Concepts and Definitions of Mental Illness

1. INTRODUCTION

The conceptualisation and definition of what is meant by the term ‘mental illness’ is not a straight forward task. This is because of two key reasons. Firstly, a given definition of mental illness will be significantly affected by the specific characteristics of the source of the definition. For example, a member of the general public would be likely to provide a definition which is significantly different from a person who worked within the legal profession. The perceptions of the member of the general public are likely to have been influenced by factors such as the media and their experiences involving people who are viewed as being mentally ill. In contrast, the legal profession would be influenced by the guidelines and recommendations set out by law (e.g. the Mental Health Act 1983 and subsequent amendments). The definition used within the health care profession is likely to differ again from these alternative approaches Such differences are likely to exist within these categories. For example, the definition used by a Psychiatrist may not be the same as that which is used by a General Practitioner. Therefore, whenever one is discussing ‘what is meant by mental illness’, it is important to note the significant impact which is made by the perspectives and experiences of those providing the definition. For the purposes of the following discussion, the definitions which are employed within the health care industry will be predominantly focussed upon but references will be made to the perceptions of other relevant groups.

The second reason why the definition of ‘mental illness’ is not a simple one is because of the wide range of different symptoms, behaviours and personal characteristics which may be perceived as signs of mental illness. A person may be perceived as mentally ill if they claim to hear voices, experience prolonged episodes of depression, are addicted to drugs or even because they are extremely scared of spiders. These wide range of symptoms ensure that it is difficult to derive a definition of mental illness which encompasses all of the relevant aspects and issues. In terms of behaviours, a person who is going through a period of extreme optimism may be viewed as being a very positive person by some and as experiencing a manic episode by others. Therefore, it is difficult to clearly define the boundaries as to when behaviour moves into the realm of being a sign of mental illness. Finally, the personal characteristics of the person being observed are likely to influence whether or not they are perceived as being mentally ill. For example, a young person who is forgetful may be viewed as simply having a poor memory. However, if an elderly person was to perform the same episodes of memory loss, they may be more likely to be viewed as suffering from the early signs of Alzheimer’s Disease. Therefore, the definition of mental illness is made more difficult by the range of applicable symptoms, the problems associated with clearly defining boundaries and the effect of the personal characteristics of the person being observed. The following review will discuss these relevant issues and highlight the key elements of the debate regarding ‘What is Mental Illness?’

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2. THE CONCEPT OF MENTAL ILLNESS

This section will consider the statistical approach to mental illness along with the importance of social desirability. The roles played by cultural and societal factors in determining what is labelled as mental illness will then be discussed. Finally a theoretical definition of what is meant by mental illness will be provided.

2.1 THE STATISTICAL APPROACH TO MENTAL ILLNESS

The more traditional approach to mental illness was based on the concept of how rare a given person’s characteristics, thoughts and behaviours were viewed as being. Somebody who is acting very differently and in a way which is rarely seen, had the potential to being perceived as mentally ill. For example, the extreme behaviour and actions performed by Adolf Hitler would lead many to claim that he was ‘insane’ However, This statistical approach to mental illness can be criticised in two ways. Firstly, the extreme behaviours of somebody like Picasso are viewed as talent and ability rather than as being a sign of mental illness. Rarity, it could be argued, is only relevant when it is combined with behaviour which is socially undesirable. The statistical approach can be criticised in a second way. There are certain categories of mental illness which are not that rare. For example, a significant number of people in the world suffer with depression. One could not argue that depression is not a mental illness merely based on the theory that there are too many people suffering with it. Thus the traditional statistical approach was shown to not be a comprehensive and appropriate conceptualisation of mental illness.

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2.2 CULTURAL AND SOCIETAL FACTORS IN MENTAL ILLNESS

Subsequent approaches to mental illness have focussed on the concept of ‘deviance’ (Maher 1966). This highlights the key role which is played by cultural and societal factors in determining what is labelled as mental illness. The case of homosexuality provides a good demonstration of this point. In previous centuries, performing homosexual acts was seen as a sign of mental illness by both society and the mental health profession. However, over subsequent years homosexuality has become a more accepted form of sexual behaviour. Although some people would still view it as a mental illness, a societal shift appears to have taken place relative to the historical treatment of homosexual people. Heather (1976) argues that there is a moral aspect to mental illness as well as the underlying medical condition. The case of homosexuality outlines this point of view and shows that the concept of mental illness is not a fixed one but rather has the capability to change over time.

Szasz (1962) also supported this view and argued that mental illness is as ‘real’ as witch craft was in the past. It is the way in which society perceives mental illness which has a significant impact on what is actually labelled as mental illness. Other cultural aspects have a part to play. Cultural norms regarding a situation are important. For instance, undressing is an acceptable behaviour if one is just about to have a shower However, if one was to undress in the middle of the high street then it would not be seen as acceptable. Similarly there are developmental norms within given cultures. Temper tantrums are expected when a child is around two years of age. However, if the same behaviour was performed by a 30 year old then it is likely that this would be seen as unacceptable and potentially viewed as a sign of mental illness. This section has shown that cultural and societal factors have an important influence on what is seen as mental illness. A given behaviour in one community may be acceptable but the exact same behaviour in a different community may be seen as a sign of mental illness.

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2.3 DEFINING MENTAL ILLNESS

Johoda’s (1958) Framework of mental illness will be outlined here as well as the importance of distress and consequences.

3. CATEGORIES OF MENTAL ILLNESS

This section of the review will outline three of the more prevalent categories of mental illness. This discussion will enable a more comprehensive understanding of what is meant by mental illness. Within each category, an example of a mental illness will be provided as a further illustration. The first category is Psychosis. A definition of psychosis will be given and the case of Schizophrenia will be discussed as an example. The second broad category to be considered is Substance Abuse.. The case of people being addicted to recreational drugs will be provided as a modern example. The third and final category is Depression. Bipolar Disorder will be discussed as another example of mental illness. For each of these examples, both the causes and different treatments will be briefly outlined.

3.1 PSYCHOSIS

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The first category of mental illness to be covered in this discussion is Psychosis. The term ‘psychosis’ has been defined as a range of symptoms that can be found within the diagnostic categories of Schizophreniform illness^[1] (Gregory 1987). A variety of different experiences can be described as psychotic symptoms. They can be viewed as ‘highly convoluted expressions of everyday experiences (Beck & Rector 2000). They include auditory hallucinations (e.g. the patient may hear a voice instructing them to perform certain behaviours), disturbing thoughts (e.g. the patient may become paranoid that they are being targeted by someone) or a distressing inability to distinguish what is ‘reality’. Combinations of these psychotic symptoms are associated with different forms of psychosis, including both Acute and Chronic Schizophrenia. The mental illness which is labelled as ‘Schizophrenia’ will now be outlined in more detail. The symptoms associated with this illness will be outlined along with the different possible causes and treatments.

3.1.1 SCHIZOPHRENIA

The term Schizophrenia was first used by Bleuler (1911). It was intended to mean ‘Split Mind’ or ‘Divided Self’. Clare (1976) stated that a person can be said to be suffering from Schizophrenia if they have at least one of the ‘first rank’ symptoms, outlined below, and do not suffer from a diagnosed brain disease. The ‘First Rank’ Schizophrenic symptoms were outlined by Schneider (1959). They are:

• Passivity experiences and thought disturbances
• Auditory hallucinations in the third person
• Primary delusions or false beliefs

The potential consequences for a person suffering with Schizophrenia are both serious and wide ranging. One of the most significant problems can be social exclusion. This has the potential to cause great distress on the part of the patient and may lead to a relapse and or increase in their psychotic symptoms. Therefore it is an important issue to consider and one which needs to be carefully addressed by the mental health nurse.

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3.1.2 CAUSES OF SCHIZOPHRENIA

Information regarding the different causes of Schizophrenia will be added here.

3.1.3 TREATMENTS

Many different approaches to the treatment of Schizophrenia and psychotic symptoms have been taken over the past fifty years. These have ranged from Neuroleptic medication and Electro-Convulsive Therapy through to Social Support and Family Therapy. The 1960s witnessed the introduction of Phenothiazine as a medication for treating psychotic symptoms (Fenton 2000). Subsequent research evaluating a purely drug-BASED approached suggested that it may be somewhat limited. For example, research has revealed that between 25 and 50% of patients ON medication still experience persistent psychotic symptoms (Garety et al 2000). Furthermore, even when the patients strictly adhere to their medication regime, they still can experience difficulties (Hogarty & Ulrich 1998). Other research has supported the view that patients suffering from psychotic symptoms who are on medication still experience residual symptoms as well as social disabilities such as having difficulty with interpersonal skills (Sandford & Gournay 1996). Such social disabilities can negatively effect the patient’s ability to socially interact and to form relationships. This in turn may help to reinforce the stereotypes that people have regarding the mentally ill and hence contribute to the stigmatisation which they have to suffer.

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Other alternative and supplementary approaches to the treatment of psychotic symptoms have been offered. For instance, based upon Social Learning Theory, Social Skills Training was developed. This involves training and re-training the motor and interpersonal skills of the patient. However, evaluations of this approach have suggested that any positive effects were short term and that rather than dealing with the psychotic symptoms Social Skills Training merely allows the patient to disguise them and to avoid talking about them (Bradshaw 1995). It may be the case that such training needs to be provided via the mental health nurse and this could be one way in which they could help a patient who is suffering from Schizophrenia. Other treatments based on a psychodynamic approach have also been tested and evaluated in terms of their effectiveness and efficacy for the treatment of psychotic symptoms. It was found that there was no significant effect (Malmberg & Fenton 2002). However, other similar research suggested that approaches which emphasise problem-solving seem to be more effective than those which simply focused on analysis (Fenton 2000). Such findings have led people to advocate the psychological management of psychotic symptoms whilst also emphasising the possible role that could be played by the mental health nurse in addressing problems which are not effectively overcome by the treatments which are presently given for Schizophrenia.

3.2 SUBSTANCE ABUSE

Another major area of mental illness concerns addiction. It has been included here as it is not generally perceived as being a mental illness by the public although it is included within the DSM-IV classification framework. Humans can become addicted to a wide range of different stimuli from gambling and sexual behaviour through to drugs and alcohol consumption. As a result of the prevalence of such addictions, and the potentially serious consequences for the sufferer, the topic of addiction has attracted a considerable amount of research projects and theories from a variety of different theoretical perspectives. The case of people being addicted to recreational drugs will now be provided as an example which is of particular relevant to the modern debates within this field.

3.2.1 ADDICTION TO RECREATIONAL DRUG USE

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The system within the brain which is activated by the consumption of water and food, as well as during sexual activity, can also respond to the taking of drugs. This is associated with an increase in the release of dopamine from the nucleus accumbens within the brain. This effect has been seen with amphetamines, cocaine, nicotine, PCP, opiates and cannabis. Recreational drugs are primarily taken by individuals because of the feelings of euphoria, alterations in sensory perception or to experience an increase in their perceived mental or physical abilities. The issue of recreational drug use has seen a significant amount of coverage within the UK media over the last decade. Through a combination of the prevalence of recreational drug use, the reporting of drug-related deaths and the Government’s deliberations over the relevant legal considerations, a growing interest in the topic has been facilitated. The Government and researchers in the field are working to gain an understanding of the drugs which are being used, who is using them, how addictive behaviour can develop and what interventions can be taken in order to ensure the safety of those at risk.

Research has been conducted which has attempted to quantify the extent to which recreational drugs are used within the United Kingdom. For instance, Wadsworth et al (2004a) conducted a postal survey which revealed that 12% of the respondents had taken elicit recreational drugs within the last year and 7% had done so within the last month. For respondents under the age of 25, it was found that 34% reported having taken recreational drugs in the last year and 19% in the last month. It appears that these figures are increasing and that they have been increasing for a number of years. Bauman & Phongsavan (1999) performed a review of the epidemiology of drug use and found that it had been steadily increasing since 1990. They also note, however, that it is difficult to collect accurate data regarding the true extent of recreational drug use as people may be reluctant to admit using drugs and to report the amount that they usually take.

3.22 CAUSES OF ADDICTION

An addiction involves a person having a compulsion to take a given substance or perform a specific behaviour. They also have an inability, or find it very difficult to limit their in-take of the substance or to control their performance of the given behaviour. Explanations for the development of an addiction have been proposed from a number of different theoretical perspectives. Some of the more prominent approaches will now be outlined.

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The biological approach, often cited as ‘the disease model’, suggests that a person has a pre-disposition to becoming addicted to a specific stimuli. This does not necessarily mean that they will become addicted, just that they are vulnerable to it and that the onset of any addiction may occur more easily or rapidly. The Genetic approach suggests that people may inherit addictions from their parents through their genetic make-up. Therefore, the children of a person who is addicted to a specific stimuli are said to be more vulnerable to becoming addicted to that stimuli than would normally be expected. The Sociological perspective emphasises the role played by societal factors in the development of addictions among its members. For instance, within a society which creates a stressful environment, high levels of conflict and which allows significant advertising of products to which people may become addicted, more people with addictions may exist relative to another less stressful society with lower levels of conflict and advertising. Other explanations have been offered which are fundamentally based on psychological principles. It is these approaches which are being proposed as most appropriate for understanding recreational drug addiction.

This approach is fundamentally based on the assumption that human behaviour is learned. Such learning is said to be shaped by positive and negative reinforcements which are associated with performing the behaviour. A negative reinforcement may come in the form of information regarding recreational drugs. Such information may be provided by family members, a friend, the media or through the education system. Through emphasising the potential health-related consequences of recreational drug use, the likelihood of an individual taking recreational drugs should be reduced. Negative reinforcement could also occur through an individual experiencing or witnessing an unpleasant event regarding drugs and involving themselves or their friends.

Positive reinforcement regarding recreational drug taking could also be provided by an individual’s friends. It could also occur through witnessing other people taking recreational drugs and focussing on the positive consequences of such behaviour. Perhaps the most powerful positive reinforcement, however, occurs when an individual takes recreational drugs and experiences positive feelings as a result. These positive feelings are likely to go beyond the actual physical reaction to include potential factors such as the individual’s acceptance into a social group or scene and a significant rise in their reputation. All of these positive reinforcements are likely to combine, to varying degrees, to encourage the individual to repeat the recreational drug taking behaviour in the future. The addiction can begin when they become tolerant to such positive feelings. This psychopharmacological approach suggests that this tolerance takes two forms.

Firstly, the individual can become Contingency Tolerant This relates to their behaviour after the stimuli and it is this which they become tolerant of rather than the stimuli itself. Therefore, to continue with the recreational drug-taking example, the individual may become tolerant of the positive feeling experienced when taking a drug and hence they go in search of a larger effect by taking more of the same drug or by experimenting with other substances. The second form of tolerance is Conditioned Tolerance This relates to the environment in which the behaviour is performed. The drug taker may experience a positive response when they walk into a night club or to a friends house where drugs are usually taken. It is suggested that the individual with the addiction can become conditioned to consuming the given substance or performing the specific behaviour when in a given environment or situation.

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3.3 MOOD DISORDERS

The two major conditions which are included within this category of mental illness are Depression and Bipolar Disorder. They are both amongst the more common forms of mental illness. As an example of this kind of mental illness, the case of Bipolar Disorder will now be outlined in more detail.

3.3.1 BIPOLAR DISORDER

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Bipolar Disorder is a form of psychotic illness which involves the patient experiencing episodes of mania and depression. The periods of mania may involve the patient being in extremely high spirits and exhibiting high levels of optimism. In contrast, depression may witness the patient feeling very low and even suicidal. These extreme moods will be separated by times in which the patient is in a ‘normal’ mood. This cyclical pattern of moods can become more rapid over time (Goodwin & Jamison 1990). A distinction can be drawn between two forms of the disorder. Bipolar Disorder 1 is the classic form in which the patient experiences recurrent episodes of mania and depression. Bipolar Disorder 2 involves milder episodes of hypomania and depression. If the patient is witnessed to go through four or more episodes in a year then they can be categorised as suffering from Rapid Cycling Bipolar Disorder.

It has been estimated that around 1% of people who are over the age of 18 can suffer with Bipolar Disorder in any one year (Regier et al 1993). As a result of the prevalence of this illness, combined with the potential for it leading to suicide (Brent et al 1993), research has been conducted in order to gain an understanding of the causes and the most effective treatments for Bipolar Disorder. This field of investigation has attracted theorists and researchers from a psychological and sociological perspective. This move has been facilitated by the findings of research which has demonstrated that the traditional approach of medication may not address all of the relevant issues. For example, Ameen & Ram (2001) suggest that only 60% of patients respond to Lithium and other Anti-Convulsion medication. Furthermore, they also suggest that just 40% of sufferers remain without relapse for three years after initial treatment despite adhering to their medication regime. Such statistics have served to highlight the potential role that could be played by people working from a psychological and/or sociological perspective. The following discussion will now consider and critically review these perspectives with reference to the causes and then the treatment of Bipolar Disorder.

3.3.2 CAUSES OF BIPOLAR DISORDER

A significant amount of research has been conducted to investigate the underlying causes of Bipolar Disorder. The role played by genetics and biological factors does appear to be a significant one. Research has demonstrated that one identical twin can suffer with Bipolar Disorder where as the other identical twin may not. However, they are significantly more likely to suffer with the illness relative to another sibling (Genetics Workgroup 1998). Therefore genetics seem to have a significant impact but it is not the only potential contributory factor. Other psychological and sociological factors have been offered as possible explanations for the development of Bipolar Disorder. These will now be discussed with reference to three key areas, the individual, their family and environmental factors.

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The psychological perspective would highlight the potential causal factors which relate to the individual sufferer themselves. Factors such as substance abuse and alcoholism have been linked with Bipolar Disorder (Winokur et al 1996). A number of psychological issues could under-pin such behaviour and these need to be addressed if a comprehensive understanding of Bipolar Disorder is to be gained. For example, the individual may not be equipped with sufficient coping skills or an ability to manage stress which in turn leads to their use of alcohol or drugs which then contributes to their Bipolar Disorder. The psychological perspective emphasises the influence of factors relating to the individual’s characteristics which cause or contribute to their illness.

The second key area which relates to the psychosocial perspective is the family. The interactions between family members during a person’s developmental years appears to have a significant impact on the onset of Bipolar Disorder. Research has been conducted which has assessed what sufferers of Bipolar Disorder view as the main causes of their illness. Lish et al (1994) found that sufferers believe that their illness started in their childhood. The way in which parents act towards a child in forming their behavioural patterns is an important consideration. This is of particular importance when the parents themselves suffer with Bipolar Disorder (Grigoroiu-Serbanescu et al 1989). The child will observe the behaviour of their parents and this in turn will play a significant part in developing their behaviour in given situations. The learning of social skills and the interactions which take place within the family are viewed by those from a psychosocial perspective to be an important consideration in understanding the causes of Bipolar Disorder.

As well as family related issues, general environmental factors are also advocated by the psychosocial perspective as a cause of Bipolar Disorder (Pike & Plomin 1996). The social environment in which an individual lives and the events which they experience may contribute to the development of their illness. The social support which a person has when they are first experiencing a manic or depressive mood can significantly impact the course of the mood and potentially facilitate the development of a more serious problem. Furthermore, the general lifestyle of the individual, and the social settings which this puts them in, will be another influencing factor. If they live or work in an environment which facilitates significant high and low periods then this could facilitate the onset of a psychotic symptom. Therefore, if an individual lives in an environment which encourages alcoholism, provides no real social support and incurs significant episodes of highs and lows, then the environment may lead to them suffering with Bipolar Disorder.

Thus far the discussion has demonstrated that those coming from a psychosocial perspective would argue that individual, family and environmental factors all have a part to play in causing, and contributing to, Bipolar Disorder. The empirical evidence, however, for such assertions is somewhat limited and hence the argument exists mainly from a theoretical perspective. It is difficult to conduct experiments which control for all of the potentially confounding variables and because of the relevant ethical considerations involved. Research generally focuses on people with Bipolar Disorder and tries to identify the causes of their illness. Having said this, the relevant research which has taken place involving identical twins would lead one to conclude that psychological and sociological factors do merit consideration when assessing the onset of Bipolar Disorder. The remainder of this discussion will now address the treatment of Bipolar Disorder from a psychosocial perspective. Again the categories of the individual, the family and the environment will be used to structure the discussion.

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3.3.3 TREATMENT OF BIPOLAR DISORDER

Although Bipolar Disorder is a serious illness, it can be successfully treated (Sachs et al 2000). Due to the fact that the traditional medication-based approaches have significant side-effects (Vainionpaa et al 1999), and because they are not always fully effective, psychosocial treatments have been proposed. These approaches will now be discussed with reference to individual, family and environmental methods as these were the areas addressed in terms of the causes of Bipolar Disorder.

Fundamentally based on psychological principles, therapy has been offered as a possible treatment for Bipolar Disorder. For example, Cognitive Behavioural Therapy (CBT) has been used to treat mild episodes of depression and post-manic dysphoria (Leahy & Beck 1988). This approach aims to foster an improvement in the patient’s coping skills, self control technique and on their ability to manage stress. Also the patient can be taught useful strategies such as combining the taking of medication with a routine task. In evaluating this approach Satterfield (1999) used an empirical case study to demonstrate that it can enhance the treatment of rapid cycling. Therefore, CBT is a possible approach for treating the individual factors associated with Bipolar Disorder.

An alternative individual approach comes from the psychodynamic perspective. It focuses on abandonment fears, repressed rage, manic defences and the need for engagement through the testing of limits. Limited evaluations of this approach have been made. Early research indicated that there are some long term benefits (Scott 1963). However, this research only used a small sample and hence the extent to which these findings can be generalised is questionable. Much of the research in this area involves single case studies (Kestenbaum & Kron 1987). Therefore this approach is predominantly supported by theory rather than sound scientific research.

Therefore therapy based on a psychological perspective has been advocated as a method by which individual factors can be addressed. Indeed the Expert Consensus Guideline Series (1996) recommended the use of psychotherapy alongside medication so that a more comprehensive treatment programme can be achieved.

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Conflict within the family can result from the patient’s desire for the situation to ‘go back to normal’ after an episode, their dependency on a family member for medication and because the family become concerned at the first signs of anger or sadness. Such conflicts can be addressed with therapeutic programmes like that which is proposed by Miklowitz & Goldstein (1990). Family Focussed Therapy (FFT) involves assessing and educating the family as well as providing training in communication and problem-solving skills. Evaluations of this approach for treating Bipolar Disorder have shown that it significantly reduces relapse rates whilst improving communication (Miklowitz et al 2000). A key element of approaches within this field is education. Information and hence improved knowledge can help to enhance the patient’s illness management skills. Spouses, other family members and care-givers all need to be involved within this process. Honig et al (1997) found that a psycho-educational family approach can reduce relapse rates, increase social support and significantly improve a family’s expression of their emotions. Therefore Family Therapy can be used to help address some of the causes of manic and depressive episodes whilst also improving the family’s ability to cope with them if and when they do occur.

The third and final area of treatments of Bipolar Disorder from a psychosocial perspective concerns environmental factors. By manipulating the environment, it should be possible to both reduce the number of manic or depressive episodes whilst also reducing the negative consequences of them should they happen. For example, Frank et al (2000) proposed Social Rhythms Training. This aims to stabilise a patient’s social rhythms, such as sleeping patterns, and their patterns of behaviour. It also aims to identify the factors which disrupt a person’s social rhythms. Similarly, Wehr et al (1998) advocates the creation of an environment which facilitates regular and healthy sleepi

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