Which Jack is Normal?


Back in residency training, the atmosphere was a bit competitive at times, and a smart ass colleague told me that he had read most of Freud’s works in the original German, thus rendering him more erudite on the subject of analytic theory. I told him that since he was from Hamburg this was no great accomplishment, and that he really probably grew up in Freudenstadt.  At which point he thought I should deal with my obvious issues around envy and hostility.

He suggested that I read “Psychology of Everyday Life”, as he felt so called normal folks were much more interesting than psychiatric patients. His plan was to open a practice on St Clair Ave. and treat the rich and shameless. He thought my desire to study Eskimos on the frozen tundra was indicative of my instability. This was all in jest of course. But I digress.

Freud did think everybody (who wasn’t analyzed) was neurotic, and health was an elusive goal. In “Psychology of Everyday Life”, Freud believed that various deviations from the stereotypes of everyday conduct-seemingly unintended reservation, forgetting words, random movements and actions-are a manifestation of unconscious thoughts and impulses. Considering the numerous cases of such deviations, he concluded that the boundary between the normal and abnormal human psyche is unstable, and that we are all a bit neurotic. Such symptoms are able to disrupt eating, sexual relations, work, and communication with others. This is tantamount to saying that the distinction between normal and not is simply one of degree-a slippery slope.

This brings me to the bible and holy grail of clinical psychiatry: the DSM 5.  In the absence of physical findings  diagnoses in psychiatry are a purely descriptive lumping together of symptom clusters.

Diagnoses based on brain biology – such as assessing levels of neurotransmitters or interpreting images, or those based on measuring the psychological dimensions of personality (introversion/extraversion, impulsivity, psychopathic deviation etc) or that which is based on the development of the mind are not considered robust enough for clinical use.

This means that behaviors that were once diseases, like homosexuality are now a normal sexual variation (and rightly so), consigned as such by the stroke of a pen. Kids can’t have temper tantrums anymore, now it is “disruptive mood dysregulation disorder”. Yes, little Johnny can now go on Tegretol because the doc said he has DMDD. Women are not just crabby once a month anymore, now they have their own disease: PMDD, premenstrual dysphoric disorder.

The Brits always having been more pragmatic, have this to say…”We believe that any classification system should begin from the bottom up – starting with specific experiences, problems, symptoms or complaints.”

This brings me to the holistic approach, embodied in a bio-psychosocial formulation. This is a tentative working hypothesis, which attempts to explain the biological, psychological and environmental/social factors, which have combined to create, and maintain the presenting clinical problem. It is a guide to treatment planning and selection. No pejoratives. No labels. Just a paradigm to help prescribe a custom made treatment plan.

So to be succinct, the Rx for someone who is homeless with psychosis: Biological…antipsychotics
Psychological… supportive therapy
Environmental… subsidized housing, drop in centre for socialization.

Schizophrenia, which is a meaningless descriptive term anyway in the absence of hard core neurological findings, fades into the pages of psychiatric history.

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