Psychiatry Reconsidered

From Medical Treatment to Supportive Understanding

H. Middleton

• Publisher: Palgrave Macmillan
• Year: 2015
• Print ISBN: 9781349681716, 9781137411365
• eBook ISBN: 9781137384904
• Topic: Psychology
• Subtopic: Psychiatry & Mental Health
• Index: Psychology

Psychiatry suffers a lot of criticism, not least from within its own scientifically founded medical world. This book provides an account of mental health difficulties and how they are generally addressed in conventional medical circles, alongside critical reviews of the assumptions underpinning them to encourage more humanitarian perspectives.

1

International Classification of Diseases Chapter V and Diagnostic and Statistical Manual: Cataloguing Mental Illness

A first step towards understanding contemporary psychiatry is a grasp of how mental illnesses are identified and classified by those whose work is to do so. Classification is fundamental to all forms of scientific enquiry and investigation.¹ Classification is also an essential feature of ordered social life. Without agreed ways of categorising people, their qualities or their actions bureaucracies, labour markets and systems of justice would not function. People have to be defined by age (child, working age or pensioner) and level of employment in order to administer an agreed system of taxation. A person’s skills and qualifications have to be identified by some form of classification before a decision can be made about their suitability for a particular occupation, and actions have to be classified as lawful, reprehensible or criminal if they are to be judged appropriately.

Illnesses are classified in a variety of ways. This may be by cause; bacterial or viral meningitis, on the basis of assumed understanding of underlying mechanisms; obstructive or hepatocellular jaundice (respectively, something wrong with the drainage of bile or something wrong with the liver), by appearance; different forms of eczema, or by location in the body; breast, bowel or lung cancer. Each of these routes to classification provides its own information about the similarities and differences between conditions that do or do not fall into the same category. Knowledge of the underlying cause or mechanism can provide useful information about how to proceed with treatment. The appearance of eczematous skin can tell the dermatologist much about prognosis, likely causes and possible reactions to treatment. Where a cancer lies in the body and how far it has spread are powerful determinants of how it might threaten vital organs and even life itself.

In order to make sense of all this information and to allow scientific, therapeutic and epidemiological research various medical bodies have developed widely agreed schemes for classifying illnesses. The most comprehensive of these is the International Classification of Diseases (ICD), which is made up of 20 chapters covering each of 20 sets of medical conditions ranging from ‘Infectious and Parasitic Diseases’ to ‘Injury and Poisoning’. There are two additional chapters that provide classifications of ‘Factors Influencing Health Status and Contact with Health Services’ and ‘Codes for Special Purposes’. The ICD has been through several revisions since it first appeared in 1900.² The current ICD classification of mental illnesses is found in Chapter V, ‘Mental and Behavioural Disorders’ of version 10 (ICD-10; World Health Organization, 1992). At the time of writing ICD-11 was under development.

Recent times have also seen the development of an alternative but very similar classification of mental illnesses overseen by the American Psychiatric Association (APA). The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was introduced in 1952. It, too, has been subject to serial revisions, and the current version is DSM-5, which was published in 2013. Other schemes for classifying mental illnesses include the Chinese Society of Psychiatry’s Chinese Classification of Mental Disorders and the Latin American Guide for Psychiatric Diagnosis. Sponsorship by the World Health Organization (WHO) and the APA, respectively, has ensured that ICD Chapter V and the DSM are and remain the most influential. All of these, but most notably ICD Chapter V and the DSM, are essentially catalogues of the many and various forms distressed or distressing human behaviour has been found to take.

As a result of this wide scope ICD-10 Chapter V and DSM-5 are each both complex and comprehensive. ICD defines some 80 distinct mental and behavioural disorders grouped together into ten subchapters or blocks, and provides criteria for even more refined subclassification. This enables more than 700 permutations. DSM-5 identifies 19 sets of disorder based upon common presenting symptoms, typical age at onset and presumed cause (American Psychiatric Association, 2013). Together, these comprise some 140 potentially distinguishable conditions. Many of these are then further subdivided so that this manual offers some 500 possible permutations. ICD-10 might, therefore, identify someone as suffering from schizophrenia as one of the conditions covered in subchapter or block three, ‘Schizophrenia, Schizotypal and Delusional Disorders’, narrow this down to paranoid schizophrenia as opposed to another of the eight different types of schizophrenia it recognises, and then the person might be further classified on the basis of how their condition is progressing as ‘Paranoid Schizophrenia, Episodic Remittent’, meaning that they suffer a pattern of repeated episodes of mental state disturbance characteristic of paranoid schizophrenia as opposed to continuous symptoms or symptoms currently in remission. DSM-5 would regard the same person similarly, as suffering ‘Schizophrenia’; one of the conditions grouped together under ‘Schizophrenia and Other Psychotic Disorders’ and then further define them as suffering ‘multiple episodes, currently in partial (with inter-episode residual symptoms) or full (without inter-episode residual symptoms) remission’ depending upon the course of the condition and their current mental state. Whether it is helpful or distracting to try and classify or catalogue to this level of detail is a debate to return to, but the framework they are based upon does offer a way of classifying and therefore making some sense of what mental disorders are and how they compare and contrast with one another. What follows is a brief guide to how mental disorders are classified by ICD-10 Chapter V.³ Similarities and differences with DSM-5 are provided later in the chapter.

Organic Mental Disorders

These are described and defined in the first block or subchapter of ICD-10 Chapter V. They are disturbances of mental state or intellectual capacity believed to be due to potentially identifiable damage to the brain or to neuronal degeneration. Here we find classificatory criteria for different types of dementia: Alzheimer’s disease (early or late onset, atypical or mixed type, unspecified or residual category), six forms of vascular dementia,⁴ and six forms of dementia arising during the course of another identifiable disease such as Parkinson’s disease or HIV. There is a residual category of ‘unspecified dementia’. This subchapter also defines organic amnesia not attributable to alcohol or other intoxicants,⁵ such as a memory loss after head injury. It refers to four different forms of delirium and to 14 different forms of disturbed mental state such as alterations of mood or hallucinations that could arise as a result of brain damage or physical illness. There is a separate section concerning five possible types of personality and behavioural disorder other than dementia that are considered to be due to brain disease, damage or physical dysfunction.

Substance Misuse

The second subchapter refers to mental and behavioural disorders attributable to the harmful effects of psychoactive substance use: intoxication, dependency, withdrawal and toxicity. It is ordered around the various forms these might take following the misuse of any one of nine identifiable psychoactive substances such as alcohol or cocaine, or a residual category of ‘multiple drug use and use of other psychoactive substances’. The harmful effects of any one of these offending substances are identified as one of ten possibilities, such as ‘acute intoxication’, ‘dependence syndrome’ or ‘amnesic (memory loss) syndrome’. Using this system a person considered addicted to opiates and successfully taking prescribed methadone replacement would be classified as suffering ‘Mental and behavioural disorders due to opioids: Dependent syndrome: Currently on a clinically supervised maintenance or replacement regime’. Someone suffering delirium tremens with convulsions following withdrawal from heavy habitual alcohol consumption would be classified as suffering ‘Mental and behavioural disorders due to alcohol: Withdrawal state with delirium: With convulsions’.

Schizophrenia, Schizotypal and Delusional Disorders

These form the substance of subchapter three. The most important of these, schizophrenia, is the term that has been used to identify classic ‘madness’ since early in the twentieth century.⁶ The other conditions considered in this subchapter—schizoptypal disorder, delusional disorders, acute or transient psychosis, and schizoaffective disorder—are all conditions that display some but not all of the features of ‘full-blown’ schizophrenia. ‘Full-blown’ schizophrenia is associated with the so-called Schneiderian first-rank symptoms.⁷ These form an essential feature of schizophrenia itself, although they are sometimes found, to some degree, in other conditions. They are particular forms of the hallucinations and delusions common to all forms of psychosis and could be considered the more striking forms hallucinations and delusions take. In this context, the term ‘hallucination’ refers to the convinced experience of one or more voices, sounds, smells, visual imagery, sights, other forms of visual experience or bodily sensations for which there can be no agreed external source. The term ‘delusion’ refers to a strongly held belief or understanding that others do not share, and which is resistant to debate, argument or persuasion. Religious beliefs are conventionally differentiated from ‘delusions’ by reference to the fact that others of the same religious tradition will share them.

A disturbed or distressing state of mind might be classified as evidence of schizophrenia if it includes one or more Schneiderian first-rank hallucinations and/or delusions, and it would be confirmed as such if the experiences continued for a month. ICD-10 further subclassifies schizophrenia on the basis of associated features such as prominent concerns about being under surveillance or the victim of a conspiracy (paranoid), prominent disturbances of thoughts and organisation (hebephrenic), posturing or other abnormalities of movement or compliance (catatonic), over-riding social deficits after a longer period of classic symptoms (residual), and undifferentiated or simple.

Schizotypal disorder is identified as a condition characterised by eccentric behaviour, anomalies of thinking and reactions to others, which resemble those found in schizophrenia, but without evidence of the first-rank symptoms that define it. Delusional disorders are conditions in which a person is troubled by one or more persistent convictions, which usually have distressing implications but no grounding in fact. They include morbid jealousy or Othello Syndrome where, as in Shakespeare’s play of that name, someone has become groundlessly convinced of their conjugal partner’s infidelity with distressing and sometimes tragic consequences.

Subchapter three also includes criteria and codes for acute and transient psychosis. These are disturbances of mental state that might include features of schizophrenia but which only last for a few days, and are frequently associated with stressful circumstances, and schizoaffective disorders. Schizoaffective disorders are conditions in which the disturbance of mental state includes some of the features of schizophrenia and some of the features of a mood disorder (outlined below), without amounting to grounds for full classification as either.

Given their close association with traditional concerns about ‘madness’, namely unpredictable and violent behaviour, descent into incompetence and dependency, and the visceral discomfort of witnessing another person tortured by distressing thoughts and experiences, schizophrenia and associated conditions are probably the most notorious of the ‘mental illnesses’. As a result, only modestly convincing experiences of ‘voices’ or unconventional beliefs can raise unwarranted concerns. The presence of voices per se does not mean a person has schizophrenia and even if a condition does meet criteria for classification as ‘schizophrenia’, that is by no means automatic condemnation to a life of torment and incapacity.

Mood (Affective) Disorders

Subchapter or block four of ICD-10 Chapter V considers conditions in which the predominant disturbance of mental state is undue sadness or undue happiness. A period of undue sadness may be classified as an episode of ‘depression’. A period of undue happiness or irritability with others’ attempts to dampen high spirits may be classified as a ‘hypomanic’ episode. The term ‘mania’ is reserved for more striking presentations of these difficulties, and because of the wide availability of sedating medications, it is now a relative rarity.

As changes in mood are a feature of everyday life, ICD-10 sets out formal criteria that are used to discriminate between ‘normal’ and ‘abnormal’ mood states, or signs of a disorder. A period of noticeable happiness or irritability with others’ attempts to dampen high spirits would be considered an episode of hypomania if it is considered abnormal for the individual concerned, lasts for at least four days and includes at least three of increased activity or physical restlessness, increased talkativeness, difficulty in concentration or distractibility, decreased need for sleep, increased sexual energy, mild overspending or other types of reckless or irresponsible behaviour, increased sociability or overfamiliarity. A period of noticeable unhappiness would be considered a mild depressive episode if it has been continuous for two weeks, includes at least two of depressed mood that is definitely abnormal for the individual and present for most of every day uninfluenced by circumstances, loss of interest or pleasure in activities that are normally pleasurable, decreased energy or increased fatigability, and one or two of the following, depending upon whether two or three of the former are present (four symptoms have to be present in total): loss of confidence or self-esteem, unreasonable feelings of self-reproach or excessive and inappropriate guilt, recurrent thoughts of death or suicide, complaints or evidence of diminished ability to think or concentrate, changes in the level of physical activity resulting in agitation or retardation (either subjective or objective), disturbed sleep, and change in appetite (decrease or increase) with a corresponding change in weight. An episode would be considered to be of moderate severity if the total symptom count is six, and severe if all of the first three symptoms are present and the total symptom count is eight.

Criteria for bipolar disorder are the experience of at least one hypomanic (or manic) episode and one or more past episodes of either depression or hypomania. This subchapter also provides criteria for the classification of persistent mood disorders such as cyclothymia, in which there are fluctuations of mood that do not fulfil criteria for episodes of depression or hypomania, and dysthymia, in which there is persistent or episodically low mood that does not fulfil the criteria for depression. Particularly intense disturbances of mood can be associated with disturbed thinking and related psychotic (schizophrenia-like) experiences. As a result, subchapter four identifies some 35 different mood disorders on the basis of whether or not the predominant disturbance of mental state is undue sadness or undue happiness meeting criteria for a depressive or a hypomanic episode, whether or not such episodes are recurrent, their severity and whether or not they are associated with psychotic symptoms. Someone who is currently elated and believes they have special powers that enable them to heal others’ illnesses by email, who has been in this state on this occasion for at least four days, has been in a similar state in the past and who has suffered a period of low mood of at least two weeks’ duration in between times might be classified as someone with ‘Bipolar disorder: Current episode hypomanic: With psychotic symptoms’. Someone who has been unusually and persistently unhappy for at least two weeks, feels tired, has lost confidence, is having difficulty concentrating, is off their food and is having difficulty sleeping, and has been like this before might be classified as someone with ‘Recurrent depressive disorder: Current episode moderate’.

Neurotic, Stress-related and Somatoform Disorders

These are described in ICD-10, Chapter V, subchapter five. It refers to conditions in which the predominant disturbances of mental state and behavioural difficulties take the form of undue anxiety, conditions considered directly consequent upon stress and/or trauma, and conditions characterised by undue and persistent worries over health and illness. Anxiety and its big sister, fear, are not in themselves abnormal. Neither is distress following a traumatic experience or worries over health or illness. All of these only become a concern when they restrict life unduly or happen in situations with an intensity that others cannot share. In the same way as it does for mood disorders, ICD provides criteria that can be used to distinguish between ‘normal’ and ‘abnormal’ anxiety, fear, distress or concern.

Anxiety comprises behavioural components (a tendency to avoid anx...

Table of contents

• Cover
• Title
• Contents
• List of Illustrations
• Acknowledgements
• Introduction
• 1 International Classification of Diseases Chapter V and Diagnostic and Statistical Manual: Cataloguing Mental Illness
• 2 Misunderstandings of ‘Diagnosis’
• 3 Psychopharmacology: The Medicines of Psychiatry
• 4 Psychopharmacology Reconsidered
• 5 ‘Psychotherapy’
• 6 Public Service Psychiatry as it Really is
• 7 All in the Mind
• 8 So what can be Learned?
• Afterword
• References
• Index