Mental disorders

Until the end of the last century, most people thought mental disorder was the same as insanity. This view changed following the careful observations of the German psychiatrist Kraepelin, who established the classification of psychoses and differentiated depression into two categories: endogenous (coming from within) and reactive (having an external or social cause). During this century, a great deal of thought has been devoted to such classification and definition.

Freud and Jung, seated left and right of G. Stanley Hall, their host, visited Clark University, Worcester, Massachusetts in 1909 during their visit to the United States, where their ideas were received with great interest Their colleagues A. A. Brill, Ernest Jones, and Sandor Ferenczi (left to right) stand behind them in this photo-graph.

Definition of mental disorders

The definition and diagnosis of mental disorders and what is considered to lie within the bounds of normality varies, inevitably, with different cultures. In many non-European cultures in all parts of the world, states of “possession” by spirits, involving trances and hallucinations, are considered normal, while in our society such behavior would almost certainly be seen to indicate some form of mental disorder. Even among Western societies, there is disagreement about the details of what constitutes mental disorder and how it should be classified. The diagnosis of schizophrenia, for instance, is made more frequently in the United States and Canada than in Western Europe, although research indicates that the incidence of the disease is fairly uniform throughout the world.

Despite these arguments about the borderlines between normality and abnormality, there are certain disorders of mind and behavior about which there is general agreement. These include altered states of mind such as abnormal anxiety, depression, or phobias, in which the individual is subject to considerable personal suffering, and aspects of individual behavior that are clearly regarded as disordered by the community as a whole.

Early schools of psychoanalysis, such as those of Jung and Adler, and the Neo-Freudian analysts, such as Klein and Horney, can trace their origins to the work of Freud. The links between Freud and other psychotherapies are more tenuous.

Basic concepts

The development of ideas about mental disorder reflects the history of society itself. In the Middle Ages, disordered behavior was usually attributed to witchcraft; in the late nineteenth century, to brain disorder or heredity; and today, there is disagreement between social or psychodynamic and biological psychiatrists about causes of mental disorder, particularly about what is socially or environmentally determined.

One of the major contributions of Sigmund Freud was to show that unconscious factors play a crucial part in determining an individual’s behavior. In particular, he established the idea that the unconscious is a reservoir of wishes and fantasies, basically sexual and aggressive (love and hate), and showed how unconscious conflict can give rise to psychopathology. He also supplied the method (psychoanalysis) for further study of the unconscious by later investigators.

In developing his theories about unconscious mental processes, Freud used three concepts termed id, ego, and superego, to denote interacting forces in human behavior. The id is the sum of primitive instinctive forces in an individual, which seek expression constantly through the search for pleasure and the avoidance of pain. The ego is the conscious self that mediates between the primitive id and the third aspect of the mind, the superego, and through this mediation controls behavior. The superego is perhaps best described as the “conscience.” It is developed through upbringing and experience, and often conflicts with the instinctual drives of the id. Such conflict is normally resolved by the ego, but if it remains unresolved, neuroses can develop. Freud thought that much neurosis was caused by the suppression of the knowledge of sexual events in childhood. Not everyone accepted this emphasis, however. Carl Jung, for example, broke away from Freud’s teachings because he was unable to accept that suppression of sexual memories was the primary cause of neurosis. He believed in the notion of a collective unconscious and dwelt more on the psychological present and future (stressing what people were capable of becoming) than on the past. Melanie Klein, who studied under Freud’s pupil Sandor Ferenczi, placed the origins of neurosis and mental disturbance earlier in a child’s psychic life than Freud proposed, maintaining that the significant period is in the first months and the first two years of childhood.

Classification

Group therapy, with its informal atmosphere, is a valuable form of psychotherapy for people who share a common problem, such as a personality disorder or psychological dependence on drugs or alcohol. Professional organizations that help people to overcome alcoholism or compulsive gambling, for example, commonly use group therapeutic techniques. The therapist may initiate the discussion, but then often takes a more passive role, allowing the group members to talk among themselves

Neuroses are distinguished from psychoses because, in the former, contact is maintained with reality, whereas in the latter this contact is lost. The classification of neuroses is somewhat arbitrary, because most patients suffer from more than one classic type. The types serve to identify symptoms, however, and include a form of anxiety, phobias, obsessive or compulsive behavior, hypochondria, hysteria, a form of depression, and neurasthenia or excessive fatigue (which often accompanies depression).

Psychosis, in contrast, describes a mental state with no evident physical cause, in which a person’s mental disorder is so great that contact with reality is lost, and delusions and possibly hallucinations occur. Manic-depressive psychosis, paranoia, and schizophrenia are the best-known psychotic syndromes.

Personality disorder, a loose classification, is usually regarded as the third major area of mental disorder. Such disorders range from minor disturbances, such as excessive shyness, irrational mood changes, and mild paranoia, none of which need be debilitating, to compulsive personality traits, often with a deviant sexual focus and extreme antisocial psychopathic behavior.

Superficial similarities between some minor personality disorders irrational mood changes (cyclothymia) for instance and psychoses, such as manic-depressive psychosis, emphasize the difficulty of classification. Other difficulties are posed by the question of whether minor sexual disorders, such as impotence or frigidity, and the states of mind associated with alcoholism, drug addiction, and even suicide are mental disorders as such or merely unfortunate aspects of the human condition.

Art therapy encourages people to express their inner thoughts and feelings through drawings and paintings, and may help to reveal repressed or unconscious aspects that contribute to a mental disorder.

Psychiatric syndromes

In the psychiatric treatment of mental illness, several specific syndromes are of particular concern. Anxiety and depression are prominent among these, because they are the two most common symptoms the psychiatrist is called upon to treat. Anxiety may be neurotic or psychotic. Neurotic anxiety is, perhaps, the commonest neurosis. Psychotic anxiety accompanies schizophrenia or manic-depressive states.

Mental subnormality, or deficiency, describes a condition of retarded, incomplete, or abnormal mental development at birth or in early childhood. Treatment is more commonly the concern of educational psychologists than psychiatrists, though where medical therapy is required the responsibilities may overlap.

The most common psychiatric illness in old age, senile dementia, is commonly manifest in childlike, perverse, or destructive behavior. The cause is unknown, but current research suggests it may be related to the pathology of Alzheimer’s disease. There is no effective treatment, though research into Alzheimer’s disease has recently made some advances.

Manic-depressive psychosis is a severe mental disorder that affects up to one person in every hundred, and is more common in women than in men. It is characterized by extreme swings of mood. In the manic phase, the person is overactive and excited, often to the extent of lacking all self-control. In the depressive phase, there is a prolonged period of deep depression and melancholia that may be severe enough to be suicidal.

Other disorders

Alcohol and drug abuse are difficult to classify in psychiatric terms, though both can be seen as attempts to allay or avoid anxiety. There is a possibility that those who become addicted to either have a psychological propensity toward addiction, which may be a neurotic compulsion, a personality disorder, or an indefinable urge toward self-neglect or self-destruction. However, both alcohol and addictive drugs are severely harmful in themselves, and mental disturbance is a frequent result of alcohol or drug abuse.

It is believed that suicide reflects a person’s feeling that he or she can no longer go on living with profound and long-standing depression. A distinction is usually made between successful and attempted suicide on the assumption that the latter is a dramatic ‘cry for help” rather than a serious attempt to die. Treatment of an attempted suicide concentrates on the underlying cause.
Minor sexual disorders can sometimes be treated by psychotherapy or psychoanalysis. More direct or interactive methods, usually described as sex therapy, may be successful.

Disorders in which the mind unconsciously affects the body are termed psychosomatic. In fact, many disorders may have a psychological component, and the term psychosomatic could describe conditions as varied as stress-related eczema and impotence. One serious psychosomatic condition is anorexia nervosa, in which an excessive desire to lose weight results in emaciation; typically, this affects teenage girls.

Drug and other medical treatments

Although many mental disorders do not seem to have an obvious physical cause, physical methods seem to be the only successful way to treat them. Drugs in particular are used extensively. Because there is no physical disorder to attack, however, drug treatment tends to concentrate on relieving and controlling symptoms. The main types of drugs used are tranquilizers and antidepressants. Antischizophrenic drugs are powerful tranquillizers, but are regarded as a separate category because of their specific uses in the treatment of schizophrenia. The use of lithium, usually in the form of lithium carbonate, in conjunction with an antidepressant, is sometimes valuable in reducing the mood changes in manic-depressive psychosis.

Two other treatments, electroconvulsive therapy (ECT) and psychosurgery, are sometimes (though ever more rarely) used. ECT induces a modified epileptic seizure in an anesthetized patient by means of electric current, in an attempt to treat severe depression. Psychosurgery involves surgery on part of the brain to prevent the symptoms of chronically depressed or obsessive patients. Both are controversial and are questioned by many psychiatrists on moral and ethical grounds.

Phobias can be caused by many things, some of which—for instance, modes of transport, crowds of people, or open spaces—give little or no cause for fear in most people. The diagram Heft) illustrates these and other common phobias.

The talking cures

Adjuncts to medical treatment are the forms of therapy that attempt to treat the psychological causes rather than the symptoms of mental disorders. Collectively, these forms of treatment are called psychotherapy.

The original “talking cure” was developed by Freud, who gave it the name psychoanalysis to stress its scientific foundation. The science of psychoanalysis has been developed by Freud’s successors into a variety of analytic techniques based on the principle of developing a close relationship between patient and analyst, which allows undesirable or abnormal aspects of the patient’s mental state to manifest themselves. The origin, nature, and effects of these can then be made clear to the patient by the analyst’s explanation.

In an alternative, more specific sense, the term psychotherapy describes modified forms of psychoanalysis in which the patient is seen only once or twice a week, and not necessarily for such an extended period as in psychoanalysis.

There is also a wealth of alternative therapies with different approaches and methods. These include behavior therapy, family therapy, group therapy, and psychodrama. Behavior therapy attempts to modify behavior by psychological conditioning. The technique does not require the patient to understand the cause of his condition. The others use a psychodynamic approach, aiming to involve patients in the process of understanding themselves and coming to terms with their problems, with the guidance of an experienced therapist who directs the course of the treatment.

Anorexia nervosa is a disorder that occurs most frequently in teen-age girls. Their refusal to eat can cause extreme loss of weight and cessation of menstruation. The condition usually needs prolonged psychiatric treatment.