Mental

Everything You Never Knew You Needed to Know about Mental Health

Steve Ellen, Catherine Deveny

• Publisher: Black Inc.
• Print ISBN: 9781863959537
• eBook ISBN: 9781925435719
• Topic: Medicine
• Subtopic: General Health

Become your own mental-health expert Psychiatrist Dr Steve Ellen and comedian Catherine Deveny combine forces to demystify the world of mental health. Providing an insider perspective, they share their personal experiences of mental illness and unpack the current knowledge about conditions and treatments. What do we know? What don't we know? How do we get help? What actually works?Punctuated with anecdotes, real-life stories and reflections on the cultural and historical context, Mental is an irreverent and entertaining guide to the full spectrum of mental health issues – from depression and anxiety to schizophrenia, personality disorders and substance abuse. Set to become a go-to guide for anyone with a mental illness or supporting someone who has one, Mental breaks the taboos around mental health and offers clear practical advice on how to live successfully.Steve Ellen is the Head of Psychiatry at Peter Mac. He is a broadcaster broadcaster on 3RRR, a weekly regular on ABC 774 and a frequent contributor to the Conversation and the Age. Catherine Deveny is a writer, commentator and comedian. She is the author of Use Your Words, The Happiness Show, Free to a Good Home, Say When and It's Not My Fault They Print Them.

WHAT IS MENTAL ILLNESS?

How do we define mental illness? Well, there’s a short answer and a long answer.

The short answer is that a mental illness is any problem with your emotions, behaviour or thinking that affects the way you function to a degree that worries you. Or, as the Australian Department of Health defines it: ‘A mental illness is a health problem that significantly affects how a person feels, thinks, behaves, and interacts with other people.’

If that’s enough for you, skip the rest of this chapter and have a cuppa instead. If not, read on!

The long definition of mental illness – and definitions of all the disorders that fall under its umbrella – is provided in large classification manuals, the most popular being the DSM – the Diagnostic and Statistical Manual of Mental Disorders. Remember that name: you’ll hear it often in the field of mental health.

Classification manuals get updated pretty regularly and there is always much debate around them. It is worthwhile knowing a little about how definitions and classification work, as they are the foundations upon which diagnosis and treatment lies.

Definitions in health care determine who gets help; who gets paid how much; and who gets all the benefits of sickness, such as time off work and sympathy. They also tell governments where to spend their health dollars. If you understand how these definitions work, psychiatry will make a lot more sense.

Diagnosis

Diagnosis can set you free; it can be liberating. It can provide clarity, it can be a relief – an ‘aha’ moment – not just for you, but for everyone around you too. Dev discovered she was dyslexic when she was thirty-eight – it was a missing part of her puzzle. She says: ‘Finding out I was dyslexic was a triumph for the eight-year-old me who was constantly told she wasn’t trying hard enough to learn her times tables or remember how to spell.’

But there’s a downside to diagnosis too: it can be limiting. Having a label can make others prejudiced towards you. They may treat you unfairly or discriminate against you. It can also lower your expectations of yourself if you take it as an excuse not to live up to your full potential.

People with disabilities carry the soft burden of low expectations.

Graeme Innes (Australia’s disability discrimination commissioner 2005–2014)

Finally, when diagnosis is used in an accusatory fashion, it can be used to stereotype people. For instance, someone might say: ‘You don’t want to travel with someone who is bipolar –they’ll be unreliable and unpredictable.’

However, in most cases, diagnosis is beneficial overall – it offers the potential for insight into your situation and helps you and the people around you have realistic expectations.

Classification

There are two main texts used to classify mental illnesses – the DSM, as mentioned above, and the ICD (International Statistical Classification of Diseases and Related Health Problems). The ICD classifies every illness and only has one chapter on mental illness. The DSM is just about mental illnesses. Both are used by mental health clinicians, but the DSM is more popular.

Both manuals are mind-numbingly dull to read, but they are often referred to as medical ‘bibles’, simply because everything in health care starts with them.

The definitions of mental illnesses in these classification manuals determine what the health industry thinks should be treated. By implication, they say: ‘These are illnesses and you should get help for them!’ With physical problems – for example, a broken arm – it’s pretty obvious something is wrong. Everyone will agree you should go to the doctor to have it treated. But when your problem is something that’s harder to see, like anxiety, do you go to a doctor or do you seek help elsewhere first?

Health professionals take these definitions and design treatments for the various conditions. They are saying: ‘If you have this mental illness (say, anxiety), as defined by this definition in this manual, this treatment should ensure you improve by a significant degree in a reasonable time frame.’

Governments and the insurance industry use the manuals to assign payments and determine what treatments they will cover officially. They say: ‘If you have anxiety as defined by this definition in this manual, you are entitled to a certain amount of treatment under the public health system in your country.’

This means that people with vested interests can use classification to push agendas. For example, the private health industry and drug companies love broad and inclusive definitions, because they mean more people get diagnosed and they make more money – disease mongering has become a serious concern. But there are also many skilled, brilliant and passionate health professionals who push for broad definitions so more people get help. On the other hand, organisations that pay for health care (like insurers) often argue for narrower and stricter definitions to limit costs.

It’s not a perfect system, but the reality is that definitions set the agenda for what gets treated and what gets funded.

What counts as a mental illness?

In psychiatry, we mostly use the term ‘disorder’ rather than ‘illness’ or ‘disease’. The term ‘illness’ is too vague – no one agrees on what it means! And ‘disease’ implies there is some underlying pathology – a disruption in the structure or function of the body. Since we don’t really know why we have mental illnesses, and since for most problems no pathology has been clearly found, we avoid using the word disease.

No matter how you define mental illness, there are two key problems: how do we define normal behaviour and how bad does a problem need to be to be called a disorder?

Everyone has their own sense of what is normal. There is no universal yardstick. We are all crazy in our own way. We view life through a lens that has been constructed from our own past experiences. This includes our personality, our culture, our beliefs (especially religious beliefs) and the era we live in.

Until 1973, the DSM included homosexuality as a disorder. This was a judgement; society regarded homosexuality as abnormal. Multiple things happened to change this view. Gay activists began protesting. More and more people came ‘out of the closet’, suggesting homosexuality wasn’t as unusual as initially thought. Research backed this up. In 1973, homosexuality was officially removed from the DSM. Treatments like conversion therapies are now more or less extinct in medicine, although some religious groups still think it’s possible to ‘pray away the gay’.

Hoarding disorder, on the other hand, is a recent addition to the DSM. Hoarding went from being an insult to becoming a formal diagnosis. People who have a conscious, ongoing urge to accumulate possessions, as well as corresponding feelings of anxiety whenever those possessions get thrown away, can now be diagnosed and treated. Until 2013, when the latest edition of the DSM came out, hoarding was an experimental category for further research. Times change; diagnoses change.

One of the most recent disorders to be included in the DSM is gambling disorder. That doesn’t mean everyone who gambles has a disorder. In order to be diagnosed with it, someone must have had at least four key symptoms of persistent and recurrent gambling behaviour, associated with impairment or distress, over a period of at least twelve months.

With symptoms we all experience at some stage in our lives, such as sadness or anxiety, the problem becomes one of degrees – how much is too much? These are human experiences and they all occur on a continuum – there is no clear cut-off between a normal amount and an abnormal amount of worry or sadness, and there never will be.

Psychiatry often gets criticised for being vague and subjective, but the problem of defining normality exists for all health issues. When does high blood pressure get defined as hypertension? When does a fastgrowing cell get defined as cancer? At what blood sugar level should diabetes be diagnosed?

To get around the problem of normal versus abnormal in psychiatry, a few simple steps are employed. First, we take a group of symptoms that seem to cluster together to form a syndrome. For example, in depression we have lowered mood, lack of enjoyment in everyday activities, weight loss, altered sleep, agitation, fatigue, guilty ruminations, poor concentration and suicidal thoughts. Then we set a cut-off point – for depression, we say you must have five of the listed nine symptoms. Then we refer to a minimum timeframe – for depression, it is a minimum of two weeks of these symptoms. Finally, we say the symptoms must either cause significant distress or impair the person’s functioning in some way – for example, interfere with their work, relationships or education.

Symptoms + a timeframe + distress or impairment = a disorder

But there is wriggle room. In clinical practice, the disorders are not meant to be used rigidly. If someone is assessed as being on the edge of a disorder, clinical judgement is required.

There are many occasions in clinical practice where a person’s problems don’t fit snugly into a category and judgement and experience are required to make a diagnosis and form a treatment plan. Classification systems provide a basis but are not sophisticated or flexible enough to take in all aspects of human experience.

Categories of disorders

The current version of the DSM (it’s up to the fifth edition: DSM-5) lists twenty major categories of psychiatric disorder and about 300 separate disorders. The major categories are:

•neuro-developmental disorders, such as intellectual disability, autism and learning disorders

•schizophrenia and psychotic disorders

•bipolar disorder

•depressive disorders, including seasonal affective disorder and grief

•anxiety disorders, including panic disorders and phobias

•obsessive-compulsive disorder

•trauma and stress-related disorders

•dissociative disorders, such as dissociative identity disorder, which used to be called multiple personality disorder

•somatic disorders, which includes a broad group of problems that present with prominent physical symptoms but are thought to have a primarily psychological basis

•feeding and eating disorders, such as anorexia

•elimination disorders

•sleep–wake disorders, such as insomnia and narcolepsy

•sexual dysfunctions, such as problems with arousal

•gender dysphoria

•disruptive, impulse-control and conduct disorders

•substance-related and addictive disorders

•neurocognitive disorders, such as dementia and delirium

•personality disorders

•paraphilic disorders, such as fetishes that cause the person distress or impairment

•medication-induced disorders (disorders that result from the side effects of medication).

It’s interesting to ponder what the DSM categories will look like in fifty years’ time. If history is anything to go by, there are bound to be some categories on this list that have been remove...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Introduction
• Part I The Big Picture
• Part II The Disorders
• Part III The Treatments
• Final Words
• References
• Resources
• Index
• Back Cover