6.2 Mental health disorders
This section is dedicated to the study of the mind and its related diseases. The mind is unlike all other physiological systems, in that its physical structure and functioning cannot be scientifically measured and described as can the anatomy and physiology of a system such as the skin or the blood. However, in many ways the mind and its related diseases are studied within conventional medicine by means of a very similar approach to that used in the study of the more physically defined systems.
In conventional medicine the diseases of the mind are termed ‘mental health disorders’. The mental health disorders are managed within the medical speciality of psychiatry and the non-medical clinical speciality of psychology.
The medical speciality of psychiatry is a relatively young discipline in the history of conventional medicine. The term is derived from the Greek words ‘psyche’ (meaning ‘mind’) and ‘iatros’ (meaning ‘doctor’). Psychiatry is the speciality dedicated to the medical treatment of the mental health disorders.
‘Psychology’ is a term used to describe the academic and clinical disciplines that are based on the study of the workings of the mind. A clinical psychologist is a therapist who has gained a degree in psychology, and then undergone further training in the practical application of psychology in the clinical situation.
Psychotherapy (literally meaning treatment for the mind) is a term which describes any approach which involves the use of the formal and systematic clinical relationship between the therapist and the client as a therapeutic tool. Psychotherapy may be utilised by psychiatrists and clinical psychologists but also by practitioners who have undergone specific training in one (or more) particular form(s) of therapy. The different types of psychotherapy will be explored in more detail in Chapter 6.2c.
The aim of this chapter is to introduce the general approach by which mental health disorders are understood conventionally. These disorders are classified by psychiatrists and psychologists in a quasi-systematic way, but unlike most of the diseases studied within the other medical specialities, the two classification systems currently used are largely based on the manifestation (symptoms and signs) of the disorder rather than on its physical cause(s).
The chapter begins with a brief exploration of how the mind is generally seen from a medical perspective as a distinct entity with respect to the other physiological systems. This is despite increasing scientific evidence that the mind is inextricably linked with (and may well even be rooted in) the function of these other systems. The chapter then goes on to consider the conventional understanding of the causation of mental illness (see Q.6.2a-1).
The very existence of the disciplines of psychiatry and psychology indicates the depth to which the mind has in recent medical history been recognised as a separate entity to the other physical systems of the body, such as the cardiovascular or the urinary systems, and even the central nervous system.
A dictionary description of the mind describes it as ‘the seat of awareness, thought, volition and feeling … concentration (and) memory’. This description does not strongly imply that the mind has any physical basis, even though most psychiatrists would agree that the mind springs from the workings of the brain. Moreover, the structure and known workings of the brain are embraced within the medical speciality of neurology. Although modern psychiatrists have a robust foundation of neurology as part of their training, the converse is not necessarily true of neurologists. This reflects the fact that, although conventional practitioners generally believe that mental health problems must originate in the physical brain, as yet the precise links between the workings of the physical brain and mental health disorders have not been adequately explained.
The link between the mind and the brain is a relatively recent phenomenon in western culture. In contrast, the idea that the mind and its disorders are rooted in the bodily humours and their imbalances was a much more prevalent and prevailing view that persisted in Europe well into the third and fourth centuries AD (this perspective is comparable to the Chinese medicine Organ perspective). Thereafter, in the west, the influence of the monasteries strengthened the concept that mental illness resulted from a possession of the spirit by devils, and the mentally ill were taken for treatment to monks and priests. It was only as the healing role of the medical profession became distinct from that of the priesthood in the late 17th century, and mind was seen as distinct from the body (Cartesian dualism), that mental illness began to be viewed more as a medical disorder, and, specifically, insanity as a disorder of the mind.
Until very recent decades, there was a tendency for doctors to attribute many psychiatric conditions to a problem stemming purely from the mind, with absolutely no physical basis. This is in keeping with the Cartesian perspective of the body, in which the mind and body are seen as separate entities, rather like a driver is separate from her car.
However, more recently, in the last two to three decades, a more holistic ‘biopsychosocial model’ has begun to replace the outmoded mind/body medical model as the theoretical basis of psychiatric practice. This model proposes that psychiatric conditions arise as the result of a combination of biological, psychological and social factors. In this way their origin is seen as linked not only to the mind, but also to physical changes in the body and to factors in the social environment of the patient.
There is an increasing body of scientific evidence that strongly links some mental health disorders with certain chemical imbalances of neurotransmitters in the brain, and, more controversially, with levels of the hormones that circulate throughout the whole body. In conventional practice, this is the realm of neuropsychiatry, a rapidly expanding discipline in which the focus is on how disease of the chemical structure of the brain might manifest as mental illness.
From a holistic perspective, neuropsychiatry offers a conventional description of an undeniable link between mind and body (i.e. the physical structure of the brain). Moreover, as it is increasingly recognised that there is a significant overlap between the diverse neurotransmitters of the central nervous system and the hormones of the endocrine system, it becomes possible that this mind–body link need no longer be confined strictly to the brain. Instead, as a product of the subtleties of hormone expression, the changes that appear to spring from the mind might have their origin in diverse sites throughout the body.
Exciting though the potential for holism in these conventional explanations may be, the concept of the mind–body divide does not really seem to have been eroded significantly in conventional medical practice. Currently, many patients of conventional hospital practitioners will experience their mental and physical problems being treated as if they have no relationship to each other (with the exception of those well-described diseases of the nervous system that are recognised to result in mental health dysfunction, such as multi-infarct dementia).
For example, it is a common experience for a specialist within in a medical speciality (such as cardiology, respiratory medicine or gastroenterology) to be referred patients whose physical symptoms are directly related to an imbalance in their mental or emotional state. For example, the tachycardia, hyperventilation and diarrhoea that can accompany chronic anxiety are very commonly seen in general medical hospital clinics. However, the explicit task of the specialist in this sort of case is to exclude a measurable physical basis for symptoms such as these. In the patient with chronic anxiety, the task is to exclude conditions such as a structural heart abnormality, asthma or ulcerative colitis. Once this has been done, the patient is discharged back to the care of the GP, and thence, if the resources are available, to a mental health specialist.
To conclude, the mind is currently seen in conventional medicine as a body system that obviously does have a relationship with the other physically described systems, but this relationship is more tenuous than those all the other physiological systems share with each other. Although the mind–body split paradigm is necessarily being eroded as a consequence of scientific study into the causation of mental illness, in current practice this paradigm frequently prevails.
each of the mental disorders is … a clinically significant behavioural or psychological syndrome … that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom … Whatever its original cause, it must be currently considered a manifestation of a behavioural, psychological or biological dysfunction in the person.
In this definition, the mental health disorder is defined as a characteristic cluster of behaviours, or psychological symptoms and signs (behavioural or psychological syndrome), which are associated with negative consequences for the individual (distress, disability, risk of death, pain or loss of freedom). Although for any one mental health state the first part of this definition, which embraces the syndromes, may be defined with a degree of objectivity, the second part is necessarily subjective and difficult to classify. What might appear as distress or loss of freedom to the diagnosing doctor might not be so interpreted by the patient or within their culture of origin.
This definition is useful in explaining how mental health professionals interpret mental health states, and also what they believe to be the root cause of mental health disorders (i.e. a ‘behavioural, psychological or biological dysfunction in the person’). The definition reflects the biopsychosocial model of thought, which has been increasingly embraced within modern psychiatry.
As implied by the APA definition of mental health disorder, the diverse mental health disorders are generally considered to have a multifactorial basis for their origin. Many psychiatrists would subscribe to this biopsychosocial model of mental illness. The term ‘biopsychosocial’ refers to the understanding that a combination of inherited and acquired physical factors (biological factors), factors related to the emotional development of the individual (psychological factors) and factors related to the cultural environment of the individual (social factors) are all relevant in the development of a mental health disorder in an individual. Ideally, in every case presenting to a psychiatrist or psychologist, biological causes, psychological causes and social causes need to be considered.
A biological theory of the causation of mental illness proposes that physical changes/illness are at the root of the development of the illness. The biological perspective is supported by the fact that many diseases or conditions that are known to involve physical changes in the brain can manifest with mental disturbance (e.g. Alzheimer disease, traumatic head injury, alcohol intoxication). Moreover, the fact that certain conditions tend to run in families is strongly suggestive of a genetic inheritance, and thus physical basis, of a condition.
Adoptive studies, which demonstrate that children who have been adopted shortly after birth appear to carry the risk of developing mental health disorders apparent in their blood relations, are very strongly suggestive of the genetic inheritance of mental illness. Studies of twins who have been separated at birth and adopted by different families offer even more powerful evidence of the inheritance of mental health disorders. Conditions such as schizophrenia, manic depression, simple depression, anxiety and panic disorder, obsessive–compulsive disorder and alcoholism have all been shown by these sorts of studies to have an inherited component in their causation. This means that a child of someone with one of these conditions is more likely than the average person to develop that condition.
The neuropsychiatric explanation offered for an inherited tendency to mental health disorders is usually given in terms of an inherited neurochemical makeup. For example, it is recognised that in schizophrenia there is increased activity of those brain systems that involve the release of the neurotransmitter dopamine. It is possible that the increased tendency for schizophrenia to run in families is due, in part, to an inherited tendency for these physical systems to be overactivated. This chemical basis for the genesis of schizophrenia is further supported by the fact that dopamine-stimulating drugs, such as amphetamines and cannabis, can trigger a psychosis similar in form to schizophrenia. Moreover, the drugs discovered originally by chance to be of benefit in schizophrenia, the major tranquillisers (first developed as anaesthetic agents), are now known to act by blocking the action of dopamine.
Similarly, the tendency to develop depression may be, in part, a result of an inherited reduction in the expression of monoamine neurotransmitters such as noradrenaline and serotonin (5HT). This is supported by the fact that the various classes of antidepressant drugs all seem to increase the levels of monoamines in the brain. It is increasingly recognised that some of the addictive recreational drugs (e.g. nicotine, ecstasy) may induce a release of serotonin after their use, which is then followed by a more long-term depletion of this neurotransmitter in the brain. Because of this, use of the drug forces the user to face a long-term state of low mood if they choose to withdraw from the drug, particularly if the use of the drug has been prolonged over a period of months to years.
However, an inherited tendency to a condition does not in itself destine a child to develop that condition. It is clear that other factors are usually required to force the expression of a condition such as schizophrenia or depression. These other factors are considered to be either psychological or social in nature.
The psychological explanation of mental illness rests on the principle that experiences during childhood and early adulthood can have a profound bearing on a person’s mental and emotional health. This is such a commonly accepted principle that few would argue against the suggestion that a shocking experience or a period of deprivation in childhood would have long-term psychological repercussions. However, it is only in fairly recent years that studies of traumatic events in childhood have clearly demonstrated a link between certain forms of childhood deprivation and long-term mental ill-health. One of the earliest studies (by the psychologist John Bowlby in the 1950s) demonstrated that prolonged or recurrent absence of a consistent mother figure in early life was associated with difficulties in forming emotional bonds and a tendency to anxiety and depression in later life.
Since that time, psychological studies have shown that diverse factors in the family environment, including expressed angry discord, maternal depression, divorce, bereavement, overprotection, lack of parental authority, physical and sexual abuse, unremitting criticism, and taunting and inconsistent discipline, can all be risk factors for misbehaviour in children and mental health disorders in later life.
Even theories that propose psychological mechanisms for the causation of mental illness are only just over a century old. Sigmund Freud, now considered the founder of psychoanalysis, first proposed that there are both conscious and unconscious aspects to the mind. He theorised that unconscious forces deriving from deeply ingrained value systems originating from parents or society (the superego), or instinctive drives (the id) could, together with pressures in one’s external life, challenge and cause conflict with the conscious self (the ego). The conscious self was considered by Freud to develop to its healthy adult form in distinct stages throughout childhood. Freud proposed that the healthy child has to progress appropriately through oral, anal, phallic, latent and genital phases in order to mature as a healthy adult, and problems encountered in any of the stages could result in lasting psychological disorder. For example, he proposed that the anal stage was when the toddler ideally achieves a sense of separateness and becomes independent in terms of toilet training and feeding. Problems in this phase might appear in adulthood as a fear of losing control, obsessional traits or depression because of not living up to expectations.
Freud’s theories and their rigid distinctions are less accepted nowadays, but his beliefs that the psyche undergoes progressive development throughout childhood, and that unconscious ‘material’ originating from episodes scattered along the course of that development can persist to lead to mental illness, still very much influence modern psychotherapeutic practice.
The concept of defence mechanisms, proposed first by Freud and later developed by his daughter Anna Freud, is one that is still very much recognised in modern psychology. ‘Defence mechanism’ is a term used to describe any mental response used by a person to protect himself from psychological pain such as guilt, anxiety or shame. The naming of the various defence reactions has entered common usage. Commonly described defence reactions include denial, repression, regression, rationalisation, displacement, projection, introjection, sublimation and reaction formation.
Defence mechanisms can be healthy, and responses such as distraction (e.g. looking for the positive, use of humour) are likely to be used by people who enjoy good mental health. However, mechanisms such as repression of unpleasant feelings (such as might follow an episode of severe abuse), or denial of what has really happened (e.g. an inability to take in a diagnosis of cancer), may actually lead to long-term problems in mental health. The theory is that these sorts of defence mechanisms simply shift conscious mental pain into the unconscious, where the pain may still be felt in the form of depression or anxiety, but from where it is much harder to treat the pain at its root. With this perspective on causation, a psychotherapist works to enable the patient to arrive at a place where this unconscious material is made conscious and the roots of the pain can be understood, and so transformed.
The cognitive–behavioural psychological perspective on the causation of disease is based on the idea that the patient has learned inappropriate responses to the world around them because of negative past experience. The cognitive–behavioural model interprets unhelpful behaviours in the light of the incorrect thoughts that underlie them. For example, a child who was shocked by the barking of a dog might then tend to be fearful whenever a dog comes close. A behavioural response of avoidance, and maybe even a physiological response of palpitations and sweating, might then persist into adulthood. The cognitive–behavioural interpretation of this problem (termed a ‘simple phobia’) is that, because of the childhood experience, the belief that ‘dogs will make me frightened’ has been learned, and the inappropriate reaction to dogs has become ingrained as a result of that belief.
Anxiety disorders, eating disorders and depressive disorders are examples of disorders that can be analysed according to cognitive–behavioural theory. The negative responses to the world expressed in these disorders can be related in cognitive–behavioural theory to unhelpful learned patterns of thought.
A social perspective on the causation of mental illness necessarily overlaps with the psychological perspective, because it sees factors in the social environment as impacting on the developing psyche. Social theories of the causation of mental illness are particularly bound up in the studies of cultural factors common to communities. Studies on the incidence of mental illness in communities have identified that mental illness can relate to variables such as gender, age, marital status, social support and economic status. For example, there is a recognised link between depression in men and being divorced, a link that is far less pronounced in women who are divorced.
A psychiatrist or psychologist seeks to understand the evolution of mental illness in terms of three factors of causation: predisposing, precipitating and perpetuating factors. Ideally, the factors that have predisposed to the condition, those that have precipitated the condition and those that might be perpetuating the condition need to be clarified if the most appropriate treatment is to be chosen.
Predisposing factors are those factors that might have led a person to have become more at risk of developing a mental illness before the illness became apparent. For example, if one looks at the case of schizophrenia appearing for the first time as the sudden onset of a paranoid psychosis in a 22-year-old male student, the predisposing factors might include a family history of serious mental illness (grandfather was in an asylum for 10 years and mother had an episode of postnatal psychosis after the birth of his younger brother). There might also be volatile emotional environment in the family home (mother and father have frequent arguments, and mother often breaks down in tears when stressed). As a child, this student was recognised to be withdrawn and awkward socially.
Precipitating factors are those factors that have triggered a particular episode of illness. In this case these might include the stress of leaving home for the first time, and the inability to fit into a supportive network of people at college. A recent history of experimenting with ecstasy and frequent use of cannabis could also be included as precipitating factors.
Perpetuating factors are those factors that might prevent the resolution of the mental illness. In this case these could include the lack of social support, continued drug use and self-neglect (see Q6.2a-2).
Although there is a general appreciation amongst conventional practitioners that there are diverse factors at play in the generation of mental illness, psychiatrists and psychologists vary in their treatment approaches as a direct result of the way in which they might emphasise the importance of one factor in the causation of mental health problems over any other. For example, for a patient with a mental health issue, a hospital psychiatrist might favour medical drug treatments (biological causation of illness), whereas a psychoanalyst might concentrate on enabling the patient to explore primitive emotional reactions experienced in a relationship which started to emerge in childhood (psychological causation of illness) (see Q6.2a-3). The diverse approaches to the treatment of mental health disorders and their relationship to the perceived underlying cause of the disorder are explored in more detail in Chapter 6.2c (see Q6.2a-4).
Information Box 6.2a-I Mental health disorders: a Chinese medicine perspective
The mind (Shen) is seen in Chinese medicine as a fundamental aspect of Qi. Therefore, any imbalance or disturbance in the flow of Qi will have a manifestation at the level of the Shen. All Chinese medicine patterns, therefore, may include signs and symptoms of a mental and/or emotional nature. Unlike conventional medicine, in Chinese medicine mental health is not seen as a distinct speciality, but instead as one aspect of health as a whole. Psychiatric or psychological diseases are described in Chinese medicine as Jing Shen Bing (Essence Spirit diseases).
There are many terms used in Chinese medicine texts associated with the mind, but Shen (Spirit) and compound terms that include the term Shen, such as Jing Shen (Spirit Essence), are those that are used most commonly. In Chinese medicine the Shen, together with Qi and Jing (Essence), are described as the ‘three treasures’. These three substances are the interdependent manifestations of Qi. The Shen is classically the most insubstantial and rapidly moving form of Qi, and is specifically associated with the mind. Shen is mainly associated with Heart Qi, and the Heart is said to ‘house the Shen’. Spirit, in the Chinese sense, has many layers of meaning, but when used from the perspective of the psychological diseases it embraces the outward manifestation of life, together with consciousness, thinking and feeling.
The Chinese considered the Shen to consist of the five spiritual aspects of a human being, each of which is associated with a Yin Organ. The five aspects are the Hun (Liver), the Yi (Spleen), the Zhi (Kidney), the Po (Lung) and the specific spiritual aspect of the Heart Organ, also given the name Shen. To minimise confusion, in this text this last particular aspect of the Shen will be called ‘Heart Shen’.
The Heart Shen is that aspect of the spirit which specifically resides in the Heart, but which also embraces the other four Shen. It is considered to be responsible for consciousness, intelligence, thought, insight, the generation of ideas and memory.
The Heart Shen is also important for the ability to fall to sleep easily and to have sleep that is deep and refreshing. ‘Shen’ is also used to describe the quality of liveliness that is inherent in someone who is emotionally very healthy.
The Heart Shen gives the capacity to have insight and to feel the emotions. The ability to form healthy relationships and to feel love and joy is a characteristic of the Heart and Pericardium, which must in turn be related to their spiritual aspect, the Heart Shen.
The Hun was thought to be that part of the spirit which leaves the body after death. It is rooted in the Liver Yin, from where it enables a sense of purpose, vision and direction in life. It is also linked with the courage required to face life’s challenges, and the ability to make decisions.
If the Hun is well rooted, sleep is normal and dreams are few. However, the ability to gain inspiration, be intuitive and have dreams is a characteristic of the Hun. The Hun can make images, archetypes and symbols accessible to the conscious mind, and has a link with the ‘universal mind’ (comparable to the collective unconscious as described by Jung).
The ability to move easily between introspection and relationships with other people has been attributed to the Hun. A balanced Hun prevents the emotions from becoming excessive, so underlying a healthy emotional life.
The Po was thought to be that part of the spirit which is linked to the body, and which remains with the body after death. The Po enables the body to move, and gives the skills of agility, balance and coordination.
The Po was also seen to be very important in enabling appropriate movement of the Jing (Essence), and so is involved in the first physiological processes after birth (such as the perception of the senses and the onset of breathing).
The Po is also important for the acuity of the senses. The Po is responsible for the experience of grief and for crying. It is also closely linked to breathing, and so can be calmed if the breath is regulated.
The Yi was thought to reside in the Spleen, and is responsible for clear thought. The ability to study, concentrate, assimilate new ideas and retain facts, and to work things out are all functions of the Yi. Memory will be good if the Yi is healthy, and this particularly relates to the memory of facts and ideas.
The Zhi was thought to reside in the Kidneys, and is also important in the function of memory. The Zhi appears to be linked with long-term retention of facts and ideas, whereas the Yi is related to the laying down of memory of facts and ideas.
The Zhi is also linked to the drive and determination required to follow through with an idea. It also has the characteristic of tenaciousness in following an idea through to its conclusion. The Zhi is also characterised by the courage required to stand up to the challenges that life presents and which threaten to prevent success in one’s endeavours.
There are three general patterns described in Chinese medicine that result from imbalance of the Shen: Deficient Shen, Disturbed Shen and Obstructed Shen. The general patterns of pathology of the Shen are:
These patterns describe general imbalances that are seen in all manner of mental illness. However, each of the five Shen have their own characteristics, which when out of balance may be discerned in mental illness. The characteristics of imbalance of the five Shen are:
|Aspect of the Shen||Associated Organs||Characteristics of imbalance|
|Shen (mind/spirit)||Heart, Small Intestine, Pericardium, Triple Burner|
|Hun (ethereal soul)||Liver, Gallbladder|
|Po (corporeal soul)||Lung, Large Intestine|
|Yi (intellect)||Spleen, Stomach|
|Zhi (will)||Kidney, Bladder|
As described earlier, the Shen is simply an aspect of Qi. If Qi is out of balance when an Organ pattern is being expressed, it is to be expected that there will be some accompanying imbalance of the Shen. For example, in a state of Qi Deficiency one might expect Shen Deficiency, and in Qi Stagnation one might expect some degree of Shen disturbance. As Qi is a Yang substance, the same applies to any pattern in which Yang is out of balance. In Yang Deficiency one might expect Shen Deficiency, and when Yang is Rising one might expect Shen Disturbance.
Similarly, a disorder of the Shen can be expected if there is an imbalance of Blood, as Blood is not only directly related to Qi as the ‘mother of Qi’, but is also said to House the Shen. If Blood is Deficient, Shen might be expected to be Deficient, but also Disturbed as it can no longer be properly rooted. As Blood is a Yin Substance, a deficiency of Yin might also be expected to be accompanied by a Deficiency and Disturbance of the Shen.
In Full Patterns it is also possible to predict the effect that certain Pathogenic Factors might have on the Shen. One might expect Heat and Wind to disturb the Shen, and Phlegm and Damp to Obstruct it. Empty Heat simply disturbs the Shen, but Full Heat can affect consciousness and thus can Obstruct as well as disturb the Shen.
|Shen pathology||Chinese medicine pathologies|
It is possible to use these correspondences to understand more about the mental–emotional disturbances described in the particular Organ Syndromes. Even more insight will be gained if the mental–emotional correspondences of the five Shen are also used to inform an interpretation of a particular Organ Syndrome.
For example, in the Syndrome of Spleen Qi Deficiency, some features of deficient Shen and also some features of imbalance of the Yi might be expected. It is no surprise then that tiredness, lassitude and overthinking are features of this pattern, which reflect Shen Deficiency, but with a particular ‘flavour’ associated with imbalance of the Yi. On this basis, difficulties in thinking, generation of ideas and memory for facts might also be expected to be features of Spleen Qi Deficiency, and these are indeed familiar symptoms seen in patients in clinical practice.
In conclusion, using the approach described above it is possible to describe what sort of mental–emotional features might be apparent in a presentation of any particular Chinese medicine Syndrome. This aspect of the Chinese medicine interpretation of mental health symptoms and signs has been elaborated in some detail, as it will provide a foundation for the Chinese medicine interpretation of conventional descriptions of mental illness in subsequent chapters in this section.
Self-test 6.2a Introduction to mental health disorders
3. For each of the three possible categories of the causation of mental illness, describe two forms of evidence that are strongly suggestive that mental illness can indeed result from factors within each category:
2. According to the American Psychiatric Association, a mental health disorder is a constellation of behavioural or psychological symptoms and signs that is associated with negative consequences for the individual. In other words, it represents a way of performing or reacting to the world which is not helpful for the patient. Also, a characteristic of a mental health disorder is that it is a manifestation of dysfunction in one or more of the biological, psychological or social realms.
In conventional medicine, the mental health disorders are classified in a systematic way. Superficially, this is comparable to the classification of diseases of any one of the more readily measurable physiological systems. However, the diseases of the mind are classified according to their symptoms and signs, rather than according to the underlying pathological process. For example, the various phobias are classified according to the nature of the phobia, rather than what precisely is going on in the nervous system in these disorders. This is in contrast to the basis on which the diseases of systems such as the cardiovascular or gastrointestinal systems are classified.
The process of classification in psychiatry involves sorting episodes of mental illness into diagnostic groups on the basis of common clinical features. For example, two episodes of depression might be very different, in that one might be triggered by a bereavement, and so be characterised by extreme sadness, and the other might occur in the postnatal period, and so be characterised by feelings of guilt. However, both episodes will be recognised by a psychiatrist as cases of depression because of the common features of pervasive low mood, poor sleep, altered appetite and the presence of suicidal ideas.
The systematic classification of psychiatric diseases is recognised to be of benefit for the purposes of communication about the condition, for facilitation of research and also for developing treatment protocols. Thus is because once a condition can be assigned a category, it can be compared readily with other cases diagnosed to fall within the same category. The responses to different treatments for people with the same sort of condition can be compared. Moreover, a new patient suffering from a condition from a recognised category can be offered treatment which has been shown to benefit other people diagnosed with the same sort of condition (see Q6.2b-1).
However, the benefits of psychiatric classification and its corollary, the labelling of patients with a diagnosis of mental illness, are the subject of debate. The psychiatrist Kendell, when writing about the role of diagnosis in psychiatry, stated ‘in the last resort, all diagnostic concepts stand or fall by the strength of the diagnostic and therapeutic implications they embody’ (Bloch and Singh 1994). What Kendell means is that a classification system is only of value if the diagnostic categories actually enable a truly therapeutic outcome for the majority of people who fall into each of the categories.
It can be argued that the diagnostic categories used in modern psychiatry are too simplistic. For example, consider a person who has a unique make-up and who is exposed to unique and diverse stressors in his life. At a point of crisis he has a mental breakdown, which likewise has its own very unique characteristics. No other person has ever before experienced the same pattern and range of troubling thoughts and disability as this person, and yet a psychiatrist might focus in on a few key characteristics of this man’s disorder and give him the diagnosis ‘paranoid schizophrenia’.
First, we need to question whether the diagnostic category of schizophrenia is appropriate. Although this man may share some clinical features in common with other patients, is it really right to group him together with these patients for the purpose of choosing treatment? On the basis of his diagnosis, this man might be hospitalised against his will, and forced to be treated with the most widely accepted therapeutic option for acute schizophrenia, drugs from the major tranquilliser group. These drugs may lead to a wide range of side-effects, including sedation, confusion, weight gain, parkinsonian (i.e. akin to the stiffness seen in Parkinson disease) muscle stiffness and restless movements (tardive dyskinesia). It is important to be sure that these side-effects are ‘worth’ the hoped-for benefit of improved mental health.
The problem of choosing one treatment to fit all members of a diagnostic category has raised earlier in this text. Just because the majority of people in a clinical trial of treatment for, say, hypertension, respond positively to a given drug, this does not guarantee that every individual with hypertension will respond positively. One drug does not necessarily fit all cases of hypertension. It is arguable that this issue is of even more significance in psychiatry, in which the clinical presentations of two people with the same diagnosis can be very different. Is it reasonable to expect one drug to fit all cases of depression or panic attack?
In the case of schizophrenia, it is not always clear whether or not the therapeutic option has conferred a benefit. In many cases, after a first episode of schizophrenia there is a prolonged period of up to a few years in which the patient may not regain his previous level of functioning in society. Some of this disability may well result from the side-effects of hospitalisation and drug treatment. Can we be sure that this treatment option was the best for this man in his unique situation?
The diagnosis of schizophrenia is undoubtedly one that is stigmatising in western culture. The label provokes the memories and images that western culture associates with the term. Most of these will not be positive, and importantly may actually be irrelevant to the person’s individual situation. The label carries consequences, not just in terms of the treatment that is offered, but also may affect the person’s self-image and the way in which he will be able to integrate back into his community.
To summarise, the classification of mental health disorders, as well as offering benefits in terms of communication, and aiding in research and the design of treatment protocols, can also carry some negative consequences. Being assigned to a diagnostic category may oversimplify an individual case of mental illness. Being assigned to a category may imply that only a certain recommended treatment path is suitable for a particular patient (e.g. antidepressants in diagnosed depression), when this might not be the case at all. Moreover, categorisation may actually lead to harm as a result of the application of a label that is perceived to be stigmatising to a patient.
There are two widely accepted systems of the classification of mental health diseases: the International Classification of Diseases (ICD), a system drawn up by the World Heath Organization (WHO); and the Diagnostic and Statistical Manual of Mental Disorders (DSM), designed by the American Psychiatric Association.
The most recent revision of the International Classification of Diseases, ICD 10, was drawn up in 1992. ICD 10 consists of a number of chapters, each dedicated to a different physiological system or disease group. By means of this system, each disease category can be ascribed a unique numerical code, which can be useful for the purposes of studying the epidemiology of disease. Chapter 5 of ICD 10 is dedicated to the mental health disorders.
This is a term which is used in all aspects of conventional medicine to describe a condition which has a measurable physical basis. From a psychiatric perspective, the organic mental health disorders include Alzheimer disease and other forms of dementia, and any mental health disorders which result from brain damage, brain tumour or generalised disease.
The term affective literally means relating to the mood. In psychiatry, the term affect is used almost interchangeably with the word mood. This category includes all the depressive disorders and also the condition of mania which manifests as periods of elevated mood.
Neurotic is an adjective which is derived from the term used in psychiatry to describe a minor mental health disorder, a neurosis. By definition the neuroses are those conditions in which there is mental health disturbance but that the patient’s insight into the fact there is a mental health disturbance is maintained. By this definition, any person with a neurosis would readily admit that that was their problem. For example, minor depression and phobias are examples of neuroses in that the patient suffering from these conditions would be prepared to agree with the doctor about the nature of their problem.
N.B. The formal definition of a neurosis given in ICD 10 is as follows: “a mental disorder in which the patient may have considerable insight and has unimpaired reality testing, in that he does not easily confuse his morbid subjective experiences and fantasies with reality”.
In contrast the psychoses (singular psychosis) are those mental health conditions in which the patient has lost insight into the fact they have a mental illness. A psychosis is characterised by a degree of denial that there is any thing wrong, and possibly by a reluctance to admit that treatment is necessary. Broadly speaking this technical term corresponds to the commonly used words insanity and madness. Psychotic is a term which in psychiatry describes a state of mental health in which insight is lost. It might be used, for example, to describe a case of acute schizophrenia. It does not in any way imply dangerousness which is the unfortunate common misunderstanding of the term.
N.B. The formal definition of a psychosis given in ICD 10 is as follows: “a mental disorder in which impairment of the mental function has developed to such a degree that interferes grossly with insight, ability to meet some ordinary demands of life or to maintain adequate contact with reality.”
Somatoform literally means a condition in which a mental health disorder is largely experienced as physical discomfort and attributed by the patient to a bodily problem. Somatisation is the term used to describe the tendency to experience recurrent functional disease (such as headache, irritable bowel disease, and dysmenorrhoea) when the medical interpretation of the root of the problem is a mental illness such as depression or anxiety.
Personality disorder is a term defined in ICD 10 as “deeply ingrained and enduring behaviour patterns manifesting as inflexible responses to a broad range of personal and social situations”. What this means is that person diagnosed with a personality disorder has emerged from childhood as an adult with what the psychiatrist would consider an abnormal and often unhelpful way of responding to the world.
A tendency to mood swings, “cyclothymia”, a tendency to low mood “dysthymia” and a tendency to negatively interpret the intentions of the others “paranoia”, are all examples of ways of responding to the world, which, if extreme, could be classed as personality disorders. Using these examples, a person markedly exhibiting these tendencies might be diagnosed as having respectively a cyclothymic, dysthymic or paranoid personality disorder.
The American Psychiatric Association’s fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) classifies the mental health disorders under five ‘axes’. This system explicitly avoids classification on the basis of known pathology, but rather categorises purely on what can be gleaned from the clinical features (symptoms and signs) of the condition. This system also introduces lists of diagnostic criteria, which are lists of features that have to be present in order for a diagnosis to be made. These criteria were designed to increase the reliability of forming a psychiatric diagnosis.
Axis I of DSM IV embraces all the currently recognised mental health disorders, but excludes personality disorders and learning disability. These two categories are conditions that have long-term and enduring mental aspects, and are included in Axis II. General medical conditions that might manifest in mental health disturbance are listed in Axis III. Axis IV embraces problems that result from environmental or social factors, and Axis V is a summary of the psychiatric clinician’s opinion of general functioning. What this means is that a patient who receives a diagnosis according to DSM IV will have a clinical label (Axis I), a description of whether or not there is an enduring mental health problem (Axis II), a description of any coexistent medical psychological and social factors (Axes III and IV), and a summary of how their condition impacts on their skills of daily living (Axis V). Table 6.2b-II gives the clinical categories listed under Axis I of DSM IV.
The structure of DSM IV reflects the biopsychosocial model of the causation of mental illness. A DSM IV diagnosis allows for separate assessment of the various factors that might have contributed to the development of an episode of mental illness (see Q6.2b-3–Q6.2b-4).
Delirium is a state in which although there is consciousness, it is clouded and the level of consciousness may fluctuate. Delirium is characterised by restlessness and the tendency to experience visual hallucinations. It is commonly seen accompanying severe medical conditions such as septicaemia and liver failure, and is much more likely to develop in elderly people and children. Delirium tremens (the “DTs”) is a well known form of delirium resulting from acute withdrawal from alcohol.
Factitious is an adjective used in conventional medicine to describe those conditions which do not really exist, but instead have been wilfully staged by the patient. In other words the factitious disorders are not what they seem to be in that the evidence for them, the symptoms and signs, have been exaggerated or falsified by the patient. A factitious disorder is not the same as malingering in which the pretence of illness is for some obvious gain such as financial compensation. It is presumed that the gain from factitious illness comes in the form of the care given to a person in the sick role. Munchausen syndrome is a well known factitious condition in which the patient self harms to generate the symptoms of illness.
Self-test 6.2b Classification of mental health disorders
4. The following lists of conditions can be sorted so that neighbouring conditions come from the same diagnostic category in both ICD 10 and DSM IV. Sort the lists so that conditions from the same category are next to each other.
|brief psychotic disorder||generalised anxiety disorder|
|nicotine addiction||Alzheimer disease|
|tic disorder of childhood||acute alcohol intoxication|