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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]