mental health: what's normal, what's not
What's the difference between mental health and mental illness? Sometimes the answer is pretty clear.
People who hear voices in their heads may have schizophrenia, for instance. And those with such grandiose ideas as becoming the secretary-general of the United Nations without any experience may have a form of bipolar disorder.
But more often, the distinction between mental health and mental illness isn't as clear-cut. If you're afraid of giving a speech in public, does it mean you have a disease or simply a run-of-the-mill case of nerves? If you feel sad and discouraged, are you just experiencing a passing case of the blues, or is it full-fledged depression requiring medication?
Just what is normal mental health, anyway?
Scientists, researchers and mental health experts have wrestled with this issue for hundreds of years, and even today the line between normal and abnormal is often blurred. This is why the fields of psychiatry and psychology are sometimes mired in controversy.
"There's a broad range of what's normal," says psychologist Donald E. Williams, Ph.D., a medical specialty editor at Mayo Clinic, Rochester, Minn.
What's normal is often determined by who's defining it. Normalcy is ambiguous and often tied to value judgments particular to a certain culture or society. And even within cultures, concepts of normal mental health may evolve over time if societal values or expectations change. New medical research and knowledge also can lead to changes in definitions of normal mental health.
One thing that makes it so difficult to distinguish normal mental health and abnormal mental health is that there's no easy test to show if something's wrong. There's no blood test for obsessive-compulsive disorder, no ultrasound for depression and no X-ray for bipolar disorder, for example. That's not to say mental disorders aren't biologically based. Most mental health experts do believe that some mental disorders are linked to chemical changes within the brain, and they're beginning to map these changes visually using imaging studies. But for now, there's no physiological diagnostic test for mental illness.
Distinguishing mental health from mental illness
Mental health providers define mental disorders by signs, symptoms and functional impairments. Signs are what objective observers can document, such as agitation or rapid breathing. Symptoms are subjective, or what you feel, such as euphoria or hopelessness. Functional impairment is the inability to perform certain routine or basic daily tasks, such as bathing or going to work.
In mental illness, signs and symptoms commonly show up as:
Behaviors, such as repeated hand washing
Feelings, such as sadness
Thoughts, such as delusions that the television is controlling your mind
Physiological responses, such as sweating
Signs, symptoms and functional impairments that mark specific mental illnesses are spelled out in detail in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This 2-inch-thick book classifies and describes more than 300 types of mental disorders. The book, published by the American Psychiatric Association, is used by mental health providers to diagnose everything from anorexia to voyeurism. For instance, a mental health provider can evaluate your signs and symptoms and refer to the DSM to see which illness you might have. The first edition of the DSM was published in 1952, and revisions have been made periodically since. The most recent update was published in 2000, and it has been translated into nearly two dozen languages.
Why is it important to diagnose people and attach labels that could be stigmatizing? Why does a specific diagnosis even matter if the line between mental health and mental illness is sometimes blurry? One reason is that the health insurance industry uses the diagnoses spelled out in the DSM to determine coverage and benefits and to reimburse mental health providers. But more important is that in order to get appropriate treatment, you must know what condition to treat — and whether it needs to be treated.
Determining what's normal mental health and what's not
How do mental health providers determine whether the signs, symptoms and dysfunctions you're experiencing are normal or abnormal? Experts often use a combination of the following approaches:
Your own perceptions. How you perceive your own thoughts, behaviors and functioning can help determine what's normal for you. You may realize that you aren't coping well or that you aren't able to or don't care to do routine activities or the things you used to enjoy. If you have depression, the dishes may go unwashed for days, you may stop bathing or you may lose interest in hobbies. You may feel sad, hopeless or discouraged and realize that something's amiss, that you don't enjoy life anymore. Or you may not be able to pinpoint what's wrong.
Others' perceptions. Your own perceptions are subjective and may not give you an accurate assessment of your behavior, thoughts or functioning. Objective observers, on the other hand, might be able to do so. To you, your life may seem perfectly normal or typical. Yet to those around you, it may seem odd or abnormal. This is often the case with schizophrenia. If you have schizophrenia, you may have auditory hallucinations — you hear voices and carry on conversations with them, believing it's a normal interaction with another person. To witnesses who observe this behavior, it may seem abnormal. "It's common that people have something wrong and not know it," Dr. Williams says. "That's true of both mental and physical disorders. People can have heart disease and not know it. Similarly, an individual may be clinically depressed and be unaware of the problem."
Cultural and ethnic norms
Many times what's normal behavior or thinking is defined by your culture. But that means what's normal within the bounds of one culture may be labeled abnormal within another. Conversing with voices only you can hear may be an indicator of schizophrenia in Western cultures. But these kinds of hallucinations may be a normal part of religious experience in other cultures.
And something may be normal or acceptable within your own family culture that's considered abnormal and in need of changing outside of your home. For instance, the behavior of a child with attention-deficit/hyperactivity disorder may be unacceptable in a structured school environment, but be perceived as normal and acceptable in a less structured home environment, notes Jennifer Fisher, Ph.D., a psychologist at Mayo Clinic, Rochester, Minn.
Statistical values
Normal is often defined by what's statistically average. Most people fall in the middle ground, the average, while others fall to one extreme or the other. Those in the extremes are often labeled abnormal because they aren't average, or the same as most others.
Evaluating your mental health
In evaluating your mental health, all four of these approaches — your own perceptions, others' perceptions, cultural and ethnic norms, and statistical values — are typically taken into consideration. Mental health experts may ask how you feel, whether others have noticed a difference in your behavior or mood, and what your cultural background is. They also may ask you to fill out psychological questionnaires.
Other factors also are considered. Among them:
* How long you've had symptoms
* How severe your symptoms are
* How upsetting the symptoms are to you
* How the symptoms disrupt your life
It's normal to feel sad after a valued relationship ends. But if you feel intensely sad and upset for several weeks and you lose interest in daily activities, you may have depression. Similarly, if you get anxious before a presentation to a big client but 
manage the signs and symptoms, such as sweating or rapid breathing, you may just have a case of normal stage fright, and not social anxiety disorder. And if you cut someone off in traffic or yell at a store clerk, you may just be having a bad day or be a generally ornery person. But if you're abusive, violent, manipulative, exploitive and disregard the law, you may have antisocial personality disorder, sometimes known as sociopathy.
Mental health as an evolving continuum
Despite these criteria and efforts to back up diagnoses with sound science, a precise definition of normal mental health remains elusive. The Diagnostic and Statistical Manual acknowledges the difficulty and resorts to defining mental disorders as behavioral or psychological syndromes or patterns that cause distress, disability in functioning, or a significantly increased risk of death, pain or disability. And that syndrome or pattern can't just be an expected and culturally accepted response to a particular event, such as grieving the death of a loved one.
The Surgeon General's 1999 report on mental health states that mental disorders are "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning."
By most accounts, mental health and mental illness don't have well-defined boundaries.
"I think of it more as a continuum than an absolute," Dr. Fisher says.
It's not just a continuum, it's an evolving continuum. In some ways, this is no different from the diagnosis or classification of physical disorders. For years, a blood pressure of 120/80 was considered normal, for instance. That changed overnight in 2003 when scientists announced that 120/80 was an abnormal condition called prehypertension, putting you at risk of life-threatening cardiovascular problems.
Just as with blood pressure, new medical information can lead to changes in the classification of mental disorders. New disorders will be added while existing ones will be removed, or the associated signs and symptoms will be modified as new opinions develop over time. Today, some mental health experts, for instance, are proposing that severe premenstrual signs and symptoms that some women experience every month be classified as a mental disorder — premenstrual dysphoric disorder.
Revisions may also reflect evolving social and cultural attitudes. Homosexuality, for instance, used to be classified as a mental disorder but was removed from the Diagnostic and Statistical Manual in 1973.
Mental health treatment available but not always needed
Even if you do have a diagnosable mental disorder, it may not pose a problem in your daily life to such an extent that it requires treatment.
"It can be abnormal but be OK," Dr. Fisher notes. 
Consider spiders, for example. You may have a terrible fear of spiders, but if you never encounter spiders, or you can get someone else to dispatch them for you, that phobia may have little or no impact on your life. It doesn't impair your ability to go about your normal routine.
"Would we recommend therapy in a case like that?" Dr. Fisher asks. "No. The condition may be diagnosable but not require therapy. You're in need of therapy when something impairs your functioning."
Some critics even contend that too many characteristics or quirks are being pathologized — labeled abnormal — to make money. The pharmaceutical industry in particular has come under fire for bringing new drugs to market to treat recently labeled conditions that used to be chalked up to harmless eccentricity or normal parts of life.
But there is a bit of good news amid the controversy.
"We have many effective treatments for the abnormal mental health problems people experience," Dr. Williams points out. "Chances are, something is going to help you."
©1998-2009 Mayo Foundation for Medical Education and Research (MFMER).