Mental Illness, disorder characterized by disturbances in a person’s thoughts, emotions, or behavior. The term mental illness can refer to a wide variety of disorders, ranging from those that cause mild distress to those that severely impair a person’s ability to function. Mental health professionals sometimes use the terms psychiatric disorder or psychopathology to refer to mental illness.
II THE EXPERIENCE OF MENTAL ILLNESS
Severe mental illness almost always alters a person’s life dramatically. People with severe mental illnesses experience disturbing symptoms that can make it difficult to hold a job, go to school, relate to others, or cope with ordinary life demands. Some individuals require hospitalization because they become unable to care for themselves or because they are at risk of committing suicide.
The symptoms of mental illness can be very distressing. People who develop schizophrenia may hear voices inside their head that say nasty things about them or command them to act in strange or unpredictable ways. Or they may be paralyzed by paranoia—the deep conviction that everyone, including their closest family members, wants to injure or destroy them. People with major depression may feel that nothing brings pleasure and that life is so dreary and unhappy that it is better to be dead. People with panic disorder may experience heart palpitations, rapid breathing, and anxiety so extreme that they may not be able to leave home. People who experience episodes of mania may engage in reckless sexual behavior or may spend money indiscriminately, acts that later cause them to feel guilt, shame, and desperation.
Other mental illnesses, while not always debilitating, create certain problems in living. People with personality disorders may experience loneliness and isolation because their personality style interferes with social relations. People with an eating disorder may become so preoccupied with their weight and appearance that they force themselves to vomit or refuse to eat. Individuals who develop post-traumatic stress disorder may become angry easily, experience disturbing memories, and have trouble concentrating.
Experiences of mental illness often differ depending on one’s culture or social group, sometimes greatly so. For example, in most of the non-Western world, people with depression complain principally of physical ailments, such as lack of energy, poor sleep, loss of appetite, and various kinds of physical pain. Indeed, even in North America these complaints are commonplace. But in the United States and other Western societies, depressed people and mental health professionals who treat them tend to emphasize psychological problems, such as feelings of sadness, worthlessness, and despair. The experience of schizophrenia also differs by culture. In India, one-third of new cases of schizophrenia involve catatonia, a behavioral condition in which a person maintains a bizarre statuelike pose for hours or days. This condition is rare in Europe and North America.
With appropriate treatment, most people can recover from mental illness and return to normal life. Even those with persistent, long-term mental illnesses can usually learn to manage their symptoms and live productive lives.
III ATTITUDES TOWARD MENTAL ILLNESS
In most societies mental illness carries a substantial stigma, or mark of shame. The mentally ill are often blamed for bringing on their own illnesses, and others may see them as victims of bad fate, religious and moral transgression, or witchcraft. Such stigma may keep families from acknowledging that a family member is ill. Some families may hide or overprotect a member with mental illness—keeping the person from receiving potentially effective care—or they may reject the person from the family. When magnified from individuals to a whole society, such attitudes lead to underfunding of mental health services and terribly inadequate care. In much of the world, even today, the mentally ill are chained, caged, or hospitalized in filthy, brutal institutions. Yet attitudes toward mental illness have improved in many areas, especially owing to health education and advocacy for the mentally ill.
IV SOCIAL AND ECONOMIC COSTS
Mental illness creates enormous social and economic costs. Depression, for example, affects some 500 million people in the world and results in more time lost to disability than such chronic diseases as diabetes mellitus and arthritis. Estimating the economic cost of mental illness is complex because there are direct costs (actual medical expenditures), indirect costs (the cost to individuals and society due to reduced or lost productivity, for example), and support costs (time lost to care of family members with mental illnesses). One study estimated that in 1985 the economic costs of mental illness in the United States totaled $103.7 billion. Of this, treatment and support costs totaled $42.5 billion, which represented 11.5 percent of the total cost of care for all illnesses.
Another method of estimating the cost of mental illness to society measures the impact of premature deaths and disablements. Research by the World Health Organization and the World Bank estimated that in 1990, among the world’s population aged 15 to 44 years, depression accounted for more than 10 percent of the total burden attributable to all diseases. Two other illnesses, bipolar disorder and schizophrenia, accounted for another 6 percent of the burden. This research has helped governments recognize that mental illnesses constitute a far greater challenge to public health systems than previously realized.
V DEFINING MENTAL ILLNESS
No universally accepted definition of mental illness exists. In general, the definition of mental illness depends on a society’s norms, or rules of behavior. Behaviors that violate these norms are considered signs of deviance or, in some cases, of mental illness.
Because norms vary between cultures, behaviors considered signs of mental illness in one culture may be considered normal in other cultures. For example, in the United States, a person who experiences trance and possession states (altered states of consciousness) is usually diagnosed as suffering from a mental illness. Yet, in many non-Western countries, people consider such states an essential part of human experience. In Native American culture, it is common for people to hear the voices of recently deceased loved ones. In contrast, most mental health professionals in Western cultures would consider such behavior a possible symptom of schizophrenia or psychosis.
The variation in behavioral norms does not mean, however, that definitions of mental illness are necessarily incompatible across cultures. Many behaviors are recognized throughout the world as being indicative of mental illness. These include extreme social withdrawal, violence to oneself, hallucinations (false sensory perceptions), and delusions (fixed, false ideas).
Another way of defining mental illness is based on whether a person’s behaviors are maladaptive—that is, whether they cause a person to experience problems in coping with common life demands. For example, people with social phobia may avoid interacting with other people and experience problems at work as a result. Critics note that under this definition, political dissidents could be considered mentally ill for refusing to accept the dictates of their government.
Mental illness affects people of all ages, races, cultures, and socioeconomic classes. The prevalence of mental illness refers to how many people experience a mental illness during a specified time period.
A United States and Worldwide
In the United States, researchers estimate that about 24 percent of people 18 or older, or about 44 million adults, experience a mental illness or substance-related disorder during the course of any given year. The most common of these disorders are depression, alcohol dependence (see alcoholism), and various phobias (irrational fears of things or situations). An estimated 2.6 percent of adults in the United States, or about 4.8 million people, suffer from a severe and persistent mental illness—such as schizophrenia, bipolar disorder, or a severe form of depression or panic disorder—in any given year. An additional 2.8 percent of adults, or about 5.2 million people, experience a mental illness that seriously interferes with one or more aspects of their daily life, such as their ability to work or relate to other people. All of these figures exclude people who are homeless and those living in prisons, nursing homes, or other institutions—populations that have high rates of mental illness.
International surveys have demonstrated that from 30 to 40 percent of people in a given population experience a mental illness during their lives. These surveys also reveal that anxiety disorders are usually even more common than depression.
B Among Children and Adolescents
Young people can suffer from mental illnesses and psychological problems just as adults can. Prevalence estimates in industrialized countries indicate that from 14 to 20 percent of individuals under age 18 suffer from a diagnosable mental disorder. In the United States, an estimated 9 to 13 percent of children between the ages of 9 and 17 suffer from a serious emotional disturbance—that is, a disorder that severely disrupts a child’s daily functioning in the family, school, or community.
Anxiety disorders are the most common childhood mental disorders, affecting an estimated 8 to 10 percent of children and adolescents in the United States. Children with these disorders experience persistent, unrealistic worry or uneasiness that interferes with their ability to function normally. About 4 percent of children and young adolescents experience severe separation anxiety and worry excessively about becoming separated from their parents. Depression is another common childhood mental disorder, affecting up to 2.5 percent of children (under age 13) and up to 8.3 percent of adolescents in the United States. Depression in children can lead to failure in school, poor self-image, troubled social relations, and even suicide.
A number of mental disorders are usually first diagnosed in infancy, childhood, or adolescence. Autism is a relatively rare disorder that appears before the age of three and severely impairs a child’s ability to interact socially and to communicate with others. Attention-deficit hyperactivity disorder begins before the age of seven. Its symptoms include an inability to sit still, focus attention, or control impulses. Eating disorders, such as anorexia nervosa and bulimia nervosa (see Bulimia), most often affect adolescent girls.
C Among the Elderly
With a greater percentage of people living beyond the age of 65—both in the industrialized nations of the West and the developing countries of Asia, Africa, and Latin America—the problem of mental illness among the elderly has grown significantly. Researchers estimate that from 15 to 25 percent of elderly people in the United States suffer from significant symptoms of mental illness. Dementia, characterized by confusion, memory loss, and disorientation, occurs mostly among the elderly. A study of residents of Boston, Massachusetts, revealed that about 10 percent of people over the age of 65 suffer from Alzheimer’s disease, the most common form of dementia, and research on residents of Shanghai, China found that 4.6 percent of people over 65 suffer from this condition.
Major depression, the most severe form of depression, affects from 1 to 2 percent of people aged 65 or older who are living in the community (rather than in nursing homes or other institutions). The prevalence of depression and other mental illnesses is much higher among elderly residents of nursing homes. Although most older people with depression respond to treatment, many cases of depression among the elderly go undetected or untreated. Research indicates that depression is a major risk factor for suicide among the elderly in the United States. People over age 65 in the United States have the highest suicide rate of any age group.
D Among the Poor
Like physical diseases, the highest rates of mental illness occur among people in the lower socioeconomic classes, especially those living in severe poverty. Rates of almost all mental illnesses decline as levels of income and education increase. A national survey published in 1994 indicated that people who earned $19,000 or less annually in the United States were twice as likely to have experienced an anxiety disorder as people who earned $70,000 or more. The hardships associated with poverty seem to contribute to the development of some mental illnesses, particularly anxiety disorders and depression. In addition, debilitating mental illnesses, such as schizophrenia, may cause individuals to drift to lower socioeconomic classes.
E Among Men and Women
Generally, the overall prevalence rates of mental illnesses among men and women are similar. However, men have much higher rates of antisocial personality disorder and substance abuse. In the United States, women suffer from depression and anxiety disorders at about twice the rate of men. The gender gap is even wider in some countries. For example, in China, women suffer from depression at nine times the rate of men.
F Changing Rates of Mental Illness
Mental illness is becoming an increasing problem for two reasons. First, increases in life expectancy have brought increased numbers of certain chronic mental illnesses. For example, because more people are living into old age, more people are suffering from dementia. Second, a number of studies provide evidence that rates of depression are rising throughout the world. The reasons may be related to such factors as economic change, political and social violence, and cultural disruptions. While some have questioned these findings, dramatic increases in the numbers of refugees and people dislocated from their homes by economic forces or civil strife are associated with great increases in a variety of mental illnesses for those populations. According to the United Nations High Commissioner for Refugees, the number of refugees worldwide increased from 2.5 million in 1971 to 13.2 million in 1996, peaking at 17 million in 1991.
VII KINDS OF MENTAL ILLNESSES
A number of mental illnesses—such as depression, anxiety disorders, schizophrenia, and bipolar disorder—occur worldwide. Others seem to occur only in particular cultures. For example, eating disorders, such as anorexia nervosa (compulsive dieting associated with unrealistic fears of fatness), occur mostly among girls and women in Europe, North America, and Westernized areas of Asia, whose cultures view thinness as an essential component of female beauty. In Latin America, people who experience overwhelming fright after a dangerous or traumatic event are said to have susto (fright), an illness in which their soul has been frightened away. In some societies of West Africa and elsewhere, brain fag describes individuals (usually students) who experience difficulties in concentrating and thinking, as well as physical symptoms of pain and fatigue.
Most mental health professionals in the United States use the Diagnostic and Statistical Manual of Mental Disorders(DSM), a reference book published by the American Psychiatric Association, as a guide to the different kinds of mental illnesses. The fourth edition, known as DSM-IV, describes more than 300 mental disorders, behavioral disorders, addictive disorders, and other psychological problems and groups them into broad categories. This article describes some of the major categories, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders, personality disorders, cognitive disorders, dissociative disorders, somatoform disorders, factitious disorders, substance-related disorders, eating disorders, and impulse-control disorders. Mental health professionals in many other parts of the world use a different classification system, the International Classification of Diseases (ICD), published by the World Health Organization.
The DSM and ICD are both categorical systems of classification, in which each mental illness is defined by its own unique set of symptoms and characteristics. In theory, each disorder should possess diagnostic criteria that are independent of one another, just as tuberculosis and lung cancer are discrete diseases. Yet symptoms of many mental disorders overlap, and many people—such as those who experience both depression and severe anxiety—show symptoms of more than one disorder at the same time. For these reasons, some mental health professionals advocate a dimensional system of classification. In contrast to the categorical approach, which sees mental disorders as qualitatively distinct from normal behavior, a dimensional system views behavior as falling along a continuum of normality, with some behaviors considered more abnormal than others. In a dimensional system, diagnoses do not describe discrete diseases but rather portray the relative importance of an array of symptoms.
Definitions and classifications of mental illnesses change as research improves understanding of them. For example, DSM-IV allows a diagnosis of schizophrenia only when characteristic symptoms have lasted at least one month, whereas the previous edition of DSM required a duration of only one week.
A Anxiety Disorders
Anxiety disorders involve excessive apprehension, worry, and fear. People with generalized anxiety disorder experience constant anxiety about routine events in their lives. Phobias are fears of specific objects, situations, or activities. Panic disorder is an anxiety disorder in which people experience sudden, intense terror and such physical symptoms as rapid heartbeat and shortness of breath. People with obsessive-compulsive disorder experience intrusive thoughts or images (obsessions) or feel compelled to perform certain behaviors (compulsions). People with post-traumatic stress disorder relive traumatic events from their past and feel extreme anxiety and distress about the event.
B Mood Disorders
Mood disorders, also called affective disorders, create disturbances in a person’s emotional life. Depression, mania, and bipolar disorder are examples of mood disorders. Symptoms of depression may include feelings of sadness, hopelessness, and worthlessness, as well as complaints of physical pain and changes in appetite, sleep patterns, and energy level. In mania, on the other hand, an individual experiences an abnormally elevated mood, often marked by exaggerated self-importance, irritability, agitation, and a decreased need for sleep. In bipolar disorder, also called manic-depressive illness, a person’s mood alternates between extremes of mania and depression.
C Schizophrenia and Other Psychotic Disorders
People with schizophrenia and other psychotic disorders lose contact with reality. Symptoms may include delusions and hallucinations, disorganized thinking and speech, bizarre behavior, a diminished range of emotional responsiveness, and social withdrawal. In addition, people who suffer from these illnesses experience an inability to function in one or more important areas of life, such as social relations, work, or school. See Psychosis.
D Personality Disorders
Personality disorders are mental illnesses in which one’s personality results in personal distress or a significant impairment in social or work functioning. In general, people with personality disorders have poor perceptions of themselves or others. They may have low self-esteem or overwhelming narcissism, poor impulse control, troubled social relationships, and inappropriate emotional responses. Considerable controversy exists over where to draw the distinction between a normal personality and a personality disorder.
E Cognitive Disorders
Cognitive disorders, such as delirium and dementia, involve a significant loss of mental functioning. Dementia, for example, is characterized by impaired memory and difficulties in such functions as speaking, abstract thinking, and the ability to identify familiar objects. The conditions in this category usually result from a medical condition, substance abuse, or adverse reactions to medication or poisonous substances. See Senile Dementia.
F Dissociative Disorders
Dissociative disorders involve disturbances in a person’s consciousness, memories, identity, and perception of the environment. Dissociative disorders include amnesia that has no physical cause; dissociative identity disorder, in which a person has two or more distinct personalities that alternate in their control of the person’s behavior; depersonalization disorder, characterized by a chronic feeling of being detached from one’s body or mental processes; and dissociative fugue, an episode of sudden departure from home or work with an accompanying loss of memory. In some parts of the world people experience dissociative states as “possession” by a god or ghost instead of separate personalities. In many societies, trance and possession states are normal parts of cultural and religious practices and are not considered dissociative disorders.
G Somatoform Disorders
Somatoform disorders are characterized by the presence of physical symptoms that cannot be explained by a medical condition or another mental illness. Thus, physicians often judge that such symptoms result from psychological conflicts or distress. For example, in conversion disorder, also called hysteria, a person may experience blindness, deafness, or seizures, but a physician cannot find anything wrong with the person. People with another somatoform disorder, hypochondriasis (see Hypochondria), constantly fear that they will develop a serious disease and misinterpret minor physical symptoms as evidence of illness. The term somatoform comes from the Greek word soma, meaning “body.”
H Factitious Disorders
In contrast to people with somatoform disorders, people with factitious disorders intentionally produce or fake physical or psychological symptoms in order to receive medical attention and care. For example, an individual might falsely report shortness of breath to gain admittance to a hospital, report thoughts of suicide to solicit attention, or fabricate blood in the urine or the symptoms of rash so as to appear ill. Munchausen syndrome represents the most extreme and chronic variant of the factitious disorders.
I Substance-Related Disorders
Substance-related disorders result from the abuse of drugs, side effects of medications, or exposure to toxic substances. Many mental health professionals regard these disorders as behavioral or addictive disorders rather than as mental illnesses, although substance-related disorders commonly occur in people with mental illnesses. Common substance-related disorders include alcoholism and other forms of drug dependence. In addition, drug use can contribute to symptoms of other mental disorders, such as depression, anxiety, and psychosis. Drugs associated with substance-related disorders include alcohol, caffeine, nicotine, cocaine, heroin (see Opium), amphetamines, hallucinogens, and sedatives.
J Eating Disorders
Eating disorders are conditions in which an individual experiences severe disturbances in eating behaviors. People with anorexia nervosa have an intense fear about gaining weight and refuse to eat adequately or maintain a normal body weight. People with bulimia nervosa (see Bulimia) repeatedly engage in episodes of binge eating, usually followed by self-induced vomiting or the use of laxatives, diuretics, or other medications to prevent weight gain. Eating disorders occur mostly among young women in Western societies and certain parts of Asia.
K Impulse-Control Disorders
People with impulse-control disorders cannot control an impulse to engage in harmful behaviors, such as explosive anger, stealing (kleptomania), setting fires (pyromania), gambling (see Pathological Gambling), or pulling out their own hair (trichotillomania). Some mental illnesses—such as mania, schizophrenia, and antisocial personality disorder—may include symptoms of impulsive behavior.
VIII CAUSES OF MENTAL ILLNESS
People have tried to understand the causes of mental illness for thousands of years. The modern era of psychiatry, which began in the late 19th and early 20th centuries, has witnessed a sharp debate between biological and psychological perspectives of mental illness. The biological perspective views mental illness in terms of bodily processes, whereas psychological perspectives emphasize the roles of a person’s upbringing and environment.
These two perspectives are exemplified in the work of German psychiatrist Emil Kraepelin and Austrian psychoanalyst Sigmund Freud. Kraepelin, influenced by the work in the mid-1800s of German psychiatrist Wilhelm Griesinger, believed that psychiatric disorders were disease entities that could be classified like physical illnesses. That is, Kraepelin believed that the fundamental causes of mental illness lay in the physiology and biochemistry of the human brain. His classification system of mental disorders, first published in 1883, formed the basis for later diagnostic systems. Freud, on the other hand, argued that the source of mental illness lay in unconscious conflicts originating in early childhood experiences. Freud found evidence for this idea through the analysis of dreams, free association, and slips of speech.
This debate has continued into the late 20th century. Beginning in the 1960s, the biological perspective became dominant, supported by numerous breakthroughs in psychopharmacology, genetics, neurophysiology, and brain research. For example, scientists discovered many medications that helped to relieve symptoms of certain mental illnesses and demonstrated that people can inherit a vulnerability to some mental illnesses. Psychological perspectives also remain influential, including the psychodynamic perspective, the humanistic and existential perspectives, the behavioral perspective, the cognitive perspective, and the sociocultural perspective.
Many mental health professionals today favor a combination of perspectives, acknowledging that both biology and a person’s environment play important roles in mental illness. This approach recognizes that people are not only products of the genes inherited from their parents, but products of the families and social worlds into which they are born. In this view, environments shape how biological factors will be manifested. For example, an infant may inherit genes that could enable her to become a tall adult, but if she is malnourished as a child, she will never achieve that potential. Likewise, an individual who does not possess a biological vulnerability for depression may nevertheless become severely depressed following the death of a loved one or after experiencing an act of torture.
A Biological Perspective
Psychiatry has increasingly emphasized a biological basis for the causes of mental illness. Studies suggest a genetic influence in some mental illnesses, such as schizophrenia and bipolar disorder, although the evidence is not conclusive.
Scientists have identified a number of neurotransmitters, or chemical substances that enable brain cells to communicate with each other, that appear important in regulating a person’s emotions and behavior. These include dopamine, serotonin, norepinephrine (see epinephrine), gamma-amino butyric acid (GABA), and acetylcholine. Excesses and deficiencies in levels of these neurotransmitters have been associated with depression, anxiety, and schizophrenia, but scientists have yet to determine the exact mechanisms involved.
Advances in brain imaging techniques, such as magnetic resonance imaging (MRI) and positron emission tomography (PET), have enabled scientists to study the role of brain structure in mental illness. Some studies have revealed structural brain abnormalities in certain mental illnesses. For example, some people with schizophrenia have enlarged brain ventricles (cavities in the brain that contain cerebrospinal fluid). However, this may be a result of schizophrenia rather than a cause, and not all people with schizophrenia show this abnormality.
A variety of medical conditions can cause mental illness. Brain damage and strokes can cause loss of memory, impaired concentration and speech, and unusual changes in behavior. In addition, brain tumors, if left to grow, can cause psychosis and personality changes. Other possible biological factors in mental illness include an imbalance of hormones, deficiencies in diet, and infections from viruses.
B Psychodynamic Perspective
The psychodynamic perspective views mental illness as caused by unconscious and unresolved conflicts in the mind. As stated by Freud, these conflicts arise in early childhood and may cause mental illness by impeding the balanced development of the three systems that constitute the human psyche: the id, which comprises innate sexual and aggressive drives; the ego, the conscious portion of the mind that mediates between the unconscious and reality; and the superego, which controls the primitive impulses of the id and represents moral ideals. In this view, generalized anxiety disorder stems from a signal of unconscious danger whose source can only be identified through a thorough analysis of the person’s personality and life experiences. Modern psychodynamic theorists tend to emphasize sexuality less than Freud did and focus more on problems in the individual’s relationships with others.
C Humanistic and Existential Perspectives
Both the humanistic and existential perspectives view abnormal behavior as resulting from a person’s failure to find meaning in life and fulfill his or her potential. The humanistic school of psychology, as represented in the work of American psychologist Carl Rogers, views mental health and personal growth as the natural conditions of human life. In Rogers’s view, every person possesses a drive toward self-actualization, the fulfillment of one’s greatest potential. Mental illness develops when circumstances in a person’s environment block this drive. The existential perspective sees emotional disturbances as the result of a person’s failure to act authentically—that is, to behave in accordance with one’s own goals and values, rather than the goals and values of others.
D Behavioral Perspective
The pioneers of behaviorism, American psychologists John B. Watson and B. F. Skinner, maintained that psychology should confine itself to the study of observable behavior, rather than explore a person’s unconscious feelings. The behavioral perspective explains mental illness, as well as all of human behavior, as a learned response to stimuli. In this view, rewards and punishments in a person’s environment shape that person’s behavior. For example, a person involved in a serious car accident may develop a phobia of cars or generalize the fear to all forms of transportation.
E Cognitive Perspective
The cognitive perspective holds that mental illness results from problems in cognition—-that is, problems in how a person reasons, perceives events, and solves problems. American psychiatrist Aaron Beck proposed that some mental illnesses—such as depression, anxiety disorders, and personality disorders—result from a way of thinking learned in childhood that is not consistent with reality. For example, people with depression tend to see themselves in a negative light, exaggerate the importance of minor flaws or failures, and misinterpret the behavior of others in negative ways. It remains unclear, however, whether these kinds of cognitive problems actually cause mental illness or merely represent symptoms of the illnesses themselves.
F Sociocultural Perspective
The sociocultural perspective regards mental illness as the result of social, economic, and cultural factors. Evidence for this view comes from research that has demonstrated an increased risk of mental illness among people living in poverty. In addition, the incidence of mental illness rises in times of high unemployment. The shift in the world population from rural areas to cities—with their crowding, noise, pollution, decay, and social isolation—has also been implicated in causing relatively high rates of mental illness. Furthermore, rapid social change, which has particularly affected indigenous peoples throughout the world, brings about high rates of suicide and alcoholism. Refugees and victims of social disasters—warfare, displacement, genocide, violence—have a higher risk of mental illness, especially depression, anxiety, and post-traumatic stress disorder.
Social scientists emphasize that the link between social ills and mental illness is correlational rather than causal. For example, although societies undergoing rapid social change often have high rates of suicide the specific causes have not been identified. Social and cultural factors may create relative risks for a population or class of people, but it is unclear how such factors raise the risk of mental illness for an individual.
There are no blood tests, imaging techniques, or other laboratory procedures that can reliably diagnose a mental illness. Thus, the diagnosis of mental illness is always a judgment or an interpretation by an observer based on the speech, ideas, behaviors, and experiences of the patient.
For the most part, mental health professionals determine the presence of mental illness in an individual by conducting an interview intended to reveal symptoms of abnormal behavior. That is, the professional asks the patient questions about his or her mental state: “Do you hear voices of people who are not with you?” “Have you felt depressed or lost interest in most activities?” “Have you experienced a marked increase or decrease in your appetite?” “Have you been sleeping less than normal?” “Are you easily distracted?” The answers to these questions will suggest other questions. Eventually, the clinician will feel that he or she has enough information to determine whether the patient is suffering from a mental illness and, if so, to make a diagnosis.
The process of diagnosis is not as simple as it might seem. Patients often have difficulty remembering symptoms or feel reluctant to talk about their fantasies, sex life, or use of drugs and alcohol. Many patients suffer from more than one disorder at a time—for example, depression and anxiety, or schizophrenia and depression—and determining which symptoms constitute the primary problem is complex. In addition, symptoms may not be specific to mental illnesses. For example, brain tumors, malaria, and infections of the central nervous system can produce symptoms that mimic those of psychotic disorders.
Another problem in diagnosis is that mental health professionals may interpret symptoms differently based on their personal or cultural biases. One study examined this effect by showing 300 American and British psychiatrists videotaped interviews of eight patients with mental illnesses. Although the psychiatrists’ diagnoses substantially agreed for patients with “textbook” cases of schizophrenia, their diagnoses varied widely for patients who had symptoms of both schizophrenia and other disorders, depending on whether the psychiatrist was American or British. The risk of misdiagnosis is even greater when the mental health professional and the patient come from different cultural groups.
Mental health professionals use a number of methods to treat people with mental illnesses. The two most common treatments by far are drug therapy and psychotherapy. In drug therapy, a person takes regular doses of a prescription medication intended to reduce symptoms of mental illness. Psychotherapy is the treatment of mental illness through verbal and nonverbal communication between the patient and a trained professional. A person can receive psychotherapy individually or in a group setting.
The type of treatment administered depends on the type and severity of the disorder. For example, doctors usually treat schizophrenia primarily with drugs, but specialized forms of psychotherapy may more effectively relieve phobias. For some mental illnesses, such as depression, the most effective treatment seems to be a combination of drug therapy and psychotherapy. Although some people with severe mental illnesses may never fully recover, most people with mental illnesses improve with treatment and can resume normal lives. Despite the availability of effective treatments, only about 40 percent of people with mental illnesses ever seek professional help.
A variety of mental health professionals offer treatment for mental illness. These include psychiatrists, psychologists, psychotherapists, psychiatric social workers, and psychiatric nurses.
A Drug Therapy
Drugs introduced in the mid-1950s enabled many people who otherwise would have spent years in mental institutions to return to the community and live productive lives. Since then, advances in psychopharmacology have led to the development of drugs of even greater effectiveness. These drugs often relieve symptoms of schizophrenia, depression, anxiety, and other disorders. However, they may produce undesirable and sometimes serious side effects. In addition, relapse may occur when they are discontinued, so long-term use may be required. Drugs that control symptoms of mental illness are called psychotherapeutic drugs. The major categories of psychotherapeutic drugs include antipsychotic drugs, antianxiety drugs, antidepressant drugs, and antimanic drugs.
Antipsychotic drugs, also called neuroleptics and major tranquilizers, control symptoms of psychosis, such as hallucinations and delusions, which characterize schizophrenia and related disorders. They can also prevent such symptoms from returning. Antipsychotic drugs may produce side effects ranging from dry mouth and blurred vision to tardive dyskinesia, a permanent condition that produces involuntary movements of the lips, mouth, and tongue.
Antianxiety drugs, also called minor tranquilizers, reduce high levels of anxiety. They may help people with generalized anxiety disorder, panic disorder, and other anxiety disorders. Benzodiazepines, a class of drugs that includes diazepam (Valium), are the most widely prescribed antianxiety drugs. Benzodiazepines can be addictive and may cause drowsiness and impaired coordination during the day.
Antidepressant drugs help relieve symptoms of depression. Some antidepressant drugs can relieve symptoms of other disorders as well, such as panic disorder and obsessive-compulsive disorder. Antidepressant drugs comprise three major classes: tricyclics, monoamine oxidase inhibitors (MAO inhibitors), and selective serotonin reuptake inhibitors (SSRIs). Side effects of tricyclics may include dizziness upon standing, blurred vision, dry mouth, difficulty urinating, constipation, and drowsiness. People who take MAO inhibitors may experience some of the same side effects, and must follow a special diet that excludes certain foods. SSRIs generally produce fewer side effects, although these may include anxiety, drowsiness, and sexual dysfunction. One type of SSRI, fluoxetine (Prozac), is the most widely prescribed antidepressant drug.
Antimanic drugs help control the mania that occurs as part of bipolar disorder. One of the most effective antimanic drugs is lithium carbonate, a natural mineral salt (see Lithium). Common side effects include nausea, stomach upset, vertigo, and increased thirst and urination. In addition, long-term use of lithium can damage the kidneys.
B Individual Psychotherapy
Psychotherapy can be an effective treatment for many mental illnesses. Unlike drug therapy, psychotherapy produces no physical side effects, although it can cause psychological damage when improperly administered. On the other hand, psychotherapy may take longer than drugs to produce benefits. In addition, sessions may be expensive and time-consuming. In response to this complaint and demands from insurance companies to reduce the costs of mental health treatment, many therapists have started providing therapy of shorter duration.
Psychotherapy encompasses a wide range of techniques and practices. Some forms of psychotherapy, such as psychodynamic therapy and humanistic therapy, focus on helping people understand the internal motivations for their problematic behavior. Other forms of therapy, such as behavioral therapy and cognitive therapy, focus on the behavior itself and teach people skills to correct it. The majority of therapists today incorporate treatment techniques from a number of theoretical perspectives. For example, cognitive-behavioral therapy combines aspects of cognitive therapy and behavioral therapy.
Psychodynamic therapy is one of the most common forms of psychotherapy. The therapist focuses on a person’s past experiences as a source of internal, unconscious conflicts and tries to help the person resolve those conflicts. Some therapists may use hypnosis to uncover repressed memories. Psychoanalysis, a technique developed by Freud, is one kind of psychodynamic therapy. In psychoanalysis, the person lies on a couch and says whatever comes to mind, a process called free association. The therapist interprets these thoughts along with the person’s dreams and memories. Classical psychoanalysis, which requires years of intensive treatment, is not as widely practiced today as in previous years.
Both humanistic therapy and existential therapy treat mental illnesses by helping people achieve personal growth and attain meaning in life. The best-known humanistic therapy is client-centered therapy, developed by Carl Rogers in the 1950s. In this technique, the therapist provides no advice but restates the observations and insights of the client (the person in treatment) in nonjudgmental terms. In addition, the therapist offers the person unconditional empathy and acceptance. Existential therapists help people confront basic questions about the meaning of their lives and guide them toward discovery of their own uniqueness.
Psychotherapists who practice behavioral therapy do not focus on a person’s past experiences or inner life. Instead, they help the person to change patterns of abnormal behavior by applying established principles of conditioning and learning. Behavioral therapy has proven effective in the treatment of phobias, obsessive-compulsive disorder, and other disorders. See Behavior Modification.
The goal of cognitive therapy is to identify patterns of irrational thinking that cause a person to behave abnormally. The therapist teaches skills that enable the person to recognize the irrationality of the thoughts. The person eventually learns to perceive people, situations, and himself or herself in a more realistic way and develops improved problem-solving and coping skills. Psychotherapists use cognitive therapy to treat depression, panic disorder, and some personality disorders.
Rehabilitation programs assist people with severe mental illnesses in learning independent living skills and in obtaining community services. Counselors may teach them personal hygiene skills, home cleaning and maintenance, meal preparation, social skills, and employment skills. In addition, case managers or social workers may help people with mental illnesses obtain employment, medical care, housing, education, and social services. Some intensive rehabilitation programs strive to provide active follow-up and social support to prevent hospitalization.
Therapists often use play therapy to treat young children with depression, anxiety disorders, and problems stemming from child abuse and neglect. The therapist spends time with the child in a playroom filled with dolls, puppets, and drawing materials, which the child may use to act out personal and family conflicts. The therapist helps the child recognize and confront his or her feelings.
C Group and Family Therapies
In group therapy, a number of people gather together to discuss problems under the guidance of a therapist. By sharing their feelings and experiences with others, group members learn their problems are not unique, receive emotional support, and learn ways to cope with their problems. Psychodrama is a type of group therapy in which participants act out emotional conflicts, often on a stage, with the goals of increasing their understanding of their behaviors and resolving conflicts. Group therapy generally costs less per person than individual psychotherapy.
Family intervention programs help families learn to cope with and manage a family member’s chronic mental illness, such as schizophrenia. Family members learn to monitor the illness, help with daily life problems, ensure adherence to medication, and cope with stigma.
D Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a treatment for severe depression in which an electrical current is passed through the patient’s brain for one or two seconds to induce a controlled seizure. The treatments are repeated over a period of several weeks. For unknown reasons, ECT often relieves severe depression even when drug therapy and psychotherapy have failed. The treatment has created controversy because its side effects may include confusion and memory loss. Both of these effects, however, are usually temporary.
Even more controversial than ECT is psychosurgery, the surgical removal or destruction of sections of the brain in order to reduce severe and chronic psychiatric symptoms. The best known example of psychosurgery is the lobotomy, a procedure developed by Portuguese neurologist António Egas Moniz that was widely performed in the 1940s and early 1950s. Psychosurgery is now rarely performed because no research has proven it effective and because it can produce drastic changes in personality and behavior.
F Treatment Settings
Treatment for mental illness takes places in a number of settings. Mental hospitals or psychiatric wards in general hospitals are used to treat patients in acute phases of their illnesses and when the severity of their symptoms requires constant supervision. Most individuals who suffer from severe mental illness, however, do not require such close attention, and they can usually receive treatment in community settings.
Often, patients who have just completed a period of hospitalization go to group homes or halfway houses before returning to independent living. These facilities offer patients the opportunity to take part in group activities and to receive training in social and job skills. In supportive housing, mentally ill individuals can live independently in an environment that offers an array of mental health and social services. Some people with chronic and severe mental illnesses require care in long-term facilities, such as nursing homes, where they can receive close supervision.
Unfortunately, many areas have a shortage of treatment centers, especially community mental health centers and supportive housing environments. This shortage may partly account for the large number of mentally ill people who are homeless or in jail. See Homelessness.
G Treatment in Non-Western Countries
Most non-Western countries still lack adequate treatment facilities and services for the mentally ill. In China, with its 1.2 billion people, there are 4.5 million patients with schizophrenia, but only about 100,000 beds for the mentally ill and fewer than 10,000 psychiatrists. On the other hand, there are hundreds of thousands of traditional healers, many of whom treat mentally ill patients. Other people with mental illnesses receive treatment from general physicians. In most countries of sub-Saharan Africa, psychiatric services are so limited that most people with mental illnesses receive little if any professional care. Some developing countries, however, have begun substantial reform and expansion of mental health services.
XI HISTORICAL PERSPECTIVES OF MENTAL ILLNESS
A Preliterate Societies
Evidence for trepanning, the surgical procedure of cutting a hole in the skull, dates back 4,000 to 5,000 years. Some anthropologists speculate that Stone Age societies performed trepanning on people with mental illnesses to release evil spirits or demons from their heads. In the absence of written records, however, it is impossible to know why the operation was performed.
B Ancient Societies
The literature of ancient Greece and Rome contains evidence of the belief that spirits or demons cause mental illness. In the 5th century bc the Greek historian Herodotus wrote an account of a king who was driven mad by evil spirits. The legend of Hercules describes how, driven insane by a curse, he killed his own children. The Roman poets Virgil and Ovid repeated these themes in their works. The early Babylonian, Chinese, and Egyptian civilizations also viewed mental illness as possession, and used exorcism—which sometimes involved beatings, restraint, and starvation—to drive the evil spirits from their victim.
Not all ancient scholars agreed with this theory of mental illness. The Greek physician Hippocrates believed that all illnesses, including mental illnesses, had natural origins. For example, he rejected the prevailing notion that epilepsy had its origins in the divine or sacred, viewing it as a disease of the brain. Hippocrates classified mental illnesses into categories that included mania, melancholia (depression), and phrenitis (brain fever), and he advocated humane treatment that included rest, bathing, exercise, and dieting. The Greek philosopher Plato, although adhering to a somewhat supernatural view of mental illness, believed that childhood experiences shaped adult behaviors, anticipating modern psychodynamic theories by more than 2000 years.
C The Middle Ages
The Middle Ages in Europe, from the fall of the Roman empire in the 5th century ad to about the 15th century, was a period in which religious beliefs, specifically Christianity, dominated concepts of mental illness. Much of society believed that mentally ill people were possessed by the devil or demons, or accused them of being witches and infecting others with madness (see Witchcraft). Thus, instead of receiving care from physicians, the mentally ill became objects of religious inquisition and barbaric treatment. On the other hand, some historians of medicine cite evidence that even in the Middle Ages, many people believed mental illness to have its basis in physical and psychological disturbances, such as imbalances in the four bodily humors (blood, black bile, yellow bile, and phlegm), poor diet, and grief.
The Islamic world of North Africa, Spain, and the Middle East generally held far more humane attitudes toward people with mental illnesses. Following the belief that God loved insane people, communities began establishing asylums beginning in the 8th century ad, first in Baghd?d and later in Cairo, Damascus, and Fez. The asylums offered patients special diets, baths, drugs, music, and pleasant surroundings.
D The Renaissance
The Renaissance, which began in Italy in the 14th century and spread throughout Europe in the 16th and 17th centuries, brought both deterioration and progress in perceptions of mental illness. On the one hand, witch-hunts and executions escalated throughout Europe, and the mentally ill were among those persecuted. The infamous Malleus Maleficarum,which served as a handbook for inquisitors, claimed that witches could be identified by delusions, hallucinations, or other peculiar behavior. To make matters worse, many of the most eminent physicians of the time fervently advocated these beliefs.
On the other hand, some scholars vigorously protested these supernatural views and called renewed attention to more rational explanations of behavior. In the early 16th century, for example, the Swiss physician Paracelsus returned to the views of Hippocrates, asserting that mental illnesses were due to natural causes. Later in the century, German physician Johann Weyer argued that witches were actually mentally disturbed people in need of humane medical treatment.
E The Age of Enlightenment
During the Age of Enlightenment, in the 18th and early 19th centuries, people with mental illnesses continued to suffer from poor treatment. For the most part, they were left to wander the countryside or committed to institutions. In either case, conditions were generally wretched. One mental hospital, the Hospital of Saint Mary of Bethlehem in London, England, became notorious for its noisy, chaotic conditions and cruel treatment of patients (see Bedlam).
Yet as the public’s awareness of such conditions grew, improvements in care and treatment began to appear. In 1789 Vincenzo Chiarugi, superintendent of a mental hospital in Florence, Italy, introduced hospital regulations that provided patients with high standards of hygiene, recreation and work opportunities, and minimal restraint. At nearly the same time, Jean-Baptiste Pussin, superintendent of a ward for “incurable” mental patients at La Bicêtre hospital in Paris, France, forbade staff to beat patients and released patients from shackles. Philippe Pinel continued these reforms upon becoming chief physician of La Bicêtre’s ward for the mentally ill in 1793. Pinel began to keep case histories of patients and developed the concept of “moral treatment,” which involved treating patients with kindness and sensitivity, and without cruelty or violence. In 1796 a Quaker named William Tuke established the York Retreat in rural England, which became a model of compassionate care. The retreat enabled people with mental illnesses to rest peacefully, talk about their problems, and work. Eventually these humane techniques became widespread in Europe.
F Reform in the United States
People living in the colonies of North America in the 17th and 18th centuries generally explained bizarre or deviant behavior as God’s will or the work of the devil. Some people with mental illnesses received care from their families, but most were jailed or confined in almshouses with the poor and infirm. By the mid-18th century, however, American physicians came to view mental illnesses as diseases of the brain, and advocated specialized facilities to treat the mentally ill. The Pennsylvania Hospital in Philadelphia, which opened in 1752, became the first hospital in the American colonies to admit people with mental illnesses, housing them in a separate ward. However, in the hospital’s early years, mentally ill patients were chained to the walls of dark, cold cells.
In the 1780s American physician Benjamin Rush instituted changes at the Pennsylvania Hospital that greatly improved conditions for mentally ill patients. Although he endorsed the continued use of restraints, punishment, and bleeding, he also arranged for heat and better ventilation in the wards, separation of violent patients from other patients, and programs that offered work, exercise, and recreation to patients. Between 1817 and 1828, following the examples of Tuke and Pinel, a number of institutions opened that devoted themselves exclusively to the care of mentally ill people. The first private mental hospital in the United States was the Asylum for the Relief of Persons Deprived of the Use of Their Reason (now Friends Hospital), opened by Quakers in 1817 in what is now Philadelphia. Other privately established institutions soon followed, and state-sponsored hospitals—in Kentucky, New York, Virginia, and South Carolina—-opened beginning in 1824.
Nevertheless, circumstances for most mentally ill people in the United States, especially those who were poor, remained dreadful. In 1841 Dorothea Dix, a Boston schoolteacher, began a campaign to make the public aware of the plight of mentally ill people. By 1880, as a direct result of her efforts, 32 psychiatric hospitals for the poor had opened. Increasingly, society viewed psychiatric institutions as the most appropriate form of care for people with mental illnesses. However, by the late 19th century, conditions in these institutions had deteriorated. Overcrowded and understaffed, psychiatric hospitals had shifted their treatment approach from moral therapy to warehousing and punishment. In 1908 Clifford Whittingham Beers aroused new concern for mentally ill individuals with the publication of A Mind That Found Itself, an account of his experiences as a mental patient. In 1909 Beers founded the National Committee for Mental Hygiene, which worked to prevent mental illness and ensure humane treatment of the mentally ill.
G Deinstitutionalization Movement
Following World War II (1939-1945), a movement emerged in the United States to reform the system of psychiatric hospitals, in which hundreds of thousands of mentally ill persons lived in isolation for years or decades. Many mental health professionals—seeing that large state institutions caused as much, if not more, harm to patients than mental illnesses themselves—came to believe that only patients with severe symptoms should be hospitalized. In addition, the development in the 1950s of antipsychotic drugs, which helped to control bizarre and violent behavior, allowed more patients to be treated in the community. In combination, these factors led to the deinstitutionalization movement: the release, over the next four decades, of hundreds of thousands of patients from state mental hospitals. In 1950, 513,000 patients resided in these institutions. By 1965 there were 475,000, and by 1990 state mental hospitals housed only 92,000 patients on any given night. Many patients who were released returned to their families, although many were transferred to questionable conditions in nursing homes or board-and-care homes. Many patients had no place to go and began to live on the streets.
The National Mental Health Act of 1946 created the National Institute of Mental Health as a center for research and funding of research on mental illness. In 1955 Congress created a commission to investigate the state of mental health care, treatment, and prevention. In 1963, as a result of the commission’s findings, Congress passed the Community Mental Health Centers Act, which authorized the construction of community mental health centers throughout the country. Implementation of these centers was not as extensive as originally planned, and many people with severe mental illnesses failed to receive care of any kind.
H Recent Developments
One of the most important developments in the field of mental health in the United States has been the establishment of advocacy and support groups. The National Alliance for the Mentally Ill (NAMI), one of the most influential of these groups, was founded in 1972. NAMI’s goal is to improve the lives of people with severe mental illnesses and their families by eliminating discrimination in housing and employment and by improving access to essential treatments and programs.
During the 1980s, all levels of government in the United States cut back on funding for social services. For example, the Social Security Administration discontinued benefits for approximately 300,000 people between 1981 and 1983. Of these, an estimated 100,000 were people with mental illnesses. Although the government eventually restored Social Security benefits to many of these people, the interruption of services caused widespread hardship.
The emergence of managed care in the 1990s as a way to contain health care costs had a tremendous impact on mental health care in the United States. Health insurance companies and health maintenance organizations increasingly scrutinized the effectiveness of various psychotherapies and drug treatments and put stricter limits on mental health care. In response to these restrictions, Congress passed the Mental Health Parity Act of 1996. This law required private medical plans that offer mental health coverage to set equal yearly and lifetime payment limits for coverage of both mental and physical illnesses.
In 1997 the U.S. Equal Employment Opportunity Commission issued new guidelines intended to prevent discrimination against people with mental illnesses in the workplace. The rules, based on the Americans with Disabilities Act of 1990, prohibit employers from asking job applicants if they have a history of mental illness and require employers to provide reasonable accommodations to workers with mental illnesses.
In recent years international agencies, led by the World Health Organization (WHO) of the United Nations (UN) have developed mental health policies that seek to reduce the huge burden of mental illness worldwide. These agencies are working to improve the quality of mental health services in Africa, Asia, Latin America, the Middle East, and elsewhere by educating governments on prevention and treatment of mental illness and on the rights of the mentally ill.
Arthur M. Kleinman