Download MENTAL ILLNESS IN A SOCIAL AND CULTURAL CONTEXT

MENTAL ILLNESS IN A SOCIAL
AND CULTURAL CONTEXT
Lyn Gardner
Lecturer, Centre for Mental Health
Studies
The Classification of Mental
Illnesses
• Diagnosis is the process of classification and naming/labelling of an
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illness, usually based on the presence, or absence, of particular
physical characteristics
‘In psychiatry, however, there is no such external biological referent
to act as an anchor for diagnosis’ (McPherson & Armstrong, 2005)
Classification provides a means of professional standardisation and
consensus
An aid to communication between professions (and the person given
the diagnosis??) – internationally agreed signs and symptoms
However, both historically and geographically there is ample
evidence to show considerable differences in diagnostic patterns
(Lee, 2002)
One response to this was to introduce diagnostic manuals – the ICD
fully classified mental illnesses from 1948 and the DSM was
introduced in 1952
DIAGNOSIS OF MENTAL ILLNESS
Psychiatric definitions or diagnosis of mental illness
are made using the following classifications:
IDC-10 (International Classification of Diseases)
research based concepts updated by
international committees on behalf of WHO.
Section on Mental and Behavioural Disorders
and divided into 9 groups.
DSM-IV (Diagnostic and Statistical Manual)
compiled by the American Psychiatric Assoc.
Numerous revisions over short period of time –
created debate and controversy
FROM PERSON TO PATIENT
• Is a diagnosis helpful?
• Labelling has a negative effect and any
description is a ‘linguistic straightjacket’
(James, 1998)
• A label can liberate and represents a
public recognition of personal pain (Figert,
1998)
THE PROCESS OF DIAGNOSIS
• Crowe (2000) argues that the process of
psychiatric diagnosis is based on positivistic
understandings of reality which reduce the
experience of individuals to
‘a priori categories of normality and abnormality
that reveal a strong gender, culture and class
bias’.
• In doing so, the DSM constructs what is to be
regarded as abnormal and ‘what society can
expect as normal behaviour
Cont.
Thus, according to Casey & Long (2003)
‘psychiatric diagnoses are not objective,
scientific renderings of truth, but
constructions of life experiences
inextricably linked to the social and
political context’
NON-COMPLIANCE WITH
PSYCHIATRIC CLASSIFICATIONS
OF SELF
‘…we should never forget how the
bestowal of a psychiatric label can so
usurp the person’s sense of identity that
all subsequent distress (relapse) is
reconstituted as a function of that
diagnosis’
Barker et al (1999)
ON THE RECEIVING END OF A
PSYCHIATRIC DIAGNOSIS
• Some service users fight against their diagnosis – refuse
medication, feel angry, challenge treatment – and try to
find meaning in their diagnosis:
‘prior to developing schizophrenia, the workings of my
mind had been unquestioned. Suddenly I was being told
that I could not always trust my own thoughts and
senses….Self had become a traitor and was working
against my own good’
(Champ, 1999)
Reading from Eleanor Longden’s account (Open Mind, 111,
Sept/Oct 2001,p. 12-13).
A DIAGNOSIS CAN VALIDATE
EXPERIENCE
• Some people actively seek a label or diagnosis
for their distressing or unusual thoughts,
feelings and behaviour:
‘not having a label, I think that’s the real
problem’ (Peters et al. 1998)
‘on a positive note, at least when I did learn of
my diagnosis I was able to begin coming to
terms with my illness…I discovered a common
identity and a camaraderie’ (McIntosh, 1996)
A Comment on Definitions
• The term gender is used to refer to the
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socially/culturally constructed differences
between men and women
It was introduced to conceptually separate
female and male biological factors (sex) from
social and culturally driven behaviours
It is sometimes used to replace the term sex
Gender is also associated with women-only
concerns or issues
Ethnicity is used to refer to cultural group
identity, may include sense of common culture
DIAGNOSIS – GENDER ISSUES
• Gender relations are implicated in
psychiatry at both the theoretical and
practice levels (issues for women include
childcare, single-sex accommodation,
sexism, fear of sexual violence)
• Psychiatric epidemiology reveals gender
differences in rates of diagnostic category
CONT
• Overall the proportion of people living with a diagnosed
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mental illness over a 12 month period is similar for
women (18%) and men (17.4%) (ABS, 1998)
However, within that aggregated figure, gender
differences are masked
The rate of depression for women is twice that of men
The rate of anxiety disorders for women is almost twice
that of men
The rate of substance misuse for men is over twice that
of women
DEPRESSION
• Woman-predominant conditions such as
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depression and anxiety disorders are likely to be
under-diagnosed (Busfield,1996 and Horsfall,
2001)
Current mental health service provision focuses
on caring for people with so-called ‘serious’ or
‘serious and enduring’ mental illness
Thus women may be left to feel that their
distress and the way it manifests itself is
‘illegitimate, unreal, or inconsequential by
medical practitioners, family members, or
friends’ (Horsfall, 2001)
MAD WOMEN ARE LESS TROUBLE
TO SOCIETY
• Gendered expressions and forms of pain
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internalization that are not overtly disruptive or
dangerous for society are less likely to receive
social, political, policy or medical treatment
priority (Perkins & Repper, 1998)
Women may not then be diagnosed so readily as
men, leaving them without treatment, support
and validation of their distress
Depression _ Traditional
Classifications
• Exogenous – neurotic condition caused by
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external circumstances/events. Individual usually
has clear insight into the causes. ‘It is a
pathological reaction to a loss which may be
actual, threatened or imagined’ (James, 1998)
Endogenous – thought to be caused by factors
within the person. Psychotic features may be
present. Diurnal variation of mood – worse in
morning (wakes early), improves as day goes
on.
DEFINING DEPRESSION
• Major Depression – according to WHO (1992) diagnosis requires 5
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or more specific criteria to be present:
Depressed mood or loss of interest
Significant weight loss/gain
Disturbed sleep pattern
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness
Diminished ability to think
Difficulty in concentrating
Suicidal thoughts
DEFINING DEPRESSION
• Dysthymia – present for at least 2 years – often
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insidious onset. Symptoms overlap major depression –
also include pessimism, low self-esteem, lack of energy,
irritability and decreased productivity
Minor Depression – symptoms as major depression,
but only 2 need to be present for a diagnosis
Intermittent Depression – similar to minor
depression with symptoms that are not constant
Recurrent Brief Depression – major depressive
episodes, usually one or two per month which may last
for a few hours to a few days
Epidemiology
• At primary care level depression is a major reason for patient consultation –
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approx 10% of all consultations (Baldwin & Hirschfeld, 2001)
3% of the general population is diagnosed yearly by GPs, but approx. the
same number may be unidentified as sufferers (Sheppard, 1997)
Major depression is a precipitant factor in approx. half of all suicides,
according to Murphy (1998)
The rate of depression for women is twice that of men (Baldwin &
Hirschfeld, 2001), but they are one-forth as likely to complete suicide
(Murphy, 1998)
However, some studies reveal an apparent equalising of rates of depression
among men and women (Prior, 1999)
Prevalence of depressive symptoms increase with age, however, rising
incidence of depression among children (0.5 -2.5%) and adolescence (34%) suggests Baldwin & Hirschfeld.
Social class does not seem to be a factor in prevalence, but suggestion of
slower recovery in more socially deprived people.
Theories and Models of Depression
• Genetic/biological: some increase in prevalence of
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depression among those with first generation relative
previously diagnosed.
More significant evidence of environmental factors
influencing development of depression, especially in less
severe forms.
Weak genetic links to pathophysiology of depression,
specifically bi-polar disorder.
Evidence of serotonin, dopamine and noradrenalin
neurotransmission dysfunctions among those
experiencing depression of suicidal thoughts.
Cognitive Explanations
• Cognitive models of depression, originating with Beck (1967),
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emphasis negative thinking as a factor causing or maintaining
depressed symptoms.
Different versions of cognitive models variously emphasis selfschemas (Beck, 19760), self-esteem (Roberts & Monroe, 1994),
attributional style (Barnett & Gotlib, 1988), hopelessness (Abramson
et al, 1989).
Ample evidence to suggest that depressed people are biased in
negative directions while depressed, but less research supports a
casual role of negative thinking in causing depression.
Stressors play an important role in triggering depressive reactions
(Brown & Harris, 1976)
Current stress and cognition models emphasise that the meaning of
the event to the individual determines whether it will trigger
depression.
Social Explanations
• Difficulties in social relationships may be a key
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element of many depressions: disrupted social
connectedness may cause depression and, in
turn, depression disrupts relationships,
potentially causing further depression.
Negative early childhood experiences – insecure
attachment relationships between parent and
child – may contribute to vulnerability to
depression (Bowlby, 1978; 1981).
Cont.
• Depression impacts on the family – partners and children.
• Depression has a negative impact on those outside of the family,
suggesting that depression may make other people reject the
depressed person (Coyne et al, 1991).
• Depressed people may contribute to the occurrence of stressful
life/interpersonal events, which may perpetuate depression
(Hammen, 1991).
• Depressed people may have poor social support
systems/relationships
• Depressed people may have certain ‘maladaptive’ behaviours and
personality traits that effect relationships even when not depressed
– such as dependency, introversion and poor social skills (Hirschfeld
et al, 1996).
Narratives of Depression
• By developing a phenomenology of the
experience of depression, nurses can
better understand and respond to it.
• Sources may lie in first hand accounts,
diaries, poetry, film and literature/fiction.
First Hand Accounts…
‘It is total… there is no reason to wake up in the
morning. I just let the blinds stay
down…sometimes I wonder what life will be like,
where I can find a fixed point, a hold to my life’.
‘To meet people just because it’s nice to meet
them is difficult, since I can’t convince myself
that somebody would like to get to know me. I
know that I like some people, but that
somebody would like me – that’s very difficult to
imagine’.
AN AGE OF MEALNCHOLY?
‘Truly, we have entered an age of
melancholy’
Barker, 1992
‘The medicalisation of unhappiness as
depression is one of the greatest disasters
of the 20th century’
Oakley, 1993
TROUBLESOME MEN
Men with a psychosis are seen to be more
successful at gaining psychiatric attention:
public concerns about their disruptive and
disturbing behaviour.
During the 1990s numerous media reports of
‘dangerous’ mentally ill men forced the
government into a swift response
BIG, BLACK AND DANGEROUS
• Media hyperbole generated fear about the risk
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from ‘dangerous’, mentally ill men
The murder of Jonathan Zito by diagnosed
schizophrenic patient Christopher Clunis (see
The Clunis Report, 1994)
Black people in the service are treated ‘in a
more coercive and punitive way’ (Pilgrim &
Rogers, 1993)
African-Caribbeans are over-represented in
locked wards and secure units
BIG, BLACK AND DANGEROUS
• African-Caribbean and Asians are more likely to
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receive physical treatments than their white
counterparts
Black men are more likely to be viewed by staff
as aggressive, uncooperative, violent and in
need of higher doses of medication – usually
intramuscularly
Black and Asian men more likely to be diagnosed
as schizophrenic – a misdiagnosis? Evidence of
diagnosis being significantly altered within 48
hrs of presentation (Fernando, 1991)
BOARDERLINE PERSONALITY
DISORDER
• Women are more frequently given the diagnosis of BPD – three-
quarters of people living with this diagnosis are women (Perkins &
Repper, 1998)
• Women diagnosed with BPD often perceive their care as punitive
and stigmatizing (Nehls, 1998)
• Women who self-mutilate are likely to be given a diagnosis of BPD
• BPD is often seen by the mental health services as difficult or
untreatable. At best, the coping behaviours employed by women
such as self-mutilation, are addressed (often inappropriately) but
the underlying causes of the distress (for example trauma from
childhood sexual abuse) is left unsupported (Babiker & Arnold,
1997)
SCHIZOPRENIA
• The diagnostic rates of schizophrenia are about
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the same for men and women – but there are
gender differences
Men tend to be diagnosed approx 4-6 years
earlier than women
Women are more likely to develop late-onset
schizophrenia
Women are less likely to be given a dual
diagnosis (substance misuse and
psychosis/schizophrenia)
CONT.
• Signs and symptoms of schizophrenia differ between men and
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women
The content of delusions is largely culturally determined and
accordingly tend to run along gender-role lines:
Women – less bizarre, more somatic, may have romantic
preoccupations
Men – more concerned with political conspiracy, undercover
activities (see account by Rufus May, Openmind, 106, Nov/Dec
2000), more grandiose delusions of power, royalty and divinity
Women experience more depressed mood, apathy and paucity of
speech than men.
More men than women diagnosed with schizophrenia complete
suicide – although the ratio is lower than in the general population
where men outnumber women 4:1
THE NEED FOR A CONCEPTUAL
MAP?
• Liz Sayce (former chair of MIND) argues
for a place for a classification of mental
illnesses or a frame of reference:
‘the DSM is open to considerable question
as a reliable and acceptable categorization
system, but we do need a language, a set
of categories, to describe different
experiences’ (Sayce, 2000)
VOICES FROM THE SERVICE
USER/SURVIVOR
• Increasingly mental health practitioners
(most particularly nurses) are turning to
listen to the subjective accounts of those
who experience mental illness
• By listening to service users articulations
of their experiences, mental health
practitioners can work collaboratively and
co-operatively
CONT.
‘sharing our stories finally gave us the
courage to believe that we are not mad:
we are angry…our distress and anger is
often a reasonable and comprehensible
response to real life situations which have
robbed us of our power and taught us
helplessness’
(Wallcraft, 1996)
WORKING WITH THE PERSON
‘The acceptance of a person into (or exclude from) the
mental health system invariably involves ethical and
political judgements….Gender, age, ethnicity, class and
sexual orientation impinge upon psychiatric symptom
assessment and diagnostic conclusions’ (Horsfall, 2001)
It is imperative, therefore, that to work effectively with
users of mental health services their social context must
be fully appreciated, a gender-neutral approach is not
accepted and the needs and wants of different ethnic
groups is addressed
EXPERIENCING ILLNESS
• By developing a phenomenology of the
experience of mental illness, we can better
understand and respond to it
• Making sense of mental illness ‘involves
reflection both of the individual
experiences and of social consequences
and cultural constructions of the issue’
(Kangas, 2001)
FINDING A COHERANT NARRATIVE
OF EXPERIENCE
‘I think the best professionals involved in
my care have walked alongside me,
opening themselves to the mystery that is
schizophrenia’
(Champ, 1999)
REFERENCES/READING
Babiker, G & Arnold, L (1997) The Language of Injury:
Comprehending Self-Mutilation BPS, Leicester
Barker, P et al (1999) From the Ashes of Experience: Reflections
on Madness, Survival and Growth, Whurr, London
Casey, B & Long, A (2003) Meanings of Madness, Journal of
Psychiatric and Mental Health Nursing 10:89-99
Horsfall, J (2001) Gender and Mental Illness, Issues in Mental
Health Nursing 22:421-438
Nehls, N (1998) Borderline Personality Disorder, Issues in Mental
health Nursing 19:97-112
Perkins, R & Repper, J (1998) Dilemmas in Community Mental
Health Practice, Radcliffe Medical Press, Abingdon
• NB this lecture is available at
http://shswebspace.swan.ac.uk/HNGardnerLD/
SGW
• In your group discuss the implications of the
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diagnostic process: is a diagnosis helpful? Why?
What would the consequences be if we
abandoned the concept of diagnosis?
Is Oakley correct in asserting that the
medicalisation of unhappiness as depression is
disastrous?
How can you learn about mental illness? Why do
you need to know? What do you need to know?
Are first hand accounts useful? How and why
might they be useful?