Trastorno mental

Distressing thought or behavior pattern

Medical condition

Trastorno mental
Otros nombres	Trastorno psiquiátrico, trastorno psicológico, enfermedad mental, enfermedad mental, crisis nerviosa, trastornos de salud mental [1]
Especialidad	Psiquiatría
Síntomas	Agitación , ansiedad , depresión , manía , paranoia , psicosis
Complicaciones	Deterioro cognitivo, problemas sociales, suicidio.
Tipos	Los trastornos de ansiedad , trastornos de la alimentación , trastornos del estado de ánimo , trastornos de personalidad , trastornos psicóticos , trastornos por uso de sustancias
Causas	Factores genéticos y ambientales.
Tratamiento	Psicoterapia , medicamentos
Medicamento	Antidepresivos , antipsicóticos , ansiolíticos , estabilizadores del estado de ánimo , estimulantes.
Frecuencia	18% anual (Estados Unidos) [2]

Un trastorno mental , también llamado enfermedad mental ^[3] o trastorno psiquiátrico , es un patrón de comportamiento o mental que causa angustia significativa o deterioro del funcionamiento personal. ^[4] Tales características pueden ser persistentes, recurrentes y remitentes, o ocurrir como un solo episodio. Se han descrito muchos trastornos, con signos y síntomas que varían ampliamente entre trastornos específicos. ^{[5] [6]} Estos trastornos pueden ser diagnosticados por un profesional de la salud mental , generalmente un psicólogo clínico o un psiquiatra .

Las causas de los trastornos mentales a menudo no están claras. Las teorías pueden incorporar hallazgos de una variedad de campos. Los trastornos mentales generalmente se definen por una combinación de cómo una persona se comporta, siente, percibe o piensa. ^[7] Esto puede estar asociado con regiones o funciones particulares del cerebro, a menudo en un contexto social . Un trastorno mental es un aspecto de la salud mental . Las creencias culturales y religiosas, así como las normas sociales , deben tenerse en cuenta al hacer un diagnóstico. ^[8]

Los servicios se basan en hospitales psiquiátricos o en la comunidad , y las evaluaciones son realizadas por profesionales de la salud mental como psiquiatras, psicólogos, enfermeras psiquiátricas y trabajadores sociales clínicos , utilizando varios métodos como pruebas psicométricas pero a menudo basándose en la observación y el interrogatorio. Los tratamientos son proporcionados por varios profesionales de la salud mental. La psicoterapia y la medicación psiquiátrica son dos opciones de tratamiento importantes. Otros tratamientos incluyen cambios en el estilo de vida, intervenciones sociales, apoyo de pares y autoayuda . En una minoría de casos, puede haber detención involuntaria.o tratamiento . Se ha demostrado que los programas de prevención reducen la depresión. ^{[7] [9]}

En 2019, los trastornos mentales comunes en todo el mundo incluyen la depresión , que afecta a unos 264 millones, el trastorno bipolar , que afecta a unos 45 millones, la demencia , que afecta a unos 50 millones, y la esquizofrenia y otras psicosis, que afecta a unos 20 millones de personas. ^{[10] Los} trastornos del neurodesarrollo incluyen la discapacidad intelectual y los trastornos del espectro autista que generalmente surgen en la infancia o la niñez. ^{[11] [10] El} estigma y la discriminación pueden aumentar el sufrimiento y la discapacidad asociados con los trastornos mentales, lo que lleva a varios movimientos sociales.intentando aumentar la comprensión y desafiar la exclusión social .

Definición

La definición y clasificación de los trastornos mentales son cuestiones clave para los investigadores, así como para los proveedores de servicios y para quienes pueden ser diagnosticados. Para que un estado mental se clasifique como trastorno, generalmente necesita causar disfunción. ^[12] La mayoría de los documentos clínicos internacionales utilizan el término "trastorno" mental, mientras que "enfermedad" también es común. Se ha observado que el uso del término "mental" (es decir, de la mente ) no implica necesariamente estar separado del cerebro o del cuerpo .

Según el DSM-IV , un trastorno mental es un síndrome o patrón psicológico que se asocia con angustia (por ejemplo, a través de un síntoma doloroso ), discapacidad (deterioro en una o más áreas importantes del funcionamiento), mayor riesgo de muerte o causa una pérdida de autonomía; sin embargo, excluye las respuestas normales, como el dolor por la pérdida de un ser querido, y también excluye el comportamiento desviado por razones políticas, religiosas o sociales que no surgen de una disfunción en el individuo. ^{[13] [14]}

El DSM-IV predica la definición con salvedades y afirma que, como en el caso de muchos términos médicos, el trastorno mental "carece de una definición operativa coherente que abarque todas las situaciones", y señala que se pueden utilizar diferentes niveles de abstracción para las definiciones médicas, incluida la patología. , sintomatología, desviación de un rango normal, o etiología, y que lo mismo ocurre con los trastornos mentales, de modo que a veces es apropiado un tipo de definición y, a veces, otro, según la situación. ^[15]

En 2013, la Asociación Estadounidense de Psiquiatría (APA) redefinió los trastornos mentales en el DSM-5 como "un síndrome caracterizado por una alteración clínicamente significativa en la cognición, la regulación de las emociones o el comportamiento de un individuo que refleja una disfunción en los procesos psicológicos, biológicos o de desarrollo". funcionamiento mental subyacente ". ^[16] El borrador final de la CIE-11 contiene una definición muy similar. ^[17]

Los términos "crisis nerviosa" o "crisis nerviosa" pueden ser utilizados por la población en general para referirse a un trastorno mental. ^[18] Los términos "crisis nerviosa" y "crisis mental" no se han definido formalmente a través de un sistema de diagnóstico médico como el DSM-5 o ICD-10 , y están casi ausentes de la literatura científica sobre enfermedades mentales. ^{[19] [20]} Aunque el "ataque de nervios" no se define rigurosamente, las encuestas de personas no profesionales sugieren que el término se refiere a un trastorno reactivo agudo específico por tiempo limitado, que involucra síntomas como ansiedad o depresión, generalmente precipitados por factores estresantes externos . ^[19]Hoy en día, muchos expertos en salud se refieren a un ataque de nervios como una "crisis de salud mental". ^[21]

Enfermedad nerviosa

Además del concepto de trastorno mental, algunas personas han abogado por un regreso al antiguo concepto de enfermedad nerviosa. En Cómo todos se deprimieron: el auge y la caída del ataque de nervios (2013), Edward Shorter, profesor de psiquiatría e historia de la medicina, dice:

Aproximadamente la mitad de ellos están deprimidos. O al menos ese es el diagnóstico que recibieron cuando les recetaron antidepresivos. ... Van a trabajar pero se sienten infelices e incómodos; están algo ansiosos; ellos están cansados; tienen varios dolores físicos y tienden a obsesionarse con todo el asunto. Hay un término para lo que tienen, y es un buen término pasado de moda que ya no se usa. Tienen nervios o una enfermedad nerviosa. Es una enfermedad no solo de la mente o el cerebro, sino un trastorno de todo el cuerpo. ... Aquí tenemos un paquete de cinco síntomas: depresión leve, algo de ansiedad, fatiga, dolores somáticos y pensamiento obsesivo. ... Hemos tenido enfermedades nerviosas durante siglos. Cuando estás demasiado nervioso para funcionar ... es un ataque de nervios. Pero ese término ha desaparecido de la medicina, aunque no de nuestra forma de hablar ...Los pacientes nerviosos de antaño son los depresivos de hoy. Esa es la mala noticia ... Existe una enfermedad más profunda que impulsa la depresión y los síntomas del estado de ánimo. Podemos llamar a esta enfermedad más profunda de otra manera, o inventar un neologismo, pero necesitamos sacar la discusión de la depresión y centrarnos en este trastorno más profundo en el cerebro y el cuerpo. Ese es el punto.

-  Edward Shorter, Facultad de Medicina, Universidad de Toronto ^[22]

Al eliminar la crisis nerviosa, la psiquiatría ha estado a punto de sufrir su propia crisis nerviosa.

-  David Healy , MD, FRCPsych, profesor de psiquiatría, Universidad de Cardiff, Gales ^[23]

Los nervios son el núcleo de las enfermedades mentales comunes, por mucho que tratemos de olvidarlos.

-  Peter J. Tyrer, FMedSci, profesor de psiquiatría comunitaria, Imperial College, Londres ^[24]

El "ataque de nervios" es un término pseudo-médico para describir una gran cantidad de sentimientos relacionados con el estrés y, a menudo, se ven agravados por la creencia de que existe un fenómeno real llamado "ataque de nervios".

-  Richard E. Vatz, coautor de la explicación de los puntos de vista de Thomas Szasz en " Thomas Szasz : valores primarios y argumentos principales"

Clasificaciones

Actualmente existen dos sistemas ampliamente establecidos que clasifican los trastornos mentales:

• CIE-10 Capítulo V: Trastornos mentales y del comportamiento , desde 1949 parte de la Clasificación Internacional de Enfermedades elaborada por la OMS,
• el Manual diagnóstico y estadístico de trastornos mentales (DSM-5) elaborado por la Asociación Estadounidense de Psiquiatría (APA) desde 1952.

Ambos enumeran categorías de trastornos y proporcionan criterios estandarizados para el diagnóstico. Han convergido deliberadamente sus códigos en revisiones recientes, de modo que los manuales son a menudo comparables en términos generales, aunque persisten diferencias significativas. Se pueden usar otros esquemas de clasificación en culturas no occidentales, por ejemplo, la Clasificación China de Trastornos Mentales , y los de creencias teóricas alternativas pueden usar otros manuales, como el Manual de Diagnóstico Psicodinámico . En general, los trastornos mentales se clasifican por separado de los trastornos neurológicos , las discapacidades del aprendizaje o la discapacidad intelectual .

A diferencia del DSM y el ICD, algunos enfoques no se basan en la identificación de categorías distintas de trastorno utilizando perfiles de síntomas dicotómicos destinados a separar lo anormal de lo normal. Existe un importante debate científico sobre los méritos relativos de los esquemas categóricos versus los no categóricos (o híbridos), también conocidos como modelos continuos o dimensionales. Un enfoque de espectro puede incorporar elementos de ambos.

En la literatura científica y académica sobre la definición o clasificación del trastorno mental, un extremo sostiene que se trata completamente de juicios de valor (incluido lo que es normal ), mientras que otro propone que es o podría ser completamente objetivo y científico (incluso por referencia a las normas estadísticas). ^[25] Los puntos de vista híbridos comunes sostienen que el concepto de trastorno mental es objetivo incluso si solo es un " prototipo difuso " que nunca puede definirse con precisión, o por el contrario, que el concepto siempre implica una mezcla de hechos científicos y juicios de valor subjetivos. ^[26]Aunque las categorías de diagnóstico se denominan "trastornos", se presentan como enfermedades médicas, pero no se validan de la misma manera que la mayoría de los diagnósticos médicos. Algunos neurólogos argumentan que la clasificación solo será confiable y válida cuando se base en características neurobiológicas en lugar de una entrevista clínica, mientras que otros sugieren que las diferentes perspectivas ideológicas y prácticas deben integrarse mejor. ^{[27] [28]}

El enfoque DSM y ICD sigue siendo atacado tanto por el modelo de causalidad implícita ^[29] como porque algunos investigadores creen que es mejor apuntar a las diferencias cerebrales subyacentes que pueden preceder a los síntomas por muchos años. ^[30]

Modelos dimensionales

El alto grado de comorbilidad entre trastornos en modelos categóricos como el DSM y el CIE ha llevado a algunos a proponer modelos dimensionales. El estudio de la comorbilidad entre trastornos ha demostrado dos factores o dimensiones latentes (no observados) en la estructura de los trastornos mentales que se cree que posiblemente reflejen procesos etiológicos. Estas dos dimensiones reflejan una distinción entre los trastornos internalizantes, como los síntomas del estado de ánimo o de ansiedad, y los trastornos externalizantes, como los síntomas del comportamiento o del uso de sustancias. ^[31] Se ha apoyado empíricamente un solo factor general de psicopatología, similar al factor g para la inteligencia. El factor pEl modelo apoya la distinción internalizante-externalizante, pero también apoya la formación de una tercera dimensión de trastornos del pensamiento como la esquizofrenia. ^[32] La evidencia biológica también respalda la validez de la estructura de internalización-externalización de los trastornos mentales, con estudios de gemelos y de adopción que respaldan los factores hereditarios para los trastornos de externalización e internalización. ^{[33] [34] [35]}

Trastornos

Hay muchas categorías diferentes de trastornos mentales y muchas facetas diferentes de la conducta y la personalidad humanas que pueden volverse desordenadas. ^{[36] [37] [38] [39]}

Trastorno de ansiedad

Anxiety disorder: Anxiety or fear that interferes with normal functioning may be classified as an anxiety disorder.^[37] Commonly recognized categories include specific phobias, generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, obsessive-compulsive disorder and post-traumatic stress disorder.

Mood disorder

Trastorno del estado de ánimo : otros procesos afectivos (emoción / estado de ánimo) también pueden volverse desordenados. El trastorno del estado de ánimo que implica tristeza, melancolía o desesperación inusualmente intensa y sostenida se conoce como depresión mayor (también conocida como depresión unipolar o clínica). La depresión más leve pero aún prolongada se puede diagnosticar como distimia . El trastorno bipolar (también conocido como depresión maníaca) implica estados de ánimo anormalmente "elevados" o de presión, conocidos como manía o hipomanía , que alternan con estados de ánimo normales o deprimidos. La medida en que los fenómenos del estado de ánimo unipolar y bipolar representan categorías distintas de trastorno, o se mezclan y se fusionan a lo largo de una dimensión o espectro del estado de ánimo, está sujeto a cierto debate científico.^{[40] [41]}

Desorden psicotico

Trastorno psicótico : los patrones de creencias, el uso del lenguaje y la percepción de la realidad pueden desregularse (p. Ej., Delirios , trastornos del pensamiento , alucinaciones ). Los trastornos psicóticos en este dominio incluyen esquizofrenia y trastorno delirante . El trastorno esquizoafectivo es una categoría que se utiliza para las personas que presentan aspectos tanto de la esquizofrenia como de los trastornos afectivos. La esquizotipia es una categoría que se utiliza para las personas que muestran algunas de las características asociadas con la esquizofrenia pero que no cumplen los criterios de corte.

Desorden de personalidad

Trastorno de la personalidad : la personalidad —las características fundamentales de una persona que influyen en los pensamientos y comportamientos a través de situaciones y tiempos— puede considerarse alterada si se considera que es anormalmente rígida y desadaptativa . Aunque algunos los tratan por separado, los esquemas categóricos comúnmente utilizados los incluyen como trastornos mentales, aunque en un " eje II " separado en el caso del DSM-IV. Se enumeran varios trastornos de personalidad diferentes, incluidos los que a veces se clasifican como "excéntricos", como los trastornos de personalidad paranoide , esquizoide y esquizotípico ; tipos que se han descrito como "dramáticos" o "emocionales", como antisocial ,trastornos de personalidad limítrofes , histriónicos o narcisistas ; y los que a veces se clasifican como relacionados con el miedo, como los trastornos de personalidad ansiosos-evitativos , dependientes u obsesivo-compulsivos . Los trastornos de la personalidad, en general, se definen como emergentes en la niñez, o al menos en la adolescencia o en la adultez temprana. El ICD también tiene una categoría para el cambio de personalidad duradero después de una experiencia catastrófica o una enfermedad psiquiátrica. Si la incapacidad para adaptarse lo suficiente a las circunstancias de la vida comienza dentro de los tres meses posteriores a un evento o situación particular y termina dentro de los seis meses posteriores a que el factor estresante se detiene o se elimina, puede clasificarse como un trastorno de adaptación.. Existe un consenso emergente de que los denominados "trastornos de la personalidad", como los rasgos de personalidad en general, en realidad incorporan una mezcla de comportamientos disfuncionales agudos que pueden resolverse en períodos cortos y rasgos de temperamento desadaptativo que son más duraderos. ^[42] Además, también existen esquemas no categóricos que califican a todos los individuos a través de un perfil de diferentes dimensiones de personalidad sin un límite basado en síntomas de la variación normal de la personalidad, por ejemplo, a través de esquemas basados ​​en modelos dimensionales. ^{[43] [se necesita fuente no primaria ]}

Desorden alimenticio

Trastorno de la alimentación : estos trastornos implican una preocupación desproporcionada en materia de alimentación y peso. ^{[37] Las} categorías de trastorno en esta área incluyen anorexia nerviosa , bulimia nerviosa , bulimia del ejercicio o trastorno por atracón . ^{[44] [45]}

Desorden del sueño

Trastorno del sueño : estas afecciones están asociadas con la interrupción de los patrones normales de sueño . Un trastorno del sueño común es el insomnio , que se describe como dificultad para conciliar el sueño o permanecer dormido.

Relacionado con la sexualidad

Trastornos sexuales y disforia de género : estos trastornos incluyen dispareunia y varios tipos de parafilia (excitación sexual hacia objetos, situaciones o individuos que se consideran anormales o dañinos para la persona u otros).

Otro

Trastorno del control de impulsos : las personas que son anormalmente incapaces de resistir ciertos impulsos o impulsos que podrían ser perjudiciales para ellos mismos o para los demás, pueden clasificarse como trastornos del control de impulsos y trastornos como la cleptomanía (robar) o la piromanía (prender fuego). Varias adicciones conductuales, como la adicción al juego, pueden clasificarse como un trastorno. El trastorno obsesivo compulsivo a veces puede implicar una incapacidad para resistir ciertos actos, pero se clasifica por separado como un trastorno de ansiedad principalmente.

Trastorno por uso de sustancias : este trastorno se refiere al uso de drogas (legales o ilegales, incluido el alcohol ) que persiste a pesar de los problemas o daños importantes relacionados con su uso. La dependencia de sustancias y el abuso de sustancias se incluyen en esta categoría general en el DSM. El trastorno por uso de sustancias puede deberse a un patrón de uso compulsivo y repetitivo de un fármaco que produce tolerancia a sus efectos y síntomas de abstinencia cuando se reduce o se suspende el uso.

Trastorno disociativo : las personas que sufren alteraciones graves de su propia identidad, memoria y conciencia general de sí mismas y de su entorno pueden clasificarse como personas con este tipo de trastornos, incluido el trastorno de despersonalización o el trastorno de identidad disociativo (que anteriormente se denominaba trastorno de personalidad múltiple). trastorno o "personalidad dividida").

Trastorno cognitivo : afectan las capacidades cognitivas, incluido el aprendizaje y la memoria. Esta categoría incluye el delirio y el trastorno neurocognitivo leve y grave (anteriormente denominado demencia ).

Trastorno del desarrollo : estos trastornos ocurren inicialmente en la niñez. Algunos ejemplos incluyen trastornos del espectro autista, trastorno negativista desafiante y trastorno de conducta , y trastorno por déficit de atención con hiperactividad (TDAH), que puede continuar hasta la edad adulta. El trastorno de conducta, si continúa hasta la edad adulta, puede diagnosticarse como un trastorno de personalidad antisocial (trastorno de personalidad disocial en el ICD). Las etiquetas populares como psicópata (o sociópata) no aparecen en el DSM o ICD pero están vinculadas por algunos a estos diagnósticos.

Los trastornos somatomorfos se pueden diagnosticar cuando existen problemas que parecen originarse en el cuerpo y que se cree que son manifestaciones de un trastorno mental. Esto incluye el trastorno de somatización y el trastorno de conversión . También existen trastornos de cómo una persona percibe su cuerpo, como el trastorno dismórfico corporal . La neurastenia es un diagnóstico antiguo que involucra quejas somáticas, así como fatiga y desánimo / depresión, que es oficialmente reconocido por la CIE-10 pero ya no por el DSM-IV. ^{[46] [se necesita fuente no primaria ]}

Los trastornos facticios , como el síndrome de Munchausen , se diagnostican cuando se cree que los síntomas se experimentan (se producen deliberadamente) y / o se informan (fingir) para beneficio personal.

Hay intentos de introducir una categoría de trastorno relacional , donde el diagnóstico es de una relación más que de cualquier individuo en esa relación. La relación puede ser entre los niños y sus padres, entre parejas u otras personas. Ya existe, en la categoría de psicosis, un diagnóstico de trastorno psicótico compartido en el que dos o más individuos comparten un delirio particular debido a su estrecha relación entre sí.

Hay una serie de síndromes psiquiátricos poco comunes , que a menudo reciben el nombre de la persona que los describió por primera vez, como el síndrome de Capgras , el síndrome de De Clerambault , el síndrome de Othello , el síndrome de Ganser , el delirio de Cotard y el síndrome de Ekbom , y trastornos adicionales como el de Couvade. síndrome y síndrome de Geschwind . ^[47]

Ocasionalmente se proponen varios tipos nuevos de diagnósticos de trastornos mentales. Entre los controversial considerado por los oficiales comités de los manuales de diagnóstico incluyen el trastorno autodestructivo de la personalidad , trastorno de la personalidad sádica , trastorno de personalidad pasivo-agresiva y trastorno disfórico premenstrual .

Signos y síntomas

Curso

El inicio de los trastornos psiquiátricos suele ocurrir desde la niñez hasta la edad adulta temprana. ^[48] Los trastornos del control de impulsos y algunos trastornos de ansiedad tienden a aparecer en la niñez. Algunos otros trastornos de ansiedad, trastornos por sustancias y trastornos del estado de ánimo surgen más tarde, a mediados de la adolescencia. ^[49] Los síntomas de la esquizofrenia se manifiestan típicamente desde finales de la adolescencia hasta principios de los veinte. ^[50]

El curso probable y el resultado de los trastornos mentales varían y dependen de numerosos factores relacionados con el trastorno en sí, el individuo en su conjunto y el entorno social. Algunos trastornos pueden durar un breve período de tiempo, mientras que otros pueden ser de naturaleza prolongada.

Todos los trastornos pueden tener un curso variado. Los estudios internacionales a largo plazo de la esquizofrenia han encontrado que más de la mitad de las personas se recuperan en términos de síntomas, y alrededor de un quinto a un tercio en términos de síntomas y funcionamiento, y muchos no requieren medicación. Si bien algunos tienen serias dificultades y necesitan apoyo durante muchos años, la recuperación "tardía" sigue siendo plausible. La Organización Mundial de la Salud concluyó que los hallazgos de los estudios a largo plazo convergieron con otros en "aliviar a los pacientes, cuidadores y médicos del paradigma de la cronicidad que dominó el pensamiento durante gran parte del siglo XX". ^{[51] [se necesita fuente no primaria ] [52]}

Un estudio de seguimiento realizado por Tohen y colaboradores reveló que alrededor de la mitad de las personas diagnosticadas inicialmente con trastorno bipolar logran la recuperación sintomática (ya no cumplen con los criterios para el diagnóstico) en seis semanas, y casi todas lo logran en dos años, y casi la mitad recupera sus síntomas. estado ocupacional y residencial anterior en ese período. Menos de la mitad experimenta un nuevo episodio de manía o depresión mayor en los próximos dos años. ^{[53] [se necesita fuente no primaria ]}

Invalidez

Trastorno	Años de vida ajustados por discapacidad [54]
Trastorno depresivo mayor	65,5 millones
Trastorno por consumo de alcohol	23,7 millones
Esquizofrenia	16,8 millones
Desorden bipolar	14,4 millones
Otros trastornos por consumo de drogas	8,4 millones
Trastorno de pánico	7,0 millones
Desorden obsesivo compulsivo	5,1 millones
Insomnio primario	3,6 millones
Trastorno de estrés postraumático	3.5 millones

Algunos trastornos pueden tener efectos funcionales muy limitados, mientras que otros pueden implicar una discapacidad sustancial y necesidades de apoyo. El grado de capacidad o discapacidad puede variar con el tiempo y en diferentes ámbitos de la vida. Además, la discapacidad continua se ha relacionado con la institucionalización , la discriminación y la exclusión social , así como con los efectos inherentes de los trastornos. Alternativamente, el funcionamiento puede verse afectado por el estrés de tener que ocultar una condición en el trabajo o la escuela, etc., por los efectos adversos de medicamentos u otras sustancias, o por desajustes entre las variaciones relacionadas con la enfermedad y las demandas de regularidad. ^[55]

También se da el caso de que, si bien a menudo se caracterizan en términos puramente negativos, algunos rasgos o estados mentales etiquetados como trastornos también pueden implicar creatividad, no conformidad, búsqueda de objetivos, meticulosidad o empatía por encima de la media. ^[56] Además, la percepción pública del nivel de discapacidad asociado con los trastornos mentales puede cambiar. ^[57]

Sin embargo, a nivel internacional, las personas reportan una discapacidad igual o mayor debido a condiciones mentales que ocurren comúnmente que a condiciones físicas que ocurren comúnmente, particularmente en sus roles sociales y relaciones personales. Sin embargo, la proporción con acceso a ayuda profesional para los trastornos mentales es mucho menor, incluso entre los que se considera que padecen una enfermedad gravemente discapacitante. ^{[58] La} discapacidad en este contexto puede involucrar o no cosas tales como:

• Actividades básicas de la vida diaria . Incluyendo cuidarse a sí mismo (cuidado de la salud, aseo, vestirse, ir de compras, cocinar, etc.) o cuidar el alojamiento (quehaceres, tareas de bricolaje, etc.)
• Relaciones interpersonales . Incluyendo habilidades de comunicación , capacidad para formar relaciones y mantenerlas, capacidad para salir de casa o mezclarse en multitudes o entornos particulares.
• Funcionamiento ocupacional. Capacidad para adquirir un empleo y mantenerlo, habilidades cognitivas y sociales requeridas para el trabajo, lidiar con la cultura del lugar de trabajo o estudiar como estudiante.

En términos de años de vida totales ajustados por discapacidad (AVAD), que es una estimación de cuántos años de vida se pierden debido a una muerte prematura o al estado de mala salud o discapacidad, los trastornos mentales se encuentran entre las condiciones más discapacitantes. El trastorno depresivo unipolar (también conocido como mayor) es la tercera causa principal de discapacidad en todo el mundo, de cualquier condición mental o física, lo que representa 65,5 millones de años perdidos. La primera descripción sistemática de la discapacidad global que surge en los jóvenes, en 2011, encontró que entre los 10 y los 24 años de edad, casi la mitad de toda la discapacidad (actual y según se estima que continuará) se debió a afecciones mentales y neurológicas, incluidos los trastornos por uso de sustancias. y condiciones que involucran autolesiones. En segundo lugar, las lesiones accidentales (principalmente colisiones de tráfico) representan el 12 por ciento de las discapacidades, seguidas de las enfermedades transmisibles con el 10 por ciento. Los trastornos asociados con la mayoría de las discapacidades en los países de ingresos altos fueron la depresión mayor unipolar (20%) y el trastorno por consumo de alcohol (11%). En la región del Mediterráneo oriental, fue la depresión mayor unipolar (12%) y la esquizofrenia (7%), y en África fue la depresión mayor unipolar (7%) y el trastorno bipolar (5%). ^[59]

El suicidio, que a menudo se atribuye a algún trastorno mental subyacente, es una de las principales causas de muerte entre adolescentes y adultos menores de 35 años. ^{[60] [61]} Se calcula que se producen entre 10 y 20 millones de intentos de suicidio no mortales cada año en todo el mundo. ^[62]

Factores de riesgo

The predominant view as of 2018 is that genetic, psychological, and environmental factors all contribute to the development or progression of mental disorders.^[63] Different risk factors may be present at different ages, with risk occurring as early as during prenatal period.^[64]

Genetics

A number of psychiatric disorders are linked to a family history (including depression, narcissistic personality disorder^[65][66] and anxiety).^[67] Twin studies have also revealed a very high heritability for many mental disorders (especially autism and schizophrenia).^[68] 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.^[69]

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.^[70]

Environment

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.^[64] Maternal stress and birth complications including prematurity and infections have also been implicated in increasing susceptibility for mental illness.^[71] Infants neglected or not provided optimal nutrition have a higher risk of developing cognitive impairment.^[64]

Social influences have also been found to be important,^[72] including abuse, neglect, bullying, social stress, traumatic events, and other negative or overwhelming life experiences. Aspects of the wider community have also been implicated,^[73] 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.^[7][74]

In schizophrenia and psychosis, risk factors include migration and discrimination, childhood trauma, bereavement or separation in families, recreational use of drugs,^[75] and urbanicity.^[73]

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 behaviour, and child abuse (emotional, physical and sexual).^[76] Adults with imbalance work to life are at higher risk for developing anxiety.^[64]

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.^[77]

Drug use

Mental disorders are associated with drug use including: cannabis,^[78] alcohol^[79] and caffeine,^[80] use of which appears to promote anxiety.^[81] For psychosis and schizophrenia, usage of a number of drugs has been associated with development of the disorder, including cannabis, cocaine, and amphetamines.^[82][78] There has been debate regarding the relationship between usage of cannabis and bipolar disorder.^[83] Cannabis has also been associated with depression.^[78] 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.^[64]

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 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.^[84]

Personality traits

Risk factors for mental illness include a propensity for high neuroticism^[85][86] or "emotional instability". In anxiety, risk factors may include temperament and attitudes (e.g. pessimism).^[67]

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.^[86][87] 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.

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 disorder and disability.

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.^[88] 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.^[89][90]

Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations.^[91] 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.^[92] 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.^[93] In HoNOS a score of 0–4 is given for each of 12 factors, based on functional living capacity.^[94] Research has been supportive of HoNOS,^[95] 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.^[96]

Criticism

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.^{[97][unreliable medical source]}

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."^[98] 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).^[99] 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.^[100]

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.^[101] 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.^[102]

Prevention

The 2004 WHO report "Prevention of Mental Disorders" stated that "Prevention of these disorders is obviously one of the most effective ways to reduce the [disease] burden."^[103]The 2011 European Psychiatric Association (EPA) guidance on prevention of mental disorders states "There is considerable evidence that various psychiatric conditions can be prevented through the implementation of effective evidence-based interventions."^[104]A 2011 UK Department of Health report on the economic case for mental health promotion and mental illness prevention found that "many interventions are outstandingly good value for money, low in cost and often become self-financing over time, saving public expenditure".^[105]In 2016, the National Institute of Mental Health re-affirmed prevention as a research priority area.^[106]

Parenting may affect the child's mental health, and evidence suggests that helping parents to be more effective with their children can address mental health needs.^[107][108]

Universal prevention (aimed at a population that has no increased risk for developing a mental disorder, such as school programs or mass media campaigns) need very high numbers of people to show effect (sometimes known as the "power" problem). Approaches to overcome this are (1) focus on high-incidence groups (e.g. by targeting groups with high risk factors), (2) use multiple interventions to achieve greater, and thus more statistically valid, effects, (3) use cumulative meta-analyses of many trials, and (4) run very large trials.^[109][110]

Management

"Haus Tornow am See" (former manor house), Germany from 1912 is today separated into a special education school and a hotel with integrated work/job- and rehabilitation-training for people with mental disorders

Treatment and support for mental disorders are provided in psychiatric hospitals, clinics or a range of community mental health services. In some countries services are increasingly based on a recovery approach, intended to support individual's personal journey to gain the kind of life they want.

There is a range of different types of treatment and what is most suitable depends on the disorder and the individual. Many things have been found to help at least some people, and a placebo effect may play a role in any intervention or medication. In a minority of cases, individuals may be treated against their will, which can cause particular difficulties depending on how it is carried out and perceived. Compulsory treatment while in the community versus non-compulsory treatment does not appear to make much of a difference except by maybe decreasing victimization.^[111]

Lifestyle

Lifestyle strategies, including dietary changes, exercise and quitting smoking may be of benefit.^[9][74][112]

Therapy

There is also a wide range of psychotherapists (including family therapy), counselors, and public health professionals. In addition, there are peer support roles where personal experience of similar issues is the primary source of expertise.^{[113][114][115][116]}

A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Other psychotherapies include dialectic behavioral therapy (DBT) and interpersonal psychotherapy (IPT). Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of significant others as well as an individual.

Some psychotherapies are based on a humanistic approach. There are many specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement.

Medication

A major option for many mental disorders is psychiatric medication and there are several main groups. Antidepressants are used for the treatment of clinical depression, as well as often for anxiety and a range of other disorders. Anxiolytics (including sedatives) are used for anxiety disorders and related problems such as insomnia. Mood stabilizers are used primarily in bipolar disorder. Antipsychotics are used for psychotic disorders, notably for positive symptoms in schizophrenia, and also increasingly for a range of other disorders. Stimulants are commonly used, notably for ADHD.^[117]

Despite the different conventional names of the drug groups, there may be considerable overlap in the disorders for which they are actually indicated, and there may also be off-label use of medications. There can be problems with adverse effects of medication and adherence to them, and there is also criticism of pharmaceutical marketing and professional conflicts of interest. However, these medications in combination with non-pharmacological methods, such as cognitive-behavioral therapy (CBT) are seen to be most effective in treating mental disorders.

Other

Electroconvulsive therapy (ECT) is sometimes used in severe cases when other interventions for severe intractable depression have failed. ECT is usually indicated for treatment resistant depression, severe vegetative symptoms, psychotic depression, intense suicidal ideation, depression during pregnancy, and catonia. Psychosurgery is considered experimental but is advocated by some neurologists in certain rare cases.^[118][119]

Counseling (professional) and co-counseling (between peers) may be used. Psychoeducation programs may provide people with the information to understand and manage their problems. Creative therapies are sometimes used, including music therapy, art therapy or drama therapy. Lifestyle adjustments and supportive measures are often used, including peer support, self-help groups for mental health and supported housing or supported employment (including social firms). Some advocate dietary supplements.^[120]

Reasonable accommodations (adjustments and supports) might be put in place to help an individual cope and succeed in environments despite potential disability related to mental health problems. This could include an emotional support animal or specifically trained psychiatric service dog. As of 2019 cannabis is specifically not recommended as a treatment.^[121]

Epidemiology

Deaths from mental and behavioral disorders per million persons in 2012

  0–6

  7–9

  10–15

  16–24

  25–31

  32–39

  40–53

  54–70

  71–99

  100–356

Disability-adjusted life year for neuropsychiatric conditions per 100,000 inhabitants in 2004.

  <2,200

  2,200–2,400

  2,400–2,600

  2,600–2,800

  2,800–3,000

  3,000–3,200

  3,200–3,400

  3,400–3,600

  3,600–3,800

  3,800–4,000

  4,000–4,200

  >4,200

Mental disorders are common. Worldwide, more than one in three people in most countries report sufficient criteria for at least one at some point in their life.^[122] In the United States, 46% qualify for a mental illness at some point.^[123] An ongoing survey indicates that anxiety disorders are the most common in all but one country, followed by mood disorders in all but two countries, while substance disorders and impulse-control disorders were consistently less prevalent.^[124] Rates varied by region.^[125]

A review of anxiety disorder surveys in different countries found average lifetime prevalence estimates of 16.6%, with women having higher rates on average.^[126] A review of mood disorder surveys in different countries found lifetime rates of 6.7% for major depressive disorder (higher in some studies, and in women) and 0.8% for Bipolar I disorder.^[127]

In the United States the frequency of disorder is: anxiety disorder (28.8%), mood disorder (20.8%), impulse-control disorder (24.8%) or substance use disorder (14.6%).^{[123][128][129]}

A 2004 cross-Europe study found that approximately one in four people reported meeting criteria at some point in their life for at least one of the DSM-IV disorders assessed, which included mood disorders (13.9%), anxiety disorders (13.6%), or alcohol disorder (5.2%). Approximately one in ten met the criteria within a 12-month period. Women and younger people of either gender showed more cases of the disorder.^[130] A 2005 review of surveys in 16 European countries found that 27% of adult Europeans are affected by at least one mental disorder in a 12-month period.^[131]

An international review of studies on the prevalence of schizophrenia found an average (median) figure of 0.4% for lifetime prevalence; it was consistently lower in poorer countries.^[132]

Studies of the prevalence of personality disorders (PDs) have been fewer and smaller-scale, but one broad Norwegian survey found a five-year prevalence of almost 1 in 7 (13.4%). Rates for specific disorders ranged from 0.8% to 2.8%, differing across countries, and by gender, educational level and other factors.^[133] A US survey that incidentally screened for personality disorder found a rate of 14.79%.^[134]

Approximately 7% of a preschool pediatric sample were given a psychiatric diagnosis in one clinical study, and approximately 10% of 1- and 2-year-olds receiving developmental screening have been assessed as having significant emotional/behavioral problems based on parent and pediatrician reports.^[135]

While rates of psychological disorders are often the same for men and women, women tend to have a higher rate of depression. Each year 73 million women are affected by major depression, and suicide is ranked 7th as the cause of death for women between the ages of 20–59. Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men.^[136]

History

Ancient civilizations

Ancient civilizations described and treated a number of mental disorders. Mental illnesses were well known in ancient Mesopotamia,^[137] where diseases and mental disorders were believed to be caused by specific deities.^[138] Because hands symbolized control over a person, mental illnesses were known as "hands" of certain deities.^[138] One psychological illness was known as Qāt Ištar, meaning "Hand of Ishtar".^[138] Others were known as "Hand of Shamash", "Hand of the Ghost", and "Hand of the God".^[138] Descriptions of these illnesses, however, are so vague that it is usually impossible to determine which illnesses they correspond to in modern terminology.^[138] Mesopotamian doctors kept detailed record of their patients' hallucinations and assigned spiritual meanings to them.^[137] The royal family of Elam was notorious for its members frequently suffering from insanity.^[137] The Greeks coined terms for melancholy, hysteria and phobia and developed the humorism theory. Mental disorders were described, and treatments developed, in Persia, Arabia and in the medieval Islamic world.

Europe

Middle Ages

Conceptions of madness in the Middle Ages in Christian Europe were a mixture of the divine, diabolical, magical and humoral, and transcendental.^[139] In the early modern period, some people with mental disorders may have been victims of the witch-hunts. While not every witch and sorcerer accused were mentally ill, all mentally ill were considered to be witches or sorcerers.^[140] Many terms for mental disorders that found their way into everyday use first became popular in the 16th and 17th centuries.

Eighteenth century

Eight patients representing mental diagnoses as of the 19th century at the Salpêtrière, Paris.

By the end of the 17th century and into the Enlightenment, madness was increasingly seen as an organic physical phenomenon with no connection to the soul or moral responsibility. Asylum care was often harsh and treated people like wild animals, but towards the end of the 18th century a moral treatment movement gradually developed. Clear descriptions of some syndromes may be rare before the 19th century.

Nineteenth century

Industrialization and population growth led to a massive expansion of the number and size of insane asylums in every Western country in the 19th century. Numerous different classification schemes and diagnostic terms were developed by different authorities, and the term psychiatry was coined (1808), though medical superintendents were still known as alienists.

Twentieth century

A patient in a strait-jacket and barrel contraption, 1908

The turn of the 20th century saw the development of psychoanalysis, which would later come to the fore, along with Kraepelin's classification scheme. Asylum "inmates" were increasingly referred to as "patients", and asylums were renamed as hospitals.

Europe and the United States

Insulin shock procedure, 1950s

Early in the 20th century in the United States, a mental hygiene movement developed, aiming to prevent mental disorders. Clinical psychology and social work developed as professions. World War I saw a massive increase of conditions that came to be termed "shell shock".

World War II saw the development in the U.S. of a new psychiatric manual for categorizing mental disorders, which along with existing systems for collecting census and hospital statistics led to the first Diagnostic and Statistical Manual of Mental Disorders (DSM). The International Classification of Diseases (ICD) also developed a section on mental disorders. The term stress, having emerged from endocrinology work in the 1930s, was increasingly applied to mental disorders.

Electroconvulsive therapy, insulin shock therapy, lobotomies and the "neuroleptic" chlorpromazine came to be used by mid-century.^[141] In the 1960s there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman who said that mental illness was merely another example of how society labels and controls non-conformists; from behavioral psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science by Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.^[142]

Deinstitutionalization gradually occurred in the West, with isolated psychiatric hospitals being closed down in favor of community mental health services. A consumer/survivor movement gained momentum. Other kinds of psychiatric medication gradually came into use, such as "psychic energizers" (later antidepressants) and lithium. Benzodiazepines gained widespread use in the 1970s for anxiety and depression, until dependency problems curtailed their popularity.

Advances in neuroscience, genetics, and psychology led to new research agendas. Cognitive behavioral therapy and other psychotherapies developed. The DSM and then ICD adopted new criteria-based classifications, and the number of "official" diagnoses saw a large expansion. Through the 1990s, new SSRI-type antidepressants became some of the most widely prescribed drugs in the world, as later did antipsychotics. Also during the 1990s, a recovery approach developed.

Society and culture

Different societies or cultures, even different individuals in a subculture, can disagree as to what constitutes optimal versus pathological biological and psychological functioning. Research has demonstrated that cultures vary in the relative importance placed on, for example, happiness, autonomy, or social relationships for pleasure. Likewise, the fact that a behavior pattern is valued, accepted, encouraged, or even statistically normative in a culture does not necessarily mean that it is conducive to optimal psychological functioning.

People in all cultures find some behaviors bizarre or even incomprehensible. But just what they feel is bizarre or incomprehensible is ambiguous and subjective.^[143] These differences in determination can become highly contentious. The process by which conditions and difficulties come to be defined and treated as medical conditions and problems, and thus come under the authority of doctors and other health professionals, is known as medicalization or pathologization.

Religion

Religious, spiritual, or transpersonal experiences and beliefs meet many criteria of delusional or psychotic disorders.^[144][145] A belief or experience can sometimes be shown to produce distress or disability—the ordinary standard for judging mental disorders.^[146] There is a link between religion and schizophrenia,^[147] a complex mental disorder characterized by a difficulty in recognizing reality, regulating emotional responses, and thinking in a clear and logical manner. Those with schizophrenia commonly report some type of religious delusion,^{[147][148][149]} and religion itself may be a trigger for schizophrenia.^[150]

Movements

Giorgio Antonucci

Thomas Szasz

Controversy has often surrounded psychiatry, and the term anti-psychiatry was coined by the psychiatrist David Cooper in 1967. The anti-psychiatry message is that psychiatric treatments are ultimately more damaging than helpful to patients, and psychiatry's history involves what may now be seen as dangerous treatments.^[151] Electroconvulsive therapy was one of these, which was used widely between the 1930s and 1960s. Lobotomy was another practice that was ultimately seen as too invasive and brutal. Diazepam and other sedatives were sometimes over-prescribed, which led to an epidemic of dependence. There was also concern about the large increase in prescribing psychiatric drugs for children. Some charismatic psychiatrists came to personify the movement against psychiatry. The most influential of these was R.D. Laing who wrote a series of best-selling books, including The Divided Self. Thomas Szasz wrote The Myth of Mental Illness. Some ex-patient groups have become militantly anti-psychiatric, often referring to themselves as "survivors".^[151] Giorgio Antonucci has questioned the basis of psychiatry through his work on the dismantling of two psychiatric hospitals (in the city of Imola), carried out from 1973 to 1996.

The consumer/survivor movement (also known as user/survivor movement) is made up of individuals (and organizations representing them) who are clients of mental health services or who consider themselves survivors of psychiatric interventions. Activists campaign for improved mental health services and for more involvement and empowerment within mental health services, policies and wider society.^{[152][153][154]} Patient advocacy organizations have expanded with increasing deinstitutionalization in developed countries, working to challenge the stereotypes, stigma and exclusion associated with psychiatric conditions. There is also a carers rights movement of people who help and support people with mental health conditions, who may be relatives, and who often work in difficult and time-consuming circumstances with little acknowledgement and without pay. An anti-psychiatry movement fundamentally challenges mainstream psychiatric theory and practice, including in some cases asserting that psychiatric concepts and diagnoses of 'mental illness' are neither real nor useful.^{[155][156][157]}

Alternatively, a movement for global mental health has emerged, defined as 'the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide'.^[158]

Cultural bias

Current diagnostic guidelines, namely the DSM and to some extent the ICD, have been criticized as having a fundamentally Euro-American outlook. Opponents argue that even when diagnostic criteria are used across different cultures, it does not mean that the underlying constructs have validity within those cultures, as even reliable application can prove only consistency, not legitimacy.^[159] Advocating a more culturally sensitive approach, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.^[160]

Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV. Disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, revealing to Kleinman an underlying assumption that Western cultural phenomena are universal.^[161] Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics. Common responses included both disappointment over the large number of documented non-Western mental disorders still left out and frustration that even those included are often misinterpreted or misrepresented.^[162]

Many mainstream psychiatrists are dissatisfied with the new culture-bound diagnoses, although for partly different reasons. Robert Spitzer, a lead architect of the DSM-III, has argued that adding cultural formulations was an attempt to appease cultural critics, and has stated that they lack any scientific rationale or support. Spitzer also posits that the new culture-bound diagnoses are rarely used, maintaining that the standard diagnoses apply regardless of the culture involved. In general, mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are significant only to specific symptom presentations.^[159]

Clinical conceptions of mental illness also overlap with personal and cultural values in the domain of morality, so much so that it is sometimes argued that separating the two is impossible without fundamentally redefining the essence of being a particular person in a society.^[163] In clinical psychiatry, persistent distress and disability indicate an internal disorder requiring treatment; but in another context, that same distress and disability can be seen as an indicator of emotional struggle and the need to address social and structural problems.^[164][165] This dichotomy has led some academics and clinicians to advocate a postmodernist conceptualization of mental distress and well-being.^[166][167]

Such approaches, along with cross-cultural and "heretical" psychologies centered on alternative cultural and ethnic and race-based identities and experiences, stand in contrast to the mainstream psychiatric community's alleged avoidance of any explicit involvement with either morality or culture.^[168] In many countries there are attempts to challenge perceived prejudice against minority groups, including alleged institutional racism within psychiatric services.^[169] There are also ongoing attempts to improve professional cross cultural sensitivity.

Laws and policies

Three-quarters of countries around the world have mental health legislation. Compulsory admission to mental health facilities (also known as involuntary commitment) is a controversial topic. It can impinge on personal liberty and the right to choose, and carry the risk of abuse for political, social, and other reasons; yet it can potentially prevent harm to self and others, and assist some people in attaining their right to healthcare when they may be unable to decide in their own interests.^[170] Because of this it is a concern of medical ethics.

All human rights oriented mental health laws require proof of the presence of a mental disorder as defined by internationally accepted standards, but the type and severity of disorder that counts can vary in different jurisdictions. The two most often used grounds for involuntary admission are said to be serious likelihood of immediate or imminent danger to self or others, and the need for treatment. Applications for someone to be involuntarily admitted usually come from a mental health practitioner, a family member, a close relative, or a guardian. Human-rights-oriented laws usually stipulate that independent medical practitioners or other accredited mental health practitioners must examine the patient separately and that there should be regular, time-bound review by an independent review body.^[170] The individual should also have personal access to independent advocacy.

For involuntary treatment to be administered (by force if necessary), it should be shown that an individual lacks the mental capacity for informed consent (i.e. to understand treatment information and its implications, and therefore be able to make an informed choice to either accept or refuse). Legal challenges in some areas have resulted in supreme court decisions that a person does not have to agree with a psychiatrist's characterization of the issues as constituting an "illness", nor agree with a psychiatrist's conviction in medication, but only recognize the issues and the information about treatment options.^[171]

Proxy consent (also known as surrogate or substituted decision-making) may be transferred to a personal representative, a family member, or a legally appointed guardian. Moreover, patients may be able to make, when they are considered well, an advance directive stipulating how they wish to be treated should they be deemed to lack mental capacity in the future.^[170] The right to supported decision-making, where a person is helped to understand and choose treatment options before they can be declared to lack capacity, may also be included in the legislation.^[172] There should at the very least be shared decision-making as far as possible. Involuntary treatment laws are increasingly extended to those living in the community, for example outpatient commitment laws (known by different names) are used in New Zealand, Australia, the United Kingdom, and most of the United States.

The World Health Organization reports that in many instances national mental health legislation takes away the rights of persons with mental disorders rather than protecting rights, and is often outdated.^[170] In 1991, the United Nations adopted the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, which established minimum human rights standards of practice in the mental health field. In 2006, the UN formally agreed the Convention on the Rights of Persons with Disabilities to protect and enhance the rights and opportunities of disabled people, including those with psychosocial disabilities.^[173]

The term insanity, sometimes used colloquially as a synonym for mental illness, is often used technically as a legal term. The insanity defense may be used in a legal trial (known as the mental disorder defence in some countries).

Perception and discrimination

Stigma

The social stigma associated with mental disorders is a widespread problem. The US Surgeon General stated in 1999 that: "Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others."^[174] In the United States, racial and ethnic minorities are more likely to experience mental health disorders often due to low socioeconomic status, and discrimination.^[175][176] In Taiwan, those with mental disorders are subject to general public's misperception that the root causes of the mental disorders are "over-thinking", "having a lot of time and nothing better to do", "stagnant", "not serious in life", "not paying enough attention to the real life affairs", "mentally weak", "refusing to be resilient", "turning back to perfectionistic strivings", "not bravery" and so forth.^[177]

Employment discrimination is reported to play a significant part in the high rate of unemployment among those with a diagnosis of mental illness.^[178] An Australian study found that having a mental illness is a bigger barrier to employment than a physical disability.^{[179][better source needed]} The mentally ill are stigmatized in Chinese society and can not legally marry.^[180]

Efforts are being undertaken worldwide to eliminate the stigma of mental illness,^[181] although the methods and outcomes used have sometimes been criticized.^[182]

Media and general public

Media coverage of mental illness comprises predominantly negative and pejorative depictions, for example, of incompetence, violence or criminality, with far less coverage of positive issues such as accomplishments or human rights issues.^{[183][184][185]} Such negative depictions, including in children's cartoons, are thought to contribute to stigma and negative attitudes in the public and in those with mental health problems themselves, although more sensitive or serious cinematic portrayals have increased in prevalence.^[186][187]

In the United States, the Carter Center has created fellowships for journalists in South Africa, the U.S., and Romania, to enable reporters to research and write stories on mental health topics.^[188] Former US First Lady Rosalynn Carter began the fellowships not only to train reporters in how to sensitively and accurately discuss mental health and mental illness, but also to increase the number of stories on these topics in the news media.^[189][190] There is also a World Mental Health Day, which in the US and Canada falls within a Mental Illness Awareness Week.

The general public have been found to hold a strong stereotype of dangerousness and desire for social distance from individuals described as mentally ill.^[191] A US national survey found that a higher percentage of people rate individuals described as displaying the characteristics of a mental disorder as "likely to do something violent to others", compared to the percentage of people who are rating individuals described as being "troubled".^[192]

Recent depictions in media have included leading characters successfully living with and managing a mental illness, including in bipolar disorder in Homeland (2011) and posttraumatic stress disorder in Iron Man 3 (2013).^{[original research?]}

Violence

Despite public or media opinion, national studies have indicated that severe mental illness does not independently predict future violent behavior, on average, and is not a leading cause of violence in society. There is a statistical association with various factors that do relate to violence (in anyone), such as substance use and various personal, social, and economic factors.^[193] A 2015 review found that in the United States, about 4% of violence is attributable to people diagnosed with mental illness,^[194] and a 2014 study found that 7.5% of crimes committed by mentally ill people were directly related to the symptoms of their mental illness.^[195] The majority of people with serious mental illness are never violent.^[196]

In fact, findings consistently indicate that it is many times more likely that people diagnosed with a serious mental illness living in the community will be the victims rather than the perpetrators of violence.^[197][198] In a study of individuals diagnosed with "severe mental illness" living in a US inner-city area, a quarter were found to have been victims of at least one violent crime over the course of a year, a proportion eleven times higher than the inner-city average, and higher in every category of crime including violent assaults and theft.^[199] People with a diagnosis may find it more difficult to secure prosecutions, however, due in part to prejudice and being seen as less credible.^[200]

However, there are some specific diagnoses, such as childhood conduct disorder or adult antisocial personality disorder or psychopathy, which are defined by, or are inherently associated with, conduct problems and violence. There are conflicting findings about the extent to which certain specific symptoms, notably some kinds of psychosis (hallucinations or delusions) that can occur in disorders such as schizophrenia, delusional disorder or mood disorder, are linked to an increased risk of serious violence on average. The mediating factors of violent acts, however, are most consistently found to be mainly socio-demographic and socio-economic factors such as being young, male, of lower socioeconomic status and, in particular, substance use (including alcohol use) to which some people may be particularly vulnerable.^{[56][197][201][202]}

High-profile cases have led to fears that serious crimes, such as homicide, have increased due to deinstitutionalization, but the evidence does not support this conclusion.^[202][203] Violence that does occur in relation to mental disorder (against the mentally ill or by the mentally ill) typically occurs in the context of complex social interactions, often in a family setting rather than between strangers.^[204] It is also an issue in health care settings^[205] and the wider community.^[206]

Mental health

The recognition and understanding of mental health conditions have changed over time and across cultures and there are still variations in definition, assessment, and classification, although standard guideline criteria are widely used. In many cases, there appears to be a continuum between mental health and mental illness, making diagnosis complex.^[38]:39 According to the World Health Organization (WHO), over a third of people in most countries report problems at some time in their life which meet the criteria for diagnosis of one or more of the common types of mental disorder.^[122] Corey M Keyes has created a two continua model of mental illness and health which holds that both are related, but distinct dimensions: one continuum indicates the presence or absence of mental health, the other the presence or absence of mental illness.^[207] For example, people with optimal mental health can also have a mental illness, and people who have no mental illness can also have poor mental health.^[208]

Other animals

Psychopathology in non-human primates has been studied since the mid-20th century. Over 20 behavioral patterns in captive chimpanzees have been documented as (statistically) abnormal for frequency, severity or oddness—some of which have also been observed in the wild. Captive great apes show gross behavioral abnormalities such as stereotypy of movements, self-mutilation, disturbed emotional reactions (mainly fear or aggression) towards companions, lack of species-typical communications, and generalized learned helplessness. In some cases such behaviors are hypothesized to be equivalent to symptoms associated with psychiatric disorders in humans such as depression, anxiety disorders, eating disorders and post-traumatic stress disorder. Concepts of antisocial, borderline and schizoid personality disorders have also been applied to non-human great apes.^[209][210]

The risk of anthropomorphism is often raised concerning such comparisons, and assessment of non-human animals cannot incorporate evidence from linguistic communication. However, available evidence may range from nonverbal behaviors—including physiological responses and homologous facial displays and acoustic utterances—to neurochemical studies. It is pointed out that human psychiatric classification is often based on statistical description and judgment of behaviors (especially when speech or language is impaired) and that the use of verbal self-report is itself problematic and unreliable.^[209][211]

Psychopathology has generally been traced, at least in captivity, to adverse rearing conditions such as early separation of infants from mothers; early sensory deprivation; and extended periods of social isolation. Studies have also indicated individual variation in temperament, such as sociability or impulsiveness. Particular causes of problems in captivity have included integration of strangers into existing groups and a lack of individual space, in which context some pathological behaviors have also been seen as coping mechanisms. Remedial interventions have included careful individually tailored re-socialization programs, behavior therapy, environment enrichment, and on rare occasions psychiatric drugs. Socialization has been found to work 90% of the time in disturbed chimpanzees, although restoration of functional sexuality and caregiving is often not achieved.^[209][212]

Laboratory researchers sometimes try to develop animal models of human mental disorders, including by inducing or treating symptoms in animals through genetic, neurological, chemical or behavioral manipulation,^[213][214] but this has been criticized on empirical grounds^[215] and opposed on animal rights grounds.

See also

• Mental illness portrayed in media
  • Mental disorders in film
  • Mental illness in fiction
• Mental illness in American prisons
• Parity of esteem
• Psychological evaluation

Notes

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Further reading

• Atkinson J (2006). Private and Public Protection: Civil Mental Health Legislation. Edinburgh: Dunedin Academic Press. ISBN 978-1-903765-61-6.
• Hockenbury D, Hockenbury S (2004). Discovering Psychology. Worth Publishers. ISBN 978-0-7167-5704-7.
• Fried Y, Agassi J (1976). Paranoia: A Study in Diagnosis. Boston Studies in the Philosophy of Science. 50. ISBN 978-90-277-0704-8.^{[publisher missing]}
• Fried Y, Agassi J (1983). Psychiatry as Medicine. The Hague: Nijhoff. ISBN 978-90-247-2837-4.
• National Academies of Sciences, Engineering, and Medicine (2016). Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: National Academies Press. doi:10.17226/23442. ISBN 978-0-309-43912-1. PMID 27631043.
• Porter R (2002). Madness: a brief history. Oxford [Oxfordshire]: Oxford University Press. ISBN 978-0-19-280266-8.
• Weller MP, Eysenck M (1992). The Scientific Basis of Psychiatry. London: W.B. Saunders.^{[ISBN missing]}
• Wiencke M (2006). "Schizophrenie als Ergebnis von Wechselwirkungen: Georg Simmels Individualitätskonzept in der Klinischen Psychologie". In Kim D (ed.). Georg Simmel in Translation: Interdisciplinary Border-Crossings in Culture and Modernity. Cambridge: Cambridge Scholars Press. pp. 123–55. ISBN 978-1-84718-060-5.
• Radden J (20 February 2019). "Mental Disorder (Illness)". Stanford Encyclopedia of Philosophy.
• Management of physical health conditions in adults with severe mental disorders (PDF). WHO. 2018. ISBN 978-92-4-155038-3.

External links

Classification	D ICD-10: F99 ICD-9-CM: 290-319 MeSH: D001523 DiseasesDB: 28852

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• NIMH.NIH.gov – National Institute of Mental Health
• International Committee of Women Leaders on Mental Health
• Adverse Childhood Experiences: Risk Factors for Substance Misuse and Mental Health U.S. Centers for Disease Control describes the relationship between childhood adversity and mental health (video)

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