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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
Dr. Schwartz's Weblog

What Is Normal and What Is Not? The New Diagnostic and Statistical Manual V

Allan N. Schwartz, LCSW, Ph.D. Updated: Dec 22nd 2008

 On December 18, 2008 the New York Times published an article about the fact that the American Psychiatric Association is working on then next edition of the Diagnostic and Statistical Manual. It will be published in three to four years and will be Volume 5. This is the manual used by the mental health community to diagnose patients who may be suffering from a mental illness or behavioral disorder. Based on the diagnosis, medication may be administered and psychotherapy advised to enable the individual to recover.

Work on the manual is always difficult because of the controversy over the definition of "abnormal behavior." Of course, the other side of the controversy is how to define what is "normal behavior," For example: 

Is this normal behavior?

1. A man and woman of adult age decide that they really enjoy sado-masochism during their sexual activities. In fact, he enjoys having her smack his bottom as hard as she can as part of their foreplay. She is more than happy to accommodate because doing so fulfills her fantasies of dominating men and she imagines she can inflict any pain she wishes. Powerfully aroused, they then engage in intercourse and each experiences a powerful orgasm. Are they normal or sick?

2. A husband loves to wear lip stick, make-up and women's under garments when making love to his wife. His wife enjoys pulling her hair back, wearing men's clothes and looking as masculine as possible. There are four children in the household and even though he walks around the house wearing women's underwear, he is convinced that no one except his wife ever knows. They reportedly have a great sex life and no one is doing anything they dislike. Is this normal?

3. A young man has been recruited by Al Queda to strap himself into a car while being laden with bombs. He is intent on driving the car into a busy market place, blowing up himself and thousands of others in the market. He believes he is fulfilling Allah's will.

4. A forty year old married man, with a wife and children, experiences powerful urges to have sex with girls who range from 10 to 13 years of age. Actually, he is convinced that there is no reason why children should not have sex with adults because they can make their own decisions, there is no violence and the children with whom he has had sex have all enjoyed it. He belongs to an international group that advocates legalizing child sex just like homosexuality was legalized and defined as normal by the DSM IV in the year 2000. Is he normal or sick?

5. A man, living within the United States and an American citizen, is married to three women and has nine children. All the wives know one another and they live in a community where others do the same thing. Is he normal or sick and what about the women and community: normal or sick?

6. A man is convinced that he is a woman trapped inside a man's body. He is being prepared for a sex change operation during which his penis will be removed and the skin shaped into a vagina. Is he normal or abnormal?

7. A wife complains that her husband is an obsessional work-a-holic who never has time for the family. While she admits he provides a good living for the family, she states that it does not make up for his absence, especially where the children are concerned. The husband agrees and describes himself as obsessional because he is always working. Is he normal or abnormal?

Some of these questions may seem easy to answer but others less so. A major problem in coming up with answers to these seven examples is that psychiatrists must be very clear and precise in their quest to define certain behaviors as abnormal.

The implications for the fields of mental health, including psychology, psychiatry and social work, as well as the general public, are great. The DSM is used by mental health workers to decide such things as whether or not a person is safe to go home from a psychiatric emergency room, psychiatric in-patient facility and whether or not a patient needs medications of one type or another. The categories of syndromes listed and described in the DSM are also the handy guides used by health insurance companies when deciding whether or not treatments for certain illnesses should be reimbursed.

It is generally agreed that psychiatry, unlike medical fields such as cardiology, is not so precise. That leaves many gray areas that allow for all types of controversy.

An example of this controversy was that, prior to 2000, there remained an open question in the minds of many doctors as to whether or not homosexuality was dysfunctional or abnormal. When the DSM IV was developed, homosexuality was removed from the manual as a disorder and is no longer considered to be an illness.

Psychiatrists are struggling over issues of where to place such things as obsessional thinking, people who are transgender and those who are binge eaters. For example, many people have obsessional thinking and that allows them to deeply focus on problems at work. Are we about to say that anyone with obsessional thinking is abnormal? In other words, what distinguishes a hard working person from that of someone who truly has obsessional thinking. How much eating must a person do in order to fall under the category of "binge eating disorder." This is a pertinent and difficult question in a society where food is abundant and being over weight is a major health problem. However, when should someone be categorized as having a disorder and why or how are they different from others who over-eat?

Possible answers to the above hypothetical cases:

1. In case number one, it may be tempting to categorize this man and woman as falling into the category of some type of sexual disorder. However: 1. they are both adults, 2. fully consenting and willing, 3. go to work, earn their living and pay their rent, 4. cause harm to absolutely no one, 5. are fully functioning members of society. I would not categorize them as "abnormal."

2. In case two, I would categorize the behavior as a possible disorder because: 1. there is real danger of the children witnessing this, 2. wearing undergarments of the opposite sex increases the risk that it will be noticed by the children and by neighbors, as well, 3. there is an increased risk, for the sake of a sexual adventure or fantasy, that this husband and father will venture out into the real world as a cross dresser.

3. Case three is all too common today but, because of political motivations, regardless of how abhorrent we may believe it to be, this young man's behavior cannot be considered to be "abnormal." After the destruction of the World Trade Center in 2001, some people were quick to label Osama bin Laden as "crazy." However, former Secretary of State Colin Powell was quick to point out that bin Laden was completely sane- heartless, but sane.

4. Case four falls into the category of abnormal behavior and is an example of pedophilia. Children do not have the wisdom, capacity and judgment to make decisions about sexual preferences. Because of their developmental stage, both physically and cognitively, they rely upon the protection of the adult world. These adults include people such as: parents, teachers, religious leaders, neighbors, family members, etc. There is no way to justify sex with children.

5. Case number five is an example of behavior that we may not like, may not approve of, may be against the law but does not fall into the category of abnormal. The Muslim world practices polygamy and so do certain sects of the Mormon religion. So long as the people involved are adults and consent to participating in this polygamous arrangement, they cannot be deemed abnormal. They may be breaking the law, but that is a different matter.

6. This case is an example of the type of issue that psychiatrists are struggling with in composing the DSM V. What do you think? Remember, the issue is not whether you approve or not but whether transgender issues are normal or abnormal?

7. Case seven is also difficult because we are a hard working society where work-a-holism is the norm. However, where does being a work-a-holic stop and being Obsessional begin? I might suggest that one handy way to think about it is to learn if the individual is able to function. In other words, for all the time at work, is the job getting done? Is the person making a good living, is he truly productive at work, and does he have a family life? Yes, there are those people who work endlessly but get nothing done. They are truly obsessional. An example would be if I, in writing this posting, spent hours ruminating about whether I should use a certain word and never getting the posting done, would be obsessional.

What do you think? Your comments are welcome and encouraged.

Allan N. Schwartz, PhD.

Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at dransphd@aol.com for details.

Reader Comments
Discuss this issue below or in our forums.

Abnormal vs. destructive - Brad Cone - Oct 23rd 2010

Dr. Schwartz,

I enjoyed these considerations for how we define "normal" vs. "abnormal" behavior.  Yet, I can't help but wonder (not having read any other responses that may have already made this point), if however symantic the caveat may appear; is "normal" vs "abnormal" reason to categorize, or diagnose?  I must say, I agree with each of your analysis, yet, the point or motivation to define an act, or presentation of circumstances as "abnormal" has in and of it's self no real relevance. Only for the purpose of defining that which merits intervention, whether voluntary or forced, is the underlying issue. 

 

Take for example the scenario whereby a in individual is recruited by a faith-based organization, and convinced to commit an act such as a suicide bombing.  I agree, these days, depending on where you are in the world, or the current political and religious climate, there is a temptation to propose that the man's true belief in his riteousness renders his act "normal" behavior.  In much the same way as I "Go to church" because I believe in God. Or I teach my children about God, because I believe in God, and my role with them.  However, since it is by far (common sense reference), the minority of the population commiting acts such as this, there is no choice but to label the behavior as "abnormal".  In much the same way, our vocabulary and acceptance of vague, general words, to communicate complex concepts; evidenced most clearly in the old saying "half of the population is below average."  "Normal" is the melting pot, and by nature conveys acceptance of all, with achievment of a mean being the goal.

First, the criteria for DSM must establish the goals of such a manual, within a specific context.  If maximizing an individual's potential for achievment of cultural norms is the goal, then certainly the manual must be adapted for 1000's of different cultural "norms" around the world.  Aptly, is is "Normal" for a Pakistani woman who is guilty of adultery to be stoned by the masses in the streets?  Yes, in Pakistan.  In downtown Wilmington, DE.......NO.  Is it destructive in BOTH places?  That depends on to whom we allege the greater good serves; the individual, or society.  Adultery IS normal behavior everywhere around the world.  Punishable by consequences ranging from social stigma, to inprisonment, to physical punishment in others. 

So I can stop thinking through each sentence before I type, I'm going to start winging it....

Manuals like the dsm are just the best we can do at saying what we think is a good guideline for deciding what type of behaviors warrant attention or intervention via psychotherapy, drugs, or both.  Right and wrong have absolutely no bearing on the book, and although the whole world of psychology is comprised of people that have to watch out before their brain gets sucked into itself, at some point, there has to be consensus, of that which merits consequence, and that which does not. 

Mr. Smith who likes to wear pantyhose and put on lipstick, can do that, even at the "Risk" of putting his children in psychological harm's way.  The same goes for teaching children to "Stay away from those kids, because they like to talk about army guys, and shooting guns", or Mothers over-protecting children, or just whatever.  While some behaviors are so obviously going to have far reaching affects on neighbors, children, whatever, only that which crosses the bounds of legal vs illegal really merit any intervention, unless someone asks for help to change their behavior.

"Hey, did you notice Roger's backswing?  That's really abnormal"

It's certainly no one's job to "inform" roger of his abnormality.  It's questionable if we should tell him, even if we're a doctor, and we know that his weight distribution is going to lead to a big problem with his sacrum, or a tendon, or whatever-without invitation to make those suggestions.

I'm sure you've skimmed through articles pertaining to female libido.  Did you know that 60% of women have abnormally low libido? (according to some studies).  You're sharp enough to see the errant logic here, I am sure. I would venture to guess that men conducted that study, and the first study could not be published because the data showed the number to actually be more like 80%, and coincidentally, the remaining 20% with "Normal" libido were allowed to remain in the study, despite having comorbid conditions such as Bipolar Disorer, hyperthyroidism, and a documented history of amphetamine abuse. 

All the world's definitions are relative.  In fact, I can't even get your answers any closer to reasonable than to say something so cliche' as "What is normal?".  Better yet, "what is our goal", and who gets to Decide? 

I enjoyed your questions.

Re: No.6 & No.7 - Zarmeen Amirali - Jul 28th 2009

I think the issue in scenario no.6 is more cultural based and our understanding and acceptance of transgender as a phenomenon. Sometimes we let the culture or the society we live in decide whats normal- the problem with that is that its very vague and can change as the situation or social views change. Therefore, even though it may be considered social bizarre and it is not a mental disorder. However if after the operation the persons feels the other way around- that may raise some concern.

Scenario No.7 I think how the husband is with everything else besides work should be taken into account. May be he is obssessed with work due to a certain goal or insecurity he may have. Also it depends on how he functions and if his obssesive work behavior is satisfied does he replace it with an alternative obssesion.

This seems unnecessary - Dr.T - Dec 23rd 2008

Interesting post below! I've heard what you've said so many times and sometimes, I must admit, that appears to be true, espeically during the holidays and in families!

In relation to the article, we have defined and redefined the DSM so many times that I was almost sure we wouldn't redefine it again and widen it to include more symptoms and behaviors to classify as "abnormal" or "problematic to one's life and daily functioning." Does a disorder, say, like "addiction to the internet" or "Apathy disorder" or "Parental Alienation Syndrome" and "Compulsive Buying Disorder" really rank as a mental problem or behavioral problem? I guess this would depend on the magnitude of the issue. But this is not schizophrenia or PTSD, or bipolar disorder and major depression or even autism.

      I know as mental health professionals we rely on symptom identification through such systems as the DSM; however, must we rely on an expanded DSM to identify behavior that really could be as simple as an addiction or some emotional need that propels one to repeat behaviors (e.g., video game addiction)? I guess what I am saying here is that...I have always believed that the DSM included information that was beyond the scope of "some peroxide and a bandage," that is, disorders needing true intervention. Today, we have everything in the DSM, and espeically in the new DSM.

However, expanding the DSM to the DSM-IV-TR has helped us to identify symptoms that once were so mild that clinicians could not identify them or just didn't understand them. Such clinicians might include Leo Kanner and Hans Asperger who identified autism and Aspergers syndrome. As time progressed, the DSM widened and symptoms became more apparent and diagnosis was available most times. This led to the Autism spectrum disorders classification and the varied symtoms of ADHD and other disorders.

 My point: well...I guess we need a widened DSM so that we can better identify symptoms that are most problematic to people. In contrast, my argument is that if we're not careful, we'll include every symptom in the DSM and will not be able to identify the truly problematic and severe disorders seriously needing attention.

Editor's Note:  Some revision is necessary to accomodate emerging evidence regarding condition listed in the manual.  What makes the process difficult is negotiating the political aspects of the diagnostic process.  

Normal is like Perfection - Silentmist - Dec 23rd 2008

As far as I'm concerned 'normal' is unknowable.  The level of situational awareness that a perceptee would have to have in order to accurately know what is typical with a perceived event of behaviour would infringe on most peoples desire for privacy.

Normal is like Perfection ... you'll only find it in the dictionary.

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