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Posts tagged ‘defining normal’

Putting the “D” in

When do we add the “D” to the PTS?

Author’s note: I wrote this paper for my abnormal psychology class last year. My professor told me I should publish it. I don’t think this is what he meant, but in light of Sarah’s post yesterday, and my own review of a book that aggravated me beyond reason, I felt it was good timing to share it. It isn’t directly related to writing, but I am certain you can make the connections between character development and a thorough understanding of the human psyche.

In slightly related news, I will be appearing at Millennicon in Cincinatti this weekend. I’ll be signing in the lobby on Sunday between 11-noon, drop in and see me! I’ll have an escort, my beloved First Reader, because I am mildly agoraphobic, and although I face my fears on a daily basis, and refuse to let past traumas rise to the level of embracing the “D” I will still need a friend when there are crowds of strangers. 

Table of Contents

1. Medical Definitions of Normal

2. Practical Definitions of Normal

3. The Internet as an Interactive Tool

4. Seeking the Truth of Abnormality

5. Medical Intervention and the Internet’s Role

6. The Fuzzy Edge of Normality

Sanity: “It is thinner than the edge on a knife, sharper than a guard dog’s tooth, more elusive than a ghost.  Perhaps it doesn’t exist.  Perhaps it is a ghost.” – Philip K. Dick

1. Medical Definitions of Normal.

Where is the boundary between normal and a disorder, and how has that changed in the last few decades? By the definitions of the Global Assessment of Functioning Scale (Axis V of the DSM-IV), that boundary lies somewhere between fifty and fifty-one. By the definitions of the man on the street, normal is ‘not creepy, or weird’ and most will say that normal does not really exist. The reality is, most people are normal, even if they do not define themselves that way. Most people lay somewhere between a sixty-one and the perfect one hundred on the Axis V assessment (Kearney & Trull, p. 75). They may feel mild symptoms from time to time, but nothing lingers.

Normal shatters in the face of severe trauma, not always a single initiating event, but ongoing stressors as well. After a trauma, or a series of them, life that once looked solid can suddenly give under the feet and leave the sufferer floundering. If the person can maintain a life on their own, are they normal? What if they can no longer leave their own house, or simply cannot mingle with others in a public place? Once, this would have meant they could not earn a living, have a social life, or meaningfully contribute to society. With the technological advances, this is no longer the case, and the boundary line of ‘normal’ has been moved.

“But, in my expe­ri­ence, PTSD doesn’t get fixed. That’s because it was never about get­ting shot at, or seeing people die. It was never the snap trauma, the quick moment of action that breaks a person. PTSD is the wages of a life spent in crisis, the slow, the­matic build that grad­u­ally changes the way the suf­ferer sees the world. You get boiled by heating the water one degree each hour. By the time you finally suc­cumb, you realize you had no idea it was get­ting hotter.

Because you kept adjusting. Because PTSD isn’t a dis­ease, it’s a world view.”

(Cole)

2. Practical Definitions of Normal

Since the rise of the internet as we know it in the mid-1990s, our culture has been shifting slightly, allowing those who were once ostracized or were unable to participate in society, made abnormal by their own fears, to once again join in social activities and hold jobs. The internet provides a buffer between the sufferer and the normal people outside their homes, allowing those with PTSD, agoraphobia, autism spectrum, anxiety disorders, and many other ailments to partake in life again. When work, interactions, and supplies can be had easily with a few clicks of the mouse, the abnormality is easy to hide.

This is good, certainly, both in allowing people to become productive and happy, but also may have the effect of allowing those who suffer to simply withdraw further into a shell. Some may not even be aware that they are so different from others that they could not hold down a ‘normal’ life and job. For people who grew up before the internet, they are aware, but in the rising generation might be oblivious, as their normal is defined by the ability to subsist online.

One such case involves a man in his early thirties, who displays physical characteristics of autism (high-functioning, what was once called Aspergers). When in a conversation he prefers not to make eye contact, when standing he shows restless, bird-like movements, and holds his hands in a characteristic guarding cupped position. He has a speech impediment, and while he is highly intelligent and well-spoken online, in person he comes across very difficult to those who do not know him with his rapid-fire stuttering and need for constant movement. Online, he is very articulate indeed, able to chat, play games, and earn his living writing with a higher level of competence than most, as a freelance writer and editor. Evaluated against the Axis V assessment, he would likely fall into the high thirties, a level considered abnormal, or impaired. Yet he is comfortable in his life, living vicariously through the internet and even outside it, in certain arenas where he is considered odd, but not abnormal.

3. The Internet as an Interactive Tool

While the internet allows some to remain hidden behind the glow of their screen, it allows others to find those who they identify with, creating global connections of those who would never have met otherwise. This, then can lead to in-person interactions and a support system for sufferers who might not have had this option if they were limited to their geographical community. For sufferers of PTSD, this has become a way of finding reassurance that they are not alone, particularly in the military community, where a certain stigma applies to what was once called ‘combat fatigue.’ “When I was coming up in the Army as a young Private it was looked down upon if you wanted to get help for anything; it was considered a sign of weakness. Times have changed, but we still (although not nearly as bad) have this stigma in the military, primarily in the Senior Noncommissioned Officer Corp, that anyone who wants to get help is weak.” (Gibson)

Recent political decisions endanger that fragile lifeline, however, as veterans who fear losing their rights will likely shrink from seeking professional help. Online, some anonymity is available, but with the passage of CISPA, that will be eroded. Already, the VA hospital routinely questions veterans about their mental health and possession of weapons during routine visits.

“’We do not believe an assumption should be made based on anecdotal evidence that an individual diagnosed with PTSD should automatically be considered incapable of governing one’s anger and thoughts of violence,’ he wrote. ‘This kind of assumption fosters the social stigma and discrimination that challenges individuals in their efforts towards mental health rehabilitation and recovery.’ That stigma has caused active-duty troops to try to hide problems from commanders and has long been a reason veterans avoid seeking help…” (Jordan)  

Even if enforcement of CISPA is not forthcoming, the perception of loss of privacy will drive fears and reduce the willingness of sufferers to share pain and seek recovery. With the line between normality and abnormality being so blurry to the average person, the decision to seek help will become even harder to make when balanced with these fears. It isn’t paranoia when they really are out to get you. “Therapists’ chief concern is that patients feeling suicidal or homicidal might conceal their troubles to avoid having their guns removed” (Bakeman).

While the outliers into abnormality are easily found and defined by the DSM IV, and we can all agree that hallucinations, hearing voices, and rage outbursts are not normal, what about fleeting flashbacks, nightmares, and depressed emotional responses? A person could suffer from the last, especially, and from altered emotional responses, without being consciously aware of it. Through internet discussions, those problems might come out and be talked about, as distance lends safety to the speaker. When talking face-to-face, the emotions are harder to control  and express than they are when anonymity is assumed. One study, published in Cyber Psychology, shows that reduced hostility is seen in patients who spend time chatting and interacting with others online. (Yen, et. al., p 649) Due to the stigma of suffering from post-traumatic stress, even below the threshold of disorder and abnormality, the sufferer may suppress their self-analysis and remain unaware of the depth to which the trauma has affected them. Online groups might help them to understand the true toll of their problems.

4. Seeking Truth of Abnormality

Children in particular may develop from the point of trauma unaware that how they feel, act, or react, is abnormal until they are told by others. A child well able to mimic others, or to avoid the company of people, can evade that observation for great lengths of time, until the affect has become acutely abnormal. In the Journal of Traumatic Stress, a study points out “It may be that parents of children with psychiatric disorders and complex behavioural presentations have difficulty recognizing PTSD symptoms in their children” (Loeb, et. al., p 434). Parents and friends may unwittingly aid in the child’s adaptations either through empathy or indifference. In empathy, they overlook the minor oddities and see the good traits of their loved one, or having sought advice, are told that a child will recover best if the trauma is never talked about. In indifference, they simply do not see the pain and stress at the root of misbehaviors, and sometimes exacerbate the problem by punishing those symptoms. Through these experiences, the child learns to fit into the culture around them, at least on the surface.

When the onset of the traumatic stress occurs in adulthood, the symptoms may be more easily observed, but become more difficult to determine where the boundaries of normal and abnormal are. As adults, most normal people have experienced mood swings, short periods of depression known colloquially as the blues, and their corollaries, days of elation or stretches of unadulterated happiness. In the early days of reaction to a traumatic event, while those reactions border on abnormality at any given hour or day, the sufferer may experience some confusion over whether something is indeed wrong with them. This is worsened if an atypical reaction is triggered.

In rare cases, for instance, a sexual assault can lead to hypersexuality. A woman responding in this fashion to an assault is understandably confused, often ashamed, and very unlikely to discuss her symptoms of PTSD and seek help. Even in the absence of an atypical response, the person’s willingness to disclose and discuss hidden symptoms makes the difference between being considered normal or abnormal, and possibly even a professional will misdiagnose someone who falls in the hazy borderline and hides well. The human brain is amazingly resilient, and able to stimulate normal behavior in the person’s own culture simply by the learned patterns instilled since infancy through direct lessons or the indirect method of observation.

5. Medical Intervention and the Internet’s Role

The lack of resilience may mark one threshold which the path to abnormality crosses over. If the traumatic event affects the person enough to cause them to no longer care, or know, what behaviors are normal, they quickly become obvious to those around them as adversely affected by the event. When the stress slips into disordered life, when the symptoms are severe enough to be obviously abnormal, then treatment becomes no longer a choice but a mandate by family, friends, and the medical community. By the patient’s choice, in seeking help, or through outside pressures, as when required after a failed suicide attempt. Dr. Roland Pies points out that: “In psychiatry, as in general medicine, it is often a family member or the soon-to-be patient who first recognizes that something is terribly wrong. This is based on our ordinary perception of suffering and incapacity in the absence of an obvious external cause (such as a knife wound).” (Pies, p. 36)

Treatment may include therapy, where someone who has been hiding their symptoms has, in effect, a mirror held up to them that reveals the true extent of their adaptations. The internet can become a safe place, a positive in a life that has become disordered, and the interactions with a screen instead of the intimacy of a face become a safer way to slowly rejoin the outside world. The intervening ‘screen’ of the computer or device serves as an emotional buffer and attentuates the interactions to the point that the wounded can get along with others. Robert Sapolsky, in an article about relieving stress, has this to say:

“In short, you are more likely to get a stress response—more likely to subjectively feel stressed, more likely to get a stress-related disease—if you feel like you have no outlets for what’s going on, no control, no predictability, you interpret things as getting worse, and if you have nobody’s shoulder to cry on” (Sapolsky).

There is a case of a woman who was precipitated into depression and agoraphobia through a breaking trauma in her life. While she had most likely been prone to the disorders before the event, after it she was no longer able to work, socialize, or control her self-harming impulses. For a period of several years she was hospitalized every few months, and in mandated therapy when back at home. In an informal interview, she expressed her appreciation for the internet, and the way she had been able to utilize it to maintain contact with reality during times when she could not bear to be face-to-face with other people very often, or for very long. It gave her a buffer, she said, and she could walk away from a screen when overwhelmed far easier than from a person, who might not understand, and be hurt.

Many studies portray the internet in a negative light. Internet Addiction is being considered for inclusion in the upcoming DSM V, under the same criteria that contains behaviors such as gambling addiction. Ronald Pies, writing for Psychiatry, points out: “There are enduring philosophical controversies regarding fundamental concepts in psychiatry, such as the boundaries between “normal” and “disordered” mental states; and the degree to which certain behaviors represent biologically based disorders as opposed to freely chosen lifestyles.” (Pies, p 31)

There may be cause for concern when an otherwise normal person binges on the ‘net, staying online for hours and neglecting their family and work. But for those who are already beyond that line between normal and abnormal, it can be a lifeline leading them back to health and productivity. Most often, those who are being diagnosed with internet addiction show comorbidity with some other disorder, revealing that their dependence on the internet is a symptom, not a cause (Pies, p 35).

6. The Fuzzy Edge of Normality

“I can pass as normal, if nobody has to spend a whole lot of time around me. It’s much better to be online and just be me. I can drop the mask and just be me.” -S.B.

“Without the internet — or, at least, my friends who live in the computer, as it were — I would have slit my wrists years ago. The complete isolation would have consumed me. I never had the capacity to interact with other people in a normal fashion. “Here,” I can pretend to be more normal than I am. “Here,” I come across as more outgoing than I actually am. “Here,” there are a scant precious few who can keep me from self-destructing.” -J.S.

“When Byte opened Bix to the public in 1981, it was Such a blessing. Suddenly, I had people who got what I was trying to say without going to a Con. My kids suffered for it. I was emotionally and mentally absent many evenings, but it kept me from sinking into depression.” -R.B.

“What is normal? Facebook and such give me a chance to talk to interesting people. Meetup (internet driven) helps me find folks that share my hobbies. I don’t think I am more “normal” because of the internet but I am less isolated. PS, I joined Baen’s bar just after 9/11 because I very much needed a group to talk to at that time and there was website listed in the back of one of my paperbacks.” -J.L.

An impromptu poll with a question, posed on Facebook, yielded the quotes above, taken with permission. The question asked was: “If you didn’t have the internet as an outlet, would you be normal? Do you think being able to interact online helps you live a fuller, more productive life? No, I’m not asking about the time-suck that is facebook in general. I’m very serious, I’m writing a paper on how technology is redefining what ‘normal’ is. If you’d like to PM me, please do. Anything I use in the paper will be completely anonymous.” Out of 998 ‘friends,’ fourteen responded to to the question in comments and emails. Two chose to contact privately, the remainder simply commented on the thread. All of the respondents are adults, most in the 40-60 age range.

As was expected from the group polled, a largely positive response to the internet and what the online community offers to people who self-identify as odd, slightly broken, and abnormal. Most of those who responded are also part of the overall Science Fiction ‘fan group,’ another support system for those who do not fit with normal society. Yet they have chosen to form a psychological sense of community (Obst, 87)

“While much current rhetoric points to the danger of the internet in destroying community and promoting social isolation, the present results suggest that community and a strong sense of community can exist among those interacting within cyberspace. This may have an important impact in reducing the social isolation of those who currently find themselves isolated due to living in remote areas or to physical disabilities. Perhaps rather than technology breaking down communities, communities themselves are evolving in meaning and spirit, in line with technological and societal trends.” (Obst, 103)

While few of those who responded to my survey might be considered abnormal by the Axis V on the assessment scale, some do fall below a fifty on that scale, and yet, through the use of technology, they have found a way to contribute, to participate, and to live a life, rather than lurking in the corners of society. What was once considered fringe behaviour is rapidly gaining general acceptance, as the borders of normal are redefined by our digital era.

Works Cited

Bakeman, Jessica. “Mental-health Officials Clash on N.Y. Gun Law Reporting.” USA Today. Gannett, 24 Mar. 2013. Web. 25 Apr. 2013.

Cole, Myke. “What PTSD Is | Myke Cole.” Myke Cole. Myke Cole, 18 Mar. 2013. Web. 25 Apr. 2013.

Gibson, James. “Nightmare: Changing the ‘Suck It Up’ Culture.” Leader Development for Army Professionals. Mark Gerecht, 13 Feb. 2013. Web. 25 Apr. 2013.

Jordan, Bryant. “Vet Group Responds to Proposed PTSD Gun Limits | Military.com.” Vet Group Responds to Proposed PTSD Gun Limits | Military.com. Military Advantage, 12 Mar. 2013. Web. 25 Apr. 2013.

Kearney, Christopher A., and Timothy J. Trull. “Chapter 4 | Diagnosis, Assessment, and the Study of Mental Disorders.” Abnormal Psychology and Life: A Dimensional Approach. Belmont, CA: Wadsworth Pub, 2011. N. pag. Print.

Loeb, Joanne, Erin M. Stettler, Traci Gavila, Adam Stein, and Susan Chinitz. “The Child Behavior Checklist PTSD Scale: Screening for PTSD in Young Children with High Exposure to Trauma.” Journal of Traumatic Stress 24.4 (2011): 430-34. Print.

Obst, Patricia L., Lucie Zinkiweicz, and Sandy G. Smith. “Sense of Community in Science Fiction Fandom.” Journal of Community Psychology 30.1 (2001): 87-103. Print.

Pies, Roland. “Should DSM-V Designate “Internet Addiction” a Mental Disorder?” Psychiatry 6.2 (2009): 31-37. NCBI. Web. 25 Apr. 2013. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719452/&gt;.

Sapolsky, Robert M. “Greater Good.” How to Relieve Stress. University of California, Berkeley, 22 Mar. 2012. Web. 25 Apr. 2013.

Yen, Ju-wu, Chen-Fang Yen, Hsu-Yi Wu, and Chih-Hung Ko. “Hostility in the Real World and Online: The Effect of Internet Addiction, Depression, and Online Activity.” CyberPsychology, Behavior & Social Networking 14.11 (2011): 645-55. Print.