Understanding Mental Health and Mental Illness

• The concept of "mental illness" is plastic, elastic, and heavily debated.
• Scholars and clinicians don’t always agree on the nature of mental illness, who "has" it, and what to do about it.

Contentious Topics

• Some view mental disorders as brain diseases best treated by somatic interventions like medications.
• Others find that model harmful, misleading, unlikely to work, and oppressive.
• What qualifies as good mental health is also contested.
• Minimalist perspective: not having a diagnosable mental disorder means that a person is mentally healthy.
• Maximalist perspective: being mentally healthy involves qualities like empathy, self-confidence, independence, and happiness.
• "Mental illness" and "mental health" are moving and evolving targets.

Defining Mental Health (Problems)

• "Mental Health" relates to our thoughts, moods, and behavior.
• Mental Illness is a general term that describes a disruption related to these phenomena.
• "Mental disorder" refers to specific subtypes of mental illness.
• Many symptoms are physical.
• Some believe the cause is ultimately biological.
• Mental and physical health differ as mental health is not isolated to an organ, involves stigma, and involves value judgements in diagnosis.

A History (and Present) of Uncertainty

• Similar questions and perspectives on mental illness have existed for hundreds of years, with only the details changing.
• People have historically thought about mental health issues as a somatic problem, a spiritual problem, a problem of awareness, a result of social pressures, and a "problem in living."

What are we describing?

• Mental illness discussions involve abnormality, personal suffering, and poor functioning.
• Norms are culturally mediated.
• Anguish and pain may not be reducible to a diagnosable disorder.
• Functioning is about a person’s environment.

Key Questions and Arguments

• A major question is whether mental disorders are intrinsic diseases or metaphors that describe experiences and behaviors.
• This is not simply a question of environment versus heredity.
• It is also a question of materiality and ontology.
• How we think about and define mental health and illness reflects society's principles, goals, and concerns.

Who is Involved in Mental Healthcare?

• Psychiatrists, psychotherapists, social workers, and psych nurses are all regulated professions.
• Family MDs, peer support workers, and OTs are also involved.
• Though presented as a horizontal team, they often function vertically.
• Responsibilities are messy with overlap, aside from prescribing and forming.

Models of Mental Illness

• (Bio)medical model: mental disorders are biological diseases with biological interventions needed.
• Psychological/behavioral model: mental disorders reflect internal phenomena treatable via psychotherapy.
• Social model:
  • First variant: society causes mental illness.
  • Second variant: disorders are labels to discipline social deviants.

Why so many models?

• They are conceptual ideals that people combine to differing degrees.
• There is much debate between adherents of any given model.
• Some work better with different types of disorders.
• Some people find particular models offensive.
• Groups may benefit from one model more.
• Many advocate for a Biopsychosocial model, but some argue that the medical model dominates.

Classification of Mental Disorders

• The DSM and ICD act as official lists of mental disorders and their symptoms.
• The DSM was first published by the APA in 1952 and is now DSM-5.
• It has had consistent growth since the 1st edition.
• It is the official account of disorders used by clinicians, governments, researchers, insurers, etc.
• It has a symptomatic focus with diagnoses based on symptoms rather than cause.
• Committees decide what gets included/excluded (both disorders and symptoms).

Defining a mental disorder

• DSM: “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.”
• Key questions include how to determine clinical significance, whether this is excessively broad, and whether this is too vague.

Schizophrenia

• How can one know that it actually exists
• How can one validate its existence
• Can we validate its existence?
• It Reinforces ideas about good behavior

The Difficulty w/ Diagnoses

• Diagnosis is formed after an interview.
• Subjectivity exists in where the line is drawn between “normal” and “clinically significant.”
• Gary Greenberg: “There’s a conflict of interest – if I don’t determine clinical significance, I don’t get paid.”
• Co-morbidity exists as well.
• Heterogeneity: “A person must meet 5 of 15 symptoms.”
• There are race, gender, class, and weight biases and culture shapes whether something is judged or reported as a symptom.

How common are mental disorders?

• Roughly 24-50% of people report symptoms of mental disorder at some point in life.
• It is unknown if there is an epidemic of psychopathology.
• There are recent increases in social anxiety disorder, panic disorder, PTSD, OCD, generalized anxiety disorder, anorexia nervosa, bulimia, depression, ADHD, dissociative identity disorder, and apotemnophilia, among others.
• This is a consequence of more awareness, a real rise in mental illness, and medicalization.

Debates

Key debates include:

• Are mental disorders value-free scientific concepts or a reflection of the sociopolitical climate?
• What is the relationship between mental illness, mental healthcare, and social norms?
• What functions are served by a diagnosis?
• With mental healthcare, are we talking about a science or an art?

Psychosis v Schizophrenia

• Psychosis: a mental state characterized by profound disturbances in thought, “losing touch with reality.”

Symptom Clusters

• Schizophrenia is divided into symptoms that are (acute) positive, (chronic) negative, and disorganized.
• Schizophrenia Society of Ontario: “Schizophrenia is a disease of the brain…which involves a loss of contact with reality, making it very hard for a person to distinguish between what is real and what is not.”
• WHO: “Schizophrenia is a severe mental disorder, characterized by profound disruptions in thinking, affecting language, perception, and the sense of self.”

Symptom Clusters

• Positive Symptoms include hallucinations and delusions.
  • Hallucinations are sensory experiences w/o a clear stimulus that may be variations of normal experience.
  • Delusions are beliefs maintained despite improbable or impossible nature, even when demonstrably false that sometimes might be ‘correct.’
  • Delusional beliefs are inherently tied to social context.
• Negative symptoms include the As (flat affect, anhedonia, asociality, avolition, etc.).
• Disorganized symptoms impact speech, cognition, or motor behavior.
• There is not an exhaustive symptom list with substantial variability in what is deemed schizophrenia, which has implications, especially w/o biomarkers

Classification of Schizophrenia

• It is unknown how long schizophrenia has existed.
• Schizophrenia is defined by the symptoms
• The concept of schizophrenia did not come into being until late 19th / early 20th c, with Hare’s recency hypothesis.
• Knowing if it is a timeless biological disease and might be caused by something tied to modern life is important.

Epidemiology and Prognosis

• Schizophrenia is reportedly found in all cultures across the world.
• The typical age of onset is 15-35.
• WHO: 1% incidence of schizophrenia in almost every society across the world.
• It is typically thought of as a chronic, lifelong condition.
• The outcome for those in the Global South is much better than developed countries, due to stigma, support, or employment.

Causes of Schizophrenia

• There is no consensus on this issue.
• There are lots of stakeholders in this debate with questions of who is at fault, who can fix it, and what should be done about it.

“Refrigerator Mothers”

• A now rejected theory described the “cold” parenting style of mothers as a potential cause of schizophrenia in mid 20th c.
• It infuriated many parents who felt “blamed” for their offspring’s problems and built alliances with biologically-minded psychiatry to form the National Alliance on Mental Illness (NAMI).
• NAMI has demanded more access to treatment and less stigma around schizophrenia.
• While biological explanations have become dominant, some psychological theories persist (e.g. experiencing abuse, bullying, etc.).

Genetic and Biological Causes?

• There are figures for average risk of developing schizophrenia:
• General pop: 1%
• Spouses of people w/ schizophrenia: 2%
• Children of one parent w/ schizophrenia: 7-15%
• Offspring of two parents w/ schizophrenia: 27-46%
• Monozygotic twins: 7-50% (why not 100%?)
• Genetics may play a role, but far more complex than simple genetics that cannot “predict” schizophrenia and has wide variation in statistics.
• The speculated genetic risk for developing schizophrenia is not limited to schizophrenia, but is shared for schizophrenia, bipolar disorder, major depressive disorder and ADHD.
• There are many other theories (pre-natal viral infections, dopamine hypothesis, etc.).
• The consensus is, finding definitive evidence is hard, with scientists unable to agree who has genes relating to it and who does not

Social Factors

• The highest prevalence of schizophrenia is found in neighborhoods w/ lowest socioeconomic status.
• Two differing theories explain this phenomenon:
  • (a) Social Causation and life events.
  • (b) Social Drift.
• These theories might also work hand-in-hand with others (e.g. biological theories, psychological theories).

Conclusions

• Schizophrenia is the subject of substantial debate and disagreement.
• There is substantial debate over etiology (cause).

Mood Disorders

• There are questions of how to understand booming rates of mood disorders, at what point suffering becomes pathological, and whether "illness" can have utility or purpose.

Major Depressive Disorder (MDD)

• DSM: “One or more major depressive episodes without mania."
• Five+ symptoms during a two-week period are required.
• Symptoms include depressed mood, anhedonia, substantial weight loss/gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feeling of worthlessness or excessive guilt, diminished ability to think or concentrate, indecisiveness, recurrent thoughts of death, and recurrent thoughts of suicide.
• There are questions on what we can draw from heterogeneity.

Persistent Depressive Disorder:

• This is chronic, but milder depression.

Bereavement Exclusion

• DSM-5 controversially removed that proviso.
• There is debate about whether this is aggressive medicalization or recognition of professional autonomy, whether this is culturally more sensitive or less so, an attack on humans as cultural beings more generally, or whether death should have exalted status vis-a-vis other stressors.
• New disorders (like persistent complex bereavement disorder) push debate further.
• There is a tension in how we delineate between the ups and downs of life and symptoms of mental illness.
• Debates demonstrate how many disagreements over mental illness are really debates over what it means to be human.

Depression and Sadness

• For those who argue that depression and sadness are not points on a continuum of misery, but distinct phenomena (feelings v. disease), depression is pervasive and persistent, doesn’t have a clear/understandable stimulus, involves impaired social/occupational functioning, and feels like “being consumed by black cloud.”
• It is unknown if there are biomarkers for depression.

Bipolar Disorder (BD)

• DSM: Cycling b/t depressive and manic episodes.
• Mania involves an abnormally and persistently elevated or irritable mood, an unrealistic belief in one’s own abilities and unrealistic creativity.
• There are instances of gregariousness, flirtatiousness, decreased need for sleep, flight of ideas, racing thoughts, distractibility, an increase in goal-directed activity, and excessive involvement in pleasurable activities w/ high potential for painful consequences.
• An individual may also experience psychosis.
• One question to consider is how to draw the line between a grandiose delusion and an exaggerated sense of one’s own capabilities.

Hypomania

• This is a “super-functional semi-mania” (bipolar II).
• Although typically framed as “negative,” these experiences can contain value.
• Mania may inspire greatness and depression may give pause for thought, but others see these suggestions as selective, unrealistic, and harmful.

Premenstrual Dysphoric Disorder (PMDD)

• In most menstrual cycles, 5+ symptoms in the week before menses are present.
• Symptoms include affective liability, irritability or increased interpersonal conflicts, depressed mood, feelings of hopelessness, anxiety, tension, decreased interest in usual activities, a sense of difficulty in concentration, lethargy, a change in appetite, overeating, or specific food cravings, hypersomnia or insomnia, feeling overwhelmed or out of control, and physical symptoms.

PMDD Controversies

• There are questions of what the line between PMDD and PMS is and what it means to tell people that something that naturally happens as a result of bodily processes is "disordered."
• PMDD was only included in the DSM after Sarafem launched.

Disruptive Mood Dysregulation Disorder (DMDD)

• This is new to DSM-5.
• It involves recurrent temper outbursts grossly disproportionate to the situation.
• Between outbursts, children are irritable and angry.
• It is observed in 2 of 3 settings: parents, teachings, and peers and the child symptoms must begin observed by age 10 but child must be aged 6-18
• "Child must be aged 6-18, w/ symptoms beginning by 10."

DMDD Controversies

• There is a broader trend of medicalizing childhood that has increased diagnostic rates since 1990: 3x ADHD, 20x autism, 40x childhood bipolar disorder.
• Oppositional defiant disorder (ODD) involves “an ongoing pattern of anger guided disobedience, hostilely defiant behavior toward authority figures that goes beyond the bounds of normal childhood behavior.”
• DMDD is an “untested diagnosis.”
• Members of the DSM group on childhood resigned in protest and Frances called it “number one diagnosis to ignore."

The “Great Depression”

• Diagnosed younger than ever, depression causes 10% of global disability.
• Modernization, greater individualism and isolation, and a cultural proclivity to “avoid negative feelings" may play a role,.
• This may also be a false epidemic (not more depressed, but diagnostic changes mean it’s easier to be diagnosed than in the past), or may be a product of greater awareness or decreased stigma.

Anxiety Disorders

• There are questions of whether mental illness is better conceptualized as a series of discrete disorders or as a continuum/spectrum.
• There are questions of what is implied in framing difficult feelings and behaviors as illness and what might be gained or lost by thinking about these feelings and behaviors as non-pathological reactions.
• In framing difficult feelings and behaviours as illness, what is implied?
• What might be gained – or lost – by thinking about these feelings and behaviours as non-pathological reactions?

Fear vs Anxiety

• Fear: response to real & present danger that helps organize responses to threat, like “fight or flight.”
• Anxiety: apprehension about anticipated events with physiological changes and difficulty controlling thoughts.
• Some anxiety is helpful.

Classification of Anxiety Disorders

• This emerged as a distinct group of disorders in DSM-III and was previously part of “neuroses” (emotional disturbance, w/ awareness).
• Awareness dropped in DSM-5, is now merely necessary for fear & worry to be “disproportionate to the situation"
• The splitting movement has divided anxiety disorders which shares the core symptom of intense worry that's disproportionate to actual environmental danger.

Rise of Interest in Anxiety

• Asylums primarily housed those deemed psychotic and/or dangerous.
• Freud’s emphasis on neuroses opened an entirely new domain of human emotion: anxiety.
• What counts as a “psychiatric concern” is not fixed.

Panic Disorder

• This is characterized by recurrent, unexpected panic attacks that usually occur without warning and finish within ten minutes.
• There is a preponderance of physical symptoms.
• Derealization (unreality) or depersonalization (detachment from oneself) may occur. The person may obsessively worry about another attack.

Specific (Simple) Phobia

• This involves persistent, excessive, narrowly defined fears associated with a specific object or situation.
• Phobias are “irrational or unreasonable.”
• Daily life is consumed on some level with avoidance, fear, and dread.

Agoraphobia

• This involves extreme fear about situations where escape is difficult or embarrassing, unlike other phobias, not closeness to a specific object but distance from “safety” that’s the problem.
• It is “most complex and incapacitating phobic disorder.”

Social Anxiety Disorder

• This is focused on performance or interpersonal interactions.
• It involves concerns of being humiliated or embarrassed.
• If anxiety is related to a specific situation (e.g. a speech), anxiety disappears if the task is performed privately.
• Introduced in DSM-III:
  • 1980s: 0.5%, 2019: 9-15%
• Criteria have expanded to be more inclusive with subsequent editions.
• It is both culture-bound and an archetype of medicalization.

Generalized Anxiety Disorder

• This involves “chronic worriers”, and distress/impairment in occupational or social functioning.
• Worry is not fixed, may not even have a clear source, and is accompanied by minor disturbances in sleep, irritability, concentration, and restlessness.

Comorbidity

• 50% of people who meet criteria for one anxiety disorder meet criteria for another.
• There is a high degree of comorbidity between anxiety and mood disorders (e.g. 61% of those diagnosed w/ MDD qualify for an anxiety disorder).
• Those diagnosed w/ anxiety disorders are diagnosed 3x more likely to be diagnosed w/ substance use disorder. Splitting movement” behind high level of comorbidity.
• Artificial divisions create overlapping disorders, with “pure” cases very rare.

Diagnostic Growth

• Anxiety disorders are at the forefront of an increase in the prevalence of psychopathology.
• Medicalization of ‘uncomfortable’ feelings produce stress.

Women and Anxiety Disorders

• Women are diagnosed w/ anxiety disorders at a greater rate than men for reasons relating to gender differences in seeking treatment, biology, life events, social roles, and diagnostic bias.

Benzo Boom and Backlash

• Anxiolytics - benzodiazepine boom, including Valium, Xanax, and Ativan.
• They work on immediate symptoms, but don’t alter thinking about future events
• They are often physiologically addictive, prompting withdrawal.
• After the 1970s and 1980s benzo backlash, SSRIs were branded as anti-depressants in the 1990s.

Conclusions

• Boundaries b/t anxiety disorders and b/t anxiety disorders and others are among the finest, prompting questions about how and why diagnostic boundaries get drawn.
• There is a widespread belief that we are becoming more anxious as a population.

OCD, PTSD, and Anxiety

• OCD and PTSD, once conceptualized as anxiety disorders, each get their own chapter in DSM-5.
• Question of why we separate disorders, do we separate them, is it because there is symptom overlap?
• Is it treatment?

Post Traumatic Stress Disorder (PTSD)

• A person must have been exposed to a traumatic event, involving actual or threatened death, serious injury, or sexual violation.
• These circumstances could have occurred to others.
• Exposure cannot simply happen via electronic media (unless exposure is work related).

OCD and Related Disorders

Obsessions and compulsions must be present.

• Hoarding Disorder:
  • This is the persistent difficulty & distress discarding possessions due to perceived need, resulting in clutter that causes impairment.
  • What counts as “junk” is subjective.

The Question of Distinctiveness

• OCD/PTSD share much in common w/ other disorders:
  • Feelings of anxiety central to obsessions and re-experiencing.
  • Centrality of avoidance shared w/ anxiety disorders.
  • OCD and anxiety disorders tend to respond to similar treatments.

Conclusions: does categorization matter?

• Categorization may affect how a disorder is understood and treated, as well as issues of identity and self-concept.
• Debates on categorization underscore the ways in which our ideas about mental disorders are constructed and subject to continual change.

Explore the multifaceted perspectives on mental health, including the importance of empathy, self-confidence, and independence. This quiz delves into historical perceptions, distinctions from physical health, and the complexities of defining 'abnormality'. It also addresses how mental disorders are classified and the challenges in ensuring good mental healthcare.