What is mental illness?How do you define a mental disorder?

Iglehart J. N Engl J Med 2004;350:507-514

Causes of Disability in the United States, Canada, and Western Europe in 2000

Mental Disorders are Internal Dysfunctions that a Particular Culture Defines as Inappropriate and

Severely Interfere with an Individual’s Daily Living

the “hikikomori” or “shut-ins” in Japan

What is a Valid Mental Disorder?

Andrea Yates & Post-Partum Depression w/psychosis

Eli Robins & Samuel GuzeWashington University School of Medicine

Department of PsychiatrySt. Louis, 1950s-1990s

Four basic validators for psychiatric diagnoses:

1.) symptoms

2.) course

3.) genetics/heritability

4.) treatment response

For major adult psychiatric illnesses, approximately 5-10% of persons at any time in their life will be diagnosed with major depression, about 2-5% with bi-polar disorder, and roughly 1% with schizophrenia.

Overview of Different Treatment Eras1.) The Psychoanalytic Hiatus: 1930s-late 1960s/early 1970s

2.) The Rise of the 2nd Biological Psychiatry: early 1960s-present

3.) The Rise of (Cosmetic) Psychopharmacology: 1990s-present

The Psychoanalytic Hiatus

American origins: 1909 visit by Freud to Clark University

• Key catalyst: “The Arrival of the Europeans” in the 1930s

Years of triumph: late 1940s to late 1960s

• Symptoms were meaningless because disease entities didn’t mean anything when it came to mental illness

Practically everyone had some measure of mental maladjustment.

Question: What else made psychoanalytic and dynamic psychiatry so popular?

The Psychoanalytic Hiatus

deep insulin coma therapy, ECT

Metrozol shock therapy, lobotomy

The Rise of the 2nd Biological Psychiatry1949 - Lithium* (not FDA-approved until 1970)

1954 - Chlorpromazine (Thorazine)

Reserpine

1955 - Meprobamate (Miltown)

1957 - Haloperidol (Haldol)

1958 - Imipramine (Tofranil)

Iproniazid (MOAI)

1960 - Librium (Valium)

1961 - Methylphenidate (Ritalin)

Leo Sternbach, inventor of Valium, died on September 28, 2005, aged 97

What exactly is a Mental Disorder? DSM-III

Critics of Psychiatry

Ken Kesey

Michel Foucault

Dilemma & Running Debate• Type 1 errors (person has a mental disorder but is not diagnosed)

• Type 2 errors(person does not have a mental disorder, but is diagnosed with one)

famous “Rosenhan” experiment (1972)

The aim of this study was to test the hypothesis that psychiatrists cannot reliably tell the difference between people who are sane and those who are insane.

The study consisted of two parts with 8 pseudo-patients in 12 hospitals in 5 states.

Dilemma & Running Debate• Type 1 errors (fear of “medical malpractice” cases and “self-medicating”)

(person has a mental disorder but is not diagnosed)

• Type 2 errors (fear of “cosmetic psychopharmacology”)

(person does not have a mental disorder, but is diagnosed with one)

Kate Russell for The New York Times

Sarah Couch, who has bipolar disorder,

opposes the effort to force treatment on the mentally ill.

De'Nora Hill: "I am living in fear and I want it to end."

The Rise of the 2nd Biological Psychiatry• Deinstitutionalization en masse from 1960s to 1980s

• Community Mental Health Centers Act (1963)

• turmoil in the 1970’s and the publication of the DSM-III (1980)

The Rise of PsychopharmacologyType of Coverage 1988 1993 1995 Indemnity (fee-for-service) 71% 49% 30% Managed Care (HMO, PPO) 29% 51% 70%

ExamplesSexual Dysfunction in the United States Prevalence and Predictors Edward O. Laumann, PhD; Anthony Paik, MA; Raymond C. Rosen, PhD

JAMA. 1999;281:537-544.

Objective  To assess the prevalence and risk of experiencing sexual dysfunction across various social groups and examine the determinants and health consequences of these disorders.

Design  Analysis of data from the National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative, 1992 cohort of US adults.

Participants  A national probability sample of 1749 women and 1410 men aged 18 to 59 years at the time of the survey.

Main Outcome Measures  Risk of experiencing sexual dysfunction as well as negative concomitant outcomes.

Results  Sexual dysfunction is more prevalent for women (43%) than men (31%) and is associated with various demographic characteristics, including age and educational attainment. Women of different racial groups demonstrate different patterns of sexual dysfunction. Differences among men are not as marked but generally consistent with women. Experience of sexual dysfunction is more likely among women and men with poor physical and emotional health. Moreover, sexual dysfunction is highly associated with negative experiences in sexual relationships and overall well-being.

[sounds fairly ENVIRONMENTAL]

Conclusions  The results indicate that sexual dysfunction is an important public health concern, and emotional problems likely contribute to the experience of these problems.

ED: a common issue! Do you have ED?

What Paxil CR Treats:

If your doctor has prescribed Paxil CR for you, you are now taking an FDA-approved medication proven safe and effective for the treatment of depression and panic disorder.

It Could Be Depression.

If you have felt persistent feelings of worthlessness and hopelessness, or have an inability to feel pleasure or take an interest in life, you may have depression.Learn more about Depression.

It Could Be Panic Disorder.

If you have experienced repeated feelings of intense, sudden terror or impending doom, racing or pounding heartbeat or even chest pains, you may have panic disorder. Learn more about Panic Disorder.

It Could Be Social Anxiety Disorder.

If you have felt excessive, persistent fear and avoidance of social or performance situations, accompanied by sweating, shaking, tense muscles, or a pounding heart, you may have social anxiety disorder. Learn more about Social Anxiety Disorder.

“Pfizer Launches 'Zoloft For Everything' Ad Campaign”

the ONION

Premenstrual dysphoric disorder (PMDD) isn’t just part of "being a woman." It’s a real medical condition, and it causes real suffering. PMDD is much more serious than PMS. If you have PMDD, learning more about it can be the first step toward feeling better and getting control of your life again.

Controversies over Treatment Choices…stem primarily from differences between the 4 large groupings (and their

subdivisions) of psychiatric disorders:

1.] those with physical diseases: schizophrenia, Alzheimer’s (damage to the brain provokes psychiatric symptoms)

2.] those who are intermittently distressed by some aspect of their mental constitution—a weakness in their cognitive power or an instability in their affective control—when facing challenges in school, employment, or marriage: dysthymia, moderate depression, generalized anxiety disorder (they do not have disease or any obvious damage to their brain; rather, they are vulnerable because of who they are (temperament, personality, character)—that is, how they are constituted

3.] those whose behavior—alcoholism, drug addiction, sexual paraphilia, anorexia nervosa, and the like—has become a warped way of life: They are patients not because of what they have or who they are, but because of what they are doing and how they have become conditioned to doing it

4.] those in need of psychiatric assistance because of emotional reactions provoked by events that injure or thwart their commitments, hopes, and aspirations. They suffer from states of mind like grief, homesickness, jealousy, demoralization—states that derive not from what they have or who they are or what they are doing, but from what they have encountered in life

Hans Eysenck’s personality theory (1947)

Dangers of Over- and Under-Diagnosing

Based on combined per capita rates of

diagnosed depression and suicide, here are

the top six “happiest” or

“least depressed” states:

1. South Dakota 2. Hawaii

3. New Jersey 4. Iowa

5. Maryland 6. Minnesota

“Most Depressed” or “Least Happy”

State in terms of combined

per capita rates of diagnosed depression

and suicide?

Rosenthal, J. M. et al. N Engl J Med 2005;353:1085-1088

Rates of Depression among Medical Students (Panel A) and Treatment of Depressed Medical Students (Panel B)

The Futile Pursuit of Happiness: Environmental Stress

Gilbert, Wilson, Loewenstein, & Kahneman:

“We consistently misestimate the intensity and duration of something’s utility; this is known as the ‘impact bias’.”

Our ability to predict the emotional consequences of a decision, purchase, or event is less than we think.

Our mistakes of expectation can lead directly to mistakes in choosing what we think will give us pleasure. We often “miswant.”

Key role of “adaptation” to good things and “resilience” to bad things.

our “psychological immune system” (a sort of emotional “thermostat”)

e.g., remember when you got your first dial-up 14,400 baud modem?

The Tyranny of Choice“Starter Marriages” phenomenon

Census Bureau: 3 million divorced 18-29 year-olds (1999) 253,000 divorced 25-29 year-olds (1962)

Atul Gawande, M.D. & cancer study

- 65% of people surveyed say that if they were to get cancer, they would want to choose their own treatment; of those who do get cancer, though, only 12% actually want to choose

Steven Venti, Dartmouth economist & Employer 401k plans

The more funds employers offer their employees in 401k plans, the less likely the employees are to invest in any of them.

“Wine Warehouse” vs. “Gas Station” experiences

Depression and the Tyranny of ChoiceExcessive choice is often psychologically and emotionally burdensome.

Why?

(1) Increases burden of information gathering to make a wise decision

(2) Doing all the “cost-benefit/expected utility” calculations is exhausting

(3) Increases expectations about how good the decision will be

(4) People often assemble an idealistic composite of all the options foregone

(5) Which increases the likelihood that they will regret the decision they make

(6) And increases the chance that they will blame themselves when a decision fails to live up to expectations (more regret and second-guessing).

Perhaps colleges/universities offer too many choices now, which might help explain double-, triple-majoring, etc. (e.g., Spiderbytes)

Combating the “Paralysis of Choice” & Cultivating Contentment

Helpful countermeasures:

(1) Pro-Actively Limit Choices to “1st order,” “2nd order,” “3rd order”

(2) Counterfactual Downward

(3) Make Some Decisions Nonreversible (e.g., Harvard photography class)

(4) Anticipate Adaptation

(5) Learn to Love Constraints (Say “No”, 1 major/1minor)

(6?) Recalibrate expectations, cultivate contentment, safety,

egalitarianism, and a dose of humility