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Does Mental Illness Exist?. Patricia Casey Mater Misericordiae University Hospital & University College Dublin. Is Health The Absence of Disease?. World Health Organisation

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does mental illness exist

Does Mental Illness Exist?

Patricia Casey

Mater Misericordiae University Hospital

&University College Dublin.

is health the absence of disease
Is Health The Absence of Disease?

World Health Organisation

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”

(1946)

slide3

Is Health The Absence of Disease?

Imre Loeffler

“The World Health Organization's famous definition of health as 'complete physical, psychological, and social well-being' is achieved only at the point of simultaneous orgasm, leaving most of us unhealthy (and so, by the Chambers Dictionary definition, diseased) most of the time".

what is disease
What is Disease?

"Each civilisation," wrote Ivan Illich, "defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness, or sin in another."

The Oxford Textbook of Medicine stays away from defining a disease.

Chambers Dictionary defines disease as 'an unhealthy state of body or mind; a disorder, illness or ailment with distinctive symptoms, caused e.g by infection'.

what is disease5
What is Disease?

Collins Dictionary defines disease as:

  • any impairment in normal physiological function affecting an organism especially a change caused by infection, stress etc. producing characteristic symptoms; illness or sickness in general
  • a corresponding condition in plants
  • any condition likened to this’
what is non medical concept of illness
What is Non-medical Concept of Illness?

Cambell et al. 1979 BMJ Study of lay and medical peoples’view of what constituted disease

Illnesses due to infection and cancer were diseases

Hypertension, gall stones, fractured skull, depression uncertain

Disease was illness with a known causal agent (for infections only) whereas the presence of a know cause was not important for other conditions e.g. fractured skull.

what is non medical perception of psychiatric illness
What is Non-medical Perception of Psychiatric Illness?

The “Medical Model”

This states that psychiatric disorders are illnesses like any physical illness and therefore have specific biological lesions

This does take account of the multiple social and personal causes of psychiatric disorder

No lesions have been found for any psychiatric disorder

Therefore the idea of psychiatric illness should be abandoned

anti psychiatry school
Anti-psychiatry school

Thomas Szasz (1920- ) Psychiatrist

“Disease means bodily disease…the mind (whatever it is) is not an organ or part of the body. Hence it cannot be diseased in the same sense as the body can. When we speak of mental illness, the, we speak metaphorically” - “The Myth of Mental Illness”

Abnormal behaviours are social constructions and a function of societal values (but way are some behaviours that we distain not regarded as indicative of illness e.g. laziness, bad language, bad table manners

Bleuler and Kraeplin - “Psychiatric conquistadores” who together “invented schizophrenia”.

slide9
I. Psychic Depression

Depressed mood

Guilt

Suicide

Retardation

Helpless / Hopeless

worthless

II. Amotivation

Work & Activities

Physical Symptoms

Sexual Symptoms

Weight Loss

Hamilton Depression Scale - Factors

  • III. Psychosis
    • Insight
    • Depers / Dereal
    • Paranoia
    • Obs / Compuls.
  • IV. Anxiety
    • Agitation
    • Anxiety Psychic
    • Anxiety Somatic
    • Hypochondriasis

V. Insomnia – early / middle / late

Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

slide10

Factor I. Psychic Depression

Positive correlation with Cingulate Gyrus, Thalamus & Basal Ganglia

Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

slide11

Factor II. Loss of Motivation

Negative correlation with Patietal & Sup. Frontal Cortex

Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

slide12

Factor V. Insomnia

Positive correlation with Limbic & Basal Ganglia

Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

slide13
RD Laing (1927-1989). Psychiatrist

He rejected the anti-psychiatry label although his name has always been associated with it

Focus on psychosis. Never denied the existence of psychosis or the necessity to treat the distress associated with it.

Behaviour and speech of those with psychosis were ultimately understandable as an attempt to communicate worries and concerns in situations where this was not permitted.

slide14
RD Laing (1927-1989). Psychiatrist

Stressed role of the family in developing psychosis person unable to conform to the conflicting expectations of peers/family developed psychosis. It was an expression of distress and could be cathartic. Understanding the symbolism was important for treatment.

Provoked anger because of his view that mothers especially were to blame for schizophrenia

slide15
David Cooper (1931- ) Psychiatrist

Madness becomes the indictment of our failure to bring together our sexuality, our lives and our autonomy.

Believed in the influence of the traditional family in generating mental illness and sought alternative forms

The Death of Family

Psychiatry and anti-psychiatry

The Language of Madness

“Villa 21 project

slide16
Michel Foucault (1926-1984) Philosopher

The History of Madness 1961

The alleged scientific neutrality of modern medical treatments of insanity are in fact covers for controlling challenges to a conventional bourgeois morality.

slide17
Post Psychiatry/Critical Psychiatry (1999) The Bradford Group

Post-psychiatry: A new direction for mental health.Bracken and Thomas (BMJ 2001). 322: 724-727

Distances itself from anti-psychiatry school

Does not propose new theories about “madness”, but it “opens up spaces in which other perspectives can assume validity”

Mental health interventions do not have to be based on the framework centred on medical diagnosis and treatment

slide18
Contd….

It does not seek to replace the medical techniques of psychiatry

Wants to discard schizophrenia “Let’s scrap schizophrenia”

Wants to abandon psychopathology or the identification of psychopathological symptoms as indicating illness

slide19
Contd….

Believes medication of some value

Wants to examine the meaning of the symptom

Mutually contradictory stances

the diagnostic approach
The Diagnostic Approach

Karl Jaspers (1883-1969) psychiatrist and philosopher.

Phenomenology, the study of mental experiences tries to bridge the chasm between body and mind by describing subjective experience. However, the mind can only perceive the stimuli that the body receives and consciousness is required

Psychopathology is the study of abnormal psychic processes –

Descriptive psychopathology describes the subjective experience and the resultant behaviour but does not attempt to explain the cause e.g. hallucinations, obsessional ruminations etc. Therefore the content of the hallucination/delusion not important

Analytic or dynamic psychopathology tries to interpret their meaning and their origins using a theoretical framework of defence mechanisms and transference

new diagnoses how do they come about
New Diagnoses – How do They Come About

Case reports and observational studies e.g. anorexia nervosa

How common are these symptoms in the general population

Examine how symptoms cluster together - syndrome

How common are these symptoms in other diagnostic groups – which symptoms separate one diagnostic group from others

Examine what the risk factors and triggers - epidemiology

new diagnoses how do they come about22
New Diagnoses – How do They Come About

Examine the associated physical changes

(macroscopic, microscopic, molecular) and whether cause, effect or some relationship

Response to various treatments

Natural history and prognosis

Aetiology (cause) is usually the last element to be identified

This whole process is known as validation

history
History

Hippocrates “The Father of Medicine” (Cos) (460-377 BC) the “sick individual with his particular kind of misery”. Illness caused by imbalances in the 4 humors, inherited susceptibility or injury. The brain and not the heart was the centre of the emotions and perceptions.

Early Christianity – mental illnesses were due to demon possession

Mental Illnesses did not exist and the behaviour was under voluntary control and required punishment

history24
History

The Enlightenment – mental illness to be treated. Phillipe Pinel (1745-1826) replaced harsh methods with humane “treatments”. He believed mental illness caused by too much psychological or social stress, by heredity or by chemical changes.

Rene Descartes (1596-1650) Mind (soul) and body separate

theories of illness
Theories of illness

Roudolf Virchow ( 1821-1902). Disease is a lesion or alteration in body structure e.g. wound, fracture. He believed that lesions were present in illness but not inevitable

There are many physical illnesses that have no lesion associated – fibromyalgia, type 2 diabetes, migraine, trigemminal neuralgia, many cases of backache

Some only become recognised as illnesses when the technology becomes available e.g. ECG, X-ray, clotting factor diseases

Wilhelm Griesinger (1817-1868) took this to mean that mental diseases are diseases of the brain

theories of illness26
Theories of illness

“The diagnosis of patienthood has as its sufficient and necessary condition the experience of therapeutic concern by a person for himself/and/or the arousal of therapeutic concern for him in his social environment” Disease is what doctors treat – mental illness describes the condition of those people referred to psychiatrists

Kraupl Taylor (1980)

theories of illness27
Theories of illness

John Scadding (1967) illness is a variation from the statistical norm that carries biological disadvantage i.e. reduced fertility and increased mortality. The named disorder may be no more than a combination of symptoms and signs that occur together so frequently and so distinctively that they constitute a recognisable clinical picture - syndrome

Cohen (1981) illness is a statistical variation from the norm

jerome wakefield 1992 theory of harmful dysfunction
Jerome Wakefield (1992)theory of “harmful dysfunction”

There is a system within us that operates to allow us to adapt and ensure our functioning and survival

If this is dysfunctional then symptoms (suffering) occur

Only when these symptoms lead to impairment is illness present

  • Understandability
  • Proportionality
  • Functional incapacity
models of mental illness
Models of Mental Illness

Behavioural model: John Watson, Ivan Pavlov, Hans Eysenck

Behaviourists are not concerned with psychopathology or inner world, only with behaviour that results and the factors that reinforce or reduce it

Biological Model: Wilhelm Griesinger

Biological models examine the biological underpinnings of mental illness such as genetics, hormones, neurotransmitters, receptors

models of mental illness31
Models of Mental Illness

Psychodynamic Model: Freud

Unconscious desires and drives as well as problems at the various stages of development are responsible for mental illness

models of mental illness32
Models of Mental Illness

Social Model: George Brown

Factors in the environment cause mental illness e.g. life events, poor social supports

Cognitive Model: Aaron Beck

It is the person’s perception of themselves and of the event that cause mental illness

Biopsychosocial Model: Adolf Meyer

Bio-psycho-social model believes that all three elements are important in the genesis of mental illness but the relative size of each varies with the condition

what causes mental illness
What CausesMental Illness?

It depends on the definition of cause?

ordering the disorders
Ordering the Disorders

Psychiatric disorder are named and put into broad categories to allow for further study

The two systems of classification are:

Diagnostic and Statistical Manual (DSM)(American Psychiatric Association

International Classification of Diseases(ICD)(World Health Organisation)

ordering the disorders35
Ordering the Disorders

Both are aetiology neutral

They specify the criteria for each disorder

This allows for the study of these syndromes – treatment, aetiology, prognosis

For the collection of statistical data about them e.g. the Inspector of Mental Hospitals report

For communication among professionals about them

imperfections
Imperfections

Over-diagnosis – “false-positives”

Depressive illness - “depression” Regier et al 1998

Expect that there would be roughly similar prevalence between different studies

Over inclusive - may those spontaneously resolving reactions

imperfections37
Imperfections

PTSD and acute stress reactions

1. 9/11 “The mental health Crisis that Wasn’t” in

(Sommers and Satel in One Nation Under Therapy)

5 days after attack 90% upset and trouble sleeping (New Eng. J. Med 2001)

2 months after attack 7.5% had symptoms of PTSD

21% those living close to Centre had similar symptoms.

4 months later 1.7%

6 months later 0.6%

But no measures of severity or dysfunction

2001 estimates by FEMA that 1.5 citizens would need counselling

120,000 sought help up to June 2002

2. Follow-up studies of those witnessing atrocities in Africa

implications of over diagnosis
Implications of over diagnosis

Treatment implications -over-prescription of antidepressants

- over-utilisation of therapists

Iatrogenic illness e.g. critical incident stress debriefing, side effects of treatments

Service provision implications

Implications for research into aetiology e.g. neuroimaging, genetic, cognitive

example of mind body overlap
Example of mind-body overlap

PTSD (Wakefield – flaw in adaptation to threat)

Risk factors – temperament, age, man-made disasters, previous trauma, specific appraisal

Trigger - overwhelming traumatic event

Results – symptoms

fMRI – small hippocampus (?cause ?effect)

Treatment - cognitive therapy

slide40
Quantifiable change in functional brain response to empathic and forgivability judgments with resolution of post-traumatic stress disorder.

Farrow 2005

conclusion
Conclusion

Mental illness exists

Most comprehensive theory Wakefield’s “Harmful Dysfunction”

Objections based on dualistic assumptions and on therapeutic implications that flow from that

Mental illness over-diagnosed especially “depression”, post-traumatic stress disorder, ADHD

Need more refined diagnostic classifications that take account of context, severity and the presence of impairment in social functioning

slide48
Linear trend analysis of motor cortex being activated in controls more than patients to varying degrees in early psychosis.

fMRI activation during auditory hallucinations in schizophrenia

in vivo brain imaging paradigms in suicidal depression pet usa
In vivo Brain Imaging Paradigms in Suicidal Depression: PET (USA)

Reduced Brain Serotonin Responsivity in High vs Low Lethality Suicide Attempters (n = 27)

(Malone et al, SFN 2000; Oquendo, Malone et al, Archives Gen Psychiatry 2003)

slide50

Word Generation in Healthy Volunteers1st 15 seconds, (n=6, p<0.01)

Note activation in Broca’s Area

Malone et al (2003)

slide51

Future Thinking in Healthy Volunteers:

Negative Thinking

Positive Thinking

Amygdala & Post. Hippocampus

Retrosplenial & Ant. Cingulate

Malone et al (2003)

(n=6, p<0.01)