Does Mental Illness Exist?

1. Does Mental Illness Exist? Patricia Casey Mater Misericordiae University Hospital &University College Dublin.

2. Is Health The Absence of Disease? World Health Organisation “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (1946)

3. Is Health The Absence of Disease? Imre Loeffler “The World Health Organization's famous definition of health as 'complete physical, psychological, and social well-being' is achieved only at the point of simultaneous orgasm, leaving most of us unhealthy (and so, by the Chambers Dictionary definition, diseased) most of the time".

4. What is Disease? "Each civilisation," wrote Ivan Illich, "defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness, or sin in another." The Oxford Textbook of Medicine stays away from defining a disease. Chambers Dictionary defines disease as 'an unhealthy state of body or mind; a disorder, illness or ailment with distinctive symptoms, caused e.g by infection'.

5. What is Disease? Collins Dictionary defines disease as: • any impairment in normal physiological function affecting an organism especially a change caused by infection, stress etc. producing characteristic symptoms; illness or sickness in general • a corresponding condition in plants • any condition likened to this’

6. What is Non-medical Concept of Illness? Cambell et al. 1979 BMJ Study of lay and medical peoples’view of what constituted disease Illnesses due to infection and cancer were diseases Hypertension, gall stones, fractured skull, depression uncertain Disease was illness with a known causal agent (for infections only) whereas the presence of a know cause was not important for other conditions e.g. fractured skull.

7. What is Non-medical Perception of Psychiatric Illness? The “Medical Model” This states that psychiatric disorders are illnesses like any physical illness and therefore have specific biological lesions This does take account of the multiple social and personal causes of psychiatric disorder No lesions have been found for any psychiatric disorder Therefore the idea of psychiatric illness should be abandoned

8. Anti-psychiatry school Thomas Szasz (1920- ) Psychiatrist “Disease means bodily disease…the mind (whatever it is) is not an organ or part of the body. Hence it cannot be diseased in the same sense as the body can. When we speak of mental illness, the, we speak metaphorically” - “The Myth of Mental Illness” Abnormal behaviours are social constructions and a function of societal values (but way are some behaviours that we distain not regarded as indicative of illness e.g. laziness, bad language, bad table manners Bleuler and Kraeplin - “Psychiatric conquistadores” who together “invented schizophrenia”.

9. I. Psychic Depression Depressed mood Guilt Suicide Retardation Helpless / Hopeless worthless II. Amotivation Work & Activities Physical Symptoms Sexual Symptoms Weight Loss Hamilton Depression Scale - Factors • III. Psychosis • Insight • Depers / Dereal • Paranoia • Obs / Compuls. • IV. Anxiety • Agitation • Anxiety Psychic • Anxiety Somatic • Hypochondriasis V. Insomnia – early / middle / late Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

10. Factor I. Psychic Depression Positive correlation with Cingulate Gyrus, Thalamus & Basal Ganglia Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

11. Factor II. Loss of Motivation Negative correlation with Patietal & Sup. Frontal Cortex Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

12. Factor V. Insomnia Positive correlation with Limbic & Basal Ganglia Milak M, Parsey R, Keilp J, Oquendo M, Malone K & Mann JJ. Arch Gen Psych 2005

13. RD Laing (1927-1989). Psychiatrist He rejected the anti-psychiatry label although his name has always been associated with it Focus on psychosis. Never denied the existence of psychosis or the necessity to treat the distress associated with it. Behaviour and speech of those with psychosis were ultimately understandable as an attempt to communicate worries and concerns in situations where this was not permitted.

14. RD Laing (1927-1989). Psychiatrist Stressed role of the family in developing psychosis person unable to conform to the conflicting expectations of peers/family developed psychosis. It was an expression of distress and could be cathartic. Understanding the symbolism was important for treatment. Provoked anger because of his view that mothers especially were to blame for schizophrenia

15. David Cooper (1931- ) Psychiatrist Madness becomes the indictment of our failure to bring together our sexuality, our lives and our autonomy. Believed in the influence of the traditional family in generating mental illness and sought alternative forms The Death of Family Psychiatry and anti-psychiatry The Language of Madness “Villa 21 project

16. Michel Foucault (1926-1984) Philosopher The History of Madness 1961 The alleged scientific neutrality of modern medical treatments of insanity are in fact covers for controlling challenges to a conventional bourgeois morality.

17. Post Psychiatry/Critical Psychiatry (1999) The Bradford Group Post-psychiatry: A new direction for mental health.Bracken and Thomas (BMJ 2001). 322: 724-727 Distances itself from anti-psychiatry school Does not propose new theories about “madness”, but it “opens up spaces in which other perspectives can assume validity” Mental health interventions do not have to be based on the framework centred on medical diagnosis and treatment

18. Contd…. It does not seek to replace the medical techniques of psychiatry Wants to discard schizophrenia “Let’s scrap schizophrenia” Wants to abandon psychopathology or the identification of psychopathological symptoms as indicating illness

19. Contd…. Believes medication of some value Wants to examine the meaning of the symptom Mutually contradictory stances

20. The Diagnostic Approach Karl Jaspers (1883-1969) psychiatrist and philosopher. Phenomenology, the study of mental experiences tries to bridge the chasm between body and mind by describing subjective experience. However, the mind can only perceive the stimuli that the body receives and consciousness is required Psychopathology is the study of abnormal psychic processes – Descriptive psychopathology describes the subjective experience and the resultant behaviour but does not attempt to explain the cause e.g. hallucinations, obsessional ruminations etc. Therefore the content of the hallucination/delusion not important Analytic or dynamic psychopathology tries to interpret their meaning and their origins using a theoretical framework of defence mechanisms and transference

21. New Diagnoses – How do They Come About Case reports and observational studies e.g. anorexia nervosa How common are these symptoms in the general population Examine how symptoms cluster together - syndrome How common are these symptoms in other diagnostic groups – which symptoms separate one diagnostic group from others Examine what the risk factors and triggers - epidemiology

22. New Diagnoses – How do They Come About Examine the associated physical changes (macroscopic, microscopic, molecular) and whether cause, effect or some relationship Response to various treatments Natural history and prognosis Aetiology (cause) is usually the last element to be identified This whole process is known as validation

23. History Hippocrates “The Father of Medicine” (Cos) (460-377 BC) the “sick individual with his particular kind of misery”. Illness caused by imbalances in the 4 humors, inherited susceptibility or injury. The brain and not the heart was the centre of the emotions and perceptions. Early Christianity – mental illnesses were due to demon possession Mental Illnesses did not exist and the behaviour was under voluntary control and required punishment

24. History The Enlightenment – mental illness to be treated. Phillipe Pinel (1745-1826) replaced harsh methods with humane “treatments”. He believed mental illness caused by too much psychological or social stress, by heredity or by chemical changes. Rene Descartes (1596-1650) Mind (soul) and body separate

25. Theories of illness Roudolf Virchow ( 1821-1902). Disease is a lesion or alteration in body structure e.g. wound, fracture. He believed that lesions were present in illness but not inevitable There are many physical illnesses that have no lesion associated – fibromyalgia, type 2 diabetes, migraine, trigemminal neuralgia, many cases of backache Some only become recognised as illnesses when the technology becomes available e.g. ECG, X-ray, clotting factor diseases Wilhelm Griesinger (1817-1868) took this to mean that mental diseases are diseases of the brain

26. Theories of illness “The diagnosis of patienthood has as its sufficient and necessary condition the experience of therapeutic concern by a person for himself/and/or the arousal of therapeutic concern for him in his social environment” Disease is what doctors treat – mental illness describes the condition of those people referred to psychiatrists Kraupl Taylor (1980)

27. Theories of illness John Scadding (1967) illness is a variation from the statistical norm that carries biological disadvantage i.e. reduced fertility and increased mortality. The named disorder may be no more than a combination of symptoms and signs that occur together so frequently and so distinctively that they constitute a recognisable clinical picture - syndrome Cohen (1981) illness is a statistical variation from the norm

28. Jerome Wakefield (1992)theory of “harmful dysfunction” There is a system within us that operates to allow us to adapt and ensure our functioning and survival If this is dysfunctional then symptoms (suffering) occur Only when these symptoms lead to impairment is illness present • Understandability • Proportionality • Functional incapacity

30. Models of Mental Illness Behavioural model: John Watson, Ivan Pavlov, Hans Eysenck Behaviourists are not concerned with psychopathology or inner world, only with behaviour that results and the factors that reinforce or reduce it Biological Model: Wilhelm Griesinger Biological models examine the biological underpinnings of mental illness such as genetics, hormones, neurotransmitters, receptors

31. Models of Mental Illness Psychodynamic Model: Freud Unconscious desires and drives as well as problems at the various stages of development are responsible for mental illness

32. Models of Mental Illness Social Model: George Brown Factors in the environment cause mental illness e.g. life events, poor social supports Cognitive Model: Aaron Beck It is the person’s perception of themselves and of the event that cause mental illness Biopsychosocial Model: Adolf Meyer Bio-psycho-social model believes that all three elements are important in the genesis of mental illness but the relative size of each varies with the condition

33. What CausesMental Illness? It depends on the definition of cause?

34. Ordering the Disorders Psychiatric disorder are named and put into broad categories to allow for further study The two systems of classification are: Diagnostic and Statistical Manual (DSM)(American Psychiatric Association International Classification of Diseases(ICD)(World Health Organisation)

35. Ordering the Disorders Both are aetiology neutral They specify the criteria for each disorder This allows for the study of these syndromes – treatment, aetiology, prognosis For the collection of statistical data about them e.g. the Inspector of Mental Hospitals report For communication among professionals about them

36. Imperfections Over-diagnosis – “false-positives” Depressive illness - “depression” Regier et al 1998 Expect that there would be roughly similar prevalence between different studies Over inclusive - may those spontaneously resolving reactions

37. Imperfections PTSD and acute stress reactions 1. 9/11 “The mental health Crisis that Wasn’t” in (Sommers and Satel in One Nation Under Therapy) 5 days after attack 90% upset and trouble sleeping (New Eng. J. Med 2001) 2 months after attack 7.5% had symptoms of PTSD 21% those living close to Centre had similar symptoms. 4 months later 1.7% 6 months later 0.6% But no measures of severity or dysfunction 2001 estimates by FEMA that 1.5 citizens would need counselling 120,000 sought help up to June 2002 2. Follow-up studies of those witnessing atrocities in Africa

38. Implications of over diagnosis Treatment implications -over-prescription of antidepressants - over-utilisation of therapists Iatrogenic illness e.g. critical incident stress debriefing, side effects of treatments Service provision implications Implications for research into aetiology e.g. neuroimaging, genetic, cognitive

39. Example of mind-body overlap PTSD (Wakefield – flaw in adaptation to threat) Risk factors – temperament, age, man-made disasters, previous trauma, specific appraisal Trigger - overwhelming traumatic event Results – symptoms fMRI – small hippocampus (?cause ?effect) Treatment - cognitive therapy

40. Quantifiable change in functional brain response to empathic and forgivability judgments with resolution of post-traumatic stress disorder. Farrow 2005

41. Figure 2a. Empathic judgments pre-therapy (see full figure legends)

42. Figure 3a. Forgivability judgments pre-therapy (see full figure legends)

43. Figure 2b. Empathic judgments post-therapy (see full figure legends)

44. Figure 3b. Forgivability judgments post-therapy (see full figure legends)

45. Figure 2c. Empathic judgments post- minus pre-therapy (see full figure legends)

46. Figure 3c. Forgivability judgments post- minus pre-therapy (see full figure legends)

47. Conclusion Mental illness exists Most comprehensive theory Wakefield’s “Harmful Dysfunction” Objections based on dualistic assumptions and on therapeutic implications that flow from that Mental illness over-diagnosed especially “depression”, post-traumatic stress disorder, ADHD Need more refined diagnostic classifications that take account of context, severity and the presence of impairment in social functioning

48. Linear trend analysis of motor cortex being activated in controls more than patients to varying degrees in early psychosis. fMRI activation during auditory hallucinations in schizophrenia

49. In vivo Brain Imaging Paradigms in Suicidal Depression: PET (USA) Reduced Brain Serotonin Responsivity in High vs Low Lethality Suicide Attempters (n = 27) (Malone et al, SFN 2000; Oquendo, Malone et al, Archives Gen Psychiatry 2003)

50. Word Generation in Healthy Volunteers1st 15 seconds, (n=6, p<0.01) Note activation in Broca’s Area Malone et al (2003)