* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download MENTAL ILLNESS IN A SOCIAL AND CULTURAL CONTEXT
Emergency psychiatry wikipedia , lookup
Community mental health service wikipedia , lookup
Anti-psychiatry wikipedia , lookup
Mentally ill people in United States jails and prisons wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Psychiatric and mental health nursing wikipedia , lookup
Critical Psychiatry Network wikipedia , lookup
Sluggish schizophrenia wikipedia , lookup
Child psychopathology wikipedia , lookup
Political abuse of psychiatry in Russia wikipedia , lookup
Abnormal psychology wikipedia , lookup
Mental health professional wikipedia , lookup
Mental disorder wikipedia , lookup
Political abuse of psychiatry wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Cases of political abuse of psychiatry in the Soviet Union wikipedia , lookup
Deinstitutionalisation wikipedia , lookup
Mental status examination wikipedia , lookup
Major depressive disorder wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Biology of depression wikipedia , lookup
Postpartum depression wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
History of psychiatry wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Behavioral theories of depression wikipedia , lookup
Evolutionary approaches to depression wikipedia , lookup
History of mental disorders wikipedia , lookup
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 • • • • • 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 • • • • 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 • • • • 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 • • 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 • 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 • 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 • • • • • • • • • 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 • • • 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 – • • • • • • 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 • • • 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), • • • • 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 • 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 • • • 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 • • 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 • • • 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 • • • • • 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 • • 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?