Mental Health Disorders

Some disorders may be very limited in their functional effects, while others may involve substantial disability and support needs. In this context, the terms psychiatric disability and psychological disability are sometimes used instead of mental disorder.[2][3] The degree of ability or disability may vary over time and across different life domains. Furthermore, psychiatric disability has been linked to institutionalization, discrimination and social exclusion as well as to the inherent effects of disorders. Alternatively, functioning may be affected by the stress of having to hide a condition in work or school, etc., by adverse effects of medications or other substances, or by mismatches between illness-related variations and demands for regularity.[75]

It is also the case that, while often being characterized in purely negative terms, some mental traits or states labeled as psychiatric disabilities can also involve above-average creativity, non-conformity, goal-striving, meticulousness, or empathy.[76] In addition, the public perception of the level of disability associated with mental disorders can change.[77]

Nevertheless, internationally, people report equal or greater disability from commonly occurring mental conditions than from commonly occurring physical conditions, particularly in their social roles and personal relationships. The proportion with access to professional help for mental disorders is far lower, however, even among those assessed as having a severe psychiatric disability.[78] Disability in this context may or may not involve such things as:

Basic activities of daily living. Including looking after the self (health care, grooming, dressing, shopping, cooking etc.) or looking after accommodation (chores, DIY tasks, etc.)

Interpersonal relationships. Including communication skills, ability to form relationships and sustain them, ability to leave the home or mix in crowds or particular settings

Occupational functioning. Ability to acquire an employment and hold it, cognitive and social skills required for the job, dealing with workplace culture, or studying as a student.

In terms of total disability-adjusted life years (DALYs), which is an estimate of how many years of life are lost due to premature death or to being in a state of poor health and disability, psychiatric disabilities rank amongst the most disabling conditions. Unipolar (also known as Major) depressive disorder is the third leading cause of disability worldwide, of any condition mental or physical, accounting for 65.5 million years lost. The first systematic description of global disability arising in youth, in 2011, found that among 10- to 24-year-olds nearly half of all disability (current and as estimated to continue) was due to psychiatric disabilities, including substance use disorders and conditions involving self-harm. Second to this were accidental injuries (mainly traffic collisions) accounting for 12 percent of disability, followed by communicable diseases at 10 percent. The psychiatric disabilities associated with most disabilities in high-income countries were unipolar major depression (20%) and alcohol use disorder (11%). In the eastern Mediterranean region, it was unipolar major depression (12%) and schizophrenia (7%), and in Africa it was unipolar major depression (7%) and bipolar disorder (5%).[79]

Suicide, which is often attributed to some underlying mental disorder, is a leading cause of death among teenagers and adults under 35.[80][81] There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide.[82]

Risk factors

Main article: Causes of mental disorders

The predominant view as of 2018 is that genetic, psychological, and environmental factors all contribute to the development or progression of mental disorders.[83] Different risk factors may be present at different ages, with risk occurring as early as during prenatal period.[84]

Genetics

Main article: Psychiatric genetics

A number of psychiatric disorders are linked to a family history (including depression, narcissistic personality disorder[85][86] and anxiety).[87] Twin studies have also revealed a very high heritability for many mental disorders (especially autism and schizophrenia).[88] Although researchers have been looking for decades for clear linkages between genetics and mental disorders, that work has not yielded specific genetic biomarkers yet that might lead to better diagnosis and better treatments.[89]

Statistical research looking at eleven disorders found widespread assortative mating between people with mental illness. That means that individuals with one of these disorders were two to three times more likely than the general population to have a partner with a mental disorder. Sometimes people seemed to have preferred partners with the same mental illness. Thus, people with schizophrenia or ADHD are seven times more likely to have affected partners with the same disorder. This is even more pronounced for people with Autism spectrum disorders who are 10 times more likely to have a spouse with the same disorder.[90]

Environment

Main article: Brain health and pollution

The prevalence of mental illness is higher in more economically unequal countries.

During the prenatal stage, factors like unwanted pregnancy, lack of adaptation to pregnancy or substance use during pregnancy increases the risk of developing a mental disorder.[84] Maternal stress and birth complications including prematurity and infections have also been implicated in increasing susceptibility for mental illness.[91] Infants neglected or not provided optimal nutrition have a higher risk of developing cognitive impairment.[84]

Social influences have also been found to be important,[92] including abuse, neglect, bullying, social stress, traumatic events, and other negative or overwhelming life experiences. Aspects of the wider community have also been implicated,[93] including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures. The specific risks and pathways to particular disorders are less clear, however.

Nutrition also plays a role in mental disorders.[10][94]

In schizophrenia and psychosis, risk factors include migration and discrimination, childhood trauma, bereavement or separation in families, recreational use of drugs,[95] and urbanicity.[93]

In anxiety, risk factors may include parenting factors including parental rejection, lack of parental warmth, high hostility, harsh discipline, high maternal negative affect, anxious childrearing, modelling of dysfunctional and drug-abusing behavior, and child abuse (emotional, physical and sexual).[96] Adults with imbalance work to life are at higher risk for developing anxiety.[84]

For bipolar disorder, stress (such as childhood adversity) is not a specific cause, but does place genetically and biologically vulnerable individuals at risk for a more severe course of illness.[97]

Drug use

Mental disorders are associated with drug use including: cannabis,[98] alcohol[99] and caffeine,[100] use of which appears to promote anxiety.[101] For psychosis and schizophrenia, usage of a number of drugs has been associated with development of the disorder, including cannabis, cocaine, and amphetamines.[102][98] There has been debate regarding the relationship between usage of cannabis and bipolar disorder.[103] Cannabis has also been associated with depression.[98] Adolescents are at increased risk for tobacco, alcohol and drug use; Peer pressure is the main reason why adolescents start using substances. At this age, the use of substances could be detrimental to the development of the brain and place them at higher risk of developing a mental disorder.[84]

Chronic disease

People living with chronic conditions like HIV and diabetes are at higher risk of developing a mental disorder. People living with diabetes experience significant stress from the biological impact of the disease, which places them at risk for developing anxiety and depression. Diabetic patients also have to deal with emotional stress trying to manage the disease. Conditions like heart disease, stroke, respiratory conditions, cancer, and arthritis increase the risk of developing a mental disorder when compared to the general population.[104]

Personality traits

Risk factors for mental illness include a propensity for high neuroticism[105][106] or "emotional instability". In anxiety, risk factors may include temperament and attitudes (e.g. pessimism).[87] Key personality traits, including Neuroticism, Extraversion, Agreeableness, Conscientiousness, and Openness, significantly influence various dimensions of mental health, as measured by the General Health Questionnaire(GHQ-12). The GHQ-12 assesses mental health across three dimensions: GHQ-12A (social dysfunction & anhedonia), GHQ-12B (depression & anxiety), and GHQ-12C (loss of confidence).[107] Neuroticism was found to be strongly linked to all three dimensions, indicating greater vulnerability to mental health issues, while Extraversion was negatively associated with social dysfunction and depression, suggesting better mental health outcomes.Agreeableness and Conscientiousness were both negatively related to social dysfunction and loss of confidence, highlighting their protective roles. Openness showed a negative relationship with depression and anxiety.

These findings support several models of personality's impact on mental health, including the predisposition/vulnerability, complication/scar, and pathoplasty/exacerbation models.[108] This underscores the importance of considering personality traits in mental health assessments and interventions, as they help identify individuals at higher risk for mental health challenges and guide targeted psychological care.

Causal models

Mental disorders can arise from multiple sources, and in many cases there is no single accepted or consistent cause currently established. An eclectic or pluralistic mix of models may be used to explain particular disorders.[106][109] The primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial model which incorporates biological, psychological and social factors, although this may not always be applied in practice.

Biological psychiatry follows a biomedical model where many mental disorders are conceptualized as disorders of brain circuits likely caused by developmental processes shaped by a complex interplay of genetics and experience. A common assumption is that disorders may have resulted from genetic and developmental vulnerabilities, exposed by stress in life (for example in a diathesis–stress model), although there are various views on what causes differences between individuals. Some types of mental disorders may be viewed as primarily neurodevelopmental disorders.[citation needed]

Evolutionary psychology may be used as an overall explanatory theory, while attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context of mental disorders. Psychoanalytic theories have continued to evolve alongside and cognitive-behavioral and systemic-family approaches. A distinction is sometimes made between a "medical model" or a "social model" of psychiatric disability.[citation needed]

Diagnosis

Psychiatrists seek to provide a medical diagnosis of individuals by an assessment of symptoms, signs and impairment associated with particular types of mental disorder. Other mental health professionals, such as clinical psychologists, may or may not apply the same diagnostic categories to their clinical formulation of a client's difficulties and circumstances.[110] The majority of mental health problems are, at least initially, assessed and treated by family physicians (in the UK general practitioners) during consultations, who may refer a patient on for more specialist diagnosis in acute or chronic cases.

Routine diagnostic practice in mental health services typically involves an interview known as a mental status examination, where evaluations are made of appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of other professionals, relatives, or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in rare specialist cases neuroimaging tests may be requested, but such methods are more commonly found in research studies than routine clinical practice.[111][112]

Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations.[113] It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice.[114] In addition, comorbidity is very common in psychiatric diagnosis, where the same person meets the criteria for more than one disorder. On the other hand, a person may have several different difficulties only some of which meet the criteria for being diagnosed. There may be specific problems with accurate diagnosis in developing countries.

More structured approaches are being increasingly used to measure levels of mental illness.

HoNOS is the most widely used measure in English mental health services, being used by at least 61 trusts.[115] In HoNOS a score of 0–4 is given for each of 12 factors, based on functional living capacity.[116] Research has been supportive of HoNOS,[117] although some questions have been asked about whether it provides adequate coverage of the range and complexity of mental illness problems, and whether the fact that often only 3 of the 12 scales vary over time gives enough subtlety to accurately measure outcomes of treatment.[118]

Criticism

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Since the 1980s, Paula Caplan has been concerned about the subjectivity of psychiatric diagnosis, and people being arbitrarily "slapped with a psychiatric label." Caplan says because psychiatric diagnosis is unregulated, doctors are not required to spend much time interviewing patients or to seek a second opinion. The Diagnostic and Statistical Manual of Mental Disorders can lead a psychiatrist to focus on narrow checklists of symptoms, with little consideration of what is actually causing the person's problems. So, according to Caplan, getting a psychiatric diagnosis and label often stands in the way of recovery.[119]

In 2013, psychiatrist Allen Frances wrote a paper entitled "The New Crisis of Confidence in Psychiatric Diagnosis", which said that "psychiatric diagnosis... still relies exclusively on fallible subjective judgments rather than objective biological tests." Frances was also concerned about "unpredictable overdiagnosis."[120] For many years, marginalized psychiatrists (such as Peter Breggin, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality." More recently these concerns have come from insiders who have worked for and promoted the American Psychiatric Association (e.g., Robert Spitzer, Allen Frances).[121] A 2002 editorial in the British Medical Journal warned of inappropriate medicalization leading to disease mongering, where the boundaries of the definition of illnesses are expanded to include personal problems as medical problems or risks of diseases are emphasized to broaden the market for medications.[122]

Gary Greenberg, a psychoanalyst, in his book "the Book of Woe", argues that mental illness is really about suffering and how the DSM creates diagnostic labels to categorize people's suffering.[123] Indeed, the psychiatrist Thomas Szasz, in his book "the Medicalization of Everyday Life", also argues that what is psychiatric illness, is not always biological in nature (i.e. social problems, poverty, etc.), and may even be a part of the human condition.[124]