Chapter 2: History of Psychiatric Care PDF

Chapter 2 The consideration of mental health and mental illness has its basis in the cultural beliefs of the society in which the behavior takes place. What may be considered acceptable behavior in one culture may be considered abnormal in another. A study of the history of psychiatric care reveal...

Chapter 2 The consideration of mental health and mental illness has its basis in the cultural beliefs of the society in which the behavior takes place. What may be considered acceptable behavior in one culture may be considered abnormal in another. A study of the history of psychiatric care reveals some shocking truths about past treatment of individuals with mental illness. Many were kept in control by means that today could be considered abuse. This chapter deals with the evolution of psychiatric care from ancient times to the present. Mental health and mental illness are defined, and the psychological adaptation to stress is explained in terms of the two major responses: anxiety and grief. Behavioral responses are conceptualized along the mental health/mental illness continuum. Historical Overview of Psychiatric Care Primitive thoughts regarding mental disturbances varied and were often rooted in cultural and religious beliefs. Some cultures thought that an individual with mental illness had been dispossessed of their soul and wellness could be achieved only if the soul was returned. Others believed that evil spirits or supernatural or magical powers had entered the body. The "cure" for these individuals involved a ritualistic exorcism that often consisted of brutal beatings, starvation, or other harsh means to purge the body of these unwanted forces. Still other cultures considered that the mentally ill individual may have broken a taboo or sinned against another individual or God, for which ritualistic purification was required or various types of retribution were demanded. The correlation of mental illness to demonology or witchcraft led to some mentally ill individuals being executed. These ancient beliefs dwindled with increasing knowledge about mental illness and changes in cultural, religious, and sociopolitical attitudes. Around 400 BCE, the work of Hippocrates was the first to place mental illness in a physical rather than supernatural context. Hippocrates theorized that mental illness was caused by irregularity in the interaction of the four body fluids: blood, black bile, yellow bile, and phlegm. He called these body fluids humors and associated each with a particular disposition. Disequilibrium among these four humors was often treated by inducing vomiting and diarrhea with potent cathartic drugs. During the Middle Ages (CE 500 to 1500), the association of mental illness with witchcraft and the supernatural continued to prevail in Europe. During this period, many people with mental illness were set to sea alone in sailing boats with little guidance to search for their lost rationality, a practice from which the expression "ship of fools" was derived. But in Middle Eastern countries, mental illness began to be perceived as a medical problem rather than a result of supernatural forces. This notion gave rise to the establishment of specialized hospital units and residential institutions specifically designed for clients with mental illness. They can likely be considered the first asylums for individuals with mental illness. Colonial Americans tended to reflect the attitudes of the European communities from which they had emigrated. Particularly in the New England area, individuals were punished for behavior attributed to witchcraft. In the 16th and 17th centuries, institutions for people with mental illness did not exist in the United States, and care of these individuals was a family responsibility. Those without family or other resources became the responsibility of the communities in which they lived and were incarcerated in places where they could not harm themselves or others. The first hospital in America to admit clients with mental illness was established in Philadelphia in the middle of the 18th century. Benjamin Rush, often called the father of American psychiatry, was a physician at the hospital. He initiated the provision of humanistic treatment and care for clients with mental illness. Although he included kindness, exercise, and socialization in his care, he also employed harsh methods such as bloodletting, purging, various types of physical restraints, and extremes of temperatures, reflecting the medical therapies of that era. The 19th century brought the establishment of a system of state asylums, largely the result of the work of Dorothea Dix, a former New England schoolteacher who lobbied tirelessly on behalf of the mentally ill population. She was unwavering in her belief that mental illness was curable and that state hospitals should provide humanistic therapeutic care. This system of hospital care for individuals with mental illness grew, but the mentally ill population grew faster. The institutions became overcrowded and understaffed, and conditions deteriorated. Therapeutic care reverted to custodial care in state hospitals, which provided the largest resource for individuals with mental illness until the initiation of the community health movement of the 1960s (see Chapter 35, "Community Mental Health Nursing"). The emergence of psychiatric nursing began in 1873 with the graduation of Linda Richards from the nursing program at the New England Hospital for Women and Children in Boston. She has come to be known as the first American psychiatric nurse. During her career, Richards was instrumental in the establishment of a number of psychiatric hospitals and the first school of psychiatric nursing at the McLean Asylum in Waverly, Massachusetts, in 1882. This school and others like it provided training in custodial care for clients in psychiatric asylums---training that did not include the study of psychological concepts. Significant change in psychiatric nursing education did not occur until 1955, when incorporation of psychiatric nursing into the curricula became a requirement for all undergraduate schools of nursing. This new curriculum emphasized the importance of the nurse--patient relationship and therapeutic communication techniques. Nursing intervention in the somatic therapies (e.g., insulin and electroconvulsive therapy) provided impetus for the incorporation of these concepts into the profession's body of knowledge. With the increasing need for psychiatric care in the aftermath of World War II, the government passed the National Mental Health Act of 1946. This legislation provided funds for the education of psychiatrists, psychologists, social workers, and psychiatric nurses. Graduate-level education in psychiatric nursing was established during this period. Around the same time, the introduction of antipsychotic medications made it possible for clients with psychoses to participate in their treatment more readily, including psychological therapies. Knowledge of the history of psychiatric-mental health care contributes to the understanding of the concepts presented in this chapter and those in online Chapter 38, "Theoretical Models of Personality Development," which describe the theoretical models of personality development according to various 19th- and 20th-century leaders in the mental health movement. Modern American psychiatric care has its roots in ancient times. A great deal of opportunity exists for continued advancement of this specialty within the practice of nursing. Mental Health A number of theorists have attempted to define the concept of mental health. Many of these concepts focus on how well the individual is able to function. Maslow (1970) emphasized that mental health is associated with an individual's motivation toward self-actualization. He identified a "hierarchy of needs," with the most basic needs requiring fulfillment before those at higher levels can be achieved and with self-actualization defined as fulfillment of one's highest potential. An individual's position within the hierarchy may fluctuate on the basis of life circumstances. For example, an individual facing major surgery who has been working to achieve self-actualization may become preoccupied, if only temporarily, with the need for physiological safety. A representation of the needs hierarchy is presented in Figure 2--1. FIGURE 2-1 Maslow's hierarchy of needs. Maslow described self-actualization as being "psychologically healthy, fully human, highly evolved, and fully mature" (p. 149). He believed that self-actualized individuals possess the following characteristics:   An appropriate perception of reality   The ability to accept oneself, others, and human nature   The ability to manifest spontaneity   The capacity for focusing concentration on problem-solving   A need for detachment and desire for privacy   Independence, autonomy, and a resistance to enculturation   An intensity of emotional reaction   A frequency of "peak" experiences that validate the worthwhileness, richness, and beauty of life   An identification with humankind   The ability to achieve satisfactory interpersonal relationships   A democratic character structure and strong sense of ethics   Creativeness   A degree of nonconformance Jahoda (1958) identified a list of six indicators that are a reflection of mental health: 1.  A positive attitude toward self: This indicator refers to an objective view of self, including knowledge and acceptance of strengths and limitations. The individual feels a strong sense of personal identity and security within their environment. 2.  Growth, development, and the ability to achieve self-actualization: This indicator correlates with whether the individual successfully achieves the tasks associated with each level of development (see Chapter 31, "Personality Disorders," and online Chapter 38). With successful achievement in each level, the individual gains motivation for advancement to their highest potential. 3.  Integration: The focus of this indicator is on maintaining equilibrium or balance among various life processes. Integration includes the ability to adaptively respond to the environment and the development of a philosophy of life, both of which help the individual maintain a manageable anxiety level in response to stressful situations. 4.  Autonomy: This indicator refers to the individual's ability to perform in an independent, self-directed manner. The person makes choices and accepts responsibility for the outcomes. 5.  Perception of reality: Accurate reality perception is a positive indicator of mental health. It includes perception of the environment without distortion as well as the capacity for empathy and social sensitivity---a respect and concern for the wants and needs of others. 6.  Environmental mastery: This indicator suggests that the individual has achieved a satisfactory role within the group, society, or environment and is able to love and accept the love of others. When faced with life situations, the person is able to strategize, make decisions, change, adjust, and adapt. Life offers satisfaction to the individual who has achieved environmental mastery. Robinson (1983) offered this definition of mental health: "A dynamic state in which thought, feeling, and behavior that is age-appropriate and congruent with the local and cultural norms is demonstrated" (p. 74). Expanding on this model, mental health may be viewed as a relative state that occurs along a continuum of thoughts, feelings, and behaviors that are all part of the human psychological experience and are influenced by the perceived magnitude of stressors in interaction with adaptive capabilities. In keeping with the framework of stress and adaptation, this text will use a modification of Robinson's definition of mental health. Thus, mental health will be defined as "the successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms." Mental Illness Arriving at a universal concept of mental illness is difficult because of the many cultural factors that influence this concept. Horwitz (2010) attempted to define mental illness from a sociocultural perspective characterized by two elements: incomprehensibility and cultural relativity. Incomprehensibility relates to the inability of the general population to understand the motivation behind an individual's behavior. When observers are unable to find meaning or comprehensibility in behavior, they are likely to label that behavior as mental illness. Horwitz stated, "Observers attribute labels of mental illness when the rules, conventions, and understandings they use to interpret behavior fail to find any intelligible motivation behind an action" (p. 17). The element of cultural relativity considers that these rules, conventions, and understandings are conceived within an individual's own particular culture. Behavior that is considered "normal" and "abnormal" is defined by one's cultural or societal norms. Therefore, a behavior that is recognized as evidence of mental illness in one society may be viewed as normal in another society, and vice versa. The American Psychiatric Association (APA) (2022), in its Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), defined mental disorder as: a syndrome characterized by clinically significant disturbance in an individual's cognitions, 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. An expected or culturally approved response to a common stressor or loss such as the death of a loved one is not a mental disorder (p. 14). In this text, and in keeping with the transactional model of stress and adaptation, mental illness is characterized as "maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and that interfere with the individual's social, occupational, and/or physical functioning." Psychological and Behavioral Adaptation to Stress All individuals exhibit characteristics associated with both mental health and mental illness at any given point in time. Chapter 1, "The Concept of Stress Adaptation," described how an individual's response to stressful situations is influenced by physiological factors, their personal perception of the event, and a variety of predisposing factors such as heredity, temperament, learned response patterns, developmental maturity, existing coping strategies, and support systems of caring others. Anxiety and grief have been described as two primary psychological response patterns to stress. A variety of thoughts, feelings, and behaviors are associated with each of these response patterns. Adaptation is determined by the degree to which the thoughts, feelings, and behaviors interfere with an individual's functioning. CORE CONCEPT Anxiety Anxiety is a feeling of discomfort and apprehension related to fear of impending danger. Individuals may be unaware of the source of their anxiety, which is often accompanied by feelings of uncertainty and helplessness. Anxiety Feelings of anxiety are so common in our society that they are almost considered universal. Anxiety arises from the chaos and confusion that exists in the world. Fear of the unknown and conditions of ambiguity allow anxiety to take root and grow. Low levels of anxiety are adaptive and can provide the motivation required for survival. Anxiety becomes problematic when the individual is unable to prevent their response from escalating to a level that interferes with the ability to meet basic needs. Peplau (1963) described four levels of anxiety: mild, moderate, severe, and panic. A synopsis of the characteristics associated with each of the four levels of anxiety is presented in Table 2--1. A variety of psychological and behavioral responses occur at each level of anxiety. Figure 2--2 depicts these responses on a continuum of anxiety ranging from mild to panic. Nurses must be able to recognize the symptoms associated with each level to plan for appropriate intervention with anxious individuals. TABLE 2--1    Levels of Anxiety LEVEL PERCEPTUAL FIELD ABILITY TO LEARN PHYSICAL CHARACTERISTICS EMOTIONAL AND BEHAVIORAL CHARACTERISTICS Mild Heightened perception (e.g., noises may seem louder; details within the environment are clearer) Increased awareness Increased alertness Learning is enhanced Restlessness Irritability May remain superficial with others Rarely experienced as distressful Motivation is increased Moderate Reduction in perceptual field Reduced alertness to environmental events (e.g., someone talking may not be heard; part of the room may not be noticed) Learning still occurs but not at optimal ability Decreased attention span Decreased ability to concentrate Increased restlessness Increased heart and respiration rates Increased perspiration Gastric discomfort Increased muscular tension Increase in speech rate, volume, and pitch A feeling of discontent May lead to a degree of impairment in interpersonal relationships as individual begins to focus on self and the need to relieve personal discomfort Severe Greatly diminished; only extraneous details are perceived, or fixation on a single detail may occur May not take notice of an event even when attention is directed by another Extremely limited attention span Unable to concentrate or problem-solve Effective learning cannot occur Headaches Dizziness Nausea Trembling Insomnia Palpitations Tachycardia Hyperventilation Urinary frequency Diarrhea Feelings of dread, loathing, horror Total focus on self and intense desire to relieve the anxiety Panic Unable to focus on even one detail within the environment Misperceptions of the environment common (e.g., a perceived detail may be elaborated and out of proportion) Learning cannot occur Unable to concentrate Unable to comprehend even simple directions Dilated pupils Labored breathing Severe trembling Sleeplessness Palpitations Diaphoresis and pallor Muscular incoordination Immobility or purposeless hyperactivity Incoherence or inability to verbalize Sense of impending doom Terror Bizarre behavior, including shouting, screaming, running about wildly, clinging to anyone or anything from which a sense of safety and security is derived Hallucinations, delusions Extreme withdrawal into self FIGURE 2-2 Adaptation responses on a continuum of anxiety. Mild Anxiety This level of anxiety is seldom a problem for the individual. It is associated with the tension experienced in response to the events of day-to-day living. Mild anxiety prepares people for action. It sharpens the senses, increases motivation for productivity, and results in a heightened awareness of the environment. Learning is enhanced, and the individual is able to function at an optimal level. At the mild level, individuals employ any of a number of coping behaviors that satisfy their needs for comfort. Menninger (1963) described the following types of coping mechanisms that individuals use to relieve mild anxiety in stressful situations:   Sleeping   Yawning   Eating   Drinking   Physical exercise   Daydreaming   Smoking   Laughing   Crying   Cursing   Pacing   Nail biting   Foot swinging   Finger tapping   Fidgeting   Talking to someone with whom one feels comfortable Undoubtedly, there are many more coping mechanisms, too numerous to mention here, considering that individuals develop their own unique ways to relieve anxiety at the mild level. Some of these behaviors are more adaptive than others. The term coping skills is used to describe those coping behaviors that enhance one's adaptation. These include enhancing knowledge, social affiliation with others, and problem-solving. Moderate Anxiety As the level of anxiety increases, the extent of the perceptual field diminishes. The moderately anxious individual is less alert to events occurring in the environment. The individual's attention span and ability to concentrate decrease, although they may still attend to needs with direction. Assistance with problem-solving may be required. Increased muscular tension and restlessness are evident. Sigmund Freud (1961) identified the ego as the reality component of the personality, governing problem-solving and rational thinking. As the level of anxiety increases, the strength of the ego is tested, and energy is mobilized to confront the threat. Anna Freud (1953) identified a number of ego defense mechanisms employed by the ego in the face of threat to biological or psychological integrity. Some of these ego defense mechanisms are more adaptive than others, but all are used either consciously or unconsciously as protective devices by the ego to relieve moderate anxiety. They become maladaptive when an individual uses them to such a degree that the defense mechanism interferes with the ability to deal with reality, with interpersonal relations, or with occupational performance. Maladaptive use of defense mechanisms promotes disintegration of the ego. The major ego defense mechanisms identified by Anna Freud are summarized in Table 2--2. Anxiety at the moderate-to-severe level that remains unresolved over an extended period can contribute to a number of physiological disorders. The DSM-5-TR (APA, 2022) described these disorders under the category "Psychological Factors Affecting Other Medical Conditions." The psychological factors may exacerbate symptoms of, delay recovery from, or interfere with treatment of the medical condition. The condition may be initiated or exacerbated by an environmental situation that the individual perceives as stressful. Measurable pathophysiology can be demonstrated. It is thought that psychological and behavioral factors may affect the course of almost every major category of disease, including cardiovascular, gastrointestinal, neoplastic, neurological, and pulmonary conditions. TABLE 2--2    Ego Defense Mechanisms DEFENSE MECHANISM EXAMPLE COMPENSATION Covering up a real or perceived weakness by emphasizing a trait one considers more desirable A physically disabled boy is unable to participate in football, so he compensates by becoming a great scholar. DENIAL Refusing to acknowledge the existence of a real situation or the feelings associated with it A woman drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem. DISPLACEMENT The transfer of feelings from one target to another that is considered less threatening or that is neutral A patient is angry with his physician, does not express it, but becomes verbally abusive with the nurse. IDENTIFICATION An attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires A teenager who required lengthy rehabilitation after an accident decides to become a physical therapist as a result of his experiences. INTELLECTUALIZATION An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis A woman's husband is being transferred by his job to a city far away from her parents. She hides anxiety by explaining to her parents the advantages associated with the move. INTROJECTION Integrating the beliefs and values of another individual into one's own ego structure A child integrates their parents' value system into the process of conscience formation. A child says to a friend, "Don't cheat. It's wrong." ISOLATION Separating a thought or memory from the feeling, tone, or emotion associated with it A young woman describes being attacked and raped without showing any emotion. PROJECTION Attributing feelings or impulses unacceptable to one's self to another person A man who is addicted to alcohol blames his wife for his excessive drinking. RATIONALIZATION Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors A patient tells the rehab nurse, "I drink because it's the only way I can deal with my bad marriage and my worse job." REACTION FORMATION Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors A student who hates nursing and only attended nursing school to please her parents speaks to prospective students about the excellence of nursing as a career. REGRESSION Retreating in response to stress to an earlier level of development and the comfort measures associated with that level of functioning When a 2-year-old is hospitalized for tonsillitis, he will drink only from a bottle, even though his mother states he has been drinking from a cup for 6 months. REPRESSION Involuntarily blocking unpleasant feelings and experiences from one's awareness A trauma victim is unable to remember anything about the traumatic event. SUBLIMATION Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive A mother whose son was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drunk Driving. SUPPRESSION The voluntary blocking of unpleasant feelings and experiences from one's awareness "I don't want to think about that now. I'll think about that tomorrow." UNDOING Symbolically negating or canceling out an experience that one finds intolerable A man is nervous about his new job and yells at his wife. On his way home he stops and buys her some flowers. Severe Anxiety The perceptual field of the severely anxious individual is so greatly diminished that concentration may center on one particular detail only or on many extraneous details. Attention span is extremely limited, and the individual has difficulty completing even the simplest task. Physical symptoms (e.g., headaches, palpitations, insomnia) and emotional symptoms (e.g., confusion, dread, horror) may be evident. Discomfort is experienced to the degree that virtually all overt behavior is aimed at relieving the anxiety. Extended periods of repressed severe anxiety can result in neurotic patterns of behaving. Neurosis is no longer considered a separate category of mental disorder. However, the term sometimes is still used in the literature to further describe the symptomatology of certain disorders and to differentiate them from behaviors that occur at the more serious level of psychosis. A neurosis is a psychiatric disturbance characterized by excessive anxiety that is expressed directly or altered through defense mechanisms. Although there is no gross distortion of reality or severe personality disorganization, the symptoms are significant enough to impair a person's functioning. The following are common characteristics of people with neuroses:   They are aware that they are experiencing distress.   They are aware that their behaviors are maladaptive.   They are unaware of any possible psychological causes of the distress.   They feel helpless to change their situation.   They experience no loss of contact with reality. The following disorders are examples of psychoneurotic responses to severe anxiety as they appear in the DSM-5-TR (APA, 2022):   Anxiety disorders: Disorders in which the characteristic features are symptoms of anxiety and avoidance behavior (e.g., phobias, panic disorder, generalized anxiety disorder, and separation anxiety disorder)   Somatic symptom and related disorders: Disorders in which the characteristic feature is a preoccupation with distressing somatic symptoms for which there is no demonstrable organic pathology; psychological factors are judged to play a significant role in the onset, severity, exacerbation, or maintenance of the symptoms (e.g., somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder)   Dissociative disorders: Disorders in which the characteristic feature is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (e.g., dissociative amnesia, dissociative identity disorder, and depersonalization-derealization disorder) Panic Anxiety In this most intense state of anxiety, the individual is unable to focus on even one detail in the environment. Misperceptions are common, and a loss of contact with reality may occur. The individual may experience hallucinations or delusions. Behavior may be characterized by wild and desperate actions or extreme withdrawal. Human functioning and communication with others is ineffective. Panic anxiety is associated with a feeling of terror, and individuals may be convinced that they have a life-threatening illness or fear that they are "going crazy," are losing control, or are emotionally weak. Prolonged panic anxiety can lead to physical and emotional exhaustion and can be a life-threatening situation. At this extreme level of anxiety, an individual is not capable of processing what is happening in the environment and may lose contact with reality. Psychosis is defined as a significant thought disturbance in which reality testing is impaired, resulting in delusions, hallucinations, disorganized speech, or catatonic behavior. The following are common characteristics of people with psychoses:   They exhibit minimal distress (emotional tone is flat, bland, or inappropriate).   They are unaware that their behavior is maladaptive.   They are unaware of any psychological problems (anosognosia).   They are exhibiting a flight from reality into a less stressful world or one in which they are attempting to adapt. Examples of psychotic responses to anxiety include delusions (fixed, false beliefs) and hallucinations (false sensory perceptions). CORE CONCEPT Grief Grief is a subjective feeling of sorrow and sadness accompanied by emotional, physical, and social responses to the loss of a loved person or thing. Grief Most individuals experience intense emotional anguish in response to a significant personal loss. A loss is anything that is perceived as such by the individual. Losses may be real, in which case they can be substantiated by others (e.g., death of a loved one, loss of personal possessions), or they may be perceived by the individual alone, unable to be shared or identified by others (e.g., loss of the feeling of femininity after mastectomy). Any situation that creates change for an individual can be identified as a loss. Failure (either real or perceived) also can be viewed as a loss. Loss is typically a very stressful event and, like other stressors, an individual's response to loss may be adaptive or maladaptive. The loss or anticipated loss of anything of value to an individual can trigger the grief response. This period of characteristic emotions and behaviors is called mourning. The "normal" mourning process, which may include feelings of sadness, guilt, anger, helplessness, hopelessness, and despair, is adaptive. Indeed, an absence of mourning after a loss may be considered maladaptive. Grief is not considered a mental illness, but maladaptive responses to grief may culminate in clinical depression or other symptoms of mental illness, including risk for suicide. In the latest edition of the DSM-5-TR (APA, 2022) a new diagnostic category, prolonged grief disorder, was added to the group of disorders identified as "Trauma and Stressor-Related" to clarify that intense distress and impaired functioning that endures beyond 12 months of the death of a loved one is beyond what is considered normal bereavement. Careful assessment to differentiate normal grief responses from those that require additional treatment is critical to maintaining patient safety. An in-depth discussion of the usual stages of grief and maladaptive grief responses can be found in Chapter 36, "The Bereaved Individual." Anxiety and grief have been described as two primary responses to stress: the severity of symptoms and the ability to adapt effectively are influential along a continuum of one's experience of mental health or mental illness. Mental Health/Mental Illness Continuum Anxiety and grief have been described as two primary responses to stress. In Figure 2--3, both of these responses are presented on a continuum according to the degree of symptom severity. Disorders, as they appear in the DSM-5-TR, are identified at their appropriate placement along the continuum. FIGURE 2-3 Conceptualization of anxiety and grief responses along the mental health/mental illness continuum. Summary and Key Points   Mental health is defined as "the successful adaptation to stressors from the internal or external environment evidenced by thoughts, feelings, and behaviors that are age appropriate and congruent with local and cultural norms."   Mental illness is defined as "maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms, and interfere with the individual's social, occupational, and/or physical functioning."   From a sociocultural perspective, behavior may be labeled as mental illness on the basis of incomprehensibility and cultural relativity.   When observers are unable to find meaning or comprehensibility in behavior, they are likely to label that behavior as mental illness. The meaning of behaviors is determined within individual cultures.   Anxiety and grief have been identified as the two primary responses to stress.   Peplau (1963) defined anxiety by levels of symptom severity: mild, moderate, severe, and panic.   Behaviors associated with levels of anxiety include coping mechanisms, ego defense mechanisms, psychophysiological responses, psychoneurotic responses, and psychotic responses.   Grief is described as a response to loss of a valued entity. It can be an adaptive or a maladaptive experience.