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CHAPTER 1 Last modified: 07 Feb 2006
INTRODUCTION
Aim and Definitions
The aim of this download is to present the basics of mental disorders. The target
population is medical students, but general public readers may also find it useful. The
mental disorders form a huge, mysterious and problematic body of knowledge. They also
indicate a huge body of ignorance. The mental disorders represent a major challenge to
contemporary science, government and humanity. When the less severe forms are
included, more than 25% of the people in western populations will experience a mental
disorder at some time in their lives (The World Health Report, 2001).
The terms mental disorder, mental illness, mental disease, psychiatric disorder,
psychiatric illness, and psychological illness, all mean much the same. These terms refer
to a group of recognized medical conditions in which the central feature is psychological
distress or disability.
There are no satisfactory definitions of these umbrella terms. This is not a great concern,
however, as while the definition of mental disorder may be elusive, there is universal
agreement about the specific disorders which are covered by such headings. There is
agreement, for example, that schizophrenia, bipolar disorder, major depressive disorder
and obsessive-compulsive disorder are among the mental disorders, and armed robbery,
chicken pox and being old are not.
Classification Systems
Over the last century many individual psychiatrists composed their own lists
(classification systems) of mental disorders
Currently, there are two main classification systems which are used around the world.
Both were composed by large teams of informed professionals using extensive resources.
These separate teams have also worked together, so that their documents are very similar,
if not the same, in most aspects.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revised, was published by the American Psychiatric Association in Washington, DC, in
2002. It is widely used, and was designed for clinical and research purposes. For
convenience it is usually referred to as the DSM-IV.
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The other major classification system can also be used in the clinical setting and is used
in this way in Great Britain. However, in many parts of the world it is predominantly
used for administrative purposes, for example, as a tool in the counting of the number of
cases of particular disorders in particular populations, and in keeping track of the type of
services being provided in particular regions. This is the International Classification of
Diseases, Edition 10, Classification of Mental and Behavioural Disorders, which was
published by the World Health Organisation in Geneva, in 1992. It is usually referred to
as the ICD-10.
Symptoms, Signs and Syndromes
These terms are used in all branches of clinical medicine. If you wake up one morning
with a severe pain in your big toe, that is a symptom – it is something the patient notices
and usually complains about. If your toe was swollen, red and tender to touch, these are
signs – these are observations a doctor can make during an examination.
Symptoms and signs usually form patterns. Recognising a particular pattern and thereby
identifying the precise disorder which the patient is suffering is called making a
diagnosis. The most likely disorder in the case of the painful, swollen, red, tender big toe
would be gout. For some disorders special tests, such as blood or X-ray examinations,
may confirm the diagnosis. Unfortunately, at this point in time, there are no special tests
which confirm the presence of particular mental disorders. However, special tests may be
used to exclude certain conditions, such as brain tumours, which may have similar signs
and symptoms to a mental disorder, such as schizophrenia.
The term syndrome also refers to a set of signs and symptoms, and for present purposes,
it can be considered to mean much the same as disorder. Technically, the term syndrome
is often used when there is some doubt and doctors are not prepared to diagnose a
specific disorder.
No single symptom is found in only one disorder. A pain in the toe may be the result of a
broken bone, an infection, a form of arthritis other than gout, pressure on a nerve in the
back or a brain disease. A pain in the toe may even occur when the toe and the entire leg
has been amputated years previously; this disorder known as phantom limb or phantom
pain.
Rarely is a single sign found in only one disorder. A leg bent at right angels following a
motor bike accident strongly suggests a fractured bone. But other possibilities would
include dislocation of the knee, or the individual may have escaped injury to the lower
limb, but carries a congenital deformity of the leg.
Thus, to diagnose a disorder, even with relatively straightforward medical conditions, it is
necessary to collect all the available symptoms and signs and to match them with
recognized, published patterns.
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There is a wide range of psychiatric signs and symptoms. Examples of psychiatric signs
include disturbances of mood (sadness/depression, elation/mania, fear/anxiety), delusions
(beliefs in the absence of evidence, such as, that one is being watched by aliens) and
hallucinations (perceptions in the absence of stimuli, such as hearing voices when no one
is present). Examples of psychiatric signs include disturbances in behaviour (slowed,
rapid or bizarre movement, or inappropriate crying or laughing) and disturbances in
thought processes (distractibility or inability to think in a logical manner).
Different mental disorders have different sets or patterns of symptoms and signs.
However, as no symptom or sign occurs exclusively in any disorder, the diagnosis in a
particular case depends on the nature and pattern of the signs and symptoms present at
the time of assessment. For example, schizophrenia, mania, drug induced psychosis, and
major depressive disorder, may all present with delusions. The nature of the symptom
may give some clue (but this can not be given too much weight): the person with
schizophrenia is more likely to believe he is being followed by spies, the person with
mania is more likely to believe he is the richest person in the world, the person with drug
induced psychosis is more likely to believe he is being watched by the police, and the
person with major depressive disorder is more likely to believe he is guilty of neglecting
his responsibilities. But, the combination of the signs and symptoms gives the most
accurate answer. While the deluded person with schizophrenia is more likely to be also
hearing voices, the deluded person with mania is more likely to be also unable to stop
talking and the deluded person with major depression is more likely to be also wringing
his hands and attempting to hang himself.
Accordingly, this download will describe some common signs and symptoms in detail, as
well as cover the main mental disorders.
Faking It
We will consider the topic of faking mental disorder in greater detail in later chapters, but
preliminary mention is necessary. For some reason, those of us who are well can be
suspicious of those of us who are not well. Perhaps we are concerned that those who are
unwell are getting some unfair advantage by being excused from some of the usual
responsibilities of life, such as going to work, and getting undeserved attention from their
families and important people (like ourselves). Perhaps some of us lack confidence and
are concerned that we could be being fooled by some of those who are unwell. Concern
that people may be faking being unwell is greater with mental disorders than with other
medical conditions, probably because there is less for the observer to see. At some point
most people with a mental disorder say they prefer to have broken leg or to have lost an
arm, so that others could then “see” they have a genuine problem.
The most pressing desire of people who are incapacitated by mental disorders it to return
to a “normal” life, and that means returning to active parenting, dressing in style, going to
work and paying taxes. Any small advantages of the sick role are generally greatly
outweighed by the disadvantages.
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The patient who is suffering major depression is not being self-indulgent or seeking
attention. In this disorder the mood is low and distressing, and recovery is beyond the
control of the patient. He or she is incapable of responding to the advice to “pull yourself
together” or “snap out of it”. Major depression may be so severe that the patient commits
suicide. This can happen to an individual who, when well, would not contemplate such
action because of family responsibilities, or on religious or moral grounds. (Suicide can
occur for reasons other than major depression, but that will be addressed later.)
The patient suffering delusions is not pretending to believe things which others find
laughable. He or she may be so convinced of the truth of their belief that suicide is seen
as the only option, or innocent others, even loved family members, may be verbally or
physically attacked. The patient with obsessive-compulsive disorder who has washed his
or her hands ninety nine times may agree that logically, his or her hands must be clean,
but may be unable to resist the compulsion to wash them one more time. More common
examples include patients who are suffering anxiety (butterflies in the stomach, tremor of
the hands, headache, worrying and irritability), who know they have nothing to fear, but
cannot shake off the symptoms which are appropriate to dangerous situations.
We are what we think, feel and do. We pick up real signals from the external world (not
hallucinations) and respond appropriately. These abilities form our essence or being, they
are central to our ability to function logically, independently and in accordance with our
own plans and decisions. They enable us to function as autonomous (self-governing)
individuals. Mental disorders, however, interfere with our ability to interpret the world
accurately, to feel appropriate emotions, to think, to plan and to act appropriately to our
external and internal circumstances. To lose a leg is a terrible loss, but to suffer a mental
disorder is to lose the sense of control, of autonomy, of being a human being. It is no
wonder that mental disorders are greatly feared.
Mental Versus Physical Disorders
It is people who develop diseases or disorders, not minds or bodies. The division of
disorders into mental and physical categories is a mistake, which began in the 18th
century when the philosopher Rene Descartes popularized his idea of “dualism”. This
was the belief that the individual can be separated into two parts, a body and a mind.
Dualism seems to fit the experience of most humans most of the time, and it has therefore
been difficult to get the public (as well as many doctors) to move beyond this unhelpful
idea. The mind is a function of the brain. Dualism seems to fit the experience of most
humans because the brain does not “see” or is unaware of itself. Thus, the mind is
encountered as something separate from the body rather than a function of the body.
The interrelationship of mind and body can be demonstrated in many ways. If the brain is
damaged, the mind may be damaged. As mentioned above, a brain tumour may present
with symptoms of hallucinations or delusions. Many mental disorders have a strong
genetic basis. Genes exert their influence by altering physical structure, in the case of
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mental disorders, genes influence the structure of the brain. Also, the mind changes the
brain. All would agree that learning a lesson represents a mental or mind function. If a
laboratory animal learns something, such as to push a lever for food, and the brain of that
animal is then examined, it is found the connections between particular brain cells are
changed. Microscopically, they became darker and thicker. It is chilling to realize that
when we were taught the two times table at school we were having our brains changed,
and the only reason we can remember our tables now is that those brain changes have
remained.
There are no distinct mental or physical disorders. For example, the early stage of
infections, from influenza to plague, is loss of emotional spark and a feeling of malaise.
Conversely, with most of the so-called mental diseases there are physical signs and
symptoms, such as loss of appetite, loss of weight, insomnia and diarrhoea or
constipation.
The DSM-IV is apologetic in using the term mental, calling it an “anachronism of
mind/body dualism”. The authors state it appears in the title of their document only,
“because we have not found an appropriate substitute”. It is used in the present download
so as to stay in step with leading authorities. It is hoped an holistic concept will be
embraced in the near future.
Mental Health and Mental Health Problems
The concept of mental health is confusing. It is a theoretical construction and has been
popularized by governments and government agencies.
Theoretically, when individuals have impaired mental health they can be experiencing
either 1) a mental disorder, or 2) a mental health problem. These categories have
unwisely, but understandably, been rolled together and made the responsibility of
government funded mental health services.
The focus of this download is mental disorders. But, let us take a moment to explore the
second category of mental health problems. The term ‘health’ is used in this setting to put
a positive spin on the facts. It is claimed “health” emphasizes wellness rather than
sickness. Health is stated to mean “much more than the mere absence of disease”. And,
mental health is defined as “the capacity of individuals within groups and the
environment to interact with one another in ways that promote subjective well being,
optimal development and use of mental abilities and the achievement of individual and
collective goals.” A central notion is that mental health has to do with “subjective well
being”.
Accordingly, mental health problems have been described as “a disruption in the
interactions between the individual, the group and the environment producing a
diminished state of mental health”. Thus, a mental health problem has occurred when
something has disturbed the individuals subjective well being. A loss at the races, a
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disagreement with the spouse, being mugged – by definition, all of these can be seen as
mental health problems.
For the sake of administrative neatness, in some settings, mental health problems have
been cobbled together with mental disorders, and made the responsibility of government
funded mental health services. This is unwise. While psychiatrists and other mental
health professional have a good understanding of personal distress, they generally have
little to offer in the case of mental health problems, which are better considered to be
social rather than medical problems.
Causes of Mental Disorders
The cause of the mental disorders is not fully understood. Nor are the causes of many
medical disorders fully understood. Pneumonia is understood, it is usually a bacterial
infection the lungs. But apart from the infections, we have much to learn about most
diseases and disorders. Even with a genetic disease, where the exact location of the gene
on the chromosome and the abnormality of the gene have been discovered, we still may
not know the cause. Huntington’s disease, a serious genetic brain disease, is a good
example. Although we know the location of the gene and the abnormality of the gene, we
still do not know why the gene becomes corrupted, or the mechanism by which the
corrupted gene results in damage to brain cells.
Mental disorders, in general, are believed to be multifactorial, meaning many factors
contribute to the cause of the disease and the appearance of symptoms and signs. These
include biological, psychological and social factors, which are rolled into the
cumbersome term “biopsychosocial”, which can be applied to both cause and treatment
(see later).
Most mental disorders are considered to have a genetic (biological) basis, meaning there
is usually an inherited genetic vulnerability or tendency. Schizophrenia is a good
example. If one monozygotic twin (monozygotic twins have exactly the same genes)
develops schizophrenia, there is a 50% chance that the other twin will also develop that
disorder. When we consider that the prevalence of schizophrenia in the population is
about 1%, it is clear that genetic factors are important. However, looked at the other way,
when one twin develops schizophrenia, 50% of the other twins do not develop the
disorder. This means that in addition to the genetic factors, other factors must also play a
part.
Stress (psychological) can contribute to mental disorders. Stress during childhood has
long been thought to contribute to anxiety and insecurity in adulthood. There is now
strong evidence that severe childhood stress, particularly the psychological stress
associated with physical and sexual abuse, contributes to the severe adult disorder called
borderline personality disorder. The more immediate, and therefore more obvious,
damaging effect of stress occurs in post-traumatic stress disorder. In this disorder, healthy
adults subjected to horrific trauma, such as warfare or rape, may develop disabling
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anxiety, difficulty with thinking and personality change. One current theory is that the
hormones which help the individual deal with stress may, when released in excessive
amounts, actually damage the brain.
Social factors contribute to mental disorders. It is recognised that the loss of status
associated with loss of employment may trigger major depressive disorder. In anorexia
nervosa, excessive purposeful weight loss, more common in females, the impact of social
factors cannot be overestimated. The fashion industry, the media and peer groups all
promote the desirability of thinness, encouraging undue attention body image and eating.
Treatment of Mental Disorders
Few branches of medicine provide cures. Most bacterial infections, such as bacterial
pneumonia, can be cured with antibiotic medicine. Broken limbs can be set and some
joints can be replaced. But most chronic disease, such as arthritis, diabetes and heart
disease, is managed rather than cured.
The treatment of most mental disorders is aimed at providing relief. There are four main
types: psychotherapy, medication and other physical treatments and rehabilitation.
Psychotherapy is a form of treatment with depends on verbal interchanges between
patient and therapist. It is “talking therapy”. There are many forms. Psychoanalysis was
described by Sigmund Freud and seeks to deal with mild to moderate mood and
personality disorders by investigating and modifying feelings and beliefs which have
their origin in the early years of life and about which the patient is not fully aware. More
recently cognitive behaviour therapy (CBT) has been described. Again, this treatment is
most suited to the mild and moderate mood and personality disorders. In CBT the
therapist is more actively involved in the session and the focus is on the self-defeating
beliefs which patients have come to accept. For certain disorders, psychotherapy may be
the sole treatment. However, most psychiatric treatment, indeed most medical treatment,
involves educational and supportive elements which are considered to be elements of
psychotherapy.
Medication is widely used in the treatment of mental disorders. Nerve cells are like long
wires and messages pass along them as electric impulses. The connections between
nerves are called synapses. At these connections the message is passed along by the
release of a chemical (neurotransmitter) by one nerve cell which travels across a tiny gap
and plugs into a specially designed receiver (receptor). There are at least two hundred
different neurotransmitters and different medications different actions. Most psychiatric
medication acts by influencing the production, destruction, release or arrival of
neurotransmitters. Others have a more direct action on the nerve cells themselves.
Medications of the future are likely to be of this latter type.
Other physical treatments include electroconvulsive therapy (ECT), light therapy and
transcranial magnetic stimulation (TMS). ECT is the strongest antidepressant available.
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The patient is given an anaesthetic and while unconscious, a small electric current is
applied to the head. TMS appears to be an effective treatment of mood disorder
(Pridmore et al 2000; Avery et al, 2005). The patient is not given anaesthetic and tiny
electrical currents are produced in localized areas of the brain using electromagnetic
apparatus.
Rehabilitation means a return to normal activities and independent living. Rehabilitation
is provided in addition to other treatments. Rehabilitation is provided to workers who
injure their backs at work and involves various treatments (including surgical) and a
graduated return-to-work. Similarly, rehabilitation return-to-work programs are provided
to workers who develop temporary mental disorders. Rehabilitation of some chronic
mental disorders (such as schizophrenia), however, may be more protracted, extending
over years and include help with daily living activities, such as personal hygiene and
budgeting. This is because chronic mental disorders may impair a wide range of functions
and there may be a need for support with housing, re-training in social skills and
assistance to increase the quality of life of the individual. Teaching and encouragement
are important tools.
Psychiatrists and Mental Health Teams
A psychiatrist is a qualified medical doctor who has obtained additional qualifications in
the diagnosis and treatment of mental disorders. Psychiatric training provides a broad
understanding of the psychological, social and biological contributions to these disorders,
and their treatments including psychotherapy, medication, electroconvulsive therapy and
transcranial magnetic stimulation.
The psychiatrist is able to contribute in many situations of distress. However, when the
distress is not a feature of a mental disorder, the psychiatrist is no better placed to help
than other helpers. In fact, the psychiatrist may be less well placed to help than social
workers or religious officers, who have their own skills, experience and support systems.
Other members of the mental health team include clinical psychologists, psychiatric
nurses, occupational therapists and social workers. Some teams have a member who has
special knowledge and skill in placing people in employment.
Clinical psychologists do not have medical training and do not order medical
investigations or prescribe medical treatments. They are skilled in psychological testing
and usually have training in talking therapies such as counselling, psychotherapy and
behaviour therapy.
Psychiatric nurses are the most numerous group and form the backbone of inpatient and
outpatient services. Their training is becoming progressively broader and more
professional. Occupational therapists help in the rehabilitation of people who have been
damaged by server mental disorder.
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Mental health teams provide comprehensive care, but they are expensive and are usually
provided only by governments or other well funded organisations.
References
Avery D, Holtzheimer P, Fawaz W, Russo J, Neumaier J, Dunner D, Haynor D,
Claypoole K, Wajdik C, Roy-Byrne P. A controlled study of repetitive transcranial
magnetic stimulation in medication-resistant major depression. Biological Psychiatry
2005; Aug 31 [Epub ahead of print].
Pridmore S, Bruno R, Turnier-Shea Y, Reid P, Rybak M. Comparison of unlimited
numbers of rapid transcranial magnetic stimulation (rTMS) and ECT treatment sessions
in major depressive episode. International Journal of Neuropsychopharmacology 2000;
3:129-134.
The World Health Report 2001: Mental health: new understanding, new hope. World
Health Organization, Geneva, 2001.
