Overview of Mental Illness
Mental illness is a term rooted in history that refers collectively to all of the diagnosable mental disorders. Mental disorders are characterized by abnormalities in cognition, emotion or mood, or the highest integrative aspects of behavior, such as social interactions or planning of future activities. These mental functions are all mediated by the brain. It is, in fact, a core tenet of modern science that behavior and our subjective mental lives reflect the overall workings of the brain. Thus, symptoms related to behavior or our mental lives clearly reflect variations or abnormalities in brain function. On the more difficult side of the ledger are the terms disorder, disease, or illness. There can be no doubt that an individual with schizophrenia is seriously ill, but for other mental disorders such as depression or attention-deficit/hyperactivity disorder, the signs and symptoms exist on a continuum and there is no bright line separating health from illness, distress from disease. Moreover, the manifestations of mental disorders vary with age, gender, race, and culture. The thresholds of mental illness or disorder have, indeed, been set by convention, but the fact is that this gray zone is no different from any other area of medicine. Ten years ago a serum cholesterol of 200 was considered normal. Today, this same number alarms some physicians and may lead to treatment. Perhaps every adult in the United States has some atherosclerosis, but at what point does this move along a continuum from normal into the realm of illness? Ultimately, the dividing line has to do with severity of symptoms, duration, and functional impairment.
Despite the existence of a gray zone between health and illness, science can study the mechanisms by which illness occurs. Indeed, understanding mood regulation and its abnormalities, for example, proceeds independently from any set of diagnostic clinical criteria. Family studies, molecular genetics strategies, epidemiology, and the tools of clinical investigation tailored to specific populations are being used to investigate the mechanisms of mental illness. Specific manifestations of mental illness will be covered in succeeding pages.
This overview of mental illness focuses on those features of the disease process that are most common and characteristic of these disorders. The chapters that follow will present specific details about major categories of mental disorders that occur across the life span. The purpose here is to provide a framework upon which subsequent discussions of specific disorders can rest. The section leads with a descriptive overview of the cardinal manifestations, signs, and symptoms of mental disorders. It then describes how mental disorders are diagnosed and classified and provides an overview of the epidemiology and societal burden of mental disorders.
Persons suffering from any of the severe mental disorders present with a variety of symptoms that may include inappropriate anxiety, disturbances of thought and perception, dysregulation of mood, and cognitive dysfunction. Many of these symptoms may be relatively specific to a particular diagnosis or cultural influence. For example, disturbances of thought and perception (psychosis) are most commonly associated with schizophrenia. Similarly, severe disturbances in expression of affect and regulation of mood are most commonly seen in depression and bipolar disorder. However, it is not uncommon to see psychotic symptoms in patients diagnosed with mood disorders or to see mood-related symptoms in patients diagnosed with schizophrenia. Symptoms associated with mood, anxiety, thought process, or cognition may occur in any patient at some point during his or her illness.
Anxiety is one of the most readily accessible and easily understood of the major symptoms of mental disorders. Each of us encounters anxiety in many forms throughout the course of our routine activities. It may often take the concrete form of intense fear experienced in response to an immediately threatening experience such as narrowly avoiding a traffic accident. Experiences like this are typically accompanied by strong emotional responses of fear and dread as well as physical signs of anxiety such as rapid heart beat and perspiration. Some of the more common signs and symptoms of anxiety are listed in Table 2-2. Anxiety is aroused most intensely by immediate threats to ones safety, but it also occurs commonly in response to dangers that are relatively remote or abstract. Intense anxiety may also result from situations that one can only vaguely imagine or anticipate.
Anxiety has evolved as a vitally important physiological response to dangerous situations that prepares one to evade or confront a threat in the environment. The appropriate regulation of anxiety is critical to the survival of virtually every higher organism in every environment. However, the mechanisms that regulate anxiety may break down in a wide variety of circumstances, leading to excessive or inappropriate expression of anxiety. Specific examples include phobias, panic attacks, and generalized anxiety. In phobias, high-level anxiety is aroused by specific situations or objects that may range from concrete entities such as snakes, to complex circumstances such as social interactions or public speaking. Panic attacks are brief and very intense episodes of anxiety that often occur without a precipitating event or stimulus. Generalized anxiety represents a more diffuse and nonspecific kind of anxiety that is most often experienced as excessive worrying, restlessness, and tension occurring with a chronic and sustained pattern. In each case, an anxiety disorder may be said to exist if the anxiety experienced is disproportionate to the circumstance, is difficult for the individual to control, or interferes with normal functioning.
In addition to these common manifestations of anxiety, obsessive-compulsive disorder and post-traumatic stress disorder are generally believed to be related to the anxiety disorders. The specific clinical features of these disorders will be described more fully in the following chapters; however, their relationship to anxiety warrants mention in the present context. In the case of obsessive-compulsive disorder, individuals experience a high level of anxiety that drives their obsessional thinking or compulsive behaviors. When such an individual fails to carry out a repetitive behavior such as hand washing or checking, there is an experience of severe anxiety. Thus while the outward manifestations of obsessive-compulsive disorder may seem to be related to other anxiety disorders, there appears to be a strong component of abnormal regulation of anxiety underlying this disorder. Post-traumatic stress disorder is produced by an intense and overwhelmingly fearful event that is often life-threatening in nature. The characteristic symptoms that result from such a traumatic event include the persistent reexperience of the event in dreams and memories, persistent avoidance of stimuli associated with the event, and increased arousal.
Disturbances of perception and thought process fall into a broad category of symptoms referred to as psychosis. The threshold for determining whether thought is impaired varies somewhat with the cultural context. Like anxiety, psychotic symptoms may occur in a wide variety of mental disorders. They are most characteristically associated with schizophrenia, but psychotic symptoms can also occur in severe mood disorders.
One of the most common groups of symptoms that result from disordered processing and interpretation of sensory information are the hallucinations. Hallucinations are said to occur when an individual experiences a sensory impression that has no basis in reality. This impression could involve any of the sensory modalities. Thus hallucinations may be auditory, olfactory, gustatory, kinesthetic, tactile, or visual. For example, auditory hallucinations frequently involve the impression that one is hearing a voice. In each case, the sensory impression is falsely experienced as real.
A more complex group of symptoms resulting from disordered interpretation of information consists of delusions. A delusion is a false belief that an individual holds despite evidence to the contrary. A common example is paranoia, in which a person has delusional beliefs that others are trying to harm him or her. Attempts to persuade the person that these beliefs are unfounded typically fail and may even result in the further entrenchment of the beliefs.
Hallucinations and delusions are among the most commonly observed psychotic symptoms. A list of other symptoms seen in psychotic illnesses such as schizophrenia appears in Table 2-3. Symptoms of schizophrenia are divided into two broad classes: positive symptoms and negative symptoms. Positive symptoms generally involve the experience of something in consciousness that should not normally be present. For example, hallucinations and delusions represent perceptions or beliefs that should not normally be experienced. In addition to hallucinations and delusions, patients with psychotic disorders such as schizophrenia frequently have marked disturbances in the logical process of their thoughts. Specifically, psychotic thought processes are characteristically loose, disorganized, illogical, or bizarre. These disturbances in thought process frequently produce observable patterns of behavior that are also disorganized and bizarre. The severe disturbances of thought content and process that comprise the positive symptoms often are the most recognizable and striking features of psychotic disorders such as schizophrenia or manic depressive illness.
However, in addition to positive symptoms, patients with schizophrenia and other psychoses have been noted to exhibit major deficits in motivation and spontaneity that are referred to as negative symptoms. While positive symptoms represent the presence of something not normally experienced, negative symptoms reflect the absence of thoughts and behaviors that would otherwise be expected. Concreteness of thought represents impairment in the ability to think abstractly. Blunting of affect refers to a general reduction in the ability to express emotion. Motivational failure and inability to initiate activities represent a major source of long-term disability in schizophrenia. Anhedonia reflects a deficit in the ability to experience pleasure and to react appropriately to pleasurable situations. Positive symptoms such as hallucinations are responsible for much of the acute distress associated with schizophrenia, but negative symptoms appear to be responsible for much of the chronic and long-term disability associated with the disorder.
The psychotic symptoms represent manifestations of disturbances in the flow, processing, and interpretation of information in the central nervous system. They seem to share an underlying commonality of mechanism, insofar as they tend to respond as a group to specific pharmacological interventions. However, much remains to be learned about the brain mechanisms that lead to psychosis.
Disturbances of Mood
Most of us have an immediate and intuitive understanding of the notion of mood. We readily comprehend what it means to feel sad or happy. These concepts are nonetheless very difficult to formulate in a scientifically precise and quantifiable way; the challenge is greater given the cultural differences that are associated with the expression of mood. In turn, disorders that impact on the regulation of mood are relatively difficult to define and to approach in a quantitative manner. Nevertheless, dysregulation of mood and the expression of mood, or affect, represent a major category among mental disorders.
Disturbances of mood characteristically manifest themselves as a sustained feeling of sadness or sustained elevation of mood. As with anxiety and psychosis, disturbances of mood may occur in a variety of patterns associated with different mental disorders. The disorder most closely associated with persistent sadness is major depression, while that associated with sustained elevation or fluctuation of mood is bipolar disorder. The most common signs of these mood disorders are listed in Table 2-4. Along with the prevailing feelings of sadness or elation, disorders of mood are associated with a host of related symptoms that include disturbances in appetite, sleep patterns, energy level, concentration, and memory.
It is not known why diverse functions such as sleep and appetite should be altered in disorders of mood. However, depression and mania are typically associated with characteristic changes in these basic functions. Mood appears to represent a complex group of behaviors and responses that undergo precise and tightly controlled regulation. Higher organisms that must adapt to changing environments depend on optimal control of basic functions such as sleep, appetite, sex, and physical activity. This regulation must adapt to diurnal and seasonal changes in the environment. In addition, more complex behaviors such as exploration, aggression, and social interaction must also undergo a similar, perhaps closely linked, regulation. In humans, these complex behaviors and their regulation are believed to be associated with the expression of mood. A depressed mood appears to reflect a kind of global damping of these functions, while a manic state may result from an excessive activation of these same functions. The mechanisms underlying the diverse changes associated with the mood disorders are largely unknown, but their appearance as clusters in specific disorders along with their collective response to specific therapeutics suggests a common mechanistic basis.
Disturbances of Cognition
Cognitive function refers to the general ability to organize, process, and recall information. Cognitive tasks may be subdivided into a large number of more specific functions depending on the nature of the information remembered and the circumstances of its recall. In addition, there are many functions commonly associated with cognition such as the ability to execute complex sequences of tasks. Disturbances of cognitive function may occur in a variety of disorders. Progressive deterioration of cognitive function is referred to as dementia. Dementia may be caused by a number of specific conditions including Alzheimers disease (to be discussed in subsequent chapters). Impairment of cognitive function may also occur in other mental disorders such as depression. It is not uncommon to find profound disturbances of cognition in patients suffering from severe mood disturbances. More recently, cognitive deficits have been reported in schizophrenia and now have become a major new topic of research. Lastly, cognitive impairment frequently occurs in a host of chemical, metabolic, and infectious diseases that exert an impact on the brain.
The manifestations of cognitive impairment can vary across an extremely wide range, depending on severity. Short-term memory is one of the earliest functions to be affected and, as severity increases, retrieval of more remote memories becomes more difficult. Attention, concentration, and higher intellectual functions can be impaired as the underlying disease process progresses. Language difficulties range from mild word-finding problems to complete inability to comprehend or use language. Functional impairments associated with cognitive deficits can markedly interfere with the ability to perform activities of daily living such as dressing and bathing.
Anxiety, psychosis, mood disturbances, and cognitive impairments are among the most common and disabling manifestations of mental disorders. It is important, however, to appreciate that mental disorders leave no aspect of human experience untouched. It is beyond the scope of the present chapter to detail the full spectrum of presentations of mental disorders. Other common manifestations include, for example, somatic or other physical symptoms and impairment of impulse control. Many of these issues will be touched upon in subsequent chapters with reference to specific disorders.
The foregoing discussion has suggested that the manifestations of mental disorders fall into a number of distinct categories such as anxiety, psychosis, mood disturbance, and cognitive deficits. These categories are broad, heterogeneous, and somewhat overlapping. Moreover, any particular patient may manifest symptoms from more than one of these categories. This is not unexpected, given the highly complex interactions that take place among the neurobiological and behavioral substrates that produce these symptoms. Despite these confounding difficulties, a systematic approach to the classification and diagnosis of mental illness has been developed. Diagnosis is essential in all areas of health for shaping treatment and supportive care, establishing a prognosis, and preventing related disability. Diagnosis also serves as shorthand to enhance communication, research, surveillance, and reimbursement.
The diagnosis of mental disorders is often believed to be more difficult than diagnosis of somatic, or general medical, disorders, since there is no definitive lesion, laboratory test, or abnormality in brain tissue that can identify the illness. The diagnosis of mental disorders must rest with the patients reports of the intensity and duration of symptoms, signs from their mental status examination, and clinician observation of their behavior including functional impairment. These clues are grouped together by the clinician into recognizable patterns known as syndromes. When the syndrome meets all the criteria for a diagnosis, it constitutes a mental disorder. Most mental health conditions are referred to as disorders, rather than as diseases, because diagnosis rests on clinical criteria. The term disease generally is reserved for conditions with known pathology (detectable physical change). The term disorder, on the other hand, is reserved for clusters of symptoms and signs associated with distress and disability (i.e., impairment of functioning), yet whose pathology and etiology are unknown.
The standard manual used for diagnosis of mental disorders in the United States is the Diagnostic and Statistical Manual of Mental Disorders. Most recently revised in 1994, this manual now is in its fourth edition (American Psychiatric Association, 1994, hereinafter cited in this report as DSM-IV). The first edition was published in 1952 by the American Psychiatric Association; subsequent revisions, which were made on the basis of field trials, analysis of data sets, and systematic reviews of the research literature, have sought to gain greater objectivity, diagnostic precision, and reliability. DSM-IV organizes mental disorders into 16 major diagnostic classes listed in Table 2-5. For each disorder within a diagnostic class, DSM-IV enumerates specific criteria for making the diagnosis. DSM-IV also lists diagnostic subtypes for some disorders. A subtype is a subgroup within a diagnosis that confers greater specificity. DSM-IV is descriptive in its listing of symptoms and does not take a position about underlying causation.
DSM-IV and its predecessors2 represent a unique approach to diagnosis by a professional field. No other sphere of health care has created such an extensive compendium of all of its disorders with explicit diagnostic criteria. The World Health Organizations International Classification of Diseases (10th edition, 1992) is a valuable compendium of all diseases. Its mental health categories are expanded upon in DSM-IV. The International Classification of Diseases (ICD) is the official classification for mortality and morbidity statistics for all signatories to the U.N. Charter establishing the World Health Organization. ICD-9CM (9th edition, Clinical Modification, 1991) is still the official classification for the Health Care Financing Administration.
Knowledge about diagnosis continues to evolve. Evolution in the diagnosis of mental disorders generally reflects greater understanding of disorders as well as the influence of social norms. Years ago, for instance, addiction to tobacco was not viewed as a disorder, but today it falls under the category of Substance-Related Disorders. Although DSM-IV strives to cover all populations, it is not without limitations. The difficulties encountered in diagnosing mental disorders in children, older persons, and racial and ethnic minority groups are discussed later in this chapter and throughout this report. Diagnosis rests on clinician judgment about whether clients symptom patterns and impairments of functioning meet diagnostic criteria. Cultural differences in emotional expression and social behavior can be misinterpreted as impaired if clinicians are not sensitive to the cultural context and meaning of exhibited symptoms, a topic discussed later in this chapter in Overview of Cultural Diversity and Mental Health Services.
2 DSM-I (American Psychiatric Association, 1952), DSM-II (American Psychiatric Association, 1968), DSM-III (American Psychiatric Association, 1979), and DSM-III-R (American Psychiatric Association, 1987).
3 Although addictive disorders are included as mental disorders in the DSM classification system, the ECA and NCS distinguish between addictive disorders and (all other) mental disorders. Epidemiologic data in this report follow that convention.
4 The term serious emotional disturbance is used in a variety of Federal statutes in reference to children under the age of 18 with a diagnosable mental health problem that severely disrupts their ability to function socially, academically, and emotionally. The term does not signify any particular diagnosis; rather, it is a legal term that triggers a host of mandated services to meet the needs of these children.