mental illness

n.
Any of various conditions characterized by impairment of an individual's normal cognitive, emotional, or behavioral functioning, and caused by social, psychological, biochemical, genetic, or other factors, such as infection or head trauma. Also called emotional illness, mental disease, Also called mental disorder.

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noun

Serious mental illness or disorder impairing a person's capacity to function normally and safely: brainsickness, craziness, dementia, derangement, disturbance, insaneness, insanity, lunacy, madness, psychopathy, unbalance. Psychiatry mania. Psychology aberration, alienation. See sane/insane.

n

Any disturbance of emotional equilibrium as manifested in maladaptive behavior and impaired functioning, caused by genetic, physical, chemical, biologic, psychologic, or social and cultural factors. Also called emotional illness, mental illness, psychiatric disorder.

It is reasonably clear that there can be chronic mental malfunction, when people's capacities to respond to the world, to absorb and remember information, respond with appropriate emotions, and form coherent plans are impaired. What is not so clear is that the mind can be the self-contained locus of an illness, or whether mental mal-function should always be thought of as the by-product of physical or bodily illness or impairment. If the former, then the mind might be cured by mental means, such as conversation with a therapist. If the latter, the only effective responses would be medical or pharmacological. So the issue has practical as well as purely philosophical importance.

A disorder of one or more functions of the mind resulting in the patient or others suffering. It does not include those conditions where the only problem is that the individual does not conform to the behavioural norms of society, nor does it include conditions of subnormality, where the individual has a general failure of normal intellectual development.

Mental Illness the Seventeenth Through the Nineteenth Centuries

The history of mental illness in the United States reflects the ever-changing landscape of mental disorders and the medical specialties responsible for their management and treatment. Mental illness (psychiatric disorders) is a nebulous term that has evolved over time. Insanity, lunacy, madness, mental illness, derangement, or unreason are among the many labels used to describe those individuals who, for various reasons, are psychologically unable to successfully function in society and require some form of intervention or treatment. The underlying causality for mental illness may be either physical (as in senile dementia), psychological (as in depression), or a combination of both. Since the middle of the nineteenth century, medical science has revolutionized treatment for numerous medical conditions, including mental illness. Many conditions previously believed to be psychological have been determined to be organic and removed from psychiatric nomenclature (conditions caused by vitamin deficiency, for example). Other conditions, such as schizophrenia and bipolar disorders, are the subject of dispute as to whether or not they are organic or psychological. Consequently, psychiatric nosology (the use of diagnostic categories) has remained fluid, as has the reported incidence of mental illness, ranging from approximately 3 percent of the population for psychotic disorders to 50 percent of the population for depression. Treatment approaches have been fluid as well, ranging from the exclusively physical to the exclusively psychological. Most mental health professionals advocate a combination of physical (psychotropic medications) and psychological (counseling) for most forms of mental disturbance.

Attitudes toward, and treatment for, the mentally ill in the United States accompanied the colonists from Europe, particularly England. By the beginning of the colonial period in America, the mad in Europe were confined to a variety of facilities called workhouses or houses of correction, along with other deviant groups. Treatment for the mad was predicated on the belief that mental illness was either the result of some mysterious physical malady or punishment for sin. What constituted treatment was extreme: bleeding, cathartics, emetics, hot and cold showers, whipping, and chaining. The history of the insane in colonial America followed a similar pattern: the mad were confined together with other deviant groups, either at home or in institutions. However, "home confinement" meant detention within the community, which led to rigorous settlement laws for newcomers, intended to prevent economic dependency on the community. If the new settler or visitor could not satisfy the settlement laws, they were "warned out" or asked to leave the settlement. Thus many of the mentally afflicted, the poor, the disabled, and petty criminals were forced to wander from township to township, occasionally housed overnight in the town jail and then forced to leave the community. As population increased and communities became more urban, hospitals were established at Philadelphia (1751) and New York (1773) that accepted both the physically and the mentally ill. However, treatment for the mentally disturbed was unchanged. Benjamin Rush, the "father of American psychiatry" and a medical practitioner at the Pennsylvania Hospital, advocated the same "heroic" treatment procedures as had his predecessors.

The emergence of a radically different approach at the Retreat in York, England (founded in 1792; first patients in 1796), established by William Tuke, ushered in a new era in the management of the mad. Similar developments had been taking place about the same time in Paris, initiated by Philippe Pinel, who unchained the mad and imposed a more humanitarian treatment regimen. Labeled moral therapy, the new form of treatment for the mad became the dominant approach for more than one hundred years. Moral therapy, or moral management, included removing the mad from their environment and secluding them in facilities exclusively for them, providing a structured daily schedule and work therapy, and confronting their "inappropriate" behavior for the purposes of reducing or eliminating such behavior. The goal of moral therapy was to restore the individual's sanity and to return the patient to society as a fully functioning, productive member of society through order, regularity, and discipline. Concurrently, the punitive treatments of the past were abolished. The introduction of moral therapy or management fostered a new optimism regarding treatment for the mad. Based on the new confidence, there followed an intense period of asylum building. Initially the new asylums were privately sponsored (corporate facilities), such as the one at the Charlestown branch of the Massachusetts General Hospital (1818; later renamed the McLean Asylum), the Bloomingdale Asylum (1821), and the Connecticut Retreat for the Insane (1824; later renamed the Hartford Retreat), but in short order, state governments began erecting public asylums. Although the first state asylum exclusively for the insane had been completed at Williamsburg, Virginia, in 1773, it remained a unique facility until 1824, when other states began to assume responsibility for the care and treatment of the insane. Between 1825 and 1865, fifty-three insane asylums were constructed, bringing the total in the United States to sixty-two. One individual, Dorothea Dix (1802– 1887), had a significant influence on asylum construction. After a visit in 1841 to a local Massachusetts jail, where she observed the deplorable conditions for the insane inmates, Dix began a forty-year campaign to reform conditions for the mad. She appealed to various individuals and government bodies with remarkable success. Dorothea Dix has been credited with the erection of thirty-two asylums, including Dorothea Dix Hospital in Raleigh, North Carolina (first patients in 1856). As state asylums were erected, they incorporated moral therapy as their treatment model, with unfortunate consequences. Whereas private, or corporate, asylums could limit patient population, public institutions could not. Populations in public facilities increased beyond the ability of the staff to realistically implement moral management. Consequently, public asylums became severely overcrowded and reduced to merely custodial institutions, a circumstance that was perpetuated well into the twentieth century.

The Association of Medical Superintendents of American Institutions for the Insane (AMSAII), organized in 1844, could do nothing to prevent or ameliorate the worsening problem of overcrowding and reduced funding. The Association was not an organization with an agreed-upon body of knowledge and theories concerning the causes and treatment of the insane that sought to inform and shape social attitudes toward the mentally ill. To the contrary, asylum superintendents and the facilities they administered had been assigned a role to play regarding a specific deviant group. Therefore, ideas articulated by the superintendents regarding the causes and treatment of mental illness were consistent with society's attitudes toward the asylum population. They were, first and foremost, agents of society and, second, physicians to the mad. Accordingly, there was a general consensus among the superintendents that most forms of madness were the consequence of some kind of physical trauma. Hallucinations, delusions, or disorders of the cognitive mind where observable aberrant behaviors were involved were easy to classify as madness and attribute to a blow to the head, fever, chronic illness, or some other easily discernible cause.

The difficulty with this theory lay in socially deviant behaviors where there was no observable mental or physical cause. How to diagnose, or classify, those individuals who committed apparently senseless, socially unacceptable acts? Were the individuals criminal, insane, or both? The answer was "moral insanity, " an ambiguous label for various forms of social deviancy in the nineteenth century. The primary cause of "moral insanity" was a disordered society, the effect of urbanization and immigration. As a result, the asylum itself became the remedy for insanity and other forms of social deviancy. If insanity could not be "cured, " at least it was confined and segregated from the remainder of society, where the mad would remain until 1964. From the beginning of the Civil War to the turn of the century, asylums continued to experience worsening overcrowding, decline in quality and quantity of personnel, reduced budgets, and a myriad of other problems.

Following the Civil War, neurology began to emerge as a new medical specialty and as one of the two major critics of asylum superintendents and asylum conditions. While neurologists agreed with asylum superintendents that insanity was a disease of the brain and that the deplorable asylum conditions were due to budgetary issues, they were critical of the superintendents. Neurologists argued that the superintendents were no more than asylum administrators, certainly not physician-scientists concerned with clinical practice and medical research concerning the origins and treatment of aberrant mental conditions. The conflict between the two specialties culminated in 1894 when Silas Weir Mitchell addressed the American-Medico-Psychological Association (AMPA) (formerly the AMSAII; the new name was adopted in 1892). Mitchell declared that the asylum physicians were not collecting adequate case histories or mental status examinations, they were neglecting autopsy and laboratory work, and they were failing to properly care for their patients. Thereafter, the two medical specialties reached an accommodation that was perpetuated well into the twentieth century.

Allied with neurologists as the other significant critic of asylum management and inmate care were state boards of charities. Once state governments determined that asylum budgets were their single greatest expense, administrative and budgetary control of the asylums was transferred to the boards of charities. As a consequence, once again the mentally disordered were grouped together with other deviant groups, criminals, the indigent, and the disabled, as a function of centralizing and rationalizing public welfare.

Thus, by the end of the nineteenth century, treatment of the mentally ill in America had come full circle. Housed in separate facilities, the mad were once again the responsibility of a centralized agency, the public welfare departments of state governments. Moreover, the earlier optimism regarding moral management had been replaced by a renewed pessimism. By the end of the nineteenth century, the asylums had failed as a cure for madness. There was no recognized medical cure for madness; confinement had only removed the mad as a threat to social order ("out of sight, out of mind"). An impasse had been reached, with no effective treatment available; all that remained was the asylum.

The Twentieth Century

The origins of a new approach to mental disorders began in the decade preceding the turn of the century. The informal adoption of Emil Kraepelin's classification system by Adolf Meyer in 1896, accompanied by the new title for the official organization of asylum physicians (AMPA), signaled a change in the approach to the treatment of the mentally ill. Both developments suggested that the profession was moving toward a disease concept of mental illness, in keeping with growing influence of scientific medicine. However, the most significant catalyst for change was Sigmund Freud (1856–1939), the creator of psychoanalysis as a valid approach for the treatment of mental disorders. Freud's innovation was the development of a systematic psychology of the mind and techniques to access the unconscious. Introduced to the American medical community during the first decade of the twentieth century, psychoanalytic techniques fundamentally altered treatment of the mentally ill. Freud and Carl G. Jung, the most prominent of Freud's followers, visited the United States to give a series of lectures at Clark University in 1909. Jung was one of the first psychoanalysts to employ psychoanalytic techniques with severely disturbed (psychotic) individuals, particularly schizophrenics. Freud's techniques were readily adapted to "office practice, " whereas Jung's methods were particularly useful with more severely disturbed, hospitalized patients.

Psychoanalysis was modified and popularized by American physicians such as A. A. Brill, Freud's American translator; Adolf Meyer, the first director of the Henry Phipps Psychiatric Clinic (1913) at Johns Hopkins Medical Center; and William Alanson White, the superintendent (1903) of the federal psychiatric hospital, St. Elizabeth's, in Washington, D.C. From their respective positions, Meyer and White became two of the most influential members of the psychiatric specialty in America. Both men shaped the evolution of psychiatric concepts and training during the first half of the twentieth century. In their professional roles, Meyer and White supported a more general reform of treatment for the mentally ill, lending their support to the National Committee for Mental Hygiene, founded by Clifford Beers, a former mental patient, in 1909. The goals of the National Committee were to prevent mental illness and to improve institutional conditions for the mentally ill.

Meyer and White symbolized the revolution in psychiatry and, more generally, medicine at the beginning of the twentieth century. Medical science had a profound impact on psychiatry, as new developments in medicine altered treatment procedures for many psychiatric disorders, as it did for physical ailments. Physical and psychological medicine fused to become modern psychiatry, a legitimate, accepted medical science of the mind. In 1921, its professional organization adopted a new name, the American Psychiatric Association, changed the name of its professional journal to the American Journal of Psychiatry, and accepted Kraepelin's nosology as the standard nomenclature for classifying psychiatric disorders. In the decades that followed to the close of the twentieth century, there were three important developments: continuing developments in medicine that directly affected the treatment of mental illness; expanding government participation in funding and oversight of patient care; and a proliferation of psychotherapeutic "schools, " most a response to the growing popularity of psychoanalysis.

Medical discoveries continued to redefine diagnostic categories and influence treatment for mental disorders. Therapeutic procedures appeared to revert to the former "heroic" measures of the past with the application of Metrazol, insulin, and electric shock therapies between 1937 and 1940. All three induced severe convulsions in the subject, who was typically chronically psychotic, with questionable results and at some risk to the patient. More effective and benign treatment appeared in the early 1950s in the form of chemical compounds known today as tranquilizers or, more accurately, psychotropic medication. The continuing evolution and effectiveness of these drugs has had a profound effect on treatment for the mentally ill, enabling many hospitalized patients to return to home and work or precluding hospitalization in the first place. As more effective treatment regimens appeared and as a response to public demand, government took a more active role in allocating funds for research and the establishment of model programs for the mentally ill. In 1946, the National Mental Health Act provided for the establishment of the National Institute of Mental Health; in 1963, the National Community Mental Health Centers Act was passed, which effectively "deinstitutionalized" most chronically ill patients and brought to an end reliance on custodial care facilities for the most severely disturbed individuals. The legislation anticipated that most former chronic patients would be managed by medications provided through local community mental health centers, but these expectations were not realized. The unfortunate consequence of this legislation has been to create an indigent homeless population in larger municipalities that absorbs law enforcement, medical, and other community resources. Nonetheless, state and federal governments have assumed a seemingly limitless role regarding mental disorders and the mentally ill.

Perhaps even more startling than any other development regarding mental illness in the United States has been an explosion in the number of mental health professionals during the past one hundred years. From an extraordinarily small group of psychiatrists, 222 in 1900, the number and variety of mental health professionals has grown enormously. No longer is psychiatry the only discipline concerned with treatment of the mentally ill. By the end of the twentieth century there were more than thirty-two thousand psychiatrists, seventy thousand psychologists, and many hundreds of thousands practicing in related professions—psychiatric social workers, pastoral counselors, sex therapists, marriage counselors, and a myriad of other quasi-professional and lay practitioners. Moreover, the number of psychotherapeutic approaches grew to nearly three hundred competing therapies, including various forms of psychoanalysis, individual and group psychotherapy, marriage and family counseling, "primal scream" therapy, "est, " transactional analysis, Gestalt therapy, and so on. Public and private hospital expenditures surpassed $69 billion and continued to increase, while private out-patient expenditures were undetermined. A vast array of psychoactive medications became available, either over the counter or by prescription. What were once private, personal problems became the subject of radio and television talk shows and newspaper advice columns.

Mental illness in America was transformed during the twentieth century. The single therapeutic tool of the nineteenth century, the asylum, virtually disappeared. Once the stepchild of medicine, psychiatry became a recognized medical specialty, a requirement in most medical schools. Underlying causes for mental illnesses are now recognized as a combination of environment and biology. One constant remains: as the medical and natural sciences continue to make new discoveries, what constitutes mental illness continues to be redefined.

Bibliography

Grob, Gerald N. Mental Institutions in America, Social Policy to 1875. New York: Free Press, 1973.

———. Mental Illness and American Society, 1875–1940. Princeton, N.J.: Princeton University Press, 1983.

———. From Asylum to Community: Mental Health Policy in Modern America. Princeton, N.J.: Princeton University Press, 1991.

Hale, Nathan G. The Beginnings of Psychoanalysis in the United States, 1876–1917. New York: Oxford University Press, 1971.

———. The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917– 1985. New York: Oxford University Press, 1995.

Porter, Roy. The Greatest Benefit to Mankind: A Medical History of Humanity. Chapter XVI, "Psychiatry." New York: Norton, 1997.

Shorter, Edward. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. 2d ed. New York: Wiley, 1998.

Most people think of mental illnesses as strange and frightening conditions, which can affect other people but not themselves or their families. But in the average family doctor's surgery psychological symptoms are surpassed in frequency only by common colds, bronchitis, and rheumatism. In the course of a year, about one in every eight people in Britain consults their general practitioner for problems which are predominantly or completely psychological in nature. General practitioners refer about 10 per cent of such patients to a psychiatrist; most of these will be treated as outpatients but some will need admission to hospital, which in Britain is nearly always on a voluntary basis. Thus, out of all those who seek medical help with psychological problems, only a small minority become psychiatric in-patients. It is then a striking indicator of the extent of such problems that psychiatric patients occupy nearly a quarter of all the hospital beds in Britain and in most other industrialized nations.

Arguments continually rage over the exact limits of mental illness. Some authorities regard the concept of mental illness as a myth while others, by contrast, consider that the majority of seemingly normal people suffer, often unknowingly, from psychiatric abnormalities amenable to treatment. Furthermore, some believe that psychiatric disorders are simply mental equivalents of physical diseases, while others argue that there are as many sorts of psychological problems as there are individuals who suffer from them.

In practice it is possible to discern certain recurring patterns of complaints and disabilities that can be regarded as reasonably discrete entities. These disorders can be divided into two broad groups: organic disorders, in which some demonstrable physical illness including brain disease underlies the psychological symptoms, and functional disorders, where no definite physical abnormality has yet been reliably demonstrated. Since most forms of mental illness fall into the latter category, the classification of psychiatric disorders is generally based on the clinical distinction between different clusters of symptoms, each with a characteristic outcome. (See classification of psychiatric disorders.) In general medicine, advances in classification occurred when technological progress allowed the elucidation of the underlying causes of illnesses. Unlike their colleagues practising general medicine or surgery, however, psychiatrists are unable to rely on laboratory or other tests to refute or confirm their clinical diagnoses. Recent attempts to develop specific diagnostic investigations, such as the dexamethasone suppression test for depressive illness, have yet to produce a procedure of proven value. Unfortunately other mental illnesses show the same response that was found with a proportion of depressed patients, but the search for laboratory tests to aid with the diagnosis of affective disorders and other conditions continues.

In the meantime it is useful to distinguish between the neuroses and the psychoses. Neurotic symptoms correspond to what is commonly called 'nerves' and comprise feelings and thoughts that most normal people have experienced at some time or other, albeit in a relatively minor form. However, if they become persistent and severe, such symptoms can become markedly disabling, and result in a frank neurotic illness or 'nervous breakdown'. Psychotic symptoms, on the other hand, are not part of normal experience and are almost invariably severe. The picture of psychotic illness is quite distinct from normality and corresponds to what in popular usage is called 'madness' or 'insanity'. Women outnumber men among neurotics by about two to one, but psychosis is equally frequent in the two sexes.

Neurotic problems account for about two-thirds of those consulting family doctors because of psychological symptoms, the remainder being made up by a variety of conditions including psychosomatic complaints, abnormalities of personality, alcoholism, and the psychoses. Most neurotics are treated by their general practitioners, but individuals with psychotic illnesses are almost always referred on to psychiatrists. Thus, while those with psychoses form only about 4 per cent of patients consulting GPs because of psychological problems, 25 per cent of psychiatric outpatients and more than half of all psychiatric in-patients suffer from psychotic illnesses.

Table 1 lists the expectancies of being affected at some time during life by the different psychiatric conditions for (i) a member of the general population and (ii) someone who has a first-degree relative (i.e. parent, sibling, or child) with one of the disorders.

1. Neuroses
2. Organic psychoses
3. Functional psychoses

1. Neuroses

Anxiety states are among the most common of all psychiatric disorders and are characterized by persistent apprehension and fear, at times amounting to panic. They are often accompanied by sensations caused by overactivity of the autonomic nervous system: these include excessive sweating, tremor, faintness, choking or breathlessness, and 'butterflies' in the stomach. (See anxiety for further discussion).Phobic neuroses have much in common with anxiety states in that the predominant symptoms are again of fear or panic together with autonomic overactivity. But in phobic neuroses the symptoms are provoked by certain specific stimuli, such as dogs, spiders, the sight of blood, or having to talk to strangers. The most common variety is agoraphobia, which means fear of open spaces. The agoraphobic is afraid of leaving home and subject to panic attacks in crowded public places such as supermarkets. He or she often dreads travelling on public transport, especially underground trains, and has great difficulty in tolerating lifts or rooms from which there is no ready exit. Since these symptoms considerably limit normal life, agoraphobic patients may become totally housebound. (See phobias for further discussion.)


Table 1. Lifetime risk of developing the disorder
Obsessive–compulsive neurosis is much rarer, but nevertheless the symptoms that form its core are phenomena with which, in milder form, most people will be familiar. There can be few people who have not at some time been unable to stop a song going round in their head, or had an irrational urge to avoid stepping on cracks in the pavement, or rechecked windows and doors which they know they have already secured. In obsessive–compulsive neurosis, such thoughts or practices become pathologically exaggerated. Fears of having been contaminated by dirt, or of having harmed someone, may preoccupy the sufferer for most of the day even though he recognizes that they are silly. Similarly, he may wash his hands or check taps a hundred times a day, while all the time trying to convince himself that his behaviour is ridiculous. Such repetitive thoughts and compulsive acts become so intrusive that productive activity becomes impossible. (See obsessive–compulsive disorder for further discussion.)

The predominant features of depressive neurosis are gloom and despondency. Bouts of weeping are common, as are edginess, irritability, and a tendency to tire easily. There is a general loss of ability to concentrate and in particular a lack of interest in things that were previously enjoyed. The symptoms tend to vary in intensity, but often cause difficulty in getting off to sleep. (See depression for further discussion.)

A variety of neurosis which was formerly common but is now much less so is hysteria, which in its classical forms beguiled 19th-century physicians such as J. M. Charcot and Sigmund Freud. Indeed, it was while studying a hysterical patient, the celebrated 'Anna O', that Freud and Breuer developed many of the concepts upon which psychoanalysis came to be based. The essence of hysteria is that, in the face of intolerable stress, symptoms develop which provide a defence against the stressful circumstances. Characteristic symptoms include a paralysed limb, loss of speech, convulsions, or blindness, and are often called conversion hysteria because the psychological trauma has figuratively been 'converted' into a bodily form. Some forms of hysteria involve a different mechanism called dissociation, in which an individual may forget even his own identity. He may wander off in a 'fugue state' that carries him many miles from home, or he may take on some new identity or switch from one identity to another — the 'split personality' of popular films, such as The Three Faces of Eve. (This phenomenon is discussed under dissociation of the personality.) Although hysterical mechanisms are usually unconscious, many psychiatrists doubt the genuineness of some of the more theatrical forms. Indeed one of the problems confronting psychiatrists in legal work is where to draw the dividing line between hysteria and conscious simulation or malingering. Fortunately, hysterical symptoms are becoming less common due to improved education and awareness of psychological matters; this allows the expression of emotional difficulties for what they are, and renders the communication of suffering via hysterical symbolism redundant. None the less, it is important to remember that conversion hysteria can develop against a background of serious organic brain disease, either pre-existing or unsuspected, in a considerable percentage of cases. (See hysteria for further discussion.)

In contrast to hysteria, anorexia nervosa appears to be on the increase, particularly among adolescent girls and young women. The central feature is self-imposed starvation, which frequently starts with a slimming diet and occasionally ends with complete inanition and death. Weight loss, physical overactivity, cessation of menstrual periods, and the growth of downy hair on the face and back are the cardinal symptoms. Surprisingly, most patients shun treatment and instead show considerable ingenuity in avoiding weight gain. Thus they hide food or secretly throw it away, and abuse laxatives. Like the obsessive–compulsive, the anorexic often recognizes the pointless irrationality of her behaviour but nevertheless feels bound to continue. Psychoanalysts have suggested that anorexia is a desperate unconscious attempt to stave off imminent sexual maturity, but a simpler explanation is that the anorexic has a distorted perception of her body that causes her consistently to overestimate her own size. The rise in anorexia has been attributed to increasing pressure on women to diet, as over the past 30 years or so the ideal female shape has become thinner and less buxom. Although the environment is of obvious importance, genetic factors have also been implicated in causing anorexia. (See anorexia nervosa and bulimia nervosa; genetics of mental illness, for further discussion.)

Two neurotic disorders that have received increased recognition over the past decade are neurasthenia and post-traumatic stress disorder. Neurasthenia, commonly termed chronic fatigue or myalgic encephalomyelitis (ME), is characterized by substantial physical and mental fatigue that significantly impairs daily activities. Although the diagnosis requires the exclusion of detectable organic disorders, neurasthenia may be triggered by physical illness — most commonly viral infection. Through advice and support, the sufferer is encouraged to return to pre-onset functioning. For the severely affected a formalized behavioural approach, including cognitive–behavioural therapy, may be required. To date, no pharmacological treatment of neurasthenia has been established.

Post-traumatic stress disorder arises as a delayed and protracted response to an exceptionally stressful event which is likely to cause pervasive distress in almost any individual. This disorder is characterized by repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams. Antidepressants and behavioural and cognitive therapy are often combined in the treatment of this disorder.Causes and treatment of neurosis. Everyone is probably capable of experiencing neurotic symptoms in some form or degree, but individuals differ in their susceptibility to stress. Some neurotic patients develop their symptoms without obvious precipitating factors, whereas others only become ill after major tragedies, such as the loss of a husband or child. Vulnerability to anxiety states and to phobic and obsessional neuroses appears to be partly influenced by genes. But it is generally agreed that life experiences play a major role. What is not generally agreed is which life events are crucial, and how they produce their effects. According to psychoanalytic theory, neurosis is an outward manifestation of deep-seated intrapsychic conflicts which were set up in early life. Treatment, which is necessarily prolonged and intensive, aims to make this unconscious material accessible to consciousness, and the resultant insight is expected to produce resolution and relief. The behaviourists, however, think that the symptom is the neurosis and that it is the result of faulty learning processes. Theoretical assumptions concerning unconscious mechanisms and insight are regarded as irrelevant. Instead the aberrant behaviour and/or cognitions are examined closely and broken down into their component parts, and the goal is then to persuade or educate the patient into adopting more appropriate and adaptive cognitions and/or patterns of behaviour. This approach is particularly useful with phobias and obsessive–compulsive neurosis. (See behaviour therapy.)

Most patients with milder neuroses never see a psychiatrist, but are instead treated by their general practitioner with a combination of simple support and antidepressants. Cognitive–behavioural therapy is the treatment of choice for the majority of neurotic disorders that require more expert clinical management. Over the past two decades new types of antidepressants, such as the selective serotonin reuptake inhibitor Prozac, have been developed. These newer antidepressants are no better than the older antidepressants in treating depressive symptoms. However, they are less dangerous when taken in overdosage and have been found to be effective in treating most neurotic disorders. Cognitive–behavioural therapy is therefore often augmented with a selective serotonin reuptake inhibitor. Previously tranquillizers such as the benzodiazepine Valium were universally prescribed for all forms of neuroses. However, recognition of their time-limited efficacy in treating symptoms, potential for abuse, and addictive properties have made their role very limited — if not contraindicated.

2. Organic psychoses

Acute. A variety of physical illnesses may produce an acute reversible mental disorder called delirium; the causes include fever or disturbance in body chemistry as well as infections of the brain. Delirium may also follow intoxication with drugs or withdrawal from heroin or alcohol ('DTs'). The most striking feature is the rapid onset of confusion. The patient has no idea where he is or what day it is, and only the most tenuous grasp of what is going on around him. He may see or hear things that are not really there (hallucinations), or experience distorted perception of things that are there (illusions). He is often very fearful and may believe he is being attacked or persecuted. Evelyn Waugh's The Ordeal of Gilbert Pinfold is an excellent, presumably first-hand, account of an acute organic psychosis that could possibly have been an example of alcoholic hallucinosis complicated by the taking of other drugs. Most delirious patients recover completely when the cause of the insult to the brain is corrected.Chronic. By contrast, dementia refers to chronic insidious organic psychoses that are usually progressive. Loss of memory for recent events is often the first symptom. Thus, an elderly woman may be able to describe vividly the days of her childhood, but be unable to recall what she has just eaten for breakfast. She then begins to forget the faces of friends and relatives, and may be unaware of where she is or what year it is. Deterioration in intellect and personality may show itself as a lack of propriety, lack of attention to personal appearance, and loss of normal social niceties and inhibitions. In about 10 per cent of cases dementia in later life is caused by remediable conditions such as benign brain tumours and hypothyroidism, but the great majority of cases are due to degenerative disease of the brain or its blood vessels. The ageing of Britain's population has rendered these disorders, senile and so-called multi-infarct dementia, so common that the increase has been called 'the quiet epidemic'. Sadly, there are at present no effective cures. (For further discussion see dementia.)

3. Functional psychoses

In 1898 Emil Kraepelin made the now classical distinction between the two major types of functional psychosis. He contrasted manic–depressive psychosis with its recurrent gross swings in mood with a more severe and progressive illness starting in young adulthood that he termed dementia praecox. Dementia praecox and manic–depressive psychosis are now termed schizophrenia and bipolar affective disorder, respectively. The distinction between these two disorders still holds; however, recent research has suggested that they may in part share the same genetic causes.Schizophrenia. Most schizophrenics suffer at some point from hallucinations that usually take the form of voices talking to or about them. Occasionally these voices are friendly but in the main they are disparaging and abusive. The schizophrenic is beset with strange beliefs (delusions). He may think, for example, that he is the victim of a plot, that everyone can read his thoughts, or that alien forces are inserting or removing thoughts from his head or controlling his body.

Schizophrenia is correctly diagnosed only when these beliefs are unshakeable and totally out of keeping with the ideas and philosophies of the sufferer's own class and culture. Thus, a rural West African who believes he is a victim of a witch doctor's spell, or a member of a spiritualist congregation receiving instructions from the dead, is unlikely to be schizophrenic. But an Englishwoman who is absolutely convinced that her every action is personally controlled by a famous pop singer through a radio receiver he has installed in her brain may well be.

About 80 per cent of schizophrenic patients make a good recovery from their first attack. Unfortunately, many patients later relapse and require further admission to hospital, and in the long term only about 50 per cent remain quite free of any disability. More severely affected people become so preoccupied with their delusions and hallucinations that they tend to withdraw from social contact, and lose touch with reality. As a result their social and occupational functioning deteriorates, and about 10 per cent of all those initially affected become long-term hospital inpatients. In spite of the disorganized and irrelevant speech and disintegration of personality of such severe schizophrenics, their basic intelligence is usually unaffected and improvement can still occur after many years of hospitalization.

If, as some claim, schizophrenia is a myth, then it is a myth with a strong hereditary component! The risk of the identical twin of a schizophrenic also developing the disorder is about 50 per cent, whereas the risk for a non-identical twin is less than 15 per cent; this difference presumably reflects the greater genetic similarity of identical twins. Similarly, children of schizophrenic parents who were adopted and raised by normal families still have an increased risk of schizophrenia, whereas children born to normal parents and by mischance raised by a schizophrenic do not. The precise way in which liability to schizophrenia is transmitted is not known, but biochemical factors may be important. Some drugs, such as amphetamines, can in excess produce a mental state mimicking schizophrenia; this has led to the suggestion that schizophrenics could be endogenously producing some aberrant chemical.

Once fashionable psychodynamic theories that abnormal parenting and childhood experiences could by themselves induce schizophrenia are now discounted. The importance of both the environment and neurodevelopment in the aetiology of schizophrenia is still recognized; however, a scientific biological perspective is taken. For example, fetal viral infection and obstetric complications have been implicated in causing abnormal neurodevelopment that may in part increase the susceptibility of an individual to schizophrenia, and traumatic life experiences or intense intrafamilial pressures have been shown to precipitate breakdown in susceptible individuals.

In treating schizophrenia, the two essential elements are antipsychotic drugs and social rehabilitation. Intrusive therapies such as psychoanalysis are harmful, but a long-term supportive relationship with a concerned psychiatrist, community psychiatric nurse, or social worker can be invaluable. Antipsychotic drugs are effective in treating and preventing florid symptoms, such as delusions and hallucinations, in 70 per cent of patients. Recent advances have resulted in the production of atypical antipsychotics — so named primarily because of their reduced propensity to cause side effects such as stiffness. Only clozapine, an atypical antipsychotic, has been found to be effective in treating the more insidious schizophrenic symptoms such as emotional flattening and poverty of thought. Clozapine has also been found to be effective in treating two-thirds of the 30 per cent of patients for whom treatment with other antipsychotics has been unsuccessful. A variety of social measures provide social and work environments to suit each patient's individual need. Rehabilitation may involve occupational therapy, attendance at a day hospital, or residence in a halfway hostel. The aim of such measures is, of course, to help the patient to find a satisfying role in the community and to stop him becoming institutionalized in hospital. Voluntary organizations such as the Schizophrenia Fellowship often play a major role in this. See also schizophrenia.Bipolar affective disorder. In its full-blown form, this is a cyclical disorder in which opposite extremes of mood are successively shown — mania and depression. Mania is characterized by an extraordinary sense of well-being, overactivity, and elation and is usually accompanied by a conviction of great self-importance which causes the individual affected to make grandiose pronouncements — for example, that he is the most talented and intelligent person in the world. He may consequently enter into wild and ruinous business ventures, or indulge in other unaccustomed excesses of spending, eating, drinking, or sex. His talk is profuse and prolix, flitting from topic to topic with an unstoppable stream of ideas interspersed with puns and feeble witticisms. His jollity may initially be infectious, but before long he becomes overbearing and tiresome. Not surprisingly most sufferers eventually dissipate their energy and return to normal, but an unfortunate minority descend straight into depression with no intermediate period of normality.

Bipolar affective disorder is much less common than depressive psychosis, the predominant symptoms of which are profound gloom and despair. Life appears futile and hopeless and suicidal ideas are usually entertained, and, not infrequently, successfully acted upon. Depression produces a marked depletion in self-confidence and self-regard and the depressive may see himself as the most evil and wicked individual who ever lived. Racked with guilt, the previously blameless character becomes convinced that he has committed some grave infamy or that he is to blame for all the sin and misery that exists in the world. Less commonly he may believe that he has been stripped of all his possessions, or that his body has become hideously diseased and is rotting and decayed. Real bodily disturbance of a less bizarre nature does usually occur. Appetite is poor, weight loss ensues, and there is often constipation and loss of sex drive. Some depressed patients physically slow down, and their talk may decrease or altogether cease, a condition known as psychomotor retardation: occasionally such a patient develops a state of mute, immobile stupor. In others restlessness and edginess may culminate in severe agitation.

Bipolar affective disorder, like schizophrenia, is partly determined by genetic factors. Again there is evidence that biochemical factors are important: for example, drugs which deplete the brain of chemical messenger substances called monoamines can induce depression, while drugs which raise the level of monoamines relieve depression and can precipitate mania. Despite the importance of these biological components, the part played by psychological factors can in no way be discounted. Adverse life circumstances or bereavement or other forms of loss are known to result frequently in depression, and psychoanalytic theory considers that it is the turning-in on the self of the consequent feelings of hostility and annoyance that produces the illness. Some behaviourists on the other hand have stressed the importance of learning experiences, such as exposure to inescapable mental trauma that produces a feeling of helplessness. This, they believe, forms the basis of the depressed state.

Bipolar affective disorder is a serious condition, not just because of the misery and the disruption it causes, but because about 15 per cent of sufferers eventually die by suicide. Fortunately, treatment is effective. Antidepressant drugs are of proven efficacy in the majority of typical cases and, although the manner in which it works remains obscure, electroconvulsive therapy can often relieve depression that has proved resistant to other treatments. Hospital admission, which is the general rule for cases of mania, provides a temporary sanctuary for those suffering depression, and is essential when the risk of suicide seems great. Psychotherapeutic help is invaluable and, in people who have recurrent episodes of illness, mood stabilizers such as lithium and carbamazepine may be used on a long-term basis to prevent further relapses.

(Published 2004)

— Harvey Wickham/Peter McGuffin/Robin M. Murray

Bibliography
• Berrios, G., and Porter, R. (eds.) (1999). A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders.
• Clare, A. (1980). Psychiatry in Dissent (2nd edn.).
• Gelder, M. G., Gath, D., Mayou, R., and Cowen, P. (1996). Oxford Textbook of Psychiatry (3rd edn.).
• Marks, I. M. (2003). Living with Fear (2nd edn.).
• Murray, R., Hill, P., and McGuffin, P. (eds.) (1997). The Essentials of Postgraduate Psychiatry (3rd edn.).
• Stefan, M., Travis, M., and Murray, R. (2002). An Atlas of Schizophrenia.

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Quotes:

"Nothing defines the quality of life in a community more clearly than people who regard themselves, or whom the consensus chooses to regard, as mentally unwell." - Renata Adler

"It is thus that the few rare lucid well-disposed people who have had to struggle on the earth find themselves at certain hours of the day or night in the depth of certain authentic and waking nightmare states, surrounded by the formidable suction, the formidable oppression of a kind of civic magic which will soon be seen appearing openly in social behavior." - Antonin Artaud

"There is no such condition as schizophrenia, but the label is a social fact and the social fact a political event." - R. D. Laing

"Schizophrenia cannot be understood without understanding despair." - R. D. Laing

"Schizophrenia may be a necessary consequence of literacy." - Marshall Mcluhan

"No further evidence is needed to show that mental illness is not the name of a biological condition whose nature awaits to be elucidated, but is the name of a concept whose purpose is to obscure the obvious." - Thomas Szasz

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