Mental health and mental illness

1. Describe the continuum of mental health and mental illness.

2. Explore the role of resilience in the prevention of and recovery from mental illness and consider resilience in response to stress.

3. Identify how culture influences the view of mental illnesses and behaviors associated with them.

4. Discuss the nature/nurture origins of psychiatric disorders.

5. Summarize the social influences of mental health care in the United States.

6. Explain how epidemiological studies can improve medical and nursing care.

7. Identify how the Diagnostic and Statistical Manual, fifth edition (DSM-5) is used for diagnosing psychiatric conditions.

8. Describe the specialty of psychiatric mental health nursing and list three phenomena of concern.

9. Compare and contrast a DSM-5 medical diagnosis with a nursing diagnosis.

10. Discuss future challenges and opportunities for mental health care in the United States.

11. Describe direct and indirect advocacy opportunities for psychiatric mental health nurses.

Visit the Evolve website for a pretest on the content in this chapter: http://evolve.elsevier.com/Varcarolis

If you are a fan of vintage films, you may have witnessed a scene similar to this: A doctor, wearing a lab coat and an expression of deep concern, enters a hospital waiting room and delivers the bad news to an obviously distraught gentleman who is seated there. The doctor says “I’m afraid your wife has suffered a nervous breakdown,” and from that point on, the woman’s condition is only vaguely described. The husband dutifully visits her at a gated asylum, where the staff regard him with sad expressions. He may find his wife confined to her bed, or standing by the window and staring vacantly into the middle distance, or sitting motionless in the hospital garden. The viewer can only speculate about the nature of the problem but may assume she has had an emotional collapse.

Continuum of mental health and mental illness

We have come a long way in acknowledging psychiatric disorders and increasing our understanding of them since the days of “nervous breakdowns.” In fact, the World Health Organization (WHO) (2010) maintains that a person cannot be considered healthy without taking into account mental health as well as physical health.

The WHO defines mental health as a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively, and make a contribution to the community. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem (U.S. Department of Health and Human Services [USDHHS], 1999). Some of the attributes of mentally healthy people are presented in Figure 1-1.

FIG 1-1 Some attributes of mental health.

Psychiatry’s definition of mental health evolves over time. It is a definition shaped by the prevailing culture and societal values, and it reflects changes in cultural norms, society’s expectations, political climates, and even reimbursement criteria by third-party payers. In the past, the term mental illness was applied to behaviors considered “strange” and “different”—behaviors that occurred infrequently and deviated from an established norm. Such criteria are inadequate because they suggest that mental health is based on conformity, and if such definitions were used, nonconformists and independent thinkers like Abraham Lincoln, Mahatma Gandhi, and Socrates would be judged mentally ill. Although the sacrifices of a Mother Teresa or the dedication of Martin Luther King Jr. are uncommon, virtually none of us would consider these much-admired behaviors to be signs of mental illness.

Mental illness refers to all mental disorders with definable diagnoses. These disorders are manifested in significant dysfunction that may be related to developmental, biological, or psychological disturbances in mental functioning. (APA, 2013). The cognition may be impaired—as in Alzheimer’s disease; emotions may be affected—as in major depression; and behavioral alterations may be apparent—as in schizophrenia; or the patient may display some combination of the three. Behavior that deviates from socially accepted norms does not indicate a mental illness unless there is significant disturbance in mental functioning.

You may be wondering if there is some middle ground between mental health and mental illness. After all, it is a rare person who does not have doubts as to his or her sanity at one time or another. The answer is that there is a definite middle ground; in fact, mental health and mental illness can be conceptualized as points along a mental health continuum (Figure 1-2).

FIG 1-2 Mental Health–Mental Illness Continuum. (From University of Michigan, “Understanding U.” [2007]. What is mental health? Retrieved from http://www.hr.umich.edu/mhealthy/programs/mental_emotional/understandingu/learn/mental_health.html.)

Well-being is characterized by adequate to high-level functioning in response to routine stress and resultant anxiety or distress. Nearly all of us experience emotional problems or concerns or occasions when we are not at our best. We may feel lousy temporarily, but signs and symptoms are not of sufficient duration or intensity to warrant a psychiatric diagnosis. We may spend a day or two in a gray cloud of self-doubt and recrimination over a failed exam, a sleepless night filled with worry and obsession about normally trivial concerns, or months of genuine sadness and mourning after the death of a loved one. During those times, we are fully or vaguely aware that we are not functioning optimally; however, time, exercise, a balanced diet, rest, interaction with others, mental reframing, or even early intervention and treatment may alleviate these problems or concerns. It is not until we experience marked distress or suffer from impairment or inability to function in our everyday lives that the line is crossed into mental illness.

People who have experienced mental illness can testify to the existence of changes in functioning. The following comments of a 40-year-old woman illustrate the continuum between illness and health as her condition ranged from (1) deep depression to (2) mania to (3) health:

1. It was horror and hell. I was at the bottom of the deepest and darkest pit there ever was. I was worthless and unforgivable. I was as good as—no, worse than—dead.

2. I was incredibly alive. I could sense and feel everything. I was sure I could do anything, accomplish any task, create whatever I wanted, if only other people wouldn’t get in my way.

3. Yes, I am sometimes sad and sometimes happy and excited, but nothing as extreme as before. I am much calmer. I realize now that, when I was manic, it was a pressure-cooker feeling. When I am happy now, or loving, it is more peaceful and real. I have to admit that I sometimes miss the intensity—the sense of power and creativity—of those manic times. I never miss anything about the depressed times, but of course the power and the creativity never bore fruit. Now I do get things done, some of the time, like most people. And people treat me much better now. I guess I must seem more real to them. I certainly seem more real to me (Altrocchi, 1980).

Contributing factors

Many factors can affect the severity and progression of a mental illness as well as the mental health of a person who does not have a mental illness (Figure 1-3). If possible, these influences need to be evaluated and factored into an individual’s plan of care. In fact, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), a 1.5-inch-thick manual that classifies 157 separate disorders, states that there is evidence suggesting that the symptoms and causes of a number of disorders are influenced by cultural and ethnic factors (APA, 2013). The DSM-5 is discussed in further detail later in this chapter.

FIG 1-3 Influences that can have an impact on an individual’s mental health.

Resilience

Researchers, clinicians, and consumers are all interested in actively facilitating mental health and reducing mental illness. A characteristic of mental health, increasingly being promoted and essential to the recovery process, is resilience. Resilience is closely associated with the process of adapting and helps people facing tragedies, loss, trauma, and severe stress. It is the ability and capacity for people to secure the resources they need to support their well-being, such as children of poverty and abuse seeking out trusted adults who provide them with the psychological and physical resources that allow them to excel. This social support actually brings about chemical changes in the body through the release of oxytocin, which mutes the destructive stress-related chemicals (Southwick & Charney, 2012).

Disasters, such as the attack on the World Trade towers in 2001 and the devastation of Hurricane Sandy in 2012, in which people pulled together to help one another and carried on despite horrendous loss, illustrate resilience. Being resilient does not mean being unaffected by stressors; it means recognizing the feelings, readily dealing with them, and learning from the experience rather than falling victim to negative emotions.

Accessing and developing this trait assists people in bouncing back from painful experiences and difficult events; it is characterized by optimism, a sense of mastery, and competence (Southwick & Charney, 2012). It is not an unusual quality; it is possessed by regular, everyday people and can be enhanced in almost everyone. One of the most important qualities is the ability to identify the problems and challenges, accepting those things that cannot be changed and then focusing on what can be overcome.

Research demonstrates that early experiences in mastering difficult or stressful situations enhance the prefrontal cortex’s resiliency in coping with difficult situations later. According to Amat and colleagues (2006), when rats were exposed to uncontrollable stresses, their brains turned off mood-regulating cells, and they developed a syndrome much like major depression. Rats that were first given the chance to control a stressful situation were better able to respond to subsequent stress for up to a week following the success. In fact, when the successful rats were faced with uncontrollable stress, their brain cells responded as if they were in control.

People who are resilient are effective at regulating their emotions and not falling victim to negative, self-defeating thoughts. You can get an idea of how good you are at regulating your emotions by taking the Resilience Factor Test in Box 1-1.

BOX 1-1

THE RESILIENCE FACTOR TEST

Use the following scale to rate each item listed below:

1. Even if I plan ahead for a discussion with my spouse, my boss, or my child, I still find myself acting emotionally.

2. I am unable to harness positive emotions to help me focus on a task.

3. I can control the way I feel when adversity strikes.

4. I get carried away by my feelings.

5. I am good at identifying what I am thinking and how it affects my mood.

6. If someone does something that upsets me, I am able to wait until an appropriate time when I have calmed down to discuss it.

7. My emotions affect my ability to focus on what I need to get done at home, school, or work.

8. When I discuss a hot topic with a colleague or family member, I am able to keep my emotions in check.

ADD YOUR SCORE ON THE FOLLOWING ITEMS:	ADD YOUR SCORE ON THE FOLLOWING ITEMS:
3 _____	1 _____
5 _____	2 _____
6 _____	4 _____
8 _____	7 _____
Positive total = _____	Negative total = _____
Positive total minus negative total = _____

A score higher than 13 is rated as above average in emotional regulation.

A score between 6 and 13 is inconclusive.

A score lower than 6 is rated as below average in emotional regulation.

If your emotional regulation is below average, you may need to master some calming skills. Here are a few tips:

• When anxiety strikes, your breathing may become shallow and quick. You can help control the anxiety by controlling your breathing. Inhale slowly through your nose, breathing deeply from your belly, not your chest.

• Stress will make your body tight and stiff. Again, you can counter the effects of stress on the body and brain if you relax your muscles.

• Try positive imagery; create an image that is relaxing, such as visualizing yourself on a secluded beach.

• Resilience is within your reach.

From The resilience factor: 7 essential skills for overcoming life”s obstacles by Karen Reivich, PhD and Andrew Shatte, PhD. Copyright © 2002 by Karen Reivich and Andrew Shatte. Used by permission of Broadway Books, a division of Random House, Inc. Any third party use of this material, outside of this publication, is prohibited. Interested parties must apply directly to Random House, Inc. for permission.

Culture

There is no standard measure for mental health, in part because it is culturally defined and is based on interpretations of effective functioning according to societal norms (WHO, 2007). One approach in differentiating mental health from mental illness is to consider what a particular culture regards as acceptable or unacceptable. In this view, the mentally ill are those who violate social norms and thus threaten (or make anxious) those observing them. For example, traditional Japanese may consider suicide to be an act of honor, and Middle Eastern “suicide bombers” are considered holy warriors or martyrs. Contrast these viewpoints with Western culture, where people who attempt or complete suicides are nearly always considered mentally ill.

Throughout history, people have interpreted health or sickness according to their own current views. A striking example of how cultural change influences the interpretation of mental illness is an old definition of hysteria. According to Webster’s Dictionary (Porter, 1913), hysteria was “A nervous affection, occurring almost exclusively in women, in which the emotional and reflex excitability is exaggerated, and the will power correspondingly diminished, so that the patient loses control over the emotions, becomes the victim of imaginary sensations, and often falls into paroxysm or fits.” Treatment for this condition, thought to be the result of sexual deprivation, often involved sexual outlets for afflicted women. According to some authors, this diagnosis fell into disuse as women’s rights improved, the family atmosphere became less restrictive, and societal tolerance of sexual practices increased.

Cultures differ in not only their views regarding mental illness but also the types of behavior categorized as mental illness. Culture-bound syndromes seem to occur in specific sociocultural contexts and are easily recognized by people in those cultures (Stern et al., 2010). For example, one syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in almost indiscriminate violent behavior. Pibloktoq, an uncontrollable desire to tear off one’s clothing and expose oneself to severe winter weather, is a recognized psychological disorder in parts of Greenland, Alaska, and the Arctic regions of Canada. In the United States, anorexia nervosa (see Chapter 18) is recognized as a psychobiological disorder that entails voluntary starvation. The disorder is well known in Europe, North America, and Australia but unheard of in many other parts of the world.

What is to be made of the fact that certain disorders occur in some cultures but are absent in others? One interpretation is that the conditions necessary for causing a particular disorder occur in some places but are absent in other places. Another interpretation is that people learn certain kinds of abnormal behavior by imitation; however, the fact that some disorders may be culturally determined does not prove that all mental illnesses are so determined. The best evidence suggests that schizophrenia (see Chapter 12) and bipolar disorders (see Chapter 13) are found throughout the world. The symptom patterns of schizophrenia have been observed in Western culture and among indigenous Greenlanders and West African villagers.

Perceptions of mental health and mental illness

Mental illness versus physical illness

People commonly make a distinction between mental illnesses and physical illnesses. It is an odd distinction, considering that mental refers to the brain, the most complex and sophisticated part of the body, the organ responsible for the higher thought processes that set us apart from other creatures. Surely the workings of the brain—the synaptic connections, the areas of functioning, the spinal innervations and connections—are physical. One problem with this distinction is that it implies that psychiatric disorders are “all in the head” and therefore under personal control and indistinguishable from a choice to indulge in bad behavior. Although some physical disorders, such as a broken arm from skiing or lung cancer from smoking, are blamed on the victim, the majority of physical illnesses are considered to be beyond personal responsibility.

Perhaps the origin of this distinction between mental and physical illness lies in the religious and philosophical tradition of explaining the unexplainable by assigning a mystical or spiritual origin to cognitive processes and emotional activities. Despite many advances in understanding, mental illnesses continue to be viewed differently from illnesses that originate in other parts of the body.

Consider that people with epilepsy were once thought to be possessed by demons, under the attack of gods, or cursed; they were subjected to horrible “cures” and treatments. Today, most people would say that epilepsy is a disorder of the mind and not under personal control because we can see epilepsy on brain scans as areas of overactivity and excitability. There are no specific biological tests to diagnose most psychiatric disorders—no cranium culture for depression and no MRI for obsessive-compulsive disorder (OCD); however, researchers are convinced that the root of most mental disorders lies in intercellular abnormalities, and we can now see clear signs of altered brain function in several mental disorders, including schizophrenia, OCD, stress disorders, and depression.

Nature versus nurture

For students, one of the most intriguing aspects of learning about mental illnesses is understanding their origins. Although for centuries people believed that extremely unusual behaviors were due to demonic forces, in the late 1800s, the mental health pendulum swung briefly to a biological focus with the “germ theory of diseases.” Germ theory explained mental illness in the same way other illnesses were being described—that is, they were caused by a specific agent in the environment (Morgan, McKenzie, & Fearon, 2008). This theory was abandoned rather quickly since clinicians and researchers could not identify single causative factors for mental illnesses; there was no “mania germ” that could be viewed under a microscope and subsequently treated.

Although ineffective biological treatments for mental illness continued to be explored, psychological theories dominated and focused on the science of the mind and behavior over the next half century. These theories explained the origin of mental illness as faulty psychological processes that could be corrected by increasing personal insight and understanding. For example, a patient experiencing depression and apathy might be assisted to explore feelings left over from childhood, when overly protective parents harshly discouraged his attempts at independence.

This psychological focus was challenged in 1952 when chlorpromazine (Thorazine) was found to have a calming effect on agitated, out-of-control patients. Imagine what this must have been like for clinicians who had resorted to every biological treatment imaginable, including wet wraps, insulin shock therapy, and psychosurgery (in which holes were drilled in the head of a patient and probes inserted in the brain) in a futile attempt to change behavior. Many began to believe that if psychiatric problems respond to medications that alter intercellular components, a disruption of intercellular components must already be present. At this point, the pendulum made steady and sure progress toward a biological explanation of psychiatric problems and disorders.

Currently, the diathesis-stress model—in which diathesis represents biological predisposition and stress represents environmental stress or trauma—is the most accepted explanation for mental illness. This nature-plus-nurture argument asserts that most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors. While one person may develop major depression largely as the result of an inherited and biological vulnerability that alters brain chemistry, another person with little vulnerability may develop depression from changes in brain chemistry caused by the insults of a stressful environment.

Social influences on mental health care

Consumer movement and mental health recovery

In the latter part of the 20th century, tremendous energy was expended on putting the notion of equality into widespread practice in the United States. Treating people fairly and extinguishing labels became a cultural focus. In regard to mental illness, decades of institutionalization had created political and social concerns that gave rise to a mental health movement similar to women’s rights movements, civil rights movements, disabilities rights movements, and gay rights movements. Groups of people with mental illnesses—or mental health consumers—began to advocate for their rights and the rights of others with mental illness and to fight stigma, discrimination, and forced treatment.

In 1979, people with mental illnesses and their families formed a nationwide advocacy group, the National Alliance on Mental Illness (NAMI). In the 1980s, individuals in the consumer movement organized by NAMI began to resist the traditional arrangement of mental health care providers who dictated care and treatment without input from the patient. This “paternalistic” relationship was not just demoralizing; it also implied that patients were not competent to make their own decisions. Consumers rebelled and demanded increased involvement in decisions concerning their treatment.

The consumer movement also promoted the notion of recovery, a new and an old idea in mental health. On one hand, it represents a concept that has been around a long time: that some people—even those with the most serious illnesses, such as schizophrenia—recover. One such recovery was depicted in the movie “A Beautiful Mind,” wherein a brilliant mathematician, John Nash, seems to have emerged from a continuous cycle of devastating psychotic relapses to a state of stabilization and recovery (Howard, 2001). On the other hand, a newer conceptualization of recovery evolved into a consumer-focused process “in which people are able to live, work, learn, and participate fully in their communities” (U.S. Department of Health and Human Services, 2003).

According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2011), recovery is defined as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” The focus is on the consumer and what he or she can do. An example of recovery follows:

VIGNETTE

Jeff was diagnosed with schizophrenia when he began to hear voices as a college student. He dropped out of school and had a series of hospitalizations, outpatient treatments, and ultimately nonadherence to the plan of care. He was put on Social Security Disability and never worked again after he lost his part-time job at a factory. For 20 years, Jeff has been told what medication to take, where to live, and what to do.

At the community health center where he receives services he met Linda, who was involved with a recovery support group. She told him about it and gave him a pamphlet with a list of the 10 guiding principles of recovery, which were: