Normal-What Does That Mean?

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.

Sullivan and his wife Jean are the parents viagra generico 5mg of three children. Erectile dysfunction is one such sexual disorder in which person has difficulty cheap viagra in having normal erection. For many people, visiting a doctor’s surgery is something they get usually generic cialis professional due to in period of menstrual, a lot of names of the medicine like Kamagra Zenegra, Forzest, and similar other information related you. The best option for reducing risk of prostate diseases tend to be slow in developing, though, there are many situations of cheapest price for viagra more assertive prostate cancer cell development. 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.

A Question of Alzheimer’s

There is a single question that may accurately and reliably differentiate between dementia and normal aging.  Not only is this question  potentially able to discriminate between normal senility and dementia, it may prove a powerful method to differentiate Alzheimer’s Disease from other types of dementia.

Here is the question.  How is your memory?

Perhaps this appears too simple to be elegant.  As with any rule to describe complex phenomenon, the rule only has power within specific boundaries.  For example, Newtonian physics is so powerful that it largely accounts for the success of NASA’s space program.  Newtonian physics loses most of its predictive power when the object is going very fast, or is very small.  This in no way renders Isaac Newton’s mechanics useless, rather his worldly physics is extremely useful within certain parameters.  If the observer loses sight of these parameters, then the power of the system may suffer.  A rule that holds true for all phenomenon is compelling, but it may come at the expense of explaining anything in the particular.

The boundaries that are important for this rule are predicated on the functioning of the person before dementia is suspected.  When a person is questioned regarding the status of their memory, this directly calls upon their level of self-awareness.  The awareness of self appears to be well correlated to intelligence, but again within specific parameters.  If one questions a person with mild mental retardation regarding a cognitive skill, they will likely have some idea of the meaning, but their responses will not be very accurate in relation to informants.  Questioning someone with moderate mental retardation will reveal that they do not understand abstract concepts regarding cognition.  Once low average intelligence is reached, self-awareness is typically functional.  There is a lack of evidence indicating that self-awareness increases with above average intelligence.  It may increase, but research that converges on this conclusion is lacking.  A general rule offered is that self-awareness is likely normal until intelligence falls below the average range.  As with any cognitive skill, self-awareness may be significantly greater or lesser than one’s Full Scale IQ, but it will likely be well correlated across thousands of individuals.
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The other boundary that needs to be considered is age.  It is unlikely that this question has much utility before the age of 75.  Purely as an artifact of testing thousands of patients, it is rare for someone before the age of 70 to complain about their memory.  By the age of 80, most non-demented patients of average intelligence complain about their memory.  People in their 80’s are self-aware that their memory has declined, which is realistic and insightful.  The ability to name common objects and freely recall verbal information starts to decline in our 50’s, and is very evident to ourselves and others by the late 70’s.  In addition, people who age well are typically irritated by their inability to recall and generate names for people and objects.  Even in the early stages of a senile dementia, the victim is not bothered by their poor performance, and they frequently generate external causes for their inability to name or recall.

The next time you speak with someone in their 80’s who is constantly bemoaning their memory, let them know their cognition is likely just fine!  Conversely, the next aged person with whom you speak reporting an excellent memory should be a cause for concern.  If this person is college educated and held a middle-class job, then be very concerned.  If the person is suspected to be below average in terms of education and vocation, then the answer to this question is less revealing.  Also remember that this question is less able to discriminate between normal aging and Alzheimer’s in those younger than 75.  There are many causes of poor verbal memory throughout our lifespan, but the early degradation of self-awareness is nearly unique to Alzheimer’s Disease.  This is likely the source of the question’s utility and power.

Whether it is termed the “dementia question” or the “Holzmacher paradigm” is less important than future research into the uses of this questions for clinical practice.  This single brief question may offer physicians a procedure to accurately make dementia referrals, as well as provide a simple way for caretakers to make treatment decisions.  The greatest difficulty with the question is that it appears too simplistic to be meaningful, let alone useful.  Perhaps Friar Ockham was correct, amongst competing explanations, the simplest solutions are most satisfactory.  If anyone knows of a simpler method to reliably differentiate between normal aging and Alzheimer’s Disease, please write as soon as possible.  It is hoped that clinicians will weigh in on this proposal, as my razor may have removed a bit too much.  As always, comments from any interested party are welcome.