Mental disorder
A mental disorder, also called a mental illness[3] or psychiatric disorder, is a behavioral or
mental pattern that causes significant distress or impairment of personal functioning.[4] Such
features may be persistent, relapsing and remitting, or occur as single episodes. Many disorders
have been described, with signs and symptoms that vary widely between specific disorders.[5][6]
Such disorders may be diagnosed by a mental health professional, usually a clinical
psychologist or psychiatrist.
Mental disorder
Other names
Psychiatric disorder, psychological disorder,
mental illness, mental disease, mental breakdown,
nervous breakdown, mental health conditions[1]
Specialty
Psychiatry
Symptoms
Agitation, anxiety, depression, mania, paranoia,
psychosis
Complications
Cognitive impairment, social problems, suicide
Types
Anxiety disorders, eating disorders, mood
disorders, personality disorders, psychotic
disorders, substance use disorders
Causes
Genetic and environmental factors
Treatment
Psychotherapy, medications
Medication
Antidepressants, antipsychotics, anxiolytics,
mood stabilizers, stimulants
Frequency
18% per year (United States)[2]
The causes of mental disorders are often unclear. Theories may incorporate findings from a
range of fields. Mental disorders are usually defined by a combination of how a person behaves,
feels, perceives, or thinks.[7] This may be associated with particular regions or functions of the
brain, often in a social context. A mental disorder is one aspect of mental health. Cultural and
religious beliefs, as well as social norms, should be taken into account when making a
diagnosis.[8]
Services are based in psychiatric hospitals or in the community, and assessments are carried
out by mental health professionals such as psychiatrists, psychologists, psychiatric nurses and
clinical social workers, using various methods such as psychometric tests but often relying on
observation and questioning. Treatments are provided by various mental health professionals.
Psychotherapy and psychiatric medication are two major treatment options. Other treatments
include lifestyle changes, social interventions, peer support, and self-help. In a minority of cases,
there might be involuntary detention or treatment. Prevention programs have been shown to
reduce depression.[7][9]
In 2019, common mental disorders around the globe include depression, which affects about
264 million, bipolar disorder, which affects about 45 million, dementia, which affects about
50 million, and schizophrenia and other psychoses, which affects about 20 million people.[10]
Neurodevelopmental disorders include intellectual disability and autism spectrum disorders
which usually arise in infancy or childhood.[11][10] Stigma and discrimination can add to the
suffering and disability associated with mental disorders, leading to various social movements
attempting to increase understanding and challenge social exclusion.
Definition
The definition and classification of mental disorders are key issues for researchers as well as
service providers and those who may be diagnosed. For a mental state to classify as a disorder,
it generally needs to cause dysfunction.[12] Most international clinical documents use the term
mental "disorder", while "illness" is also common. It has been noted that using the term "mental"
(i.e., of the mind) is not necessarily meant to imply separateness from the brain or body.
According to DSM-IV, a mental disorder is a psychological syndrome or pattern which is
associated with distress (e.g. via a painful symptom), disability (impairment in one or more
important areas of functioning), increased risk of death, or causes a significant loss of
autonomy; however it excludes normal responses such as grief from loss of a loved one and
also excludes deviant behavior for political, religious, or societal reasons not arising from a
dysfunction in the individual.[13][14]
DSM-IV predicates the definition with caveats, stating that, as in the case with many medical
terms, mental disorder "lacks a consistent operational definition that covers all situations", noting
that different levels of abstraction can be used for medical definitions, including pathology,
symptomology, deviance from a normal range, or etiology, and that the same is true for mental
disorders so that sometimes one type of definition is appropriate, and sometimes another,
depending on the situation.[15]
In 2013, the American Psychiatric Association (APA) redefined mental disorders in the DSM-5 as
"a syndrome characterized by clinically significant disturbance in an individual's cognition,
emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning."[16] The final draft of ICD-11 contains a
very similar definition.[17]
The terms "mental breakdown" or "nervous breakdown" may be used by the general population to
mean a mental disorder.[18] The terms "nervous breakdown" and "mental breakdown" have not
been formally defined through a medical diagnostic system such as the DSM-5 or ICD-10, and
are nearly absent from scientific literature regarding mental illness.[19][20] Although "nervous
breakdown" is not rigorously defined, surveys of laypersons suggest that the term refers to a
specific acute time-limited reactive disorder, involving symptoms such as anxiety or depression,
usually precipitated by external stressors.[19] Many health experts today refer to a nervous
breakdown as a mental health crisis.[21]
Nervous illness
Additionally to the concept of mental disorder, some people have argued for a return to the oldfashioned concept of nervous illness. In How Everyone Became Depressed: The Rise and Fall of
the Nervous Breakdown (2013), Edward Shorter, a professor of psychiatry and the history of
medicine, says:
About half of them are depressed. Or at least that is the diagnosis that
they got when they were put on antidepressants. ... They go to work but
they are unhappy and uncomfortable; they are somewhat anxious; they
are tired; they have various physical pains—and they tend to obsess
about the whole business. There is a term for what they have, and it is
a good old-fashioned term that has gone out of use. They have nerves
or a nervous illness. It is an illness not just of mind or brain, but a
disorder of the entire body. ... We have a package here of five symptoms
—mild depression, some anxiety, fatigue, somatic pains, and obsessive
thinking. ... We have had nervous illness for centuries. When you are
too nervous to function ... it is a nervous breakdown. But that term has
vanished from medicine, although not from the way we speak.... The
nervous patients of yesteryear are the depressives of today. That is the
bad news.... There is a deeper illness that drives depression and the
symptoms of mood. We can call this deeper illness something else, or
invent a neologism, but we need to get the discussion off depression
and onto this deeper disorder in the brain and body. That is the point.
— Edward Shorter, Faculty of Medicine, the University of Toronto[22]
In eliminating the nervous breakdown, psychiatry has come close to
having its own nervous breakdown.
— David Healy, MD, FRCPsych, Professor of Psychiatry, University of
Cardiff, Wales[23]
Nerves stand at the core of common mental illness, no matter how
much we try to forget them.
— Peter J. Tyrer, FMedSci, Professor of Community Psychiatry,
Imperial College, London[24]
"Nervous breakdown" is a pseudo-medical term to describe a wealth of
stress-related feelings and they are often made worse by the belief that
there is a real phenomenon called "nervous breakdown".
— Richard E. Vatz, co-author of explication of views of Thomas
Szasz in "Thomas Szasz: Primary Values and Major Contentions"
Classifications
There are currently two widely established systems that classify mental disorders:
ICD-10 Chapter V: Mental and behavioural disorders, since 1949 part of the International
Classification of Diseases produced by the WHO,
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the APA since
1952.
Both of these list categories of disorder and provide standardized criteria for diagnosis. They
have deliberately converged their codes in recent revisions so that the manuals are often broadly
comparable, although significant differences remain. Other classification schemes may be used
in non-western cultures, for example, the Chinese Classification of Mental Disorders, and other
manuals may be used by those of alternative theoretical persuasions, such as the
Psychodynamic Diagnostic Manual. In general, mental disorders are classified separately from
neurological disorders, learning disabilities or intellectual disability.
Unlike the DSM and ICD, some approaches are not based on identifying distinct categories of
disorder using dichotomous symptom profiles intended to separate the abnormal from the
normal. There is significant scientific debate about the relative merits of categorical versus such
non-categorical (or hybrid) schemes, also known as continuum or dimensional models. A
spectrum approach may incorporate elements of both.
In the scientific and academic literature on the definition or classification of mental disorder, one
extreme argues that it is entirely a matter of value judgements (including of what is normal)
while another proposes that it is or could be entirely objective and scientific (including by
reference to statistical norms).[25] Common hybrid views argue that the concept of mental
disorder is objective even if only a "fuzzy prototype" that can never be precisely defined, or
conversely that the concept always involves a mixture of scientific facts and subjective value
judgments.[26] Although the diagnostic categories are referred to as 'disorders', they are
presented as medical diseases, but are not validated in the same way as most medical
diagnoses. Some neurologists argue that classification will only be reliable and valid when
based on neurobiological features rather than clinical interview, while others suggest that the
differing ideological and practical perspectives need to be better integrated.[27][28]
The DSM and ICD approach remains under attack both because of the implied causality
model[29] and because some researchers believe it better to aim at underlying brain differences
which can precede symptoms by many years.[30]
Dimensional models
The high degree of comorbidity between disorders in categorical models such as the DSM and
ICD have led some to propose dimensional models. Studying comorbidity between disorders
have demonstrated two latent (unobserved) factors or dimensions in the structure of mental
disorders that are thought to possibly reflect etiological processes. These two dimensions
reflect a distinction between internalizing disorders, such as mood or anxiety symptoms, and
externalizing disorders such as behavioral or substance use symptoms.[31] A single general
factor of psychopathology, similar to the g factor for intelligence, has been empirically
supported. The p factor model supports the internalizing-externalizing distinction, but also
supports the formation of a third dimension of thought disorders such as schizophrenia.[32]
Biological evidence also supports the validity of the internalizing-externalizing structure of
mental disorders, with twin and adoption studies supporting heritable factors for externalizing
and internalizing disorders.[33][34][35] A leading dimensional model is the Hierarchical Taxonomy
of Psychopathology.
Disorders
There are many different categories of mental disorder, and many different facets of human
behavior and personality that can become disordered.[36][37][38][39]
Anxiety disorder
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
Mood disorder: Other affective (emotion/mood) processes can also become disordered. Mood
disorder involving unusually intense and sustained sadness, melancholia, or despair is known as
major depression (also known as unipolar or clinical depression). Milder, but still prolonged
depression, can be diagnosed as dysthymia. Bipolar disorder (also known as manic depression)
involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating
with normal or depressed moods. The extent to which unipolar and bipolar mood phenomena
represent distinct categories of disorder, or mix and merge along a dimension or spectrum of
mood, is subject to some scientific debate.[40][41]
Psychotic disorder
Psychotic disorder: Patterns of belief, language use and perception of reality can become
dysregulated (e.g., delusions, thought disorder, hallucinations). Psychotic disorders in this
domain include schizophrenia, and delusional disorder. Schizoaffective disorder is a category
used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy
is a category used for individuals showing some of the characteristics associated with
schizophrenia, but without meeting cutoff criteria.
Personality disorder
Personality disorder: Personality—the fundamental characteristics of a person that influence
thoughts and behaviors across situations and time—may be considered disordered if judged to
be abnormally rigid and maladaptive. Although treated separately by some, the commonly used
categorical schemes include them as mental disorders, albeit on a separate axis II in the case of
the DSM-IV. A number of different personality disorders are listed, including those sometimes
classed as eccentric, such as paranoid, schizoid and schizotypal personality disorders; types
that have described as dramatic or emotional, such as antisocial, borderline, histrionic or
narcissistic personality disorders; and those sometimes classed as fear-related, such as
anxious-avoidant, dependent, or obsessive-compulsive personality disorders. Personality
disorders, in general, are defined as emerging in childhood, or at least by adolescence or early
adulthood. The ICD also has a category for enduring personality change after a catastrophic
experience or psychiatric illness. If an inability to sufficiently adjust to life circumstances begins
within three months of a particular event or situation, and ends within six months after the
stressor stops or is eliminated, it may instead be classed as an adjustment disorder. There is an
emerging consensus that personality disorders, similar to personality traits in general,
incorporate a mixture of acute dysfunctional behaviors that may resolve in short periods, and
maladaptive temperamental traits that are more enduring.[42] Furthermore, there are also noncategorical schemes that rate all individuals via a profile of different dimensions of personality
without a symptom-based cutoff from normal personality variation, for example through
schemes based on dimensional models.[43]
Eating disorder
Eating disorders involve disproportionate concern in matters of food and weight.[37] Categories
of disorder in this area include anorexia nervosa, bulimia nervosa, exercise bulimia or binge
eating disorder.[44][45]
Sleep disorder
Sleep disorders are associated with disruption to normal sleep patterns. A common sleep
disorder is insomnia, which is described as difficulty falling and/or staying asleep.
Sexuality related
Sexual disorders include dyspareunia and various kinds of paraphilia (sexual arousal to objects,
situations, or individuals that are considered abnormal or harmful to the person or others).
Other
Impulse control disorder: People who are abnormally unable to resist certain urges or impulses
that could be harmful to themselves or others, may be classified as having an impulse control
disorder, and disorders such as kleptomania (stealing) or pyromania (fire-setting). Various
behavioral addictions, such as gambling addiction, may be classed as a disorder. Obsessivecompulsive disorder can sometimes involve an inability to resist certain acts but is classed
separately as being primarily an anxiety disorder.
Substance use disorder: This disorder refers to the use of drugs (legal or illegal, including
alcohol) that persists despite significant problems or harm related to its use. Substance
dependence and substance abuse fall under this umbrella category in the DSM. Substance use
disorder may be due to a pattern of compulsive and repetitive use of a drug that results in
tolerance to its effects and withdrawal symptoms when use is reduced or stopped.
Dissociative disorder: People who suffer severe disturbances of their self-identity, memory, and
general awareness of themselves and their surroundings may be classified as having these
types of disorders, including depersonalization disorder or dissociative identity disorder (which
was previously referred to as multiple personality disorder or "split personality").
Cognitive disorder: These affect cognitive abilities, including learning and memory. This category
includes delirium and mild and major neurocognitive disorder (previously termed dementia).
Developmental disorder: These disorders initially occur in childhood. Some examples include
autism spectrum disorder, oppositional defiant disorder and conduct disorder, and attention
deficit hyperactivity disorder (ADHD), which may continue into adulthood. Conduct disorder, if
continuing into adulthood, may be diagnosed as antisocial personality disorder (dissocial
personality disorder in the ICD). Popular labels such as psychopath (or sociopath) do not appear
in the DSM or ICD but are linked by some to these diagnoses.
Somatoform disorders may be diagnosed when there are problems that appear to originate in
the body that are thought to be manifestations of a mental disorder. This includes somatization
disorder and conversion disorder. There are also disorders of how a person perceives their body,
such as body dysmorphic disorder. Neurasthenia is an old diagnosis involving somatic
complaints as well as fatigue and low spirits/depression, which is officially recognized by the
ICD-10 but no longer by the DSM-IV.[46]
Factitious disorders are diagnosed where symptoms are thought to be reported for personal
gain. Symptoms are often deliberately produced or feigned, and may relate to either symptoms
in the individual or in someone close to them, particularly people they care for.
There are attempts to introduce a category of relational disorder, where the diagnosis is of a
relationship rather than on any one individual in that relationship. The relationship may be
between children and their parents, between couples, or others. There already exists, under the
category of psychosis, a diagnosis of shared psychotic disorder where two or more individuals
share a particular delusion because of their close relationship with each other.
There are a number of uncommon psychiatric syndromes, which are often named after the
person who first described them, such as Capgras syndrome, De Clerambault syndrome, Othello
syndrome, Ganser syndrome, Cotard delusion, and Ekbom syndrome, and additional disorders
such as the Couvade syndrome and Geschwind syndrome.[47]
Signs and symptoms
Course
The onset of psychiatric disorders usually occurs from childhood to early adulthood.[48] Impulsecontrol disorders and a few anxiety disorders tend to appear in childhood. Some other anxiety
disorders, substance disorders, and mood disorders emerge later in the mid-teens.[49]
Symptoms of schizophrenia typically manifest from late adolescence to early twenties.[50]
The likely course and outcome of mental disorders vary and are dependent on numerous factors
related to the disorder itself, the individual as a whole, and the social environment. Some
disorders may last a brief period of time, while others may be long-term in nature.
All disorders can have a varied course. Long-term international studies of schizophrenia have
found that over a half of individuals recover in terms of symptoms, and around a fifth to a third in
terms of symptoms and functioning, with many requiring no medication. While some have
serious difficulties and support needs for many years, "late" recovery is still plausible. The World
Health Organization concluded that the long-term studies' findings converged with others in
"relieving patients, carers and clinicians of the chronicity paradigm which dominated thinking
throughout much of the 20th century."[51][52]
A follow-up study by Tohen and coworkers revealed that around half of people initially diagnosed
with bipolar disorder achieve symptomatic recovery (no longer meeting criteria for the
diagnosis) within six weeks, and nearly all achieve it within two years, with nearly half regaining
their prior occupational and residential status in that period. Less than half go on to experience a
new episode of mania or major depression within the next two years.[53]
Disability
Disorder
Disability-adjusted life years[54]
Major depressive disorder
65.5 million
Alcohol-use disorder
23.7 million
Schizophrenia
16.8 million
Bipolar disorder
14.4 million
Other drug-use disorders
8.4 million
Panic disorder
7.0 million
Obsessive-compulsive disorder
5.1 million
Primary insomnia
3.6 million
Post-traumatic stress disorder
3.5 million
Some disorders may be very limited in their functional effects, while others may involve
substantial disability and support needs. The degree of ability or disability may vary over time
and across different life domains. Furthermore, continued 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.[55]
It is also the case that, while often being characterized in purely negative terms, some mental
traits or states labeled as disorders can also involve above-average creativity, non-conformity,
goal-striving, meticulousness, or empathy.[56] In addition, the public perception of the level of
disability associated with mental disorders can change.[57]
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 severely disabling
condition.[58] 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, mental
disorders 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 mental and neurological conditions,
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 disorders associated with most disabilities in highincome 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%).[59]
Suicide, which is often attributed to some underlying mental disorder, is a leading cause of death
among teenagers and adults under 35.[60][61] There are an estimated 10 to 20 million non-fatal
attempted suicides every year worldwide.[62]
Risk factors
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 cognitivebehavioral 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, selfreported 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]
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 noncompulsory 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 catatonia. 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. 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 nonWestern 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 nonWestern 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, crosscultural 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-rightsoriented 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] 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).
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, selfmutilation, 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 selfreport 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
List of mental disorders
Mental illness portrayed in media
Mental disorders in film
Mental illness in fiction
Mental illness in American prisons
Parity of esteem
Psychological evaluation
Notes
1. "Mental illness – Symptoms and causes" (https://www.mayoclinic.org/diseases-conditions/mental-illnes
s/symptoms-causes/syc-20374968) . Mayo Clinic. 8 June 2019. Retrieved 3 May 2020.
2. "Any Mental Illness (AMI) Among U.S. Adults" (https://web.archive.org/web/20170407030029/https://ww
w.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml) . National
Institute of Mental Health. U.S. Department of Health and Human Services. Archived from the original (htt
ps://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml)
on
7 April 2017. Retrieved 28 April 2017.
3. "Mental Disorders" (https://www.nlm.nih.gov/medlineplus/mentaldisorders.html) . Medline Plus. U.S.
National Library of Medicine. 15 September 2014. Archived (https://web.archive.org/web/201605081931
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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 (https://archive.org/details/studyguidetoac
co00corn) . 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.
Vol. 50. ISBN 978-90-277-0704-8.
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 (http://www.nap.edu/downloa
d/23442) . Washington, DC: National Academies Press. doi:10.17226/23442 (https://doi.org/10.1722
6%2F23442) . ISBN 978-0-309-43912-1. PMID 27631043 (https://pubmed.ncbi.nlm.nih.gov/2763104
3) .
Porter R (2002). Madness: a brief history (https://archive.org/details/madnessbriefhist0000port) .
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.
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)" (https://plato.stanford.edu/entries/mental-dis
order/) . Stanford Encyclopedia of Philosophy.
Management of physical health conditions in adults with severe mental disorders (http://apps.who.int/iris/
bitstream/handle/10665/275718/9789241550383-eng.pdf?ua=1)
(PDF). WHO. 2018. ISBN 978-92-4-
155038-3.
External links
Wikimedia Commons has media related to Mental and behavioural diseases and disorders.
Wikivoyage has a travel guide for Travelling with a mental health condition.
NIMH.NIH.gov (http://www.nimh.nih.gov/)
– National Institute of Mental Health
International Committee of Women Leaders on Mental Health (http://www.cartercenter.com/h
ealth/mental_health/intl_women.html)
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