MENTAL DISORDER

any illness with significant psychological or behavioral manifestations and that is associated with either a painful or distressing symptom or impairment in one or more important areas of functioning. Mental disorders, in particular their consequences and their treatment, are of more concern and receive more attention now than in the past. Mental disorders have become a more prominent subject of attention for several reasons. They have always been common, but, with the eradication or successful treatment of many of the serious physical illnesses that formerly afflicted humans, mental illness has become a more noticeable cause of suffering and accounts for a higher proportion of those disabled by disease. Moreover, the public has come to expect the medical profession to help it obtain an improved quality of life in its mental as well as physical functioning. And indeed, there has been a proliferation of both pharmacological and psychotherapeutic treatments in psychiatry in this regard, many of which have proved effective. The transfer of many psychiatric patients, some still showing conspicuous symptoms, from mental hospitals into the community has also increased the public's awareness of the importance and prevalence of mental illness. There is no simple definition of mental disorder that is universally satisfactory. This is partly because mental states or behaviour that are viewed as abnormal or pathological in one culture may be regarded as normal or acceptable in another, and in any case it is difficult to draw a line clearly demarcating healthy from pathological mental functioning. A narrow definition of mental illness would insist upon the presence of organic disease of the brain, either structural or biochemical; however, this condition does not pertain, as far as is known, to the majority of mental disorders. An overly broad definition would define mental illness as simply being the lack or absence of mental healththat is to say, a condition of mental well-being, balance, and resilience in which the individual can successfully work and function and in which he can both withstand and learn to cope with the conflicts and stresses encountered in life. A more generally useful definition than either of the above is that a mental disorder is an illness with significant psychological or behavioral manifestations that occurs in an individual and that is associated either with a painful or distressing symptom, with impairment in one or more important areas of functioning, or with both. The mental disorder may be due to either a psychological, social, biochemical, or genetic dysfunction or disturbance in the individual. A mental illness can have an effect on every aspect of a person's life, including thinking, feeling, mood, and outlook and such areas of external activity as family and marital life, sexual activity, work, recreation, and management of material affairs. Most mental disorders negatively affect how an individual feels about himself and impair his capacity for participating in mutually rewarding relationships. Psychopathology is the systematic study of the significant causes, processes, and symptomatic manifestations of mental disorders. The meticulous study, observation, and enquiry that characterize the discipline of psychopathology are in turn the basis for the practice of psychiatryi.e., the science and practice of treating mental disorders, as well as dealing with their diagnosis and prevention. Psychiatry and its related disciplines in turn embrace a wide spectrum of techniques and approaches for treating mental illnesses. These include the use of psychoactive drugs to correct biochemical imbalances in the brain or otherwise to relieve depression, anxiety, and other painful emotional states. Another important group of treatments are the psychotherapies, which seek to treat mental disorders by psychological means and which involve verbal communication between the patient and a trained person in the context of a therapeutic interpersonal relationship between them. An important variant of this latter mode of treatment is behavioral therapy, which concentrates on changing or modifying observable pathological behaviours by the use of conditioning and other experimentally derived principles of learning. This article treats the types, causes, and treatment of mental disorders. Neurological diseases with behavioral manifestations are treated in nervous system disease. Alcoholism and other substance use disorders are discussed in alcoholism and drug use. Disorders of sexual functioning and behaviour are treated in sexual behaviour, human. Tests used to evaluate mental health and functioning are discussed in psychological testing. The various theories of personality structure and dynamics are treated in personality, while human emotion and motivation are discussed in emotionand motivation. any illness with significant psychological or behavioral manifestations that is associated with either a painful or distressing symptom or impairment in one or more important areas of functioning. There exists no widely accepted definition of mental disorders that clearly distinguishes them from the more normal or healthy mental states or behaviours the term is intended to exclude. Moreover, specific definitions of mental disorder will vary slightly from culture to culture because of differing social and cultural norms. A disturbance or conflict between an individual and society does not in itself signify a mental disorder but may rather simply be a form of social deviance on the individual's part. Mental disorders can vary greatly in their symptoms, severity, course, outcome, and amenability to treatment. They can adversely affect any and every aspect of a person's life, including his enjoyment, mood, and attitudes, and his occupation or career, sexual functioning, family and marital life, other interpersonal relations, and the management of his financial affairs. Most mental disorders can be broadly classified as either psychoses or neuroses. Psychoses are major mental illnesses that are characterized by such severe symptoms as delusions, hallucinations, disturbances of the thinking process, serious defects in judgment and insight, and the inability to objectively evaluate reality. The psychoses can in turn be classified as either organic or functional ones. Alzheimer's disease and other organic brain diseases comprise the organic psychoses. Schizophrenia and manic-depressive psychosis are functional psychoses, i.e., psychoses for which there is no palpable evidence of organic brain disease, though there may be undetermined biochemical or other abnormalities. Neuroses are less severe and more treatable illnesses than are psychoses. It is sometimes difficult to clearly distinguish between a neurosis and simple unhappiness, fear, or problems in coping with everyday life. Simple unhappiness, however, can usually be ameliorated by a change in external circumstances, while a neurosis is more resistant to real-life improvements unaccompanied by psychic change. A neurosis may cause a person distress and may impair his functioning in certain ways, but the neurotic person is able to objectively evaluate reality and he can basically function in everyday life. The major types of neuroses are depressive disorders, anxiety disorders, obsessive-compulsive disorders, paranoid disorders, posttraumatic stress disorders, conversion hysteria and other somatoform disorders, and dissociative disorders. There are other mental disorders that cannot be classified as either psychoses or neuroses. Chief among these are personality disorders, which are long-term, maladaptive accentuations of one or a set of particular personality traits. There are also various mental disorders that typically first become evident in infancy or childhood, and there are a variety of psychosexual disorders affecting an individual's gender identity or his sexual preferences. Despite the psychiatric profession's attempt to clearly delineate distinct clinical categories of mental illness, in actuality a patient may show a mix of symptoms, and the illnesses of many patients constitute intermediate cases between clearly defined disease categories. Mental disorders occur worldwide and affect a small but proportionally significant segment of the population. Schizophrenia, the most prevalent psychosis, affects about 0.5 to 1 percent of the population, and anxiety and depressive disorders each affect about 5 percent of the population at any one time. Some mental disorders, such as Alzheimer's disease, are clearly caused by organic disease of the brain, but the causes of most other mental disorders are either obscure, unknown, or clinically unverifiable. Schizophrenia appears to be partly caused by genetic factors that are inherited. Some mood disorders, such as mania (undue and prolonged excitement) and depression, appear to be caused in some instances by imbalances of certain chemicals called neurotransmitters in the brain, and they are treatable by drugs that act to correct these imbalances. In many cases, neuroses appear to be caused by primarily psychological factors such as emotional deprivation, frustration, or abuse during childhood, with the delayed effects of these traumas manifesting themselves indirectly many years later in the production of neurotic symptoms. Certain neuroses, particularly the anxiety disorders known as phobias, may in some cases represent maladaptive responses that have been built up into the human equivalent of conditioned reflexes. Contemporary therapeutic techniques for treating mental disorders include psychotherapy, psychopharmacology, and in extreme cases, psychosurgery (qq.v.). See also psychoneurosis; psychosis. Additional reading General works The following works provide descriptions of the syndromes, causes, epidemiology, and methods of treatment of mental disorders: J.L. Gibbons (ed.), Psychiatry (1983); Sir William Trethowan and A.C.P. Sims, Psychiatry, 5th ed. (1983); Robert G. Priest and Gerald Woolfson, Handbook of Psychiatry, 8th ed. (1986); Robert J. Waldinger, Fundamentals of Psychiatry (1986); and David Stafford-Clark and Andrew C. Smith, Psychiatry for Students, 6th ed. (1983). More detailed and comprehensive sources are Michael Gelder, Dennis Gath, and Richard Mayou, Oxford Textbook of Psychiatry (1983); Harold I. Kaplan and Benjamin J. Sadock (eds.), Comprehensive Textbook of Psychiatry/IV, 4th ed., 2 vol. (1985); Silvano Arieti (ed.), American Handbook of Psychiatry, 2nd rev. ed., 8 vol. (197486); and M. Shepherd (ed.), Handbook of Psychiatry, 5 vol. (198285). Classification and epidemiology For the two classificatory systems mentioned in the text, see American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd rev. ed. (1987); and World Health Organization, Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, rev. ed., 2 vol. (197778). J.K. Wing, J.E. Cooper, and N. Sartorius, Measurement and Classification of Psychiatric Symptoms (1974), provides an example of research diagnostic classification. See also Hugh L. Freeman (ed.), Mental Health and the Environment (1984); Alan Kerr and Philip Snaith (eds.), Contemporary Issues in Schizophrenia (1986); Einar Kringlen, Heredity and Environment in the Functional Psychoses (1968); and Andrew Sims, Neurosis in Society (1983). Causation Different aspects and theories of causation are considered in P. McGuffin, M.F. Shanks, and R.J. Hodgson, The Scientific Principles of Psychopathology (1984); David M. Shaw, A.M.P. Kellam, and R.F. Mottram, Brain Sciences in Psychiatry (1982); Tom Cox, Stress (1978); and George W. Brown and Tirril Harris, Social Origins of Depression: A Study of Psychiatric Disorder in Women (1978). Gordon Claridge, Origins of Mental Illness: Temperament, Deviance, and Disorder (1985), is a study of the interdependence of mental disorders and temperament, based on classic sources. H.P. Laughlin, The Ego and Its Defenses, 2nd ed. (1979), is a detailed study of defense mechanisms. Diagnostic categories William Alwyn Lishman, Organic Psychiatry: The Psychological Consequences of Cerebral Disorder (1978), deals comprehensively with the organic psychiatric syndromes; John Cutting, The Psychology of Schizophrenia (1985), studies theoretical and psychological aspects of the disorder; Silvano Arieti, Interpretation of Schizophrenia, 2nd rev. ed. (1974), presents major notions on schizophrenia. See also Aaron T. Beck, Depression: Clinical, Experimental, and Theoretical Aspects (1967; reissued as Depression: Cases and Treatment, 1970); Franz Alexander, Psychosomatic Medicine: Its Principles and Applications (1950, reprinted with a new introduction, 1987); and Philip Snaith, Clinical Neurosis (1981). Treatment A comprehensive discussion of current treatment methods for various mental disorders is offered in John H. Greist, James W. Jefferson, and Robert L. Spitzer (eds.), Treatment of Mental Disorders (1982). Works concerned with the theoretical concepts underlying psychotherapy include Henri F. Ellenberger, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (1970); and Jerome D. Frank, Persuasion and Healing: A Comparative Study of Psychotherapy, rev. ed. (1973). A good account of the main forms of psychological treatment is given in Sidney Bloch (ed.), An Introduction to the Psychotherapies, 2nd ed. (1986). See also Peter E. Sifneos, Short-Term Dynamic Psychotherapy, 2nd ed. (1987); Irvin D. Yalom, The Theory and Practice of Group Psychotherapy, 3rd ed. (1985); and David C. Rimm and John C. Masters, Behavior Therapy: Techniques and Empirical Findings, 2nd ed. (1979).Pharmacological and physical methods of treatment are dealt with in Lothar B. Kalinowsky, Hanns Hippius, and Helmfried E. Klein, Biological Treatments in Psychiatry (1982); Ross J. Baldessarini, Chemotherapy in Psychiatry: Principles and Practice, rev. ed. (1985); and Peter Dally and Joseph Connolly, An Introduction to Physical Methods of Treatment in Psychiatry, 6th rev. ed. (1981). Elliot S. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (1986), presents a history of the methods and personalities involved. James L. Gibbons Andrew C.P. Sims Treatment of mental disorders Historical overview Early history References to mental disorders in early Egyptian, Indian, Greek, and Roman writings show that the physicians and philosophers who contemplated problems of human behaviour regarded mental illnesses as a reflection of the displeasure of the gods or as evidence of demoniac possession. Only a few realized that sufferers from mental illnesses should be treated humanely rather than exorcised, punished, or banished. Certain Greek medical writers, however, notably Hippocrates (flourished 400 BC), regarded mental disorders as diseases to be understood in terms of disturbed physiology. Hippocrates and his followers emphasized natural causes, clinical observation, and brain pathology in the study of mental disorders. Later Greek medical writers, including those who practiced in Imperial Rome, set out treatment programs for mental illness, including quiet, occupation, and the use of drugs such as the purgative hellebore. It is probable that most psychotic people during ancient times were cared for by their families and that those who were thought to be dangerous to themselves or others were detained at home by relatives or hired keepers. During the early Middle Ages in Europe, primitive thinking about mental illness reemerged, and witchcraft and demonology were used to account for the symptoms and behaviour of psychotic people. At least some of the insane were looked after by the religious orders, who offered care for the sick generally. The empirical and quasi-scientific Greek tradition in medicine was maintained not by the Europeans but by the Muslim Arabs, who are usually credited with the establishment of asylums for the mentally ill in the Middle East as early as the 8th century. In medieval Europe in general it seems that the madman was allowed his liberty, provided he was not regarded as dangerous. The founding of the first hospital in Europe devoted entirely to the care of the insane probably occurred in Valencia, Spain, in 140709, though this has also been said of a hospital established in Granada in 136667. From the 17th century onward in Europe there was a growing tendency to isolate deviant people, including the insane, from the rest of society. Thus, such socially unwanted people as the mentally ill were confined together with the handicapped, vagrants, and delinquents. Those of the insane who were regarded as violent were often chained to the wall and were treated in a barbarous and inhumane way. In the 17th and 18th centuries the development of European medicine and the rise of empirical methods of medicoscientific inquiry were paralleled by an improvement in public attitudes toward the mentally ill, which only began to emerge toward the end of that period. By the end of the 18th century, however, concern over the care of the insane had become so great among educated people in Europe and North America that governments were forced to act. After the French Revolution the physician Philippe Pinel was placed in charge of the Bictre, the hospital for the mentally ill in Paris. Under Pinel's supervision a completely new approach to the handling of mental patients was introduced. Chains and shackles were removed from the patients, and in place of dungeons they were provided with sunny rooms and were permitted to exercise on the hospital grounds. Among other reformers were the British Quaker layman William Tuke, who established the York Retreat for the humane care of the mentally ill in 1796, and the physician Vincenzo Chiarugi, who published a humanitarian regime for his hospital in Florence in 1788. In the mid-19th century Dorothea Dix carried on a campaign to arouse the public to the inhumane conditions that prevailed in American mental hospitals, and her efforts led to widespread reforms both in the United States and elsewhere. The mental hospital era Many hospitals for the insane were built in the latter half of the 18th century. Some of them, like the York Retreat in England, were run on humane and enlightened lines, while others, like the York Asylum, gave rise to great scandal because of their brutal methods and filthy living conditions. In the mid-19th century an extensive program of mental hospital building was carried out in North America, Britain, and many of the countries of continental Europe. The hospitals housed the insane poor, and their aim was to care for patients humanely and to relieve their families of the burden of caring for them. The approach was that of moral treatment, including occupation, the avoidance of physical methods of restraint, and respect for the individual patient. A widespread belief in the curability of mental illness at this time was a principal motivating factor behind such reform. The mental hospital era was an age of reform, and there is no doubt that patients were treated much more humanely. The era produced a large number of segregated institutions in which a much higher proportion of the mentally ill were confined than previously. But the medical reformers' early hopes of successful cures were not vindicated, and by the end of the 19th century the hospitals had become overcrowded, and custodial care had replaced moral treatment. Types and causes of mental disorders Major diagnostic categories Organic mental disorders. This category includes both those psychological or behavioral abnormalities that arise from structural disease of the brain and also those that arise from brain dysfunction caused by disease outside the brain. These conditions differ from those of other mental illnesses in that they have a definite and ascertainable causei.e., brain disease. Treatment, when possible, is aimed at both the symptoms and the underlying physical dysfunction in the brain. There are several types of psychiatric syndromes that arise from organic brain disease, chief among them being dementia and delirium. Dementia is a gradual and progressive loss of such intellectual abilities as thinking, remembering, paying attention, judging, and perceiving, without an accompanying disturbance of consciousness. The syndrome may also be marked by the onset of personality changes. Dementia is usually a chronic condition and frequently worsens over the long term. Delirium is a diffuse or generalized intellectual impairment marked by a clouded or confused state of consciousness, an inability to attend to one's surroundings, difficulty in thinking coherently, a tendency to perceptual disturbances such as hallucinations, and difficulty in sleeping. Delirium is generally an acute condition and is not long-lasting. Other specific psychological impairments associated with organic brain disease are amnesia (a gross loss or disorder of recent memory and time-sense without other intellectual impairment), recurring or persistent hallucinations or delusions, or marked personality changes. In the diagnosis of suspected organic disorders, a full history has first to be taken from the patient and his mental state must be examined in detail, with additional tests for particular functions added if necessary. A physical examination is also carried out with special attention to the central nervous system. In order to determine whether a metabolic or other biochemical imbalance is causing the condition, blood and urine tests, liver function tests, thyroid function tests, and other evaluations may be carried out. Chest and skull X rays are made, and computerized axial tomography (CAT scan) is used to reveal focal or generalized brain disease. Electroencephalography may show localized abnormalities in the electrical conduction of the brain caused by a lesion. Detailed psychological testing may reveal more specific perceptual, memory, or other disabilities. Senile and presenile dementia In these dementias there is a progressive intellectual impairment that proceeds to lethargy, inactivity, and gross physical deterioration and eventually to death within a few years. Presenile dementias are arbitrarily defined as those that begin in persons under the age of 65. In old age the most common causes of dementia are Alzheimer's disease and cerebral arteriosclerosis. Dementia from Alzheimer's disease usually begins in people over age 65 and is much more common in women than in men. It begins with incidences of forgetfulness, which become more frequent and serious, and the disturbances of memory, personality, and mood progress steadily toward physical deterioration and death within a few years. In dementia caused by cerebral arteriosclerosis there are multiple areas of destruction of the brain caused by pieces of the damaged lining of arteries outside the skull lodging in the small arteries of the brain. The course of the illness is stepwise, with rapid deterioration followed by periods of slight improvement. Death may be delayed slightly longer than with dementia from Alzheimer's disease and often occurs from ischemic heart disease (heart attack) or from massive cerebral infarction, causing a stroke. Other causes of dementia include Pick's disease, a rare inherited condition that occurs in women twice as often as men, usually between the ages of 50 and 60; Huntington's chorea, an inherited disease that usually begins at about the age of 40 with involuntary movements and proceeds to dementia and death within 15 years; and Creutzfeldt-Jakob disease, a rare condition that is probably caused by a transmissible agent known as a slow virus. Head injury, for instance, resulting from a boxing career or from an accident, may produce dementia. Infection, for example, with neurosyphilis or encephalitis, various tumours, toxic conditions such as chronic alcoholism or heavy metal poisoning, metabolic illnesses such as liver failure, reduced oxygen to the brain due to anemia or carbon monoxide poisoning, and the inadequate intake or metabolism of certain vitamins may all result in dementia. There is no specific treatment for the symptoms of dementia; the underlying physical cause needs to be identified and treated when possible. The aims in the care of the demented patient are to relieve distress, prevent behaviour that might result in accident, and optimize his remaining physical and psychological faculties.