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Mental Health and Illness

Overview of Approaches, Overview of Approaches, Definitions, PerspectivesDefinitions, Perspectives

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Continuous or discrete?

Continuous model:Continuous model:Mental Health Mental IllnessMental Health Mental Illness++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Healthy>>>>Adjustment reaction>>>>Neurosis>>>>PsychosisHealthy>>>>Adjustment reaction>>>>Neurosis>>>>Psychosis

We all have differing degrees of mental health at different We all have differing degrees of mental health at different times in our lives. Most people aren’t at the extremes times in our lives. Most people aren’t at the extremes but fall somewhere in the middle.but fall somewhere in the middle.

Anyone can become mentally ill, given the right Anyone can become mentally ill, given the right circumstances.circumstances.

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Discrete model Some people are mentally healthy; others Some people are mentally healthy; others

have specific mental disorders. have specific mental disorders. ““Decision trees” can distinguish who has a Decision trees” can distinguish who has a

specific mental disease and who doesn’t. specific mental disease and who doesn’t.

Mentally Healthy

Mentally Ill

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What is mental health?

In our society, a mentally healthy person:In our society, a mentally healthy person: Has self-esteem, self-acceptanceHas self-esteem, self-acceptance Is realizing potentialIs realizing potential Is able to maintain fulfilling relationshipsIs able to maintain fulfilling relationships Has a sense of psychological well-beingHas a sense of psychological well-being Has sense of autonomyHas sense of autonomy Has sense of competence, mastery, purposeHas sense of competence, mastery, purpose

However, other cultures may have different ideas about However, other cultures may have different ideas about what mental health is.what mental health is.

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Who has mental health?

We all fall short to some extent.We all fall short to some extent. Therefore, advocates of mental health Therefore, advocates of mental health

believe that a broad range of mental health believe that a broad range of mental health services should be available to general services should be available to general population, not just seriously mentally ill.population, not just seriously mentally ill.

They believe that prevention and education, They believe that prevention and education, as well as treatment, are important.as well as treatment, are important.

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What is mental illness?

Is it a disease, like diabetes or smallpox?Is it a disease, like diabetes or smallpox? Is it a form of deviant behavior—like being Is it a form of deviant behavior—like being

rebellious, choosing to dress differently, rebellious, choosing to dress differently, being extremely religious, being extremely being extremely religious, being extremely creative?creative?

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The Medical Model and Concepts of Disease ““When distress or inappropriate behavior is thought When distress or inappropriate behavior is thought

to be a consequence of a bodily dysfunction, it is to be a consequence of a bodily dysfunction, it is called a ‘disease.’” called a ‘disease.’” Mechanic, p. 14.Mechanic, p. 14.

To diagnose diseases in physical medicine, doctors To diagnose diseases in physical medicine, doctors perform laboratory tests, do body imaging, take perform laboratory tests, do body imaging, take medical history, do physical examinations.medical history, do physical examinations.

Once disease is diagnosed, doctor generally knows:Once disease is diagnosed, doctor generally knows: Its causeIts cause How disease is likely to run its courseHow disease is likely to run its course What most appropriate treatment isWhat most appropriate treatment is

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Are mental illnesses like other diseases? Mental illnesses cannot be confirmed by objective Mental illnesses cannot be confirmed by objective

laboratory tests or body imaging.laboratory tests or body imaging. Diagnosis in mental illness does not lead to an Diagnosis in mental illness does not lead to an

understanding of cause, of the course of the understanding of cause, of the course of the illness, or of the most appropriate treatment.illness, or of the most appropriate treatment.

Some (e.g., Thomas Szasz) have argued that Some (e.g., Thomas Szasz) have argued that mental illnesses are not diseases because of the mental illnesses are not diseases because of the above problems.above problems.

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Perspective of DSM Mental disorders represent a “clinically significant Mental disorders represent a “clinically significant

behavioral or psychological syndrome or pattern behavioral or psychological syndrome or pattern that occurs in an individual and that is associated that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or with present distress (e.g., a painful symptom) or disability.”disability.”

DSM tries to make psychiatric diagnoses more DSM tries to make psychiatric diagnoses more similar to medical diagnoses. Sees psychiatric similar to medical diagnoses. Sees psychiatric symptoms as indicators of disease, not deviance.symptoms as indicators of disease, not deviance.

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DSM

Strength: useful tool for practitioners, insurers, Strength: useful tool for practitioners, insurers, courts, agencies, since it allows for courts, agencies, since it allows for communication, offers consistent set of communication, offers consistent set of definitions.definitions.

Limitation: However, it is purely descriptive, Limitation: However, it is purely descriptive, doesn’t indicate causes, offers limited information doesn’t indicate causes, offers limited information about expected course of the disease, doesn’t about expected course of the disease, doesn’t suggest appropriate treatment.suggest appropriate treatment.

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Major DSM-IV categories Disorders usually first Disorders usually first

diagnosed in infancy, diagnosed in infancy, childhood, or adolescencechildhood, or adolescence

Delirium, dementia, amnestic, Delirium, dementia, amnestic, and other cognitive disordersand other cognitive disorders

Mental disorders due to a Mental disorders due to a general medical condition not general medical condition not elsewhere classifiedelsewhere classified

Substance-related disordersSubstance-related disorders Schizophrenia and other Schizophrenia and other

psychotic disorderspsychotic disorders Mood disordersMood disorders

Anxiety disordersAnxiety disorders Somatoform disordersSomatoform disorders Factitious disordersFactitious disorders Dissociative disordersDissociative disorders Sexual and gender identity Sexual and gender identity

disordersdisorders Eating disordersEating disorders Sleep disordersSleep disorders Impulse-control disorders not Impulse-control disorders not

elsewhere classifiedelsewhere classified Adjustment disordersAdjustment disorders Personality disordersPersonality disorders Other conditions that may be the Other conditions that may be the

focus of clinical attentionfocus of clinical attention

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Sociological perspective

Mental disorders are type of deviant Mental disorders are type of deviant behavior, not a disease process.behavior, not a disease process.

Those who are seen as mentally ill are those Those who are seen as mentally ill are those who violate social rules, don’t behave who violate social rules, don’t behave appropriately.appropriately.

Individuals who become labeled as Individuals who become labeled as mentally ill are those not powerful enough mentally ill are those not powerful enough to resist such labels.to resist such labels.

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Mental illness as deviant behaviorResearchers who view mental illness as deviant Researchers who view mental illness as deviant

behavior usually study processes and rules used to behavior usually study processes and rules used to define mental illness rather than symptoms in define mental illness rather than symptoms in individuals.individuals.

Szasz (1963, 1984): Szasz (1963, 1984): Mental illness is not a disease, since there are Mental illness is not a disease, since there are

no physical lesions that indicate it. no physical lesions that indicate it. Calling people mentally ill denies concepts of Calling people mentally ill denies concepts of

free will and responsibility for one’s actions.free will and responsibility for one’s actions.

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Bad or mad?

Why do we call some deviant behaviors “bad” and Why do we call some deviant behaviors “bad” and some “mad”?some “mad”?

If there is self-interest involved, we are more If there is self-interest involved, we are more likely to call the behavior “bad.”likely to call the behavior “bad.”

Same behavior, different context, can be assigned Same behavior, different context, can be assigned different labels—e.g., poor person who shoplifts is different labels—e.g., poor person who shoplifts is more likely to be considered “bad,” whereas a more likely to be considered “bad,” whereas a very wealthy person who shoplifts is likely to be very wealthy person who shoplifts is likely to be seen as “sick.”seen as “sick.”

Why?Why?

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Assumptions behind “bad” or “mad”Ambivalent ideas:Ambivalent ideas: Social and behavioral sciences are deterministic, Social and behavioral sciences are deterministic,

assuming that behavior is determined—by prior assuming that behavior is determined—by prior events, social forces, biologyevents, social forces, biology

At the same time, we assume that individuals can At the same time, we assume that individuals can distinguish between right and wrong and have distinguish between right and wrong and have “free will” and thus can be held responsible for “free will” and thus can be held responsible for their actions. their actions.

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Definitions and labeling can be problematic Not so much in voluntary treatment—if an Not so much in voluntary treatment—if an

individual seeks help from a mental health individual seeks help from a mental health professional, then common goals can be professional, then common goals can be identified and pursued.identified and pursued.

If an individual is forced into treatment, If an individual is forced into treatment, then many ethical dilemmas can arise. then many ethical dilemmas can arise.

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How can mental illness be measured? Some researchers (sociologists, public Some researchers (sociologists, public

health specialists, social workers) prefer to health specialists, social workers) prefer to study how mental illness develops in study how mental illness develops in communities, rather than its manifestations communities, rather than its manifestations in those who are being treated for mental in those who are being treated for mental illness.illness.

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Terms useful in assessment of mental illness in communities: EpidemiologyEpidemiology: study of how illness is distributed : study of how illness is distributed

in a population, rates of disease, who appears to be in a population, rates of disease, who appears to be susceptible, in an attempt to identify causes and susceptible, in an attempt to identify causes and discover interventions (example of work of John discover interventions (example of work of John Snow on cholera in London in 1854)Snow on cholera in London in 1854)

MorbidityMorbidity: prevalence of diseases in a population: prevalence of diseases in a population ComorbidityComorbidity: occurrence of more than one : occurrence of more than one

disease in the same individualdisease in the same individual

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Terms (continued):

PrevalencePrevalence: How often the disease occurs: How often the disease occurs Point prevalencePoint prevalence: percentage of : percentage of

population affected with an illness at any population affected with an illness at any given point in timegiven point in time

Lifetime prevalenceLifetime prevalence: percentage of : percentage of population ever affected with an illnesspopulation ever affected with an illness

Incidence:Incidence: rate at which new cases rate at which new cases appear within a given time periodappear within a given time period

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Epidemiological studies of mental illness 11st st in USA: Epidemiologic Catchment Area in USA: Epidemiologic Catchment Area

(ECA), 1981(ECA), 1981 22ndnd in USA: National Comorbidity Study in USA: National Comorbidity Study

(NCS) 1990’s(NCS) 1990’s Also a number of studies of prevalence and Also a number of studies of prevalence and

types of mental illness in other culturestypes of mental illness in other cultures

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Cross-cultural studies

What is normal in one culture is not What is normal in one culture is not necessarily normal in anothernecessarily normal in another

Therefore, measurement in cross-cultural Therefore, measurement in cross-cultural studies is a real problemstudies is a real problem

This holds true in cross-national studies and This holds true in cross-national studies and in studies of diverse ethnic groups within in studies of diverse ethnic groups within nationsnations

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What causes mental illness?

No one really knows. Research so far is No one really knows. Research so far is inconclusive.inconclusive.

Research is being carried out from diverse Research is being carried out from diverse perspectives:perspectives: PsychologicalPsychological BiologicalBiological SociologicalSociological

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Biological, developmental, or social? Since human beings are both biological and Since human beings are both biological and

social animals, it doesn’t make sense to social animals, it doesn’t make sense to argue about what causes mental illness.argue about what causes mental illness.

Causes are complex, involving some Causes are complex, involving some combination of biological vulnerability, combination of biological vulnerability, environmental conditions, social stressors, environmental conditions, social stressors, social network and supports, psychological social network and supports, psychological orientations, and learned behavior.orientations, and learned behavior.

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Possible psychological/ developmental causation: Psychological research into causes of mental illness Psychological research into causes of mental illness

examines individual personality (early development, examines individual personality (early development, cognitive styles, personal identity)cognitive styles, personal identity)

PerspectivesPerspectives Psychoanalytical—early developmental influences, such Psychoanalytical—early developmental influences, such

as child abuse/neglect, quality of parentingas child abuse/neglect, quality of parenting Cognitive-behavioral/behavioral—how ways of thinking Cognitive-behavioral/behavioral—how ways of thinking

affect behavior, social learningaffect behavior, social learning Phenomenological/existential—focus on choice, Phenomenological/existential—focus on choice,

responsibility, meaningresponsibility, meaning Family dynamics—focus on family roles, communication Family dynamics—focus on family roles, communication

patternspatterns

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Possible biological causation:

Factors examined by researchers:Factors examined by researchers: GeneticsGenetics NeurochemistyNeurochemisty Viral causationViral causation

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Possible environmental/social causation:Factors examined by researchers:Factors examined by researchers: Chronic strains in the environmentChronic strains in the environment

PovertyPoverty Poor living conditionsPoor living conditions Dangerous neighborhoodsDangerous neighborhoods Overwhelming role responsibilitiesOverwhelming role responsibilities

Negative life events—stress and copingNegative life events—stress and coping Natural disastersNatural disasters UnemploymentUnemployment Adjusting to new environments and rolesAdjusting to new environments and roles

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Environmental/social causation (continued):Another factor examined by researchers:Another factor examined by researchers: LabelingLabeling

Social control—how mental health diagnosis Social control—how mental health diagnosis and treatment acts as an agent of social control and treatment acts as an agent of social control

Relationship between social attitudes toward Relationship between social attitudes toward mental illness and the course of mental mental illness and the course of mental disorders—effects of stigma, discrimination, disorders—effects of stigma, discrimination, and social exclusionand social exclusion

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Environmental/social causation (continued):Collective mobilizationCollective mobilization Notion that society produces disabilities by how it:Notion that society produces disabilities by how it:

Defines persons with impairmentsDefines persons with impairments Limits access to community facilities and Limits access to community facilities and

employmentemployment Discriminates against themDiscriminates against them

Impairments can become either a major aspect or Impairments can become either a major aspect or minor aspect of a person’s identity, depending on minor aspect of a person’s identity, depending on how society and government respond to persons how society and government respond to persons with impairmentswith impairments

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Disease or problem in living?

Some problematic behaviors are given the status Some problematic behaviors are given the status of disease in DSM:of disease in DSM: Alcohol abuse and dependenceAlcohol abuse and dependence Drug abuseDrug abuse Conduct disorders in childrenConduct disorders in children

They may not really fit into the disease modelThey may not really fit into the disease model It may be more valid to consider them as problems It may be more valid to consider them as problems

in livingin living

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Public definitions of mental illness Most people who seek treatment for mental Most people who seek treatment for mental

disorders do so because they feel distressed. disorders do so because they feel distressed.

Some people, however, feel they do not Some people, however, feel they do not need help but are identified by others (e.g., need help but are identified by others (e.g., family, friends, police, schools, employers). family, friends, police, schools, employers). Evaluators have to make difficult Evaluators have to make difficult judgments in such cases. judgments in such cases.

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Role of values

Values of evaluator can influence Values of evaluator can influence judgments about individuals being judgments about individuals being evaluated. Evaluators’ notions of what is evaluated. Evaluators’ notions of what is appropriate behavior are shaped by their appropriate behavior are shaped by their culture and social context.culture and social context.

If an evaluator accepts the worldview of If an evaluator accepts the worldview of his/her society, then people with different his/her society, then people with different worldviews can be seen as deviant—mad or worldviews can be seen as deviant—mad or bad.bad.

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Value of the disease model

Disease model attempts to be objective and Disease model attempts to be objective and universal, avoiding value judgments about universal, avoiding value judgments about behaviors.behaviors.

Psychiatrists attempt to separate out Psychiatrists attempt to separate out symptoms from cultural content (e.g., symptoms from cultural content (e.g., schizophrenia).schizophrenia).

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DSM Decision Tree: Mood Disorders