Mental Illness

Mental Illness

BIBLIOGRAPHY

Mental illness is a global term for disorders of thought, mood, affect, and behavior that impair normal functioning, social relationships, and productivity. Worldwide, mental illnesses account for four of the ten leading causes of premature death or of disability in terms of lost years of healthy life. Major depression is the leading cause of disability worldwide, as measured by years of living with this disorder. Mental illnesses, including suicide, account for over 15 percent of disease burden, more than the burden from cancers, in established market economies such as the United States and Europe (National Institute of Mental Health 2006).

Mental illnesses such as schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, and adjustment, identity, and personality disorders, are defined by discrete, clinically meaningful clusters of behavioral symptoms. The German psychiatrist Emil Kraepelin (1856–1926) was the first to develop a unified classification of the psychoses. His emphasis on precision and objective behavioral criteria greatly influenced the current diagnostic system, the American Psychiatric Association’s periodically updated and revised Diagnostic and Statistical Manual of Mental Disorders (DSM -IV-TR, 2000). The DSM codes are fully compatible with those in the mental disorders section of the World Health Organization’s International Classification of Diseases (ICD -10, 2005), with worldwide applicability. Patients are assessed on five axes:

Axis I—clinical disorders and other conditions that may be a focus of clinical attention;

Axis II—personality disorders and mental retardation;

Axis III—general medical conditions;

Axis IV—psychosocial and environmental problems; and

Axis V—global assessment of functioning.

Multiaxial assessment yields multiple domains of information that indicate possible comorbidities and permit comprehensive treatment planning.

Mental illnesses vary in severity, duration, and degree of incapacitation. Some specialists distinguish between acute reactive (brief nonrecurring) and chronic (long-term episodic) mental illness. The term chronic, disavowed by consumers (present and former psychiatric patients) as promoting hopelessness, has largely been replaced by “severe and persistent mental illness.” This description typically applies to persons with major Axis I disorders who manifest long-term disability.

Despite increasing evidence that most major mental illnesses appear to be biologically based, vulnerability and prognosis seem highly sensitive to the social environment. Epidemiologic studies indicate that major mental illnesses such as schizophrenia, depression, and bipolar or manic-depressive illness are found in all cultures throughout the world. However, there is considerable variability based on immigrant and socioeconomic status, and on urban versus rural living. Studies in Great Britain have found significantly higher prevalence rates for psychotic disorders in immigrants, city dwellers, and black and ethnic minority groups than in white British natives (Kirkbride et al. 2006). Incidence rates for schizophrenia drawn from 158 studies of 32 countries were significantly higher for males, migrants, city dwellers, and individuals born in the winter months (McGrath 2006), the latter presumably because of greater exposure of fetuses and neonates to viral insults to developing brain structures. Internationally, female gender and income inequality are major risk factors for depression (Patel 2001). World Health Organization studies indicate that although the diagnostic criteria for schizophrenia are applicable cross-culturally, prognosis and recovery rates are significantly better in the developing world than in Western industrialized nations (Jablensky et al. 1992)

Prolonged hospitalization for mental illness has long been on the decline in the industrialized world. Most mental disorders currently are treated on an outpatient basis, with various forms of individual, group, and family psychotherapy and in most cases, psychotropic medications. These include antipsychotic, antidepressant, antianxiety, and antiobsessional agents, as well as mood stabilizers and psychostimulants. More disabling disorders may require brief hospitalizations and rehabilitative interventions such as supported housing, supported employment, social-skills training, and combined mental health and substance abuse treatment. There is increasing demand for research-supported evidence-based treatments. Among these, psychotropic medications, cognitive and behavioral psychotherapies, family psychoeducation, and rehabilitative interventions have yielded the most empirical validation. However, studies also suggest that the patient-therapist relationship may be more salient than particular therapeutic models. Some mental health systems are promoting the involvement of consumers as service providers in rehabilitation and in peer counseling. Persons in recovery are able to share experiences and coping strategies, provide role models, and help reduce selfstigmatization.

The concept of mental illness as a biomedical condition distinct from social context has been subject to extensive criticism by social scientists and by some psychiatrists. Prominent writers such as Michel Foucault (1926–1984), R. D. Laing (1927–1989), and Thomas Szasz (b. 1920) have disputed the validity of a concept based on cultural definitions of normalcy and often mediated by social and economic concerns. Every culture has some concept of “madness,” defined as negatively perceived deviant behaviors that are distinguished from merely antisocial behaviors because they are incomprehensible within that cultural idiom. Despite transnational acceptance of ICD codes, the identification of a behavior or behavioral syndrome as denoting mental illness by ordinary citizens, as opposed to mental health professionals, is still to a considerable extent culture-bound. In certain individuals, religious delusions or hallucinations may be viewed as extraordinary gifts rather than symptoms. It is only when the symptoms impair role functioning and productivity that the person is labeled as mentally ill. Depression is sometimes manifested as somatization (diffuse bodily complaints) in some traditional cultures and is conceptualized by the sufferer as a physical rather than psychological condition. Stigmatization of mental illness is ubiquitous, yet research shows that social factors may affect perceptions of deviance and subsequent labeling and discrimination. In many cultures stigma seems to be related to chronic dysfunction and dependency, or to assumed threat, rather than to bizarre behaviors.

There is also a substantial literature on culture-bound syndromes—seemingly unique patterns of disordered or psychotic behaviors that are manifested only in particular cultural settings. Whether or not these are unique syndromes or variant forms of universal diagnostic categories, the behaviors are locally perceived as mental disturbances with specific names. The DSM -IV-TR lists twenty-five culture-bound syndromes found in various parts of the world, most of which appear as temporary delusional or dissociative states in which the person acts out in culturally aberrant and sometimes self-harmful ways. Some culture-bound syndromes appear as anxiety states with paranoid ideation about external malevolence or sorcery, or possession by spirits, accompanied by debilitating somatic symptoms. Still others are manifested as panic reactions, sexual fears, or paralyzing phobias. Most culture-bound syndromes are time-limited and do not seem to engender stigma. If they prove to be ongoing or potentially life-threatening, remedies are sought primarily in traditional healing rituals rather than in Western medicine.

Despite local variants, there is compelling evidence of universality and genetic predisposition in major Axis I and some Axis II disorders. The literature on schizophrenia also offers proliferating research findings from neuroradiology, neuropathology, neurochemistry, hematology, and psychopharmacology, indicating biological parameters of what was once considered a psychogenic or sociogenic disorder. Depression is associated with catecholamine deficits or excess, and hormonal imbalance. Obsessive-compulsive disorders have unique neurological substrates. Lesions in the orbitofrontal cortex have been linked to the impulsivity and affective instability of borderline personality disorder and other disorders of impulse control. Many mental illnesses show abnormalities in the serotonin neurotransmitter system. The permanent effects of these biological anomalies is still in question. There is increasing evidence of recovery from disorders that were once considered lifetime disabilities with a deteriorating course. Three major long-term outcome studies of formerly hospitalized persons with schizophrenia in Europe and the United States indicated a recovery or mild impairment rate ranging from 50 percent to 66 percent (Harding 1988). Representing a heterogeneous body of behavioral symptoms varying widely in severity and potential for remission, the term mental illness remains a concept in flux and the subject of ongoing research.

BIBLIOGRAPHY

American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: Author.

Harding, Courtenay M. 1988. Course Types in Schizophrenia: An Analysis of European and American Studies. Schizophrenia Bulletin 14: 633–643.

International Statistical Classification of Diseases. 2005. ICD -10-Classification of Mental and Behavioral Disorders and Related Health Problems. Geneva, Switzerland: World Health Organization.

Jablensky, Assen, Norman Sartorius, Georg Ernberg, et al. 1992. Schizophrenia; Manifestations, Incidence, and Course in Different Cultures: A World Health Organization 10-Country Study. Psychological Medicine Monograph Supplement 20: 1–97.

Kirkbride, James B., Paul Fearon, Craig Morgan, et al. 2006. Heterogeneity in Incidence Rates of Schizophrenia and Other Psychotic Syndromes: Findings from the 3-Center AESOP Study. Archives of General Psychiatry 63 (3): 250–258.

McGrath, John J. 2006. Variations in the Incidence of Schizophrenia: Data Versus Dogma. Schizophrenia Bulletin 32 (1): 195–197.

National Institute of Mental Health. 2006. The Impact of Mental Illness on Society. NIH publication no. 01-4586. http://www.nimh.nih.gov/publicat/burden.cfm.

Patel, Vikram. 2001. Cultural Factors and International Epidemiology. British Medical Bulletin 57 (1): 33–45.

Harriet P. Lefley