There is no 'normal' and 'abnormal' in mental health

The idea that there is a quintessential distinction between normal emotions and 'mental illness' is widespread. People talk about 'clinical depression' to distinguish it from 'ordinary' depression. One influential journalist in the field of popular science recently decried how people fail to distinguish everyday feelings of depression from (real) 'depressive symptoms'. The disease model of mental health tends to reinforce the idea that the experiences and emotions of people whose problems are placed in diagnostic categories such as 'depression', 'schizophrenia' and 'bipolar disorder' are qualitatively different from 'normal' emotions and experiences. And this faces us with a real contrast. Traditional psychiatry, the 'disease model' of mental health and the diagnostic approach all conceptualise, or at least present a vision of, 'mental illnesses' as qualitatively different to and separable from normality. Research suggests something rather different: that there is no dividing line between 'normal' and 'abnormal' emotions, experiences or behaviours.

Many people, especially clinical psychologists, have suggested that these supposed 'symptoms' of mental illnesses in fact lie on a continuum with normality. Sometimes experiences and emotions become problematical, but this is the same with anything else: any human experience or tendency can become a problem if it is extreme. This idea is neither new nor unusual. I opened this chapter with a short quote from Herman Mellville's novel Billy Budd. It is worthwhile reproducing it at slightly greater length:

Who in the rainbow can draw the line where the violet tint ends and the orange tint begins? Distinctly we see the difference of the colors, but where exactly does the one first blendingly enter into the other? So with sanity and insanity. In pronounced cases there is no question about them. But in some supposed cases, in various degrees supposedly less pronounced, to draw the exact line of demarkation few will undertake tho' for a fee some professional experts will. There is nothing nameable but that some men will undertake to do it for pay.14

An editorial in the Times from 1854 expresses it equally eloquently:

Nothing can be more slightly defined than the line of demarcation between sanity and insanity. Physicians and lawyers have vexed themselves with attempts at definitions in a case where definition is impossible. There has never yet been given to the world anything in the shape of a formula upon this subject which may not be torn to shreds in five minutes by any ordinary logician. Make the definition too narrow, it becomes meaningless; make it too wide, the whole human race are involved in the drag-net. In strictness, we are all mad as often as we give way to passion, to prejudice, to vice to vanity; but if all the passionate, prejudiced, vicious, and vain people in this world are to be locked up as lunatics, who is to keep the keys to the asylum?15

I agree. I cannot see how we can draw 'a line of demarcation between sanity and insanity'. I can see why the idea that there is such a dividing line is popular: it reassures us that mental health problems are discrete, diagnosable entities, experienced by people who are different to us. But in truth, all these experiences lie on continua.

This continuum approach is best understood by thinking about common experiences such as anxiety. All of us will have experienced anxiety at some point in our lives. Some of us have experienced sheer terror, or perhaps become extremely anxious very frequently. Many more of us are often anxious, but to a lesser degree. Only a minority of us will ever experience extremes of anxiety such as a series of panic attacks, crippling obsessions or compulsions to do certain things that would be recognised in the diagnostic textbooks as justifying a diagnosis of an anxiety 'disorder'. Many of us will have had unusual perceptual experiences from time to time, but most of us will have not been disturbed by them and dismissed them as transient and trivial events. Others are plagued by continual psychosis. Some people hear disembodied voices, but regard the experience as 'normal'. Other people are terrified by what they hear. We all feel low from time to time, but some people feel so bad that they contemplate suicide. And - and this is important - all shades of experience fall in between.

Madness and sanity are not qualitatively different states of mind, but should instead be seen as lying at the extreme ends of several spectra of experience. In fact, sanity cannot really be seen as occupying the opposite end to madness on any realistic 'normal' spectrum of experience. If we imagine madness at one end of a continuum, the opposite end will be a never-experienced utopia where we are gloriously happy, rational at all times, clear-sighted and with the acute and precise hearing of an owl, and, in the words of the Times editor, free from all passion, prejudice, vice and vanity.

The editor of the Times also pointed out another fundamental truth that I am attempting to express. The factors that lead to madness are aspects of normal psychology. The Times editorial states that we are all mad so long as we give way to passion, prejudice, vice and vanity. These are - in the slightly poetic prose of a Victorian journalist - normal psychological processes. If passion, prejudice etc., change how we think about the world, then we will blur the lines that separate 'sanity' from 'insanity'.

These continua are not necessarily simple, straight-line, relationships. Part of the way that psychologists understand a wide range of mental health problems is based on understanding vicious cycles and feedback loops. When something bad happens - maybe somebody passes on a piece of bad news - we tend to feel a little low. The way that human memories work means that, when our mood drops, it makes it more likely that we think about more negative things. That is simple psychology, that's how a lot of advertising works. If we can sow a seed of an idea in somebody's mind, the network of associations will lead them to think of a wide range of related matters. So, after bad news, it's very easy to begin to experience a snowball of negative memories. This might lead us to feel even worse, and perhaps to interpret subsequent events in a more negative light than we would do otherwise. Those interpretations in turn might drive our mood down further. When we become depressed, we feel fatigued, lethargic and 'anhedonic' (we are no longer enjoying things we used to). It is then natural to withdraw - to withdraw from social events, to stop doing those things we used to do (but which we no longer enjoy so much), to let our self-care slip. When we do that, we are cutting ourselves off from things that offer us the possibility of reward and enjoyment. And so, our mood drops further. And a vicious cycle ensues, pulling us down into depression. Many problems that involve anxiety also show these kinds of feedback loops. If we are anxious about something (performing in public, perhaps) it is very tempting, very reassuring, very easy, to avoid situations that might expose us to our fears (we might decide to take the day off when our line-manager invites a theatre group to offer a 'mythodrama' session - and, yes, I was once exposed to 'mythodrama' as part of a training course!). That makes us feel better, feel less anxious ... temporarily. But it can lead to further, deeper problems. If, for example, we deal with the impending mythodrama visit (or, more precisely, with our intrusive and obsessive anxious thoughts about that visit) by deploying some compulsive rituals that make us less anxious (wearing our lucky socks, for example) we can find that we become effectively addicted to the compulsions to cope with future anxiety. The fact that many emotional problems are driven at least in part by such vicious cycles means that our journey along the pathway - down the continuum - is not a linear progression. Once we start, we can accelerate progressively downwards ... like a snowball, as we roll downhill, we pick up speed and our problems can escalate. So you can see how normal psychological processes can lead to a wide variety of sometimes quite extreme experiences and states.

We can see continua in every area of mental health and well-being. Children differ in their ability to learn, to pay attention at school, to focus their attention and to regulate their emotions. For parents, these are all part of the business of childhood, of parenting, of education. When I was a child, I was unable to remain focussed and attentive for the full range of the school day and into the evening. I wasn't one of the worst in this regard - I managed to concentrate well enough to do OK at school and go to university - but my attentiveness was certainly not 100%. Even now, I am still distracted by squirrels outside the window, by conversations in the corridor, by the nagging suspicion that there is something interesting down by the coffee machine. It is simply an inevitable part of the human condition that some of us have more difficulty than others. Occasionally children's problems with concentration cause their parents and teachers great concern. Sometimes these difficulties cause real disruption to school life. Unsurprisingly, such problems tend to be associated with other problems and difficulties. Equally unsurprisingly, there is a wide range of biological and social factors that can affect a child's ability to concentrate. But all that is hugely different to the way in which we currently often approach these problems - by invoking the idea of an 'illness' called 'attention deficit hyperactivity disorder' or 'ADHD' which only some children 'suffer from'. As Sami Timimi (who is, incidentally a child and adolescent psychiatrist) and Jonathan Leo have eloquently argued, we should not think of these things as 'illnesses', or even worse 'diseases'.16

The recent publication of DSM-5 (the fifth edition of the franchise) in 2013, galvanised into action many of us who believe that diagnosing putative diseases is an inappropriate basis for high quality mental health care. The most recent revision of the American diagnostic system saw the lowering of a swathe of diagnostic thresholds. This will have the effect of inflating the apparent prevalence of mental health problems in the general population. Just as when politicians re-define key statistics, millions more people across the world could be regarded as 'having a mental disorder', not because circumstances have made them more distressed, or because there has been a fall in resilience, but merely because the criteria have been changed. This might be good news for pharmaceutical companies, but it is a threat to the rest of us and especially to vulnerable populations such as children and older people. It makes statistics something of a nonsense, as any epidemiological data are dependent on the whim of committees. But more importantly, we all, and particularly people who use mental health services, are harmed by the continued and continuous medicalisation of their natural and understandable responses to their experiences. These responses undoubtedly have distressing consequences, and the people affected need help and support. But even extreme experiences are better understood as normal individual variation than as illnesses.

The changes in the 2013 revision of DSM-5 represent an increased emphasis on the supposed biological underpinnings of psychological distress; the language is couched in terms of biological illness. This is also worrying, since it does not reflect the widespread scientific consensus that distressing experiences are the result of complex, individual interactions between biological, social and psychological factors rather than the result of a disease process. By using the language of 'disorder', diagnostic manuals (and DSM-5 is merely the latest and possibly the worst example) undermine a humane response; they imply that these experiences are the product of an underlying biological defect. The publication of DSM-5 in 2013 provoked something of a minor revolution. We saw the growth of a significant community of opposition drawn from a range of groups. Psychiatrists, psychologists, scientists and users of mental health services alike voiced their opposition to many of its proposals and particularly the pathologising of grief.17 When someone close to us dies, many of us suffer profound, long-lasting, grief. That is not an illness, it's the price we pay for love. War is traumatic - experiences of conflict change the way we see the world and our part in it, and the traumatically emotional memories are encoded in our minds in ways that cause understandable problems into the future. But it is not a 'disorder' to remain distressed by bereavement after three months or to be traumatised by the experience of industrialised military conflict. Our children need to learn how to manage their emotions, to attend to their studies sufficiently to learn, and to grow up with a sense of moral and social responsibility. It is undeniably a problem - for the children, for their parents, for teachers and for society - when that goes wrong. We need to offer help. But it isn't an 'illness'.

This does not - absolutely not - mean that I, and those colleagues who share my views, believe the problems do not exist. It does not mean that we consider them to be trivial. There are many social problems that are not illnesses. Debt and crime are not illnesses. Of course we need to understand how and why children can manage their emotions and focus their attention. We need to study the neuroscience of these phenomena just as much as we need to study the social and cultural aspects. But they are not 'illnesses'.

 
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