Download Mental Health and Ill Health: Diagnosis or

mental health and illness: diagnosis or
distress?
David Coyle
Lecturer mental health nursing studies
School of Healthcare Sciences
Bangor University
What is mental ill-health to you?
Perhaps a classical Hogarth defines it?
A picture that changed our way of responding
Earliest beginnings of modern mental health
• The humanitarian beginnings of recovery may be seen from
the York retreat, under William Tuke and his term “moral
treatment” was coined (Borthwick et al 2001).
• He wrote in 1813 that the primary approach to support should
be the following:
“ the injunction to treat the mentally ill as though they
were mentally well.” (Applebaum & Munich 1986 in Borthwick et al 2001)
Not so very long ago
“Dr Howell drank from the special cup which was tied
around the handle with red cotton to distinguish the
staff cups from those of the patients, and thus
prevent the interchange of diseases like boredom
loneliness authoritarianism.”
(Frame 1961 p.20)
Mental illness or distress
• “We need a wholesale revision for the way we thing about
psychological distress. We should start by acknowledging that such
distress is a normal, not abnormal, part of human life – that humans
respond to difficult circumstances by becoming distressed.” (British
Psychological Society 2012)
• “…psychosocial factors such as poverty, unemployment and trauma
are the most strongly-evidenced causal factors. Rather than applying
preordained diagnostic categories to clinical populations, we believe
that any classification system should begin from the bottom up –
starting with specific experiences, problems or 'symptoms' or
'complaints‘.” (British Psychological Society 2012)
• “Any system for identifying, describing and responding to distress
should use language and processes that reflect this position.”
(Kinderman et al 2012)
Clearly we have to call distress
something: Diagnosis
• International Classification of Diseases and The Diagnostic
Statistical Manual
• DSM containing 65 pages
• DSM II 134 pages
• DSM III (r) 494 pages (1,000,000 copies sold)
• DSM IV (& TR) 886 pages
• DSM 5 Now containing over
• 1000 pages of mental health disorders
ICD Classification (F chapters)
• F0: Organic disorders
• F1: Mental and behavioural disorders arising from substance
misuse
• F2: Schizophrenia, Schizotypal and delusional disorders
• F3: Mood disorders (affective)
• F4: Anxiety, stress related Somatoform disorders
• F5: Behavioural syndromes with physiological disturbance
• F6:Personality disorders
• F7: Learning disability
• F8: Disorders of psychological development
• F9: Behavioural and emotional disorders with onset usually
occurring in childhood and adolescence
• Unspecified disorders
Not all agree with DSM
• Critics of DSM draw on a poor level of reliability for the criteria
• DSM III 1980 was heralded as a breakthrough in direction
aiming for reliability in application
• To represent good to complete inter-rater reliability Kappa
value should be around 0.7 -1
• DSM manages around 0.4 which is regarded as moderate, not
great, but moderate.
Some differences with DSM5
In
• Mixed anxiety-depression
• Disruptive Mood
Dysregulation Disorder
• Gender Dysphoria
Out
• Bereavement exclusion in
major depression within
2mths
• Catatonia as a psychotic
diagnosis
• Substance Use Disorders
• Gender identity disorder
• Premenstrual Dysphoric
• Substance abuse/dependence
Disorder
• Autistic spectrum disorder
• Autistic disorder, Asperger's
syndrome, PDNOS
This might be a bit unfair but
• 1973 paper by Rosenhan where 8 pseudo-patients were
admitted to mental health institutions across 5 on east and
West coat US states .
• Their only lie was to report “empty, hollow and thud”
• All were medicated, average 17 days incarceration
• The results caused upset in establishment circles.
• A hospital challenged Rosenhan to send pseudo-patients, they
found 47
• He sent none.
Clearly we have to call distress
something: Diagnosis
• The methods used are generally imprecise created by
discussion between clinician’s and their experience
• We might use instead :
• Distress
• Deviance
• Dysfunction
• Dyscontrol
• Some may say dangerousness (Comer 1994)
• But these are culturally bound, specific to certain populations
and not scientifically sound
Previous DSM
• Autism rates went from 1:2000 to 1:100, (inclusion of
Asperger's)
• Difficulty in coding depression where anxiety was present or
anxiety where lowering of mood occurred.
• Bipolar disorder in children estimated round 1,000,000 in US
• Robert Spitzer when asked whether he and his colleagues got
it wrong “…But I don’t like the idea of speculating how many
of the DSMIII categories are describing normal behaviour…I’d
be speculating on how much of it is a mistake…Some of it may
be.” (Ronson 2011 p264-265)
Dimensional perspective
• Mental health or rather ill-health might be seen as either
dimensional or categorical
• “Depression sits on a continuum with sadness and represents
and extreme version of something every has felt and known”
• “Categorical describes depression as a an illness totally
different from other emotions, such as stomach virus is totally
different from acid indigestion” (Solomon 2002)
Lets take a couple of
complaints
• Depression or affective disorder
• Is the expression of sadness necessarily bad?
• Or bad but necessary?
Awareness
Emotion
Sadness
Tearful etc
Behaviour change
Functional
impact
Disintegration
Withdrawal
Work/
relationships
Inaction,
Neglect,
Delusions
Tyrer and Steinberg (1987)
Lets take a couple of
complaints
• Schizophrenia or psychosis
• Feeling strange, suspicious, insightful
• Unique experiences, the mother or creativity?
Awareness
Strange
thoughts
Emotion
Worried,
suspicious
and so
forth
Behaviour change
Odd
behaviour
Functional
impact
Disintegration
Work/
Relationships
Self care
Hallucinations,
Delusions,
Negative
symptoms
Tyrer and Steinberg (1987)
Categorical dimensions
• Mental health conditions are discrete conditions
• Free from bias and rooted in science and medicine
Symptom 1
Aetiology a
Pathology 1
Symptom 2
Symptom 3
Symptom 4
Aetiology b
Pathology 2
Symptom 5
Symptom 6
Aetiology c
Pathology 3
Symptom 7
Symptom 8
Kraepelin’s idea was to be able to determine cause and
diagnosis of all delusional state.
Help on its way
• “The pharmaceutical industry has proven to be fairly
unsuccessful in developing new and improved medications. But
it is wonderfully effective at marketing existing wares”
(Frances and Widiger 2012 p.116)
Thoughts on the phenomena
• Critics argue that classificatory systems are pathologising ordinary
distress thereby making our distress medical
• The most populous area round boundaries of norms and acceptable
behaviour become the new mental illnesses
• However diagnosis can provide
• meaning a causal narrative
• identity possibly.
• Possibly an understanding
• into their experience
• and therefore meaning
So where are we
• It is likely that DSM 5 is better than anything else currently
available and judiciously used, will have benefit.
• “Our classification of mental disorders is no more than a
collection of fallible and limited constructs that seek but never
find an elusive truth. Nevertheless, this is our best current way
of defining and communicating about mental disorders.” (Frances
and Widiger 2012)
• However remember the kappa value
How to help ourselves
Five ways to wellbeing:
•
•
•
•
•
Keep active, physical exercise at what ever level
Connect, maintain relationships
Learn, keep active
Give, get involved
Take notice, stay open minded
• (Kinderman 2013)
Or as Antonovsky would say
• “Contemporary Western medicine is likened to a well
organized heroic, technologically sophisticated effort to
pull drowning people out of a raging river.
• Devotedly engaged in this task, often quite well
rewarded, the establishment members never raise their
eyes or minds to inquire upstream, around the bend in
the river, about who or what is pushing all these people
in.”
(Antonovsky 1987 p90 in McDonald 2006 p.18)
Here’s hoping
For more information or references
further reading
Contact: [email protected]