts and emotions of others. Implicit assumptions are made with a minimum of data. It is often assumed that a labile (roller-coaster) mood is a sure sign of mental illness. Patients often assert that they are more tense and anxious than normal people. Everyone knows that seeing bugs that aren’t there definitely means one is crazy. This could be termed a trinity of assumptions regarding normal people; that they are less moody, less tense, and never experience hallucinations.
There is some truth to the trinity, but more often than not, it serves as an ideal that is always out of reach. Most people seriously under appreciate the degree to which normal people suffer with low moods, anxiety and transient hallucinations. A large distinction is that for normal people, these symptoms ebb and flow, whereas for the mentally ill, these states of mind merely continue to flow. Stated another way, normal people suffer low moods and anxiety states. It surprises many people to learn that most normals experience transient hallucinations. Large well-controlled studies of average people reveal how often they experience bizarre sensory phenomenon. Almost on a weekly basis, the average person is prone to experience a bug crawling on their skin or up a wall, only to have it disappear when they look again. If the bug disappears when they again look, psychologists call this normal, if they multiply when the person takes another peek, then we label these unfortunates as psychotic.
Do not be deceived as to what normal people experience. Normalcy is not an ideal state of being, often imagined as being in a good mood and free of tension. If this were the average state of the individual, most would never be motivated to leave their homes. Tension drives behavior. Tension is interwoven with life and abandons us at our death. It is a river that needs to be channeled, not dammed into a confined space. Similarly, bad moods are inescapable, yet they also may be a vector for change. Research into the sensory experiences of normal people should convince us that we are all a little crazy. Psychotherapy is typically more effective and rapid when the patient entertains realistic goals. The ideal of the normal person is often a fantasy, and it may drive people towards emotional goals that are impossible to obtain.
Is Alzheimer’s Disease truly a disease? The word “disease” is defined as an “abnormal condition or illness” in the dictionary, and Wikipedia describes disease as “an abnormal condition affecting the body of an organism.” The word shared in common between these definitions is “abnormal.” What is labeled as “normal” or ” abnormal” is not a trivial distinction. It encompasses much of the training I received towards becoming a clinical psychologist. For something to be regarded as “normal” it must be observed to be the typical/common state of affairs. This rests on the assumption that people are accurately and reliably able to distinguish between what is common and what is exceptional. Where does one draw the line between the average and the exceptional?
Consider shoe sizes. My feet are a size 12, and about 5% of males share this large size. A size 12 foot is not the average for a male, but it is not uncommon. The same size foot in a female is not average and it is fortunately uncommon. What is considered or measured to be the average is highly dependent on the group being considered. The deviation of my foot size from the human average increases when compared to females, Asians, and pygmy tribesmen-no relation is expressed or implied. Though my feet are abnormal, they function quite well notwithstanding! The notion of “normal” is an interval centered about the average of the population under consideration. The notions of “normal” and “average” only have meaning in light of the specific population(s) being considered. A statistical analysis may discover that male shoe sizes between 6 and 10 are within the “normal” range, whereas sizes less than 6 or over 10 are labeled “abnormal.” The term “abnormal” should not be equated with the word “dysfunctional.” An IQ of 130 is certainly abnormal, but definitely not dysfunctional. These terms only have real meaning when nested within specific groups, defined by measurable functional outcomes that are evaluated over a finite period of time.
So is a senile dementia of the Alzheimer’s type really a disease? The quickest answer is that the biological process of Alzheimer’s is not a disease, but the end result of the process could be termed a disease. All humans acquire neuritic plaques and neurofibrillary tangles as we cross the age 50 boundary. Correspondingly, free verbal recall and naming decline with so-called normal aging. The tangles and plaques are the organic hallmarks of Alzheimer’s Disease. Less mentioned is that these tangles and plaques increasingly infest the brains of all middle-aged humans. It is largely a question of degree.
Once the neurofibrillary tangles and neuritic plaques encompass about 30% of the cerebral cortex (brain’s outer coating of gray cells), the unfortunate person will exhibit the early symptoms of Alzheimer’s Disease. Less than 30% of the cortical area manifests as “normal” cognitive decline, and over 30% of the cortex affected results in symptoms of early AD. The organic pathology of AD is undifferentiated from normal aging until it is observed to cause functional impairment. Even though the organic pathology is “normal,” the uncommon extent of the pathology and the unusual decline of mental skills could be termed a “disease.” Similarly, all humans lose critical neurons that help us modulate and initiate motor movements as we age. If more than 60% of these dopamine producing neurons are lost during our lifetime, we will exhibit the symptoms of Parkinson’s Disease. Generally, under a 60% loss of the dopaminergic neurons will result in “normal” age-related tremors. Once again the natural process of aging is labeled as a disease if its manifestation is unusually powerful and negative. In the near future, I will address what people can do to minimize their chance of becoming “abnormal” in their old age.