MENTAL ILLNESS IN A SOCIAL AND CULTURAL CONTEXT

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MENTAL ILLNESS IN A SOCIAL AND CULTURAL CONTEXT

• Lyn Gardner
• Lecturer, Centre for Mental Health Studies

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The Classification of Mental Illnesses

• Diagnosis is the process of classification and
  naming/labelling of an illness, usually based on
  the presence, or absence, of particular physical
  characteristics
• In psychiatry, however, there is no such
  external biological referent to act as an anchor
  for diagnosis (McPherson Armstrong, 2005)
• Classification provides a means of professional
  standardisation and consensus
• An aid to communication between professions (and
  the person given the diagnosis??)
  internationally agreed signs and symptoms
• However, both historically and geographically
  there is ample evidence to show considerable
  differences in diagnostic patterns (Lee, 2002)
• One response to this was to introduce diagnostic
  manuals the ICD fully classified mental
  illnesses from 1948 and the DSM was introduced in
  1952

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DIAGNOSIS OF MENTAL ILLNESS

• Psychiatric definitions or diagnosis of mental
  illness are made using the following
  classifications
• IDC-10 (International Classification of Diseases)
  research based concepts updated by international
  committees on behalf of WHO. Section on Mental
  and Behavioural Disorders and divided into 9
  groups.
• DSM-IV (Diagnostic and Statistical Manual)
  compiled by the American Psychiatric Assoc.
  Numerous revisions over short period of time
  created debate and controversy

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FROM PERSON TO PATIENT

• Is a diagnosis helpful?
• Labelling has a negative effect and any
  description is a linguistic straightjacket
  (James, 1998)
• A label can liberate and represents a public
  recognition of personal pain (Figert, 1998)

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THE PROCESS OF DIAGNOSIS

• Crowe (2000) argues that the process of
  psychiatric diagnosis is based on positivistic
  understandings of reality which reduce the
  experience of individuals to
• a priori categories of normality and
  abnormality that reveal a strong gender, culture
  and class bias.
• In doing so, the DSM constructs what is to be
  regarded as abnormal and what society can expect
  as normal behaviour

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Cont.

• Thus, according to Casey Long (2003)
• psychiatric diagnoses are not objective,
  scientific renderings of truth, but constructions
  of life experiences inextricably linked to the
  social and political context

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NON-COMPLIANCE WITH PSYCHIATRIC CLASSIFICATIONS
OF SELF

• we should never forget how the bestowal of a
  psychiatric label can so usurp the persons sense
  of identity that all subsequent distress
  (relapse) is reconstituted as a function of that
  diagnosis
• Barker et al (1999)

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ON THE RECEIVING END OF A PSYCHIATRIC DIAGNOSIS

• Some service users fight against their diagnosis
  refuse medication, feel angry, challenge
  treatment and try to find meaning in their
  diagnosis
• prior to developing schizophrenia, the workings
  of my mind had been unquestioned. Suddenly I was
  being told that I could not always trust my own
  thoughts and senses.Self had become a traitor
  and was working against my own good
• (Champ, 1999)
• Reading from Eleanor Longdens account (Open
  Mind, 111, Sept/Oct 2001,p. 12-13).

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A DIAGNOSIS CAN VALIDATE EXPERIENCE

• Some people actively seek a label or diagnosis
  for their distressing or unusual thoughts,
  feelings and behaviour
• not having a label, I think thats the real
  problem (Peters et al. 1998)
• on a positive note, at least when I did learn
  of my diagnosis I was able to begin coming to
  terms with my illnessI discovered a common
  identity and a camaraderie (McIntosh, 1996)

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A Comment on Definitions

• The term gender is used to refer to the
  socially/culturally constructed differences
  between men and women
• It was introduced to conceptually separate female
  and male biological factors (sex) from social and
  culturally driven behaviours
• It is sometimes used to replace the term sex
• Gender is also associated with women-only
  concerns or issues
• Ethnicity is used to refer to cultural group
  identity, may include sense of common culture

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DIAGNOSIS GENDER ISSUES

• Gender relations are implicated in psychiatry at
  both the theoretical and practice levels (issues
  for women include childcare, single-sex
  accommodation, sexism, fear of sexual violence)
• Psychiatric epidemiology reveals gender
  differences in rates of diagnostic category

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CONT

• Overall the proportion of people living with a
  diagnosed mental illness over a 12 month period
  is similar for women (18) and men (17.4) (ABS,
  1998)
• However, within that aggregated figure, gender
  differences are masked
• The rate of depression for women is twice that of
  men
• The rate of anxiety disorders for women is almost
  twice that of men
• The rate of substance misuse for men is over
  twice that of women

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DEPRESSION

• Woman-predominant conditions such as depression
  and anxiety disorders are likely to be
  under-diagnosed (Busfield,1996 and Horsfall,
  2001)
• Current mental health service provision focuses
  on caring for people with so-called serious or
  serious and enduring mental illness
• Thus women may be left to feel that their
  distress and the way it manifests itself is
  illegitimate, unreal, or inconsequential by
  medical practitioners, family members, or
  friends (Horsfall, 2001)

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MAD WOMEN ARE LESS TROUBLE TO SOCIETY

• Gendered expressions and forms of pain
  internalization that are not overtly disruptive
  or dangerous for society are less likely to
  receive social, political, policy or medical
  treatment priority (Perkins Repper, 1998)
• Women may not then be diagnosed so readily as
  men, leaving them without treatment, support and
  validation of their distress

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Depression _ Traditional Classifications

• Exogenous neurotic condition caused by external
  circumstances/events. Individual usually has
  clear insight into the causes. It is a
  pathological reaction to a loss which may be
  actual, threatened or imagined (James, 1998)
• Endogenous thought to be caused by factors
  within the person. Psychotic features may be
  present. Diurnal variation of mood worse in
  morning (wakes early), improves as day goes on.

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DEFINING DEPRESSION

• Major Depression according to WHO (1992)
  diagnosis requires 5 or more specific criteria to
  be present
• Depressed mood or loss of interest
• Significant weight loss/gain
• Disturbed sleep pattern
• Psychomotor agitation or retardation
• Fatigue
• Feelings of worthlessness
• Diminished ability to think
• Difficulty in concentrating
• Suicidal thoughts

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DEFINING DEPRESSION

• Dysthymia present for at least 2 years often
  insidious onset. Symptoms overlap major
  depression also include pessimism, low
  self-esteem, lack of energy, irritability and
  decreased productivity
• Minor Depression symptoms as major depression,
  but only 2 need to be present for a diagnosis
• Intermittent Depression similar to minor
  depression with symptoms that are not constant
• Recurrent Brief Depression major depressive
  episodes, usually one or two per month which may
  last for a few hours to a few days

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Epidemiology

• At primary care level depression is a major
  reason for patient consultation approx 10 of
  all consultations (Baldwin Hirschfeld, 2001)
• 3 of the general population is diagnosed yearly
  by GPs, but approx. the same number may be
  unidentified as sufferers (Sheppard, 1997)
• Major depression is a precipitant factor in
  approx. half of all suicides, according to Murphy
  (1998)
• The rate of depression for women is twice that of
  men (Baldwin Hirschfeld, 2001), but they are
  one-forth as likely to complete suicide (Murphy,
  1998)
• However, some studies reveal an apparent
  equalising of rates of depression among men and
  women (Prior, 1999)
• Prevalence of depressive symptoms increase with
  age, however, rising incidence of depression
  among children (0.5 -2.5) and adolescence (3-4)
  suggests Baldwin Hirschfeld.
• Social class does not seem to be a factor in
  prevalence, but suggestion of slower recovery in
  more socially deprived people.

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Theories and Models of Depression

• Genetic/biological some increase in prevalence
  of depression among those with first generation
  relative previously diagnosed.
• More significant evidence of environmental
  factors influencing development of depression,
  especially in less severe forms.
• Weak genetic links to pathophysiology of
  depression, specifically bi-polar disorder.
• Evidence of serotonin, dopamine and noradrenalin
  neurotransmission dysfunctions among those
  experiencing depression of suicidal thoughts.

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Cognitive Explanations

• Cognitive models of depression, originating with
  Beck (1967), emphasis negative thinking as a
  factor causing or maintaining depressed symptoms.
• Different versions of cognitive models variously
  emphasis self-schemas (Beck, 19760), self-esteem
  (Roberts Monroe, 1994), attributional style
  (Barnett Gotlib, 1988), hopelessness (Abramson
  et al, 1989).
• Ample evidence to suggest that depressed people
  are biased in negative directions while
  depressed, but less research supports a casual
  role of negative thinking in causing depression.
• Stressors play an important role in triggering
  depressive reactions (Brown Harris, 1976)
• Current stress and cognition models emphasise
  that the meaning of the event to the individual
  determines whether it will trigger depression.

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Social Explanations

• Difficulties in social relationships may be a key
  element of many depressions disrupted social
  connectedness may cause depression and, in turn,
  depression disrupts relationships, potentially
  causing further depression.
• Negative early childhood experiences insecure
  attachment relationships between parent and child
  may contribute to vulnerability to depression
  (Bowlby, 1978 1981).

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Cont.

• Depression impacts on the family partners and
  children.
• Depression has a negative impact on those outside
  of the family, suggesting that depression may
  make other people reject the depressed person
  (Coyne et al, 1991).
• Depressed people may contribute to the occurrence
  of stressful life/interpersonal events, which may
  perpetuate depression (Hammen, 1991).
• Depressed people may have poor social support
  systems/relationships
• Depressed people may have certain maladaptive
  behaviours and personality traits that effect
  relationships even when not depressed such as
  dependency, introversion and poor social skills
  (Hirschfeld et al, 1996).

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Narratives of Depression

• By developing a phenomenology of the experience
  of depression, nurses can better understand and
  respond to it.
• Sources may lie in first hand accounts, diaries,
  poetry, film and literature/fiction.

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First Hand Accounts

• It is total there is no reason to wake up in
  the morning. I just let the blinds stay
  downsometimes I wonder what life will be like,
  where I can find a fixed point, a hold to my
  life.
• To meet people just because its nice to meet
  them is difficult, since I cant convince myself
  that somebody would like to get to know me. I
  know that I like some people, but that somebody
  would like me thats very difficult to imagine.

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AN AGE OF MEALNCHOLY?

• Truly, we have entered an age of melancholy
• Barker, 1992
• The medicalisation of unhappiness as depression
  is one of the greatest disasters of the 20th
  century
• Oakley, 1993

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TROUBLESOME MEN

• Men with a psychosis are seen to be more
  successful at gaining psychiatric attention
  public concerns about their disruptive and
  disturbing behaviour.
• During the 1990s numerous media reports of
  dangerous mentally ill men forced the
  government into a swift response

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BIG, BLACK AND DANGEROUS

• Media hyperbole generated fear about the risk
  from dangerous, mentally ill men
• The murder of Jonathan Zito by diagnosed
  schizophrenic patient Christopher Clunis (see The
  Clunis Report, 1994)
• Black people in the service are treated in a
  more coercive and punitive way (Pilgrim
  Rogers, 1993)
• African-Caribbeans are over-represented in locked
  wards and secure units

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BIG, BLACK AND DANGEROUS

• African-Caribbean and Asians are more likely to
  receive physical treatments than their white
  counterparts
• Black men are more likely to be viewed by staff
  as aggressive, uncooperative, violent and in need
  of higher doses of medication usually
  intramuscularly
• Black and Asian men more likely to be diagnosed
  as schizophrenic a misdiagnosis? Evidence of
  diagnosis being significantly altered within 48
  hrs of presentation (Fernando, 1991)

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BOARDERLINE PERSONALITY DISORDER

• Women are more frequently given the diagnosis of
  BPD three-quarters of people living with this
  diagnosis are women (Perkins Repper, 1998)
• Women diagnosed with BPD often perceive their
  care as punitive and stigmatizing (Nehls, 1998)
• Women who self-mutilate are likely to be given a
  diagnosis of BPD
• BPD is often seen by the mental health services
  as difficult or untreatable. At best, the coping
  behaviours employed by women such as
  self-mutilation, are addressed (often
  inappropriately) but the underlying causes of the
  distress (for example trauma from childhood
  sexual abuse) is left unsupported (Babiker
  Arnold, 1997)

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SCHIZOPRENIA

• The diagnostic rates of schizophrenia are about
  the same for men and women but there are gender
  differences
• Men tend to be diagnosed approx 4-6 years earlier
  than women
• Women are more likely to develop late-onset
  schizophrenia
• Women are less likely to be given a dual
  diagnosis (substance misuse and
  psychosis/schizophrenia)

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CONT.

• Signs and symptoms of schizophrenia differ
  between men and women
• The content of delusions is largely culturally
  determined and accordingly tend to run along
  gender-role lines
• Women less bizarre, more somatic, may have
  romantic preoccupations
• Men more concerned with political conspiracy,
  undercover activities (see account by Rufus May,
  Openmind, 106, Nov/Dec 2000), more grandiose
  delusions of power, royalty and divinity
• Women experience more depressed mood, apathy and
  paucity of speech than men.
• More men than women diagnosed with schizophrenia
  complete suicide although the ratio is lower
  than in the general population where men
  outnumber women 41

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THE NEED FOR A CONCEPTUAL MAP?

• Liz Sayce (former chair of MIND) argues for a
  place for a classification of mental illnesses or
  a frame of reference
• the DSM is open to considerable question as a
  reliable and acceptable categorization system,
  but we do need a language, a set of categories,
  to describe different experiences (Sayce, 2000)

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VOICES FROM THE SERVICE USER/SURVIVOR

• Increasingly mental health practitioners (most
  particularly nurses) are turning to listen to the
  subjective accounts of those who experience
  mental illness
• By listening to service users articulations of
  their experiences, mental health practitioners
  can work collaboratively and co-operatively

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CONT.

• sharing our stories finally gave us the courage
  to believe that we are not mad we are angryour
  distress and anger is often a reasonable and
  comprehensible response to real life situations
  which have robbed us of our power and taught us
  helplessness
• (Wallcraft, 1996)

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WORKING WITH THE PERSON

• The acceptance of a person into (or exclude
  from) the mental health system invariably
  involves ethical and political judgements.Gender,
  age, ethnicity, class and sexual orientation
  impinge upon psychiatric symptom assessment and
  diagnostic conclusions (Horsfall, 2001)
• It is imperative, therefore, that to work
  effectively with users of mental health services
  their social context must be fully appreciated, a
  gender-neutral approach is not accepted and the
  needs and wants of different ethnic groups is
  addressed

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EXPERIENCING ILLNESS

• By developing a phenomenology of the experience
  of mental illness, we can better understand and
  respond to it
• Making sense of mental illness involves
  reflection both of the individual experiences and
  of social consequences and cultural constructions
  of the issue (Kangas, 2001)

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FINDING A COHERANT NARRATIVE OF EXPERIENCE

• I think the best professionals involved in my
  care have walked alongside me, opening themselves
  to the mystery that is schizophrenia
• (Champ, 1999)

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REFERENCES/READING

• Babiker, G Arnold, L (1997) The Language of
  Injury Comprehending Self-Mutilation BPS,
  Leicester
• Barker, P et al (1999) From the Ashes of
  Experience Reflections on Madness, Survival and
  Growth, Whurr, London
• Casey, B Long, A (2003) Meanings of Madness,
  Journal of Psychiatric and Mental Health Nursing
  1089-99
• Horsfall, J (2001) Gender and Mental Illness,
  Issues in Mental Health Nursing 22421-438
• Nehls, N (1998) Borderline Personality Disorder,
  Issues in Mental health Nursing 1997-112
• Perkins, R Repper, J (1998) Dilemmas in
  Community Mental Health Practice, Radcliffe
  Medical Press, Abingdon
• NB this lecture is available at
  http//shswebspace.swan.ac.uk/HNGardnerLD/

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SGW

• In your group discuss the implications of the
  diagnostic process is a diagnosis helpful? Why?
  What would the consequences be if we abandoned
  the concept of diagnosis?
• Is Oakley correct in asserting that the
  medicalisation of unhappiness as depression is
  disastrous?
• How can you learn about mental illness? Why do
  you need to know? What do you need to know? Are
  first hand accounts useful? How and why might
  they be useful?