Culture and Mental Health PDF

PART X CULTURE AND MENTAL HEALTH A wreath is laid in memoriam to victims of the Washington Navy Yard shooting. On Monday, September 16, 2013, a gunman killed 12 people as the workday began at the Washington Navy Yard in Washington, DC. Aaron Alexis, 34, had a troubled history: he thought that he w...

PART X CULTURE AND MENTAL HEALTH A wreath is laid in memoriam to victims of the Washington Navy Yard shooting. On Monday, September 16, 2013, a gunman killed 12 people as the workday began at the Washington Navy Yard in Washington, DC. Aaron Alexis, 34, had a troubled history: he thought that he was being controlled by radio waves. He called the police to complain about voices in his head and being under surveillance by “shadowy forces” (Thomas, Levine, Date, & Cloherty, 2013). While Alexis’s actions cannot be excused, it is clear that he had some form of mental illness. Mental illness is not necessarily a cause of violence, in fact it is far more likely that individuals with mental illness will be victims rather than perpetrators of violence (Stuart, 2003). If, however, Alexis had received the help he needed, this tragedy might have been averted. Culture and Mental Health | 313  When we hear about violent events it is common to ask yourself whether YOU are currently in “good” health? What are you thinking of to make that determination? Research shows that many (if not most) Americans automatically consider physical symptoms or the absence of illness to answer this question. Although many Americans acknowledge the importance of stress management and mental wellness to being productive and healthy, there remains to a tendency to highlight the physical in well-being and avoid acknowledging mental distress. In this chapter we will explore common conditions of mental illness and discuss the influence of culture in making a diagnosis and dispelling common misconceptions. Learning Objectives At the end of the chapter, you should be able to: 1. Define the concept of mental illness. 2. Distinguish between the presence of symptoms versus having a diagnosable disorder. 3. Identify the two most widely used methods to classify mental illness in the world. 4. Identify ways in which the history of classifying mental illness has changed over time. 5. Define what is means for a disorder to be “culture-specific, or culture – bound. 6. Explain contemporary understanding of culture – bound disorders. 7. Name and describe examples of culture-bound syndromes still recognized in the DSM-5. 8. Define the concept of universal mental illnesses 9. Distinguish between the most common categories of mental illness seen worldwide. 10. Compare and contrast between symptoms for these 314 | Culture and Mental Health  disorder categories. 11. Identify and discuss common barriers to receiving mental health treatment in the United States. 12. Identify and discuss common barriers to receiving mental health treatment world-wide. Culture and Mental Health | 315 What is Mental Illness? A psychological disorder is a condition characterized by abnormal thoughts, feelings, and behaviors. Psychopathology is the study of psychological disorders, including their symptoms, etiology (i.e., their causes), and treatment. The term psychopathology can also refer to the manifestation of a psychological disorder. Although consensus can be difficult, it is extremely important for mental health professionals to agree on what kinds of thoughts, feelings, and behaviors are truly abnormal in the sense that they genuinely indicate the presence of psychopathology. Certain patterns of behavior and inner experience can easily be labeled as abnormal and clearly signify some kind of psychological disturbance. The person who washes his hands 40 times per day and the person who claims to hear the voices of demons exhibit behaviors and inner experiences that most would regard as abnormal. Abnormal refers to beliefs and behaviors that suggest the existence of a psychological disorder. On the other hand, consider the nervousness a young man feels when talking to attractive women or the loneliness and longing for home a freshman experiences during her first semester of college—these feelings may not be regularly present, but they fall in the range of normal. So, what kinds of thoughts, feelings, and behaviors represent a true psychological disorder? Psychologists work to distinguish psychological disorders from inner experiences and behaviors that are merely situational, idiosyncratic, or unconventional. What is Mental Illness? | 317 The most recent edition of the DSM [Image: Rene Walter, https://goo.gl/CcJAA1, CC BY-NC-SA 2.0, https://goo.gl/Toc0ZF] Most recent edition of the ICD [Image WHO CC Public Domain] Progress in the treatment of mental illness necessarily implies improvements in the diagnosis of mental illness. A standardized diagnostic classification system with agreed- upon definitions of psychological disorders creates a shared language among mental health providers and aids in clinical research. While disorders have been recognized as far back as the ancient Greeks, it was not until 1883 that German psychiatrist Emil Kräpelin (1856–1926) published a comprehensive system of psychological disorders that centered on a pattern of symptoms (i.e., syndrome) suggestive of an underlying physiological cause. Other clinicians also suggested classification systems that became popular but the need for a single, shared system paved the way for the American Psychiatric Association’s 1952 publication of the first Diagnostic and Statistical Manual (DSM). The most recent version is the DSM-5 (2013). Each revision reflects an attempt to 318 | What is Mental Illness? help clinicians streamline diagnosis and work better with other diagnostic systems such as health diagnoses outlined by the World Health Organization (WHO). Summary Psychological disorders are conditions characterized by abnormal thoughts, feelings, and behaviors. Although challenging, it is essential for psychologists and mental health professionals to agree on what kinds of inner experiences and behaviors constitute the presence of a psychological disorder. Inner experiences and behaviors that are atypical or violate social norms could signify the presence of a disorder; however, each of these criteria alone is inadequate. Harmful dysfunction describes the view that psychological disorders result from the inability of an internal mechanism to perform its natural function. Many of the features of harmful dysfunction conceptualization have been incorporated in the American Psychological Association (APA) formal definition of psychological disorders. According to this definition, the presence of a psychological disorder is signaled by significant disturbances in thoughts, feelings, and behaviors; these disturbances must reflect some kind of dysfunction (biological, psychological, or developmental), must cause significant impairment in one’s life, and must not reflect culturally expected reactions to certain life events. What is Mental Illness? | 319 Making a Diagnosis (The 3 D’s) While the concept of mental or psychological disorders is difficult to define, and no definition will ever be perfect, it is recognized as an extremely important concept and therefore psychological disorders (aka mental disorders) have been defined as a psychological dysfunction which causes distress or impaired functioning and deviates from typical or expected behavior according to societal or cultural standards. This definition includes three components (3 Ds) Dysfunction Distress Deviance Dysfunction includes disturbances in a person’s thinking, emotional regulation, or behavior that reflects significant dysfunction in psychological, biological, or developmental processes underlying mental functioning. In other words, dysfunction refers to a breakdown in cognition, emotion, and/ or behavior. For instance, an individual experiencing the delusion that he is an omnipotent deity has a breakdown in cognition because his thought processes are not consistent with reality. An individual who is unable to experience pleasure has a breakdown in emotion. Finally, an individual who is unable to leave her home and attend work due to fear of having a panic attack is exhibiting a breakdown in behavior. Distress can take the form of psychological or physical pain, or both at the same time. Simply put, distress refers to suffering. Alone though, distress is not sufficient enough to describe behavior as abnormal. Think about it – the loss of 320 | Making a Diagnosis (The 3 D’s) a loved one causes even the most “normally” functioning individual pain and suffering. An athlete who experiences a career ending injury would display distress as well. Suffering is part of life and cannot be avoided. Impairment refers to when the person experiences a disabling condition that limits the ability to engage in activities of daily living (e.g., can no longer maintain minimum standards of hygiene, pay bills) or participate in social events (e.g., attending social events), work or school. Impairment can also interfere with the ability to perform important life roles (e.g., student, caregiver or parent). A closer examination of the word abnormal shows that it indicates a move away from what is normal, typical, or average. Deviance refers to behavior that violates social norms or cultural expectations because culture determines what is normal. When a person is said to be deviant when he or she fails to follow the stated and unstated rules of society, called social norms. As you might expect there is a lot of cultural variation in acceptable behavior. Earlier we learned about cultural relativism and what is considered normal by a culture can change over time due to shifts in accepted values and expectations. For instance, just a few decades ago homosexuality was considered taboo in the United States and it was included as a mental disorder in the first edition of the DSM; but today, it is generally accepted. Likewise, public displays of affection do not cause a second look by most people unlike the past when these outward expressions of love were restricted to the privacy of one’s own house or bedroom. In the United States, crying is generally seen as a weakness for males but if the behavior occurs in the context of a tragedy then it is appropriate and understandable. Finally, consider that statistically deviant behavior is not necessarily negative. Cognitive genius is an example of behavior that is not the norm. Abnormality alone is not an indication of a disorder or problem. Though not part of the DSM -5 conceptualization of what Making a Diagnosis (The 3 D’s) | 321 abnormal behavior is, many clinicians add a fourth D – dangerousness to this list. Dangerousness refers to when behavior represents a threat to the safety of the person or the safety of others. Individuals expressing suicidal intent, those experiencing acute paranoid ideation combined with aggressive impulses (e.g., wanting to harm people who are perceived as being out to get them), and many individuals with antisocial personality disorder may be considered dangerous. Mental health professionals (and many other professionals including researchers) have a duty to report to law enforcement when an individual expresses an intent to harm themselves or others. Individuals with depression, anxiety, and obsessive-compulsive disorder are typically no more a threat to others than individuals without these disorders. It is very important to remember that having a mental disorder does not automatically mean that a person is dangerous and most dangerous individuals are not mentally ill. 322 | Making a Diagnosis (The 3 D’s) History of Mental Illness References to mental illness can be found throughout history. The evolution of mental illness, however, has not been linear or progressive but rather cyclical. Whether a behavior is considered normal or abnormal depends on the context surrounding the behavior and thus changes as a function of a particular time and culture. In the past, uncommon behavior or behavior that deviated from the sociocultural norms and expectations of a specific culture and period has been used as a way to silence or control certain individuals or groups. History of Mental Illness | 323 Engravings from 1525 showing trephination. It was believed that drilling holes in the skull could cure mental disorders. [Image: Peter Treveris. Image provided by Noba Project] As a result, a less cultural relativist view of abnormal behavior has focused on whether behavior poses a threat to oneself or others or causes so much distress that it interferes with one’s responsibilities or relationships with family and friends. Historical Explanations Throughout history there have been three general theories of 324 | History of Mental Illness the etiology (causes) of mental illness: supernatural, somatogenic, and psychogenic. Supernatural theories attribute mental illness to possession by evil or demonic spirits, displeasure of gods, eclipses, planetary gravitation, curses, and sin. Somatogenic theories identify disturbances in physical functioning resulting from either illness, genetic inheritance, or brain damage or imbalance. Psychogenic theories focus on traumatic or stressful experiences, maladaptive learned associations and cognitions, or distorted perceptions. Etiological theories of mental illness determine the care and treatment mentally ill individuals receive. Modern treatments of mental illness are mostly associated with the establishment of hospitals and asylums, beginning in the sixteenth century, to house and confine the poor, homeless, unemployed, criminals and those with mental illness. While inhumane by today’s standards, the view of insanity at the time likened individuals with mental illness to animals (i.e., animalism) who did not have the capacity to reason, could not control themselves, were capable of violence without provocation, did not have the same physical sensitivity to pain or temperature, and could live in miserable conditions without complaint. Etiological theories coexist today in what the psychological discipline holds as the biopsychosocial model of explaining human behavior. While individuals may be born with a genetic predisposition for a certain disorder, certain psychological stressors need to be present for the development of the disorder. Sociocultural factors such as sociopolitical or economic unrest, poor living conditions, trauma or problematic interpersonal relationships are also viewed as contributing factors. As much as we want to believe that in present day we are above the historical treatments now considered inhumane, History of Mental Illness | 325 or that the present is always the most enlightened time, we should not forget that our thinking today continues to reflect the same underlying somatogenic and psychogenic theories of mental illness discussed throughout this superficial and brief history of mental illness. 326 | History of Mental Illness Culture-Bound Disorders In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric (brain) and somatic (body) symptoms that are considered to be a recognizable disease only within a specific society or culture. There are no objective biochemical or structural alterations of body organs or functions and the disease is not recognized in other cultures. The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) which also includes a list of the most common culture-bound conditions. Within the ICD-10 (Chapter V) framework culture-specific disorders are characterized by: Categorization as a disease in the culture. Widespread familiarity in the culture. Complete lack of familiarity or misunderstanding of the condition to people in other cultures. No objectively demonstrable biochemical or tissue abnormalities. The condition is usually recognized and treated by the folk medicine of the culture. Some culture-specific syndromes involve somatic symptoms (pain or disturbed function of a body part), while others are purely behavioral. Some culture-bound syndromes appear with similar features in several cultures, but with locally specific traits. The term culture-bound syndrome is controversial since it reflects the different opinions of anthropologists and Culture-Bound Disorders | 327 psychiatrists. Some examples of culture-bound syndromes currently identified in the global community include Dhat syndrome, Zar, and Susto. Dhat syndrome is a condition found in the cultures of the Indian subcontinent in which male patients report that they suffer from premature ejaculation or impotence, and believe that they are passing semen in their urine. Zar is the term for a demon or spirit assumed to possess individuals, mostly women, and to cause discomfort or illness. This condition is found in the cultures of the Horn of Africa and adjacent regions of the Middle East. Susto is a cultural illness primarily among Latin American cultures. It is described as a condition of being frightened and “chronic somatic suffering stemming from emotional trauma or from witnessing traumatic experiences lived by others.” Traditional medicine in a market in Antananarivo, Madagascar. [Image by Marco Schmidt, CC-BY-SA https://en.wikipedia.org/wiki/ Traditional_medicine#/media/ File:Market_Pharmacy_Tana_MS5179.jpg] 328 | Culture-Bound Disorders Changes to society in the last decade, including technological advancements and increased globalization, has broadened cross-cultural influences and reduced cultural isolation. Recent changes to DSM-5 (reduced from 25 to 9 disorders) and the ICD-11 suggest a trend toward better understanding cultural influences rather than culturally specific disorders. Some researchers (Ventriglio, Ayonrinde, and Bhugra, 2016) argue that this interconnection calls into question our perception of truly culturally specific conditions. Idioms and culture-specific descriptions of disorders often overlap with symptoms seen in another culture (just called something else). Rather than disorders being confined to specific cultures, the emphasis has changed to better recognition of the expression of symptoms and sources of distress within each culture in order to improve healthcare and treatment. Culture-Bound Disorders | 329 Universal Disorders I am sure you have realized that it can be difficult to get a professional consensus on the definition of a disorder and whether it exists outside of a cultural context. Universal disorder refers to the incidence of a particular set of symptoms as occurring across various cultures and circumstances and includes mental illnesses. Universal disorders focus on the genetic and biological factors contributing to the condition, in addition to cultural and contextual factors. While the debate about culturally specific versus universal conditions continues in regard to clinical diagnosis, most experts agree that viewing illness through the lens of culture is imperative when addressing symptoms, societal stigma, and treatment options. In this chapter, we will explore the symptoms and diagnostic criteria of four mental health categories seen across the globe: Major Depressive Disorder (MDD) Anxiety Disorders Eating Disorders Psychosis 330 | Universal Disorders Major Depressive Disorder (MDD) Everyone experiences brief periods of sadness, irritability, or euphoria. This is different than having a mood disorder, such as MDD or Bipolar Disorder (BD), which are characterized by a constellation of symptoms that causes people significant distress or impairs their everyday functioning. A major depressive episode (MDE) refers to symptoms that co-occur for at least two weeks and cause significant distress or impairment in functioning, such as interfering with work, school, or relationships. Core symptoms include feeling down or depressed or experiencing anhedonia—loss of interest or pleasure in things that one typically enjoys. According to the DSM-5 (APA, 2013) the criteria for an MDE require five or more of the following nine symptoms, including one or both of the first two symptoms, for most of the day: depressed mood diminished interest or pleasure in almost all activities significant weight loss or gain or an increase or decrease in appetite insomnia or hypersomnia psychomotor agitation or retardation fatigue or loss of energy feeling worthless or excessive or inappropriate guilt diminished ability to concentrate or indecisiveness recurrent thoughts of death, suicidal ideation, or a suicide attempt These symptoms cannot be caused by physiological effects Major Depressive Disorder (MDD) | 331 of a substance or a general medical condition (e.g., hypothyroidism). Perinatal depression following child birth afflicts about 5% of all mothers. An unfortunate social stigma regarding this form of depression compounds the problem for the women who suffer its effects. [Image: CC0 Public Domain, provided by Noba Project] Cross-Cultural Considerations In a nationally representative sample, the lifetime prevalence rate for MDD is 16.6% (Kessler, Berglund, Demler, Jin, 332 | Major Depressive Disorder (MDD) Merikangas, & Walters, 2005). This means that nearly one in five Americans will meet the criteria for MDD during their lifetime. Although the onset of MDD can occur at any time throughout the lifespan, the average age of onset is mid-20s, with the age of onset decreasing with people born more recently (APA, 2000). Prevalence of MDD among older adults is much lower than it is for younger cohorts (Kessler, Birnbaum, Bromet, Hwang, Sampson, & Shahly, 2010). The duration of MDEs varies widely but MDD tends to be a recurrent disorder with about 40%–50% of those who experience one MDE experiencing a second MDE (Monroe & Harkness, 2011). An earlier age of onset predicts a worse course. Women experience two to three times higher rates of MDD than do men (Nolen-Hoeksema & Hilt, 2009). This gender difference emerges during puberty (Conley & Rudolph, 2009). Before puberty, boys exhibit similar or higher prevalence rates of MDD than do girls (Twenge & Nolen-Hoeksema, 2002). Major Depressive Disorder (MDD) is inversely correlated with socioeconomic status (SES), a person’s economic and social position based on income, education, and occupation. Higher prevalence rates of MDD are associated with lower SES (Lorant, Deliege, Eaton, Robert, Philippot, & Ansseau, 2003), particularly for adults over 65 years old (Kessler et al., 2010). Independent of SES, results from a nationally representative sample found that European Americans had a higher prevalence rate of MDD than did African Americans and Hispanic Americans, whose rates were similar (Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006). The course of MDD for African Americans is often more severe and less often treated than it is for European Americans, however (Williams et al., 2007) Native Americans have a higher prevalence rate than do European Americans, African Americans, or Hispanic Americans (Hasin, Goodwin, Stinson & Grant, 2005). Depression is not limited to industrialized or western cultures; it is found in all countries that have been examined, although the symptom presentation Major Depressive Disorder (MDD) | 333 as well as prevalence rates vary across cultures (Chentsova- Dutton & Tsai, 2009). Suicide Suicide is the act of intentionally causing one’s own death. While not everyone who is clinically depressed has suicidal ideation, it is important to recognize that depression, bipolar disorder, schizophrenia, personality disorders, and substance abuse — including alcoholism and the use of benzodiazepines — are risk factors for suicide. Those who have previously attempted suicide are at a higher risk for future attempts. There are a number of treatments that may reduce the risk of suicide for individuals struggling with mental illness. There are many resources available for individuals who may be at risk for suicide. {Image by United States: Department of Defense, Public domain, via Wikimedia Commons; https://commons.wikimedia.org/ wiki/File:Suicide_prevention-DOD.jpg] Resources are also commonly in place at local colleges. 334 | Major Depressive Disorder (MDD) Consider searching your school website and/or talking with a trusted faculty/staff member to learn more about resources available to students. Major Depressive Disorder (MDD) | 335 Anxiety Disorders Anxiety is a natural part of life and, at normal levels, helps us to function at our best. For people with anxiety disorders, anxiety is overwhelming and hard to control. Anxiety disorders develop out of a blend of biological (genetic) and psychological factors that, when combined with stress, may lead to the development of impairment. Primary anxiety-related diagnoses include generalized anxiety disorder, panic disorder, specific phobia, social anxiety disorder (social phobia), post-traumatic stress disorder, and obsessive-compulsive disorder. Anxiety can be defined as a negative mood state that is accompanied by bodily symptoms such as increased heart rate, muscle tension, a sense of unease, and apprehension about the future (APA, 2013; Barlow, 2002). 336 | Anxiety Disorders The experience of anger and other related emotions can be an often-overlooked symptom in both depression and anxiety. [Image: Public Domain, https://svgsilh.com/image/1337383.html] While many individuals experience some levels of worry throughout the day, individuals with anxiety disorders experience symptoms of a greater intensity and for longer periods of times than the average person. Additionally, they are often unable to control their worry, tension, and/or predictive dread through various coping strategies, which directly interferes with their ability to engage in daily social and occupational tasks. Characteristic symptoms of anxiety: Negative mood state characterized by unease, worry, tension, and/or dread. Frequent doubts regarding self-worth and/or ability to Anxiety Disorders | 337  handle problems. Future-based, “predicative” fears for events. Difficulty with cognitive rumination, racing thoughts, and inability to calm the mind. Physiological cues (racing heart, sweat, bodily tension, among others) often accompanying cognitive symptoms, resulting in changing sleep/eating patterns. Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression and that the same environmental triggers can provoke symptoms in either condition. These factors may help to explain this high rate of comorbidity. Cross-Cultural Considerations About 12% of people are affected by an anxiety disorder in a given year, and between 5% and 30% are affected at some point in their life. They occur about twice as often in females as males and generally begin before the age of 25. The most common are specific phobia which affects nearly 12% and social anxiety disorder which affects 10% of individuals at some point in their life. Rates of anxiety appear to be higher in the United States and Europe than other parts of the world. 338 | Anxiety Disorders Eating Disorders While nearly two out of three adults in the United States struggle with issues related to being overweight, a smaller, but significant, portion of the population has eating disorders that result in being normal weight or underweight. Anorexia Nervosa Anorexia nervosa is an eating disorder characterized by the maintenance of a body weight well below average through starvation and/or excessive exercise. Individuals suffering from anorexia nervosa often have a distorted body image. A distorted body image is referred to as body dysmorphia in the research literature and it means that people with anorexia nervosa view themselves as overweight even though they are not. Anorexia nervosa is associated with a number of significant negative health outcomes including bone loss, heart failure, kidney failure, amenorrhea (cessation of the menstrual period), reduced function of the gonads, and in extreme cases, death. Furthermore, there is an increased risk for a number of psychological problems, which include anxiety disorders, mood disorders, and substance abuse (Mayo Clinic, 2012a). Estimates of the prevalence of anorexia nervosa vary from across different studies but generally range from less than 1% to just over 4% in women. Generally, prevalence rates are considerably lower for men (Smink et al., 2012). Eating Disorders | 339  Images of extremely thin models, sometimes accurately depicted and sometimes digitally altered to make them look even thinner, may contribute to eating disorders.[Image by Peter Duhon: https://cnx.org/contents/ [email protected]:7y4p-I4a@8/Hunger-and-Eating] Bulimia Nervosa People with bulimia nervosa engage in binge eating behavior (consuming large amounts of food) that is followed by an attempt to compensate for the large amount of food 340 | Eating Disorders consumed. Purging the food by inducing vomiting or through the use of laxatives are two common compensatory behaviors. Some affected individuals engage in excessive amounts of exercise to compensate for their binges. Bulimia is associated with many adverse health consequences that can include kidney failure, heart failure, and tooth decay. In addition, these individuals often suffer from anxiety and depression, and they are at an increased risk for substance abuse (Mayo Clinic, 2012b). The lifetime prevalence rate for bulimia nervosa is estimated at around 1% for women and less than 0.5% for men (Smink, van Hoeken, & Hoek, 2012). Eating Disorders and Cross-Cultural Considerations While both anorexia and bulimia nervosa occur in men and women of many different cultures, Caucasian females from Western societies tend to be the most at-risk population. Recent research indicates that females between the ages of 15 and 19 are most at risk, and it has long been suspected that these eating disorders are culturally-bound phenomena that are related to messages of a thin ideal often portrayed in popular media and the fashion world (Smink et al., 2012). While social factors play an important role in the development of eating disorders, there is also evidence that genetic factors may predispose people to these disorders (Collier & Treasure, 2004).. Eating Disorders | 341 Psychosis Most of you have probably had the experience of walking down the street in a city and seeing a person you thought was acting oddly. They may have been dressed in an unusual way, perhaps disheveled or wearing an unusual collection of clothes, makeup, or jewelry that did not seem to fit any particular group or subculture. They may have been talking to themselves or yelling at someone you could not see. If you tried to speak to them, they may have been difficult to follow or understand, or they may have acted paranoid or started telling a bizarre story about the people who were plotting against them. If so, chances are that you have encountered an individual with schizophrenia or another type of psychotic disorder. 342 | Psychosis A painting by Craig Finn, who suffers from schizophrenia, depicting hallucinations. The painting is titled “Artistic view of how the world feels like with schizophrenia”. [Image: Craig Finn and provided by Noba Project] Schizophrenia is a devastating psychological disorder that is characterized by major disturbances in thought, perception, emotion, and behavior. About 1% of the population experiences schizophrenia in their lifetime, and usually the disorder is first diagnosed during early adulthood (early to mid-20s). Schizophrenia and the other psychotic disorders are some of the most impairing forms of psychopathology, frequently associated with a profound negative effect on the individual’s educational, occupational, and social function. Sadly, these Psychosis | 343 disorders often manifest right at time of the transition from adolescence to adulthood, just as young people should be evolving into independent young adults. The spectrum of psychotic disorders includes schizophrenia, schizoaffective disorder, delusional disorder, schizotypal personality disorder, schizophreniform disorder, brief psychotic disorder, as well as psychosis associated with substance use or medical conditions. Even when they receive the best treatments available, many with schizophrenia will continue to experience serious social and occupational impairment throughout their lives. In the United States, the cost of schizophrenia, including direct costs (e.g., outpatient, inpatient, drugs, and long-term care) and non-health care costs (e.g., law enforcement, reduced workplace productivity, and unemployment) was estimated to be $62.7 billion in 2002. The main symptoms of schizophrenia include hallucinations, delusions, disorganized thinking, disorganized or abnormal motor behavior, and negative symptoms (APA, 2013). A hallucination is a perceptual experience that occurs in the absence of external stimulation. Auditory hallucinations (hearing voices) occur in roughly two-thirds of patients with schizophrenia and are by far the most common form of hallucination (Andreasen, 1987). The voices may be familiar or unfamiliar, they may have a conversation or argue, or the voices may provide a running commentary on the person’s behavior (Tsuang, Farone, & Green, 1999). Delusions are false beliefs that are often fixed, hard to change even when the person is presented with conflicting information, and are often culturally influenced in their content (e.g., delusions involving Jesus in Judeo-Christian cultures, delusions involving Allah in Muslim cultures). They can be terrifying for the person, who may remain convinced that they are true even when loved ones and friends present them with clear information that they cannot be true. There are many different types or themes to delusions. 344 | Psychosis Positive Symptoms Talking to someone with schizophrenia is sometimes difficult, as their speech may be difficult to follow, either because their answers do not clearly flow from your questions, or because one sentence does not logically follow from another. This is referred to as disorganized speech, and it can be present even when the person is writing. Disorganized behavior can include odd dress, odd makeup (e.g., lipstick outlining a mouth for 1 inch), or unusual rituals (e.g., repetitive hand gestures). Negative Symptoms Some of the most debilitating symptoms of schizophrenia are difficult for others to see. These include what people refer to as negative symptoms or the absence of certain things we typically expect most people to have. For example, anhedonia or amotivation reflect a lack of apparent interest in or drive to engage in social or recreational activities. These symptoms can manifest as a great amount of time spent in physical immobility. Importantly, anhedonia and amotivation do not seem to reflect a lack of enjoyment in pleasurable activities or events (Cohen & Minor, 2010; Kring & Moran, 2008; Llerena, Strauss, & Cohen, 2012) but rather a reduced drive or ability to take the steps necessary to obtain the potentially positive outcomes (Barch & Dowd, 2010). Flat affect and reduced speech (alogia) reflect a lack of showing emotions through facial expressions, gestures, and speech intonation, as well as a reduced amount of speech and increased pause frequency and duration. Psychosis | 345 Cross-Cultural Considerations It is clear that there are important genetic contributions to the likelihood that someone will develop schizophrenia, with consistent evidence from family, twin, and adoption studies. (Sullivan, Kendler, & Neale, 2003) but there is no such thing as the schizophrenia gene. It is more likely that the genetic risk for schizophrenia reflects the summation of many different genes that each contribute something to the likelihood of developing psychosis (Gottesman & Shields, 1967; Owen, Craddock, & O’Donovan, 2010). Further, schizophrenia is a very heterogeneous disorder, which means that two different people with schizophrenia may each have very different symptoms (e.g., one has hallucinations and delusions, the other has disorganized speech and negative symptoms). About 0.3% to 0.7% of people are affected by schizophrenia during their lifetimes. In 2013 there were an estimated 23.6 million cases globally. Males are more often affected, and on average experience more severe symptoms. About 20% of people eventually do well and a few recover completely, while about 50% have lifelong impairment. Social problems, such as long-term unemployment, poverty and homelessness, are common. The average life expectancy of people with the disorder is ten to twenty-five years less than for the general population. This is the result of increased physical health problems and a higher suicide rate (about 5%). In 2015 an estimated 17,000 people worldwide died from behavior related to, or caused by, schizophrenia. There is also a higher than average suicide rate associated with schizophrenia. The term for schizophrenia in Japan was changed from “mind-split disease” to “integration disorder,” to reduce stigma. The new name was inspired by the biopsychosocial model and as a result the percentage of people who were informed of the diagnosis increased from 37 to 70% over three years. A similar change was made in South Korea in 2012. A professor 346 | Psychosis of psychiatry, Jim van Os, has proposed changing the English term to “psychosis spectrum syndrome”. John Nash, an American mathematician and joint recipient of the 1994 Nobel Prize for Economics, who had schizophrenia. His life was the subject of the 2001 film, “A Beautiful Mind.” [Image provided by OpenStax College] Psychosis | 347 Individuals with severe mental illness, including schizophrenia, are at a significantly greater risk of being victims of both violent and non-violent crime. Schizophrenia has been associated with a higher rate of violent acts, but most appear to be related to substance abuse. Media coverage relating to violent acts by individuals with schizophrenia reinforces public perception of an association between schizophrenia and violence. 348 | Psychosis Barriers to Treatment Mental disorders are common, affecting tens of millions of people each year. Worldwide, more than one in three people in most countries report sufficient criteria for at least one at some point in their life. In the United States, 46% qualify for a mental illness within their lifetime, with less than 1 out of 5 receiving a diagnosis. An ongoing survey indicates that anxiety disorders are the most common in all but one country, followed by mood disorders in all but two countries, while substance disorders and impulse-control disorders were consistently less prevalent. Estimates suggest that less than half of people with mental illnesses in industrialized societies will receive treatment. The World Health Mental Illness and Organization (WHO, 2004) stated that the Cost to Society “Prevention of these disorders is obviously This leads us to consider the one of the most cost of mental illness to effective ways to society. The National Alliance reduce the [disease] on Mental Illness (NAMI) burden.” indicates that depression is the number one cause of disability across the world “and is a major contributor to the global burden of disease.” Serious mental illness costs the United States an estimated $193 billion in lost earnings each year. They also point out that suicide is the tenth leading cause of death in the United States and 90% of those who die from suicide have an underlying mental illness. Approximately, 37% of students with a mental disorder age 14 and older drop out of school which is the highest dropout rate of any disability group, and 70% of youth in state and local juvenile justice systems have at least one mental disorder. In Barriers to Treatment | 349 terms of worldwide impact, the costs for mental illness are greater than the combined costs of cancer, diabetes, and respiratory disorders (Whiteford et al., 2013). 350 | Barriers to Treatment Reducing Stigma around Mental Illness Negative societal responses to people with mental illnesses may be the single greatest barrier to the development of mental health programs worldwide Stigma happens when a personal with mental illness is viewed in a negative way because of their symptoms or behaviors associated with the condition. Unfortunately, negative attitudes and beliefs toward people who have a mental health condition are common. Reducing Stigma around Mental Illness | 351 Stigma is universal and can contribute to worsening symptoms and reduced likelihood of getting treatment. [CC0, https://www.dlf.pt/ ddownload/ hwiRxbh_mental-illness-stigma-mental-illness-stigma-hd-png/] Stigma can lead to discrimination, which can be experienced on a personal level (e.g., social isolation, exclusion or bullying) or it may be experienced at a structural or system level (e.g., employment, education, and housing). The stigma associated with mental illness makes most people reluctant to talk about their experiences of having strange thoughts or deep sadness. As a result of stigma, individuals are less likely to seek help or treatment for their mental illness. Discrimination may be obvious and direct, such as someone making a negative remark about a person with mental illness or someone getting 352 | Reducing Stigma around Mental Illness treatment. Or it may be unintentional or subtle, such as someone avoiding a person with mental illness because they think people with mental illness unstable, violent or dangerous. Several national and international organizations (National Alliance on Mental Health, World Health Organization, and European Commission) have provided several recommendations for reducing stigma surrounding mental illness: Know the facts about mental illness Educate others by challenging and correcting myths about mental illness Recognize personal biases Be conscious of language and power of words to perpetuate negative attitudes Support people with mental illness by offering encouragement Reducing Stigma around Mental Illness | 353 Chapter Review Psychological disorders are conditions characterized by abnormal thoughts, feelings, and behaviors. Although challenging, it is essential for psychologists and mental health professionals to agree on what kinds of inner experiences and behaviors constitute the presence of a psychological disorder. Inner experiences and behaviors that are atypical or violate social norms could signify the presence of a disorder; however, each of these criteria alone is inadequate. Harmful dysfunction describes the view that psychological disorders result from the inability of an internal mechanism to perform its natural function. Many of the features of harmful dysfunction conceptualization have been incorporated in the American Psychological Association (APA) formal definition of psychological disorders. According to this definition, the presence of a psychological disorder is signaled by significant disturbances in thoughts, feelings, and behaviors; these disturbances must reflect some kind of dysfunction (biological, psychological, or developmental), must cause significant impairment in one’s life, and must not reflect culturally expected reactions to certain life events. Vocabulary Biopsychosocial Model is a perspective that attributes disturbance(s) to the complex interaction of bodily, psychological, and sociocultural factors Cultural relativism is the idea that cultural norms and values of a society can only be understood on their own terms or in their own context. Maladaptive is a term referring to behaviors that cause 354 | Chapter Review people who have them physical or emotional harm, prevent them from functioning in daily life, and/or indicate that they have lost touch with reality and/or cannot control their thoughts and behavior (also called dysfunctional). Mental Illness is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Psychogenic refers to a disorder effect that originates from the brain instead of other physical organs (i.e. the cause is psychological rather than physiological). Somatogenic refers to a disorder developing from physical/ bodily origins Stigma happens when a personal with mental illness is viewed in a negative way because of their symptoms or behaviors associated with the condition Universal disorder refers to the incidence of a particular set of symptoms that occur across various cultures and circumstances. Chapter Review | 355