Psychiatry by Ten Teachers

Nisha Dogra, Brian Lunn, Stephen Cooper, Nisha Dogra, Brian Lunn, Stephen Cooper

• Publisher: CRC Press
• Year: 2017
• eBook ISBN: 9781498750240
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Psychiatry by Ten Teachers follows the highly-praised and successful 'Ten Teachers' tradition of providing the key information in a chosen specialty as required by the medical undergraduate, junior doctor and trainee GP, written by ten respected experts in the field. With medical students closely involved in the text's development from the outset the text focuses on what the medical student and junior really need to know, with a clear rationale for the inclusion of every topic discussed at a level appropriate for the inexperienced, and will be of value to their future career whatever field they ultimately decide to specialize in.

Completely up to date, this revised second edition encourages students and recently qualified doctors to get the most out of their psychiatry and community attachments, without overwhelming them with unnecessary detail. In line with the core curriculum recommended by the Royal College of Psychiatry, useful tips and advice ensure this is much more than a standard introduction to the subject, encouraging additional reading, supporting critical thinking and bringing exam success.

CHAPTER 1

Defining mental health and mental illness

NISHA DOGRA AND STEPHEN COOPER

Introduction

Defining mental health, mental illness and mental health problems

The classification of mental illness

Mental health: One of many factors

Interaction between mental and physical health

Sexual disorders and dysfunctions

The scale of the problem

Anti-psychiatry

Myths about mental illness

Stigma and mental illness

Children, mental illness and stigma

Media, mental illness and stigma

Interventions to reduce stigma

Summary

Further reading

KEY CHAPTER FEATURES

• Discussion of the terminology around mental health, mental health problems and mental illness
• Outline of the scale of individual suffering from mental health problems and a public health dimension of the scale of the problems
• Define stigma, how it is perpetuated and its consequences on individuals and practice
• The evidence regarding which interventions may reduce stigma
• The steps you may need to take to reflect on your views and their impact on your practice

Introduction

In this chapter, we define mental health, mental health problems and mental illness. This is important because, although it sounds fairly straightforward, our discussion will demonstrate the difficulties that abound with the terminology. The scale of the problem and access to services at a public health level are outlined. We then discuss stigma generally, explore the reasons for it and possible sequelae. We also review the interventions to reduce stigma before asking you to reflect on your own perspective and their potential impact on your future practice.

Defining mental health, mental illness and mental health problems

It is important to state at the outset that there is no widely agreed consensus on the meaning of these terms and their use. Many outside the health arena challenge the terms, and mental illness as a concept is widely challenged by the anti-psychiatry movement (which includes doctors). However, the reality remains that if an individual experiences difficulties which impact on their emotional and inner worlds, their functioning can be affected. Mental health and mental illness can be viewed as two separate, yet related, issues.

EXERCISE 1.1

On your own or with some peers answer the following questions? (You will get more from the exercise if you answer as honestly as you can.)

What is your own understanding of mental health, mental illness and mental health problems?

What sorts of problems do people experience that could be described as mental health problems or mental illness?

How can you tell if someone is experiencing mental health problems or mental illness?

How often do you use words that reflect on patients with mental health in a less than complimentary way?

How do you think you have formed your views on mental illness and what part might your cultural background have played in forming these views?

Mental health

The World Health Organization (WHO) definition of health is: ‘A state of complete physical, mental and social well-being, and not merely the absence of disease’ (www.who.int/topics/mental_health/en/). This is supported by the Royal College of Psychiatrists, who have argued that there is no health without mental health. The WHO adds:

Mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.

Another way of looking at this is that mental health includes how people look at themselves, their lives and the other people in their lives; how they feel about these different components, evaluate their challenges and problems; and how they explore choices. This includes handling stress, relating to other people and making decisions. However, even a cursory glance at the definition raises important questions as the concept is clearly rooted in societal norms and expectations. The way that the normal stresses of life are defined will vary from society to society and within subgroups. The contribution to the community is also societal and culturally based. Perhaps a useful way of viewing the definition in practice is: ‘that someone is considered as having mental health when they manage day-to-day living without too much difficulty in a way that satisfies them and fulfils familial and societal expectations of them without causing them undue stress’. Immediately this alerts you to consider the plight of those who do not meet familial or societal expectations as they conflict with individual perspectives and the significant impact this can have on mental health (for example, consider being gay in countries in which homosexuality is illegal, or forced marriages). Culture and its influence on how mental health is understood is discussed later in this chapter in the section ‘Mental health: One of many factors’.

Definitions of mental health relating specifically to children have been provided by several bodies and emphasize the expectations of a healthy child. So, a mentally healthy child is one who can, for example:

• Develop emotionally, creatively, intellectually and spiritually
• Initiate, develop and sustain mutually satisfying personal relationships
• Face problems, resolve them and learn from them

This could easily apply to adults and in some ways is developmentally rather than culturally contextual, as these functions apply in whichever society the young person is living.

Mental health problems

‘Mental health problems’ is a term that encompasses a range of experiences and situations. Mental health might usefully be viewed as a continuum of experience, from mental well-being through to a severe and enduring mental illness. Mental health problems cover a wide range of problems which affect someone’s ability to get on with their daily life. Mental health problems can affect anyone, of any age and background, as well as have an impact on the people around them such as family, friends and carers. Mental health problems result from a complex interaction of biological, social and psychological factors. Major life events such as bereavement, relationship break-up or serious illness can impact significantly on how we feel about ourselves and subsequently on our mental state and health. A minority of people may experience mental health problems to such a degree that they may be diagnosed as having a mental illness. Common mental health problems include anxiety (including phobias), obsessive compulsive disorders, adjustment disorders and milder mood problems.

Mental illness

A mental illness is an illness that causes disturbances in thinking, perception and behaviour beyond those that might be experienced even in an acutely distressed state. They can be severe, seriously interfering with a person’s life, significantly impairing a person’s ability to cope with life’s ordinary demands and routines and even causing a person to become disabled. The majority of people will not experience mental illness, but will undoubtedly experience mental health problems at different times in their lives.

Another common term is mental disorder, and this is often used in the sense that a person who is mentally ill is suffering from a mental disorder – the use is usually in the context of legislation. In practice, most clinicians tend to use mental health problems for less serious disorders and mental illness for more severe disorders. A complicating factor is that subjective components are also relevant. Clinicians may feel that the anxiety symptoms their patients have are fairly mild but for the patients the impact on their life may be significant. Some patients who are seriously mentally ill (for example someone who is manic or acutely psychotic) cannot understand why others think they are ill because from their perspective all is well.

In this book, we use the term mental health problems as that is a widely used terminology, although specific disorders such as schizophrenia, depression and the like are defined as mental illness using the International Classification of Diseases (ICD) (WHO).

The classification of mental illness

The ICD is the international standard diagnostic classification for all general epidemiological and many health management purposes, research and clinical use. It is used to classify diseases and other health problems recorded on many types of health and vital records such as death certificates. However, the way that these diagnostic categories are used in practice varies across the world. The major categories for mental health and behavioural disorders are shown in Box 1.1. The ICD is revised periodically and is currently in its tenth edition with the 11th edition being planned.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders. It is used in the United States and in varying degrees elsewhere. There is some consistency between the two classification systems, especially for mental health. However, the DSM tends to use broader categories and is considered by some too inclusive in some of the disorders it lists. The multi-axial format used by the DSM can be helpful as shown in Box 1.2.

Box 1.1 Multi-axial classification often used in child mental health services (ICD-10)

Axis 1 – Mental health diagnosis

Axis 2 – Developmental

Axis 3 – Intellectual

Axis 4 – Organic/physical

Axis 5 – Psychosocial

Mental and behavioural disorders (F00–F99)

F00–09 Organic, including symptomatic, mental disorders

F10–19 Mental and behavioural disorders due to psychoactive substance use

F20–29 Schizophrenia, schizotypal and delusional disorders

F30–39 Mood (affective) disorders

F40–48 Neurotic, stress-related and somatoform disorders

F50–59 Behavioural syndromes associated with physiological disturbances and physical factors

F60–69 Disorders of adult personality and behaviour

F70–79 Mental retardation

F80–89 Disorders of psychological development

F90–99 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence

Box 1.2 Multi-axial system used in DSM

The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability.

• Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders
• Axis II: underlying pervasive or personality conditions, as well as mental retardation
• Axis III: acute medical conditions and physical disorders
• Axis IV: psychosocial and environmental factors contributing to the disorder
• Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders i...

Table of contents

• Cover
• Half Title
• Title Page
• copyright Page
• Contents
• List of teachers
• Preface
• Acknowledgements
• List of abbreviations
• Digital resources
• Chapter 1 Defining mental health and mental illness
• Chapter 2 Personality, predisposing and perpetuating factors in mental illness
• Chapter 3 Assessment and engagement with patients
• Chapter 4 Making the most of your placement
• Chapter 5 Mental health legislation
• Chapter 6 Mood disorders
• Chapter 7 Anxiety disorders
• Chapter 8 Phobias
• Chapter 9 Schizophrenia
• Chapter 10 Substance misuse
• Chapter 11 Eating disorders
• Chapter 12 Organic disorders
• Chapter 13 Psychiatric aspects of intellectual disability
• Chapter 14 Disorders of childhood and adolescence
• Chapter 15 Old age psychiatry
• Chapter 16 Disorders of personality
• Chapter 17 Commonly used psychological treatments
• Chapter 18 Psychopharmacology and physical treatments
• Chapter 19 Psychiatric emergencies
• Index