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Main article: Classification of mental disorders The definition and classification of mental disorders is a key issue for researchers as well as service providers and those who may be diagnosed. For a mental state to classify as a disorder, it generally needs to cause dysfunction.[1] Most international clinical documents use the term mental "disorder", while "illness" is also common. It has been noted that using the term "mental" (i.e., of the mind) is not necessarily meant to imply separateness from brain or body. There are currently two widely established systems that classify mental disorders; 'ICD-10 Chapter V: Mental and behavioural disorders, since 1949 part of the International Classification of Diseases produced by the WHO, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA) since 1952. Both these list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be used in non-western cultures, for example the Chinese Classification of Mental Disorders, and other manuals may be used by those of alternative theoretical persuasions, for example the Psychodynamic Diagnostic Manual. In general, mental disorders are classified separately from neurological disorders, learning disabilities or intellectual disability. Unlike the DSM and ICD, some approaches are not based on identifying distinct categories of disorder using dichotomous symptom profiles intended to separate the abnormal from the normal. There is significant scientific debate about the relative merits of categorical versus such non-categorical (or hybrid) schemes, also known as continuum or dimensional models. A spectrum approach may incorporate elements of both. In the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms).[2] Common hybrid views argue that the concept of mental disorder is objective even if only a "fuzzy prototype" that can never be precisely defined, or conversely that the concept always involves a mixture of scientific facts and subjective value judgments.[3] Although the diagnostic categories are referred to as 'disorders', they are presented as medical diseases, but are not validated in the same way as most medical diagnoses. Some neurologists argue that classification will only be reliable and valid when based on neurobiological features rather than clinical interview, while others suggest that the differing ideological and practical perspectives need to be better integrated.[4][5] The DSM and ICD approach remains under attack both because of the implied causality model[6] and because some researchers believe it better to aim at underlying brain differences which can precede symptoms by many years.[7][full citation needed] Disorders See also: List of mental disorders as defined by the DSM and ICD There are many different categories of mental disorder, and many different facets of human behavior and personality that can become disordered.[8][9][10][11][12] Anxiety or fear that interferes with normal functioning may be classified as an anxiety disorder.[13] Commonly recognized categories include specific phobias, generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, obsessive-compulsive disorder and post-traumatic stress disorder. Other affective (emotion/mood) processes can also become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia, or despair is known as major depression (also known as unipolar or clinical depression). Milder but still prolonged depression can be diagnosed as dysthymia. Bipolar disorder (also known as manic depression) involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating with normal or depressed mood. The extent to which unipolar and bipolar mood phenomena represent distinct categories of disorder, or mix and merge along a dimension or spectrum of mood, is subject to some scientific debate.[14] Patterns of belief, language use and perception of reality can become disordered (e.g., delusions, thought disorder, hallucinations). Psychotic disorders in this domain include schizophrenia, and delusional disorder. Schizoaffective disorder is a category used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy is a category used for individuals showing some of the characteristics associated with schizophrenia but without meeting cutoff criteria. Personality—the fundamental characteristics of a person that influence thoughts and behaviors across situations and time—may be considered disordered if judged to be abnormally rigid and maladaptive. Although treated separately by some, the commonly used categorical schemes include them as mental disorders, albeit on a separate "axis II" in the case of the DSM-IV. A number of different personality disorders are listed, including those sometimes classed as "eccentric", such as paranoid, schizoid and schizotypal personality disorders; types that have described as "dramatic" or "emotional", such as antisocial, borderline, histrionic or narcissistic personality disorders; and those sometimes classed as fear-related, such as anxious-avoidant, dependent, or obsessive-compulsive personality disorders. The personality disorders in general are defined as emerging in childhood, or at least by adolescence or early adulthood. The ICD also has a category for enduring personality change after a catastrophic experience or psychiatric illness. If an inability to sufficiently adjust to life circumstances begins within three months of a particular event or situation, and ends within six months after the stressor stops or is eliminated, it may instead be classed as an adjustment disorder. There is an emerging consensus that so-called "personality disorders", like personality traits in general, actually incorporate a mixture of acute dysfunctional behaviors that may resolve in short periods, and maladaptive temperamental traits that are more enduring.[15] Furthermore, there are also non-categorical schemes that rate all individuals via a profile of different dimensions of personality without a symptom-based cutoff from normal personality variation, for example through schemes based on dimensional models.[16] Eating disorders involve disproportionate concern in matters of food and weight.[13] Categories of disorder in this area include anorexia nervosa, bulimia nervosa, exercise bulimia or binge eating disorder. Sleep disorders such as insomnia involve disruption to normal sleep patterns, or a feeling of tiredness despite sleep appearing normal. Sexual and gender identity disorders may be diagnosed, including dyspareunia, gender identity disorder and ego-dystonic homosexuality. Various kinds of paraphilia are considered mental disorders (sexual arousal to objects, situations, or individuals that are considered abnormal or harmful to the person or others). People who are abnormally unable to resist certain urges or impulses that could be harmful to themselves or others, may be classed as having an impulse control disorder, and disorders such as kleptomania (stealing) or pyromania (fire-setting). Various behavioral addictions, such as gambling addiction, may be classed as a disorder. Obsessive-compulsive disorder can sometimes involve an inability to resist certain acts but is classed separately as being primarily an anxiety disorder. The use of drugs (legal or illegal, including alcohol), when it persists despite significant problems related to its use, may be defined as a mental disorder. The DSM incorporates such conditions under the umbrella category of substance use disorders, which includes substance dependence and substance abuse. The DSM does not currently use the common term drug addiction, and the ICD simply refers to "harmful use". Disordered substance use may be due to a pattern of compulsive and repetitive use of the drug that results in tolerance to its effects and withdrawal symptoms when use is reduced or stopped. People who suffer severe disturbances of their self-identity, memory and general awareness of themselves and their surroundings may be classed as having a dissociative identity disorder, such as depersonalization disorder or Dissociative Identity Disorder itself (which has also been called multiple personality disorder, or "split personality"). Other memory or cognitive disorders include amnesia or various kinds of old age dementia. A range of developmental disorders that initially occur in childhood may be diagnosed, for example autism spectrum disorders, oppositional defiant disorder and conduct disorder, and attention deficit hyperactivity disorder (ADHD), which may continue into adulthood. Conduct disorder, if continuing into adulthood, may be diagnosed as antisocial personality disorder (dissocial personality disorder in the ICD). Popularist labels such as psychopath (or sociopath) do not appear in the DSM or ICD but are linked by some to these diagnoses. Somatoform disorders may be diagnosed when there are problems that appear to originate in the body that are thought to be manifestations of a mental disorder. This includes somatization disorder and conversion disorder. There are also disorders of how a person perceives their body, such as body dysmorphic disorder. Neurasthenia is an old diagnosis involving somatic complaints as well as fatigue and low spirits/depression, which is officially recognized by the ICD-10 but no longer by the DSM-IV.[17] Factitious disorders, such as Munchausen syndrome, are diagnosed where symptoms are thought to be experienced (deliberately produced) and/or reported (feigned) for personal gain. There are attempts to introduce a category of relational disorder, where the diagnosis is of a relationship rather than on any one individual in that relationship. The relationship may be between children and their parents, between couples, or others. There already exists, under the category of psychosis, a diagnosis of shared psychotic disorder where two or more individuals share a particular delusion because of their close relationship with each other. There are a number of uncommon psychiatric syndromes, which are often named after the person who first described them, such as Capgras syndrome, De Clerambault syndrome, Othello syndrome, Ganser syndrome, Cotard delusion, and Ekbom syndrome, and additional disorders such as the Couvade syndrome and Geschwind syndrome.[18] Various new types of mental disorder diagnosis are occasionally proposed. Among those controversially considered by the official committees of the diagnostic manuals include self-defeating personality disorder, sadistic personality disorder, passive-aggressive personality disorder and premenstrual dysphoric disorder. Two recent unique unofficial proposals are solastalgia by Glenn Albrecht and hubris syndrome by David Owen. The application of the concept of mental illness to the phenomena described by these authors has in turn been critiqued by Seamus Mac Suibhne.[19] Signs and symptoms Course The likely course and outcome of mental disorders varies, depends on numerous factors related to the disorder itself, the individual as a whole, and the social environment. Some disorders are transient, while others may be more chronic in nature. Even those disorders often considered the most serious and intractable have varied courses i.e. schizophrenia, psychotic disorders, and personality disorders. Long-term international studies of schizophrenia have found that over a half of individuals recover in terms of symptoms, and around a fifth to a third in terms of symptoms and functioning, with some requiring no medication. At the same time, many have serious difficulties and support needs for many years, although "late" recovery is still possible. The World Health Organization concluded that the long-term studies' findings converged with others in "relieving patients, carers and clinicians of the chronicity paradigm which dominated thinking throughout much of the 20th century."[20][21] Around half of people initially diagnosed with bipolar disorder achieve syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks, and nearly all achieve it within two years, with nearly half regaining their prior occupational and residential status in that period. However, nearly half go on to experience a new episode of mania or major depression within the next two years.[22] Functioning has been found to vary, being poor during periods of major depression or mania but otherwise fair to good, and possibly superior during periods of hypomania in Bipolar II.[23] Disability Some disorders may be very limited in their functional effects, while others may involve substantial disability and support needs. The degree of ability or disability may vary over time and across different life domains. Furthermore, continued disability has been linked to institutionalization, discrimination and social exclusion as well as to the inherent effects of disorders. Alternatively, functioning may be affected by the stress of having to hide a condition in work or school etc., by adverse effects of medications or other substances, or by mismatches between illness-related variations and demands for regularity.[24] It is also the case that, while often being characterized in purely negative terms, some mental traits or states labeled as disorders can also involve above-average creativity, non-conformity, goal-striving, meticulousness, or empathy.[25] In addition, the public perception of the level of disability associated with mental disorders can change.[26] Nevertheless, internationally, people report equal or greater disability from commonly occurring mental conditions than from commonly occurring physical conditions, particularly in their social roles and personal relationships. The proportion with access to professional help for mental disorders is far lower, however, even among those assessed as having a severely disabling condition.[27] Disability in this context may or may not involve such things as: Basic activities of daily living. Including looking after the self (health care, grooming, dressing, shopping, cooking etc.) or looking after accommodation (chores, DIY tasks etc.) Interpersonal relationships. Including communication skills, ability to form relationships and sustain them, ability to leave the home or mix in crowds or particular settings Occupational functioning. Ability to acquire a job and hold it, cognitive and social skills required for the job, dealing with workplace culture, or studying as a student. In terms of total Disability-adjusted life years (DALYs), which is an estimate of how many years of life are lost due to premature death or to being in a state of poor health and disability, mental disorders rank amongst the most disabling conditions. Unipolar (also known as Major) depressive disorder is the third leading cause of disability worldwide, of any condition mental or physical, accounting for 65.5 million years lost. The total DALY does not necessarily indicate what is the most individually disabling, because it also depends on how common a condition is; for example, schizophrenia is found to be the most individually disabling mental disorder on average but is less common. Alcohol-use disorders are also high in the overall list, responsible for 23.7 million DALYs globally, while other drug-use disorders accounted for 8.4 million. Schizophrenia causes a total loss of 16.8 million DALY, and bipolar disorder 14.4 million. Panic disorder leads to 7 million years lost, obsessive-compulsive disorder 5.1, primary insomnia 3.6, and post-traumatic stress disorder 3.5 million DALYs.[28] The first ever systematic description of global disability arising in youth, published in 2011, found that among 10 to 24 year olds nearly half of all disability (current and as estimated to continue) was due to mental and neurological conditions, including substance use disorders and conditions involving self-harm. Second to this were accidental injuries (mainly traffic collisions) accounting for 12 percent of disability, followed by communicable diseases at 10 percent. The disorders associated with most disability in high income countries were unipolar major depression (20%) and alcohol use disorder (11%). In the eastern Mediterranean region it was unipolar major depression (12%) and schizophrenia (7%), and in Africa it was unipolar major depression (7%) and bipolar disorder (5%).[29] Suicide, which is often attributed to some underlying mental disorder, is a leading cause of death among teenagers and adults under 35.[30][31] There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide.[32] Causes Main article: Causes of mental disorders Research Risk factors for mental illness include genetic inheritance, such as parents having depression.,[33] or a propensity for high neuroticism.[34] In depression, parenting risk factors include parental unequal treatment,[35] and there is association with high cannabis use.[36] In schizophrenia and psychosis, risk factors include migration and discrimination, childhood trauma, bereavement or separation in families, and abuse of drugs,[37] including cannabis.[36] In anxiety risk factors may include family history (e.g. of anxiety), temperament and attitudes (e.g. pessimism),[38] and parenting factors including parental rejection, lack of parental warmth, high hostility, harsh discipline, high maternal negative affect, anxious childrearing, modelling of dysfunctional and drug-abusing behaviour, and child abuse (emotional, physical and sexual).[39] Correlations of mental disorders with drug use include cannabis,[40] alcohol[41] and caffeine.[42] In February 2013 a study found common genetic links between five major psychiatric disorders: autism, ADHD, bipolar disorder, major depressive disorder, and schizophrenia.[43] Abnormal functioning of neurotransmitter systems has been implicated[citation needed] in several mental disorders, including serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity of certain brain regions in some cases. Psychological mechanisms have also been implicated, such as cognitive (e.g. reasoning) biases, emotional influences, personality dynamics, temperament and coping style. Studies have indicated[citation needed] that variation in genes can play an important role in the development of mental disorders, although the reliable identification of connections between specific genes and specific categories of disorder has proven more difficult. Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. There have been some tentative inconsistent links found to certain viral infections,to substance misuse, and to general physical health. Social influences have been found to be important[citation needed], including abuse, neglect, bullying, social stress, traumatic events and other negative or overwhelming life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated,[citation needed] including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures. Models Mental disorders can arise from multiple sources, and in many cases there is no single accepted or consistent cause currently established. An eclectic or pluralistic mix of models may be used to explain particular disorders.[34][44] The primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial model which incorporates biological, psychological and social factors, although this may not always be applied in practice. Biological psychiatry follows a biomedical model where many mental disorders are conceptualized as disorders of brain circuits likely caused by developmental processes shaped by a complex interplay of genetics and experience. A common assumption is that disorders may have resulted from genetic and developmental vulnerabilities, exposed by stress in life (for example in a diathesis–stress model), although there are various views on what causes differences between individuals. Some types of mental disorder may be viewed as primarily neurodevelopmental disorders. Evolutionary psychology may be used as an overall explanatory theory, while attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context of mental disorders. Psychoanalytic theories have continued to evolve alongside cognitive-behavioral and systemic-family approaches. A distinction is sometimes made between a "medical model" or a "social model" of disorder and disability. Diagnosis Psychiatrists seek to provide a medical diagnosis of individuals by an assessment of symptoms and signs associated with particular types of mental disorder. Other mental health professionals, such as clinical psychologists, may or may not apply the same diagnostic categories to their clinical formulation of a client's difficulties and circumstances.[45] The majority of mental health problems are, at least initially, assessed and treated by family physicians (in the UK general practitioners) during consultations, who may refer a patient on for more specialist diagnosis in acute or chronic cases. Routine diagnostic practice in mental health services typically involves an interview known as a mental status examination, where evaluations are made of appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of other professionals, relatives or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in rare specialist cases neuroimaging tests may be requested, but such methods are more commonly found in research studies than routine clinical practice.[46][47] Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations.[48] It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice.[49] In addition, comorbidity is very common in psychiatric diagnosis, where the same person meets the criteria for more than one disorder. On the other hand, a person may have several different difficulties only some of which meet the criteria for being diagnosed. There may be specific problems with accurate diagnosis in developing countries. More structured approaches are being increasingly used to measure levels of mental illness. HoNOS is the most widely used measure in English mental health services, being used by at least 61 trusts.[50] In HoNOS a score of 0–4 is given for each of 12 factors, based on functional living capacity.[51] Research has been supportive of HoNOS,[52] although some questions have been asked about whether it provides adequate coverage of the range and complexity of mental illness problems, and whether the fact that often only 3 of the 12 scales vary over time gives enough subtlety to accurately measure outcomes of treatment.[53] HoNOS is regarded as the best available tool.[54] Since the 1980s, Paula Caplan has been concerned about the subjectivity of psychiatric diagnosis, and people being arbitrarily “slapped with a psychiatric label”. Caplan says because psychiatric diagnosis is unregulated, doctors are not required to spend much time interviewing patients or to seek a second opinion. The Diagnostic and Statistical Manual of Mental Disorders can lead a psychiatrist to focus on narrow checklists of symptoms, with little consideration of what is actually causing the patient’s problems. So, according to Caplan, getting a psychiatric diagnosis and label often stands in the way of recovery.[55] In 2013, psychiatrist Allen Frances wrote a paper entitled "The New Crisis of Confidence in Psychiatric Diagnosis", which said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests". Frances was also concerned about "unpredictable overdiagnosis".[56] For many years, marginalized psychiatrists (such as Peter Breggin, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality". More recently these concerns have come from insiders who have worked for and promoted the American Psychiatric Association (e.g., Robert Spitzer, Allen Frances).[57] A 2002 editorial in the British Medical Journal warned of inappropriate medicalization leading to disease mongering, where the boundaries of the definition of illnesses are expanded to include personal problems as medical problems or risks of diseases are emphasized to broaden the market for medications.[58] Prevention The 2004 WHO report "Prevention of Mental Disorders" states that "Prevention of these disorders is obviously one of the most effective ways to reduce the [disease] burden."[59] Research The 2011 European Psychiatric Association (EPA) guidance on prevention of mental disorders states "There is considerable evidence that various psychiatric conditions can be prevented through the implementation of effective evidence-based interventions."[60] A 2011 UK Department of Health report on the economic case for mental health promotion and mental illness prevention found that "many interventions are outstandingly good value for money, low in cost and often become self-financing over time, saving public expenditure".[61] Parenting has many mental illness causality effects, and evidence suggests that helping parents to be more effective with their children can address mental health needs.[62][63] For depressive disorders, research has shown a reduction in incidence of new cases when people participated in interventions, for instance by 22% and 38% in meta-analyses.[64][65][66][67][68][69][70][71][72][73][74] In a study of patients with sub-threshold depression, those who received minimal-contact psychotherapy had an incidence of a major depressive disorder one year later a third lower (an incidence rate of 12% rather than 18%) than the control group.[75][76] Such interventions also save costs.[77] A stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older.[78] The Netherlands mental health care system provides preventive interventions, such as the Coping with Depression CBT course for people with subthreshold depression. A meta-analysis showed that people who followed this course had a 38% lower incidence of developing a major depressive disorder than the control group.[79] However one depression study found a neutral effect for CBT compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles.[80] Other studies have seen CBT effectiveness equal to other interventions,[81] or neutral.[82][83][84] For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalized anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes.[38][85][86] Other interventions (parental inhibition reduction, behaviourism, parental modelling, problem-solving and communication skills) have also produced significant benefits.[38] In another study 3% of the group receiving the CBT intervention developed GAD by 12 months postintervention compared with 14% in the control group.[87] Subthreshold panic disorder sufferers were found to significantly benefit from use of CBT.[88][89] Use of CBT was found to significantly reduce social anxiety prevalence.[90] It has also been found that teaching CBT in schools reduced anxiety in children.[91] Computerised CBT has also been found effective.[92] For psychosis and schizophrenia, usage of a number of drugs has been associated with development of the disorder, including cannabis, cocaine, and amphetamines.[93] Studies have shown reductions in onset through preventative CBT,[94][95][95][96] although this continues to be debated.[97] Another study showed that schizophrenia prevalence in people with a high genetic risk was significantly influenced by the parenting and family environment.[98] A meta-analysis concluded that it may be possible to delay or prevent transition of high risk people to psychosis.[95] For bipolar, stress (such as childhood adversity or highly conflictual families) is not a diagnostically specific causal agent, but does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness.[99] There has been considerable debate regarding the causal relationship between usage of cannabis and bipolar disorder.[100] Further research is needed both on mental health causal factors, and on the effectiveness of prevention programs.[38][73][101] Universal preventions (aimed at a population that has no increased risk for developing a mental disorder, such as school programs or mass media campaigns) need very high numbers to be statistically valid (sometimes known as the "power" problem). Approaches to overcome this are (1) focus on high-incidence groups (e.g. by targeting groups with high risk factors), (2) use multiple interventions to achieve greater, and thus more statistically valid, effects, (3) use cumulative meta-analyses of many trials, and (4) run very large trials.[68][102] A mental disorder, also called a mental illness or psychiatric disorder, is a mental or behavioral pattern or anomaly that causes either suffering or an impaired ability to function in ordinary life (disability), and which is not a developmental or social norm. Mental disorders are generally defined by a combination of how a person feels, acts, thinks or perceives. This may be associated with particular regions or functions of the brain or rest of the nervous system, often in a social context. Mental disorder is one aspect of mental health. The scientific study of mental disorders is called psychopathology. The causes of mental disorders are varied and in some cases unclear, and theories may incorporate findings from a range of fields. Services are based in psychiatric hospitals or in the community, and assessments are carried out by psychiatrists, clinical psychologists and clinical social workers, using various methods but often relying on observation and questioning. Clinical treatments are provided by various mental health professionals. Psychotherapy and psychiatric medication are two major treatment options, as are social interventions, peer support and self-help. In a minority of cases there might be involuntary detention or involuntary treatment, where legislation allows. Stigma and discrimination can add to the suffering and disability associated with mental disorders (or with being diagnosed or judged as having a mental disorder), leading to various social movements attempting to increase understanding and challenge social exclusion. Prevention is now appearing in some mental health strategies. |
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