What is mental illness? How do you define a mental disorder?

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What is mental illness?How do you define a
mental disorder?
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Causes of Disability in the United States,
Canada, and Western Europe in 2000
Iglehart J. N Engl J Med 2004350507-514
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Mental Disorders are Internal Dysfunctions that a
Particular Culture Defines as Inappropriate and
Severely Interfere with an Individuals Daily
Living
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the hikikomori or shut-ins in Japan
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What is a Valid Mental Disorder?
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Andrea Yates Post-Partum Depression w/psychosis
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Eli Robins Samuel GuzeWashington University
School of MedicineDepartment of PsychiatrySt.
Louis, 1950s-1990s

• Four basic validators for psychiatric diagnoses
• 1.) symptoms
• 2.) course
• 3.) genetics/heritability
• 4.) treatment response
• For major adult psychiatric illnesses,
  approximately 5-10 of persons at any time in
  their life will be diagnosed with major
  depression, about 2-5 with bi-polar disorder,
  and roughly 1 with schizophrenia.

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Overview of Different Treatment Eras

• 1.) The Psychoanalytic Hiatus 1930s-late
  1960s/early 1970s
• 2.) The Rise of the 2nd Biological Psychiatry
  early 1960s-present
• 3.) The Rise of (Cosmetic) Psychopharmacology
  1990s-present

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The Psychoanalytic Hiatus

• American origins 1909 visit by Freud to Clark
  University
• Key catalyst The Arrival of the Europeans in
  the 1930s
• Years of triumph late 1940s to late 1960s
• Symptoms were meaningless because disease
  entities didnt mean anything when it came to
  mental illness
• Practically everyone had some measure of mental
  maladjustment.
• Question What else made psychoanalytic and
  dynamic psychiatry so popular?

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The Psychoanalytic Hiatus

• deep insulin coma therapy, ECT
• Metrozol shock therapy, lobotomy

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The Rise of the 2nd Biological Psychiatry

• 1949 - Lithium (not FDA-approved until 1970)
• 1954 - Chlorpromazine (Thorazine)
• Reserpine
• 1955 - Meprobamate (Miltown)
• 1957 - Haloperidol (Haldol)
• 1958 - Imipramine (Tofranil)
• Iproniazid (MOAI)
• 1960 - Librium (Valium)
• 1961 - Methylphenidate (Ritalin)

Leo Sternbach, inventor of Valium, died on
September 28, 2005, aged 97
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What exactly is a Mental Disorder? DSM-III
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Critics of Psychiatry

• Ken Kesey

Michel Foucault
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Dilemma Running Debate

• Type 1 errors
• (person has a mental disorder but is not
  diagnosed)
• Type 2 errors
• (person does not have a mental disorder, but is
  diagnosed with one)
• famous Rosenhan experiment (1972)
• The aim of this study was to test the hypothesis
  that psychiatrists cannot reliably tell the
  difference between people who are sane and those
  who are insane.
• The study consisted of two parts with 8
  pseudo-patients in 12 hospitals in 5 states.

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Dilemma Running Debate

• Type 1 errors (fear of medical malpractice
  cases and self-medicating)
• (person has a mental disorder but is not
  diagnosed)
• Type 2 errors (fear of cosmetic
  psychopharmacology)
• (person does not have a mental disorder, but is
  diagnosed with one)

De'Nora Hill "I am living in fear and I want it
to end."
Kate Russell for The New York Times Sarah Couch,
who has bipolar disorder, opposes the effort to
force treatment on the mentally ill.
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The Rise of the 2nd Biological Psychiatry

• Deinstitutionalization en masse from 1960s to
  1980s
• Community Mental Health Centers Act (1963)
• turmoil in the 1970s and the publication of the
  DSM-III (1980)

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The Rise of Psychopharmacology
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Examples

• Sexual Dysfunction in the United States
  Prevalence and Predictors
• Edward O. Laumann, PhD Anthony Paik, MA Raymond
  C. Rosen, PhD
• JAMA. 1999281537-544.
• Objective  To assess the prevalence and risk of
  experiencing sexual dysfunction across various
  social groups and examine the determinants and
  health consequences of these disorders.
• Design  Analysis of data from the National Health
  and Social Life Survey, a probability sample
  study of sexual behavior in a demographically
  representative, 1992 cohort of US adults.
• Participants  A national probability sample of
  1749 women and 1410 men aged 18 to 59 years at
  the time of the survey.
• Main Outcome Measures  Risk of experiencing
  sexual dysfunction as well as negative
  concomitant outcomes.
• Results  Sexual dysfunction is more prevalent for
  women (43) than men (31) and is associated with
  various demographic characteristics, including
  age and educational attainment. Women of
  different racial groups demonstrate different
  patterns of sexual dysfunction. Differences among
  men are not as marked but generally consistent
  with women. Experience of sexual dysfunction is
  more likely among women and men with poor
  physical and emotional health. Moreover, sexual
  dysfunction is highly associated with negative
  experiences in sexual relationships and overall
  well-being.
• sounds fairly ENVIRONMENTAL
• Conclusions  The results indicate that sexual
  dysfunction is an important public health
  concern, and emotional problems likely contribute
  to the experience of these problems.

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ED a common issue! Do you have ED?
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• What Paxil CR Treats
• If your doctor has prescribed Paxil CR for you,
  you are now taking an FDA-approved medication
  proven safe and effective for the treatment of
  depression and panic disorder.
• It Could Be Depression.
• If you have felt persistent feelings of
  worthlessness and hopelessness, or have an
  inability to feel pleasure or take an interest in
  life, you may have depression.Learn more about
  Depression.
• It Could Be Panic Disorder.
• If you have experienced repeated feelings of
  intense, sudden terror or impending doom, racing
  or pounding heartbeat or even chest pains, you
  may have panic disorder. Learn more about Panic
  Disorder.
• It Could Be Social Anxiety Disorder.
• If you have felt excessive, persistent fear and
  avoidance of social or performance situations,
  accompanied by sweating, shaking, tense muscles,
  or a pounding heart, you may have social anxiety
  disorder. Learn more about Social Anxiety
  Disorder.

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Campaign the ONION
Premenstrual dysphoric disorder (PMDD) isnt just part of "being a woman." Its a real medical condition, and it causes real suffering. PMDD is much more serious than PMS. If you have PMDD, learning more about it can be the first step toward feeling better and getting control of your life again.
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Controversies over Treatment Choices

• stem primarily from differences between the 4
  large groupings (and their subdivisions) of
  psychiatric disorders
• 1. those with physical diseases schizophrenia,
  Alzheimers (damage to the brain provokes
  psychiatric symptoms)
• 2. those who are intermittently distressed by
  some aspect of their mental constitutiona
  weakness in their cognitive power or an
  instability in their affective controlwhen
  facing challenges in school, employment, or
  marriage dysthymia, moderate depression,
  generalized anxiety disorder (they do not have
  disease or any obvious damage to their brain
  rather, they are vulnerable because of who they
  are (temperament, personality, character)that
  is, how they are constituted
• 3. those whose behavioralcoholism, drug
  addiction, sexual paraphilia, anorexia nervosa,
  and the likehas become a warped way of life
  They are patients not because of what they have
  or who they are, but because of what they are
  doing and how they have become conditioned to
  doing it
• 4. those in need of psychiatric assistance
  because of emotional reactions provoked by events
  that injure or thwart their commitments, hopes,
  and aspirations. They suffer from states of mind
  like grief, homesickness, jealousy,
  demoralizationstates that derive not from what
  they have or who they are or what they are doing,
  but from what they have encountered in life

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Dangers of Over- and Under-Diagnosing

• Hans Eysencks personality theory (1947)

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Based on combined per capita rates of diagnosed
depression and suicide, here are the top six
happiest or least depressed states 1.
South Dakota 2. Hawaii 3. New Jersey 4. Iowa
5. Maryland 6. Minnesota
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Most Depressed or Least Happy State in
terms of combined per capita rates of diagnosed
depression and suicide?
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Rates of Depression among Medical Students (Panel
A) and Treatment of Depressed Medical Students
(Panel B)
Rosenthal, J. M. et al. N Engl J Med
20053531085-1088
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The Futile Pursuit of Happiness Environmental
Stress

• Gilbert, Wilson, Loewenstein, Kahneman
• We consistently misestimate the intensity and
  duration
• of somethings utility this is known as the
  impact bias.
• Our ability to predict the emotional consequences
  of a
• decision, purchase, or event is less than we
  think.
• Our mistakes of expectation can lead directly to
  mistakes in choosing what we think will give us
  pleasure. We often miswant.
• Key role of adaptation to good things and
  resilience to bad things.
• our psychological immune system (a sort of
  emotional thermostat)
• e.g., remember when you got your first dial-up
  14,400 baud modem?

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The Tyranny of Choice

• Starter Marriages phenomenon
• Census Bureau 3 million divorced 18-29
  year-olds (1999)
• 253,000 divorced 25-29
  year-olds (1962)
• Atul Gawande, M.D. cancer study
• - 65 of people surveyed say that if they were
  to get cancer, they would want to choose their
  own treatment of those who do get cancer,
  though, only 12 actually want to choose
• Steven Venti, Dartmouth economist Employer 401k
  plans
• The more funds employers offer their employees
  in 401k plans, the less likely the employees are
  to invest in any of them.
• Wine Warehouse vs. Gas Station experiences

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Depression and the Tyranny of Choice

• Excessive choice is often psychologically and
  emotionally burdensome.
• Why?
• (1) Increases burden of information gathering to
  make a wise decision
• (2) Doing all the cost-benefit/expected utility
  calculations is exhausting
• (3) Increases expectations about how good the
  decision will be
• (4) People often assemble an idealistic composite
  of all the options foregone
• (5) Which increases the likelihood that they will
  regret the decision they make
• (6) And increases the chance that they will blame
  themselves when a decision fails to live up to
  expectations (more regret and second-guessing).
• Perhaps colleges/universities offer too many
  choices now, which might help explain double-,
  triple-majoring, etc. (e.g., Spiderbytes)

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Combating the Paralysis of Choice Cultivating
Contentment

• Helpful countermeasures
• (1) Pro-Actively Limit Choices to 1st order,
  2nd order, 3rd order
• (2) Counterfactual Downward
• (3) Make Some Decisions Nonreversible (e.g.,
  Harvard photography class)
• (4) Anticipate Adaptation
• (5) Learn to Love Constraints (Say No, 1
  major/1minor)
• (6?) Recalibrate expectations, cultivate
  contentment, safety,
• egalitarianism, and a dose of humility