Models of the Mind

A Framework for Biopsychosocial Psychiatry

Stephen L. Dilts

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135895631
• Edition: 1
• Topic: Psychologie
• Subtopic: Santé mentale en psychologie

Making sense of such bewildering problems as hallucinations, paranoia, depression, and anxiety seems an incredible challenge, but modern psychiatry is able to bring understanding and change to many of those whose lives are impaired by psychiatric problems. This is not accomplished through the application of one dominant psychological theory, but through the integration of perspectives of many such theories in this diverse field into a befitting approach-the biopsychosocial model.
Application of the biopsychosocial model will allow for understanding the patient in biological, psychological, and social terms simultaneously, and provide a holistic picture with multiple strategies for treatment.
In this book, the author takes a step back from the assessment to demonstrate to the student methods of the information gathered from the patient into a clinically useful whole, essentially showing exactly how and why the psychiatrist arrives at an intervention.

Models of the Mind I

What is mental illness?

1

The purpose of psychiatry is to diagnose and treat mental disorders. From the time of the ancients, physicians have attempted to describe and devise treatments for such problems as delirium, mania, and melancholia. Whether the theory was an excess of bodily humors, demonic infestation, unconscious conflict, or neurobiological dysfunction, the psychiatric enterprise has been moved by the practical desire to treat the suffering caused by mental disorders.

So just what are mental disorders? What do they look like, what are their essential elements, and what are their causes? Before defining what constitutes a mental disorder, we need to know how to define “the mental.” Broadly, the basic elements of a mental state are thoughts, feelings, perceptions, cognitions, and behaviors. Thoughts are ideas, concepts, and the internal dialogue with one’s self. Feelings are subjective emotional states, such as happiness or sadness. Perceptions are the functionings of the five sensory modalities—sight, hearing, touch, taste, and smell. Cognitions are the basic abilities of intelligence, such as memory, attention, calculation, and language. Behaviors are actions—the outward manifestations of internal mental states—that an individual undertakes in the world.

A mental state consists of one’s thoughts, feelings, perceptions, cognitions, and behaviors.

Together, these elements constitute a mental state. Just as normal physiological functioning can become disordered, so mental functioning can become disordered. A case example shows what this might look like.

Case example

G began to feel depressed and hopeless in her early 20s, after a particularly bad romantic involvement. She began to experience severe and recurrent abdominal pain. At first, doctors attributed this to adhesive scar tissue in G’s abdomen as a result of surgery for ovarian cancer a few years before. Twice the adhesions were surgically removed, but the pain persisted. Finally, endometriosis was diagnosed and G’s uterus was removed in an attempt to alleviate her pain. But still the pain continued.

G had always been what her friends called “compulsive.” She had a driving, achievement-oriented style, graduating first in her high school class and attending a prestigious East Coast university. There she studied physics, supporting herself by working full time and compiling numerous academic honors. Then, in her junior year while she vacationed in Georgia, she met a young man who swept her off her feet. By the end of the school year G had decided to drop out of school and move to Georgia.

Then this relationship came to an end some months later, G was receiving death threats from the young man. She retreated to her home state, living with her parents again. Despite numerous attempts to correct her recurrent abdominal problems, G experienced worsening physical symptoms. The migraine headaches that had plagued her for much of her life became more frequent and severe. She found food less and less tolerable. Everything except fruit made her feel dizzy and confused. She felt a fullness in her abdomen, and she saw shadows out of the corner of her eye that disappeared when she turned toward them. Her perfectionistic style had turned into obsessional thinking and compulsive, repetitive behavior. She would clean her room, the bathroom, and the kitchen continuously, for hours every day, obsessed with a fear of germs that seemed irrational to her but that she could not ignore, despite her frustrated efforts. Mental rituals plagued her. She would find herself compelled to count items and mentally type words over and over.

G’s food intolerance worsened, and she began to lose weight. Despite her petite, athletic figure, she viewed herself as ugly and grossly overweight. She thought it was inconceivable that anyone could be attracted to her if her weight was more than 120 pounds, although men complimented her looks and pursued her even when she weighed more. She denied wanting this attention, but she dressed seductively, wearing short dresses, low-cut tops, and elaborate hairstyles.

G’s anxiety problems began to mount. In the grocery store one day she had a panic attack. She suddenly became exquisitely fearful; panting, sweating, her heart pounding, she felt dizzy and unreal. G curtailed her social activity dramatically after that, in part for fear of panic attacks, but more because of an inability to tolerate the feelings of dizziness and unreality that assailed her in noisy public gatherings. In such situations, she simply felt out of control.

Throughout all of this, G consulted physicians. She was convinced that some sort of medical illness was responsible for her woes. Doctors ran nnumerable tests, looking for anemia, lupus erythematosis, chronic fatigue syndrome, rheumatoid arthritis, anything that might explain her symptoms. Nothing was found. G invariably had normal lab tests and imaging studies. She was given trials of different antidepressant medications. All had intolerable side effects. G was able to take some antianxiety medications, which she began to administer to herself in high doses, but they provided little relief.

The psychiatrist who saw G at this time was impressed by the wide array of symptoms she presented. She also noticed that G’s reported distress seemed markedly worse than her actual appearance. G was always carefully groomed, despite her claims to virtual incapacity, and she did not appear to be in any physical distress. Each session invariably began with the statement, “I’m doing so badly.”

G’s functioning was very poor. By this time, she was on disability and leading an isolated life. Her social contact was limited to her parents and a new boyfriend whom she found unsatisfactory. They no longer had sexual relations due to her chronic pelvic pain, and she was constantly irritated at the many ways he disappointed her. G was extraordinarily angry with everybody. She invariably portrayed her physicians as insensitive fools who would not give her the time and care she required. Her parents and the rest of her family could not understand her problems, and she found their encouragement to push through symptoms and go on living infuriating.

Perhaps surprisingly, the psychiatrist found G quite likeable in many ways. She was intelligent, witty, even hilarious at times, and she seemed genuinely committed to treatment, inspiring the psychiatrist to work diligently to find some end to G’s suffering. Yet invariably, she found herself failing G. And though ostensibly working with the treatment plan, G missed appointments, saying she felt too bad to come in. She also started and stopped medications without involving her psychiatrist. G came to sessions informing the psychiatrist that she had felt suicidal over the weekend, but she had not called because every time she did, the psychiatrist was too problem-focused and not empathic enough. Yet when the psychiatrist simply listened to G’s stories of suffering, G derided her as “silent” and “not having any ideas.”

Using our definition of a mental state, we can discern which of G’s problems might represent “mental disorders.” G’s symptoms can be organized as disturbances in the areas of thoughts, feelings, perceptions, behaviors, and cognitions. G was plagued with troublesome thoughts. For example, she held the irrational belief that any type of contamination was dangerous. She also was convinced that she was grossly physically defective. Her self-concept told her that she was a horribly deformed creature. G’s feelings also proved disturbing. She suffered from depressed mood, anxiety, and overwhelming anger. Disruptive perceptions, such as a sense of abdominal fullness when she had not eaten and the sensation of shadows in her peripheral vision, also were present. G’s cognitive capacities were altered as well. For example, she showed signs of confusion, particularly after eating, and poor concentration. Finally, G evidenced problematic and upsetting behaviors, such as repetitive cleaning and frequent fighting with her boyfriend.

G also had a number of physical, or somatic, symptoms, such as pelvic pain, food intolerance, headaches, and dizziness.

When psychiatrists see someone with disturbances in these areas, they are on the way to diagnosing a “mental disorder.” A mental disorder is a disturbance in one or many of the basic elements of mental functioning: thoughts, feelings, perceptions, cognitions, or behaviors.

A mental disorder is a disturbance in thoughts, feelings, perceptions, cognitions, and behaviors.

This list is a start, but it is not sufficient. After all, everyone has problematic mental states at one time or another. Is anger at a friend a mental disorder? What about test anxiety? How do we know when someone has a mental state that qualifies as a “mental disorder?”

The descriptive model

The Diagnostic and Statistical Manual of Mental Disorders

Serious human mental problems tend to have recurring features. Depressed mood, for example, often is seen in conjunction with appetite and sleep changes. Severe panic produces symptoms such as hyperventilation, heart palpitations, sweating, and tremor.

In the last 35 years, the serious mental problems people recurrently face have been classified. Research has found that certain symptoms reliably occur together, and these sets of symptoms can be organized as syndromes. These syndromes are thus described by the symptoms that compose them. The descriptive model of mental illness attempts to describe the appearance of the major mental disorders through their symptoms.

The current state of the art in descriptive psychiatry is The Diagnostic and Statistical Manual of Mental Disorders, which is now in its fourth edition (DSM-IV). In broad headings, the DSM-IV describes the most common causes of distress and dysfunction in human beings, as shown below. These are the major disruptions in thoughts, feelings, perceptions, cognitions, and behaviors which human beings often find distressing and functionally impairing.

• Psychosis

• Mania

• Depression

• Anxiety
Obsessive-compulsive disorder
Posttraumatic stress disorder
Panic disorder
Generalized anxiety disorder
Social and specific phobias

• Psychiatric disorders secondary to general medical conditions

• Delirium

• Dementia

• Substance use disorders

• Personality disorders

The DSM-IV also contains listings for eating disorders, sleep disorders, disorders of childhood, somatoform and factitious disorders, dissociative disorders, sexual disorders, impulse-control disorders, and adjustment disorders.

For each disorder, the DSM-IV lists the symptoms that must be present to make a diagnosis. These disorders are defined and illustrated later in this book. Before proceeding to their descriptions, however, we must try to define what constitutes a mental disorder in general, compared to normal functioning.

Normal versus disordered

According to major epidemiological surveys, which have studied tens of thousands of people, over 30% of the population will experience a major mental disorder in their lifetimes. This is a large number, on par with the percentage who will die from cancer. This large number, however, raises a question. If almost one-third of the populace is going to have a serious mental disorder, are mental disorders so common that they might be said to represent the norm? If the list of mental disorders is expanded to include every conceivable human malaise, that list would be huge indeed.

Since the beginning of medical practice, the attempt to define health and normality has been an area of intense controversy. Is health simply the absence of disease? Or is it the absence of clinically significant disease, since most organisms have something about them that is not working right, if only a single cell out of trillions? Does adequate coping and functioning constitute health, even if abnormalities are present?

Psychiatry, too, has been embroiled in the question of what constitutes mental health, as well as mental illness. Sigmund Freud believed the concept of “the normal” was fictitious; in his model of mental illness, everyone has some degree of psychopathology (Sadock & Sadock, 2000). Freud did, however, suggest that a compromise was possible, and that adequate health could be said to exist when a person could “love and work” with relative freedom and facility. Others have attempted to define health and normality as success, whether in negotiating developmental stages, in adapting to the external world, or in mastering one’s fears and anxiety. Still others define illness purely as tissue abnormality.

Defining normality statistically probably is not helpful. Coronary artery disease obviously is not a normal situation for human beings—clearly, it represents abnormal, detrimental functioning. But heart disease is very common, as is cancer. That these are statistically common situations does not make them normal, in the sense that people would not wish to intervene against them. Psychiatric disorders likewise may be statistically common, but they cause severe distress and impaired functioning and thus are states people usually want to eliminate. High intelligence is statistically uncommon, but it is usually desired and so is not a disease state, because it is adaptive rather than problematic. So statistical prevalence is not helpful in defining normal versus diseased.

More useful is the concept of functional impairment. Disease in this model is present when a disturbance reaches the level that it causes significant functional impairment. Occasional premature ventricular contractions represent abnormal functioning of the heart, but cardiologists do not usually consider them to be “disease” unless they interfere with functioning or lead to worsening arrhythmias. Most people have headaches from time to time, but they are considered abnormal only if they become functionally impairing or are a symptom of another illness, such as a brain tumor. Likewise, everyone experiences some degree of sadness in life, but depression is diagnosed only if it becomes functionally impairing.

From the foregoing, it should be obvious that there is no purely objective standard that can be applied to decide such questions. How we determine what constitutes health and normality is largely dependent on values in psychiatry and in medicine in general. However, most human beings wish to function well in their environment and be free of severe distress. Distress and dysfunction are usually considered possible indicators of a disease state. This definition is not perfect. Not all distress and dysfunction indicate disease (for example, a child’s temper tantrum), while some diseases may be asymptomatic. But most disease states cause distress and dysfunction at some point in their course.

So how bad do distress and functional impairment have to be to warrant medical intervention? What problems are severe enough? The DSM-IV attempts to escape this dilemma in several ways. First, it lists specific criteria for each disorder. Simply having the blues, for example, does not warrant a diagnosis of depression. A number of other symptoms must be present, including changes in sleep, appetite, concentration, or energy; pervasive guilt; hopelessness; and suicidality. This type of depression, known as major depression, is a syndrome, a group of symptoms that are reliably found together.

One criterion for every DSM-IV disorder is that the symptoms must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” This modif...