Mental Illness Test 2

“Normalization of pathology” (Horwitz chap 2)

• Instead of seeing everyone as normal or mad, Freud normalized a system that utilized the continuum to show it as more of a spectrum

• People fell somewhere between normal and neurosis and psychosis was beyond the continuum

  • Development of dynamic psychiatry

• Normality and neurosis routine as pieces of the same developmental process which allowed for empathy, the expansion of treatment, and put normality into question

• Does not matter what disorder they have, what matters is getting to the root of the problem

  • Freud does not care about diagnostic labels

  • Pharmaceutical approaches only address the symptom, not the cause

Role of symptoms in Dynamic Psychiatry (Horwitz chap 2)

• Freud advocated for a redefining of what symptoms were

• In traditional psychology, one symptom or set of symptoms automatically signified a specific disorder. In dynamic psychology, one underlying conflict could be shown through a variety of different symptoms.

• The same underlying conflict could cause different responses in different people therefore a symptom should not be acquitted to a disorder

  • Freud was against specific diagnostic categories

• Freud shifted the understanding of unexplained physical symptoms away from the body itself and toward the mind. Rather than viewing symptoms as evidence of an underlying physical disease, he interpreted them as symbolic expressions of unconscious psychological conflicts rooted in personal experiences.

  • One important implication is that this approach gave therapists significant authority: they became the people who interpreted patients' symptoms and determined what those symptoms supposedly meant.

• Twin studies and adoption studies of genetic causes of mental illness (Horwitz chap 6)

• Adoption

  • Study the tested mental illness in adopted children

  • If the biological parents were mentally ill, and the child was as well, it was genetic. If the adoptive parents were mentally ill, and the child was as well, it was environmental.

  • If the adoptive parents know about the risk then they may raise them with some kind of knowledge of it and that could have an effect

• Twin

  • Concordance rate for disease between twins- the statistical probability or percentage that two related individuals (most commonly twin pairs) share a specific trait, disease, or psychological disorder

  • Monozygotic (identical) twins had higher rates of both having mental illness, than dizygotic (fraternal) twins

  • Identical twins are more likely to have the same mental illness, so there could be a genetic component, but there may be influence from other factors

  • Some shortcomings of the twin studies are a lack of representation of twins compared to non-twins. Many twin studies also rely on volunteers and Are unable to determine the extent to which the excessive concordance in traits between monozygotic and dizygotic twins, stems from social rather than genetic factors.

• There was no gene actually identified with a relationship to mental illness

• despite these studies, being far from definitive in general, they provide some evidence for genetic causes of some cases of schizophrenia and bipolar disorder and vying findings for the role of genes in non-psychotic conditions

• Eugenics (Whitaker)

• Biological psychology moved in as dynamic psychology declined because people became interested in the hereditary nature of human problems

• poverty, mental illness, crime, prostitution, feeblemindedness, etc. were seen as problems that affected the entire public and needed to be solved

• There was an attempt to detain and segregate misfits, and the utilization of involuntary sterilization for people who were considered to be “defective”

• Believed that people with socially undesirable behaviors and characteristics were more fertile

• Started to restrict marriage between people with low iqs

  • Do not need to be married to reproduce

• Removed people from society

• People believed that they should be killed

• A man in the 1910s proposed the use of gas for this

• The language of the American eugenics movement inspired some of the nazi movement

• The US began to sterilize “defective” people

• This was believed to be for the public good

  • Danger to others

  • Drained the economy

  • For the best for the person struggling

    • Incapable of raising kids

• Advent of Chlorpromazine (Thorazine)

• antipsychotic sedative drug that was Originally given to patients about to have surgery

• Accidentally discovered it could reduce hallucinations and delusions

• Brought to the US and was called Thorazine

  • First psychotropic drug

  • Unlike anything seen before

• soon after the drug became the principal and only treatment. The drug did not require willingness or cooperation like psychotherapy so doctors found it easier.

• drugs were an accelerator for the closing process of institutions because they made to the deinstitutionalization more accessible when they calmed patients

• Community psychiatry

• Deinstitutionalization

  • In 1955 → 558,239

    • 340 per 100,000 of population

  • In 1994 → 71,619

    • 27 per 100,000 of population

  • People thought this was only cause of the meds

    • Really also cause hospitals were being closed for states to save money

• Started only viewing institutions as bad places

• No help with reintegration

  • Rise in homelessness

  • People complain to politicians

  • 1963- community mental health centers act

    • Go from state institutions to community mental health centers before becoming fully independent

    • Federally funded

      • Establishes community psychiatry

    • Had out-patient and short term in-patient care

    • Had crisis intervention and mental health education (designed to be preventative)

      • Better to stop it from happening than react to it afterwards

        • Also cheaper

    • Go out into the community and set up offices in schools, police stations, office buildings

      • Freud made it so that psychoanalysis can take place anywhere

• Signs and symptoms in physical vs. mental illness diagnoses 

• Diagnostic process for physical problem

  • Examination (report or observe symptoms)

  • Run tests for signs

  • Diagnosis

• Diagnostic process for mental health problem

  • Examination (report or observe symptoms)

  • Diagnosis

• For mental health problems the symptoms are the disorder

• Szasz believes that only proven brain diseases could be mental illnesses, but once they are proven brain diseases, it destroys the field of psychology because they could be solved through neurology

• Medical/psychiatric practice as a “personal service occupation”

• The nature of the relationship between a practitioner and a client is that they have no real relationship but communication

• Personal service occupation separates what needs fixing and the person it belongs to but it is difficult to do that with mental health

• You trust the practitioner and assume that they are competent

• The relationship is based on the provision of a service

• Sometimes our bodies and minds are just treated as something that needs to be fixed

  • Cannot separate yourself from your body in the personal service model for physical illness

    • Anesthesia does this

    • When doctors use terminology you do not understand you are kinda removed from the conversation and healing

      • Children are excluded

    • Can you separate from your mind for personal service model for psychiatry

• Personal service occupations work best for when the owner is separated from the object, but in psychiatry, it is important to be more present. There are some ways that separation is created through hypnosis, institutionalization, legal age of consent, etc..

• Proximal and distal causality (applied to mental illness)

• Proximal- most immediate factor that leads to a particular experience

  • exact, bodily or literal causes are proximal

  • Brain signal to tear duct (everything we do has a neurological cause)

  • Zoomed in

• Distal- Underlying cause

  • less exact, metaphorical, and secondary causes are distal

  • context like a sad movie, death, stress, or pain

  • Zoomed out

• Rise of Diagnostic Psychiatry (Horwitz chap 3)

• In the 1970s, there was still Freudian influence and a large presence of dynamic psychiatry. The late 70s made way for diagnostic psychiatry.

  • Dynamic became seen as too vague and untrustworthy therefore, precision, specificity, and medical terminology was preferable

  • Major turning point for the DSM

• shift towards precisely defining symptoms to a decreased care for symptoms and a bigger focus on causes

  • dynamic psychiatry cared about the underlying cause where diagnostic psychiatry cares about managing symptoms

• psychiatry became a model based on discrete disease entities in order to make itself scientifically acceptable and respectable within the medical infrastructure

• you could distinguish between disorders through a clearly defined set of symptoms to objectively classified disease. There was an emphasis on the statistical concept of reliability through the Feighner criteria

  • The criteria categorized symptoms of 14 different and presumably distinct categories of mental illness. It assumed that psychiatry was a branch of medicine based on scientific principle, undiagnosed in classification, and on statistical methods.

• The emphasis on manifest symptoms led to the reliability focus in diagnostic psychiatry

• Critique of community prevalence rates (Horwitz chap 4)

• Mental illness became a reflection of social changes and politics of the time

  • Ex: PMDD 

  • so I’m disorders, only afflicted, a specific subset of the population like menstruating women

• we pathologies things that reflect ratification of the world and political context in our society

• The idea that there is a high prevalence of undiagnosed mental disorders and society prevailed, which made it sensible for policy makers to justify mental illness as a larger public health issue requiring high levels of funding

  • surveying was utilized to estimate the size of the problem

• Doctors use a standardized health scale to determine depression ratings where there is no way to have no depression and severe diagnoses are easy to come by

  • self reporting bias, two week reporting, Denial and dishonesty, oversimplification, etc., make for inaccurate reporting

• Horowitz believes that surveys lack context and are not effective and unreliable because they do not account for differences in personal experiences

• The construction of mental disorders and community surveys parallel, the movement of psychiatric research and practice from global, non-specific measures to well-defined categories.

• The diagnostic interview schedule was the basis for a new generation of epidemiological studies. This instrument was meant to measure specific diagnostic conditions and community populations that were supposed to be comparable to the major clinical entities such as depression, social anxiety, and generalized anxiety disorder.

  • rates of depression, anxiety, and substance abuse disorder were especially high through this survey and others

• The use of community studies to discover the pervasiveness of mental disorders has spread from adults to children, leading to extraordinarily high rates of mental disorders in children, presumably demonstrating the need for programs of prevention and for services for the youth who are suffering

• Electroconvulsive therapy

• Formally known as shock therapy but renamed to move away from the punitive nature of the previous term

• Induces a brief seizure to aid to correct severe depression and other disorders and has also previously been used as an anesthetic.

• “No one knows for certain how ECT treats mental illnesses”

• Currently utilized instead of drugs for those who prefer it, older adults who cannot deal with the side effects of drugs, pregnant women, etc

• Based off of Sakel accidentally overdosing a patient on insulin who then went into hypoglycemic shock and when she woke up from her coma was no longer addicted to opioids

• Cerletti and Bini were the electroshock pioneers they first tested on animals and then in a homeless man

• ECT is given 2 to 3 times a week for 6 to 12 times total and will be administered by doctors at a lower level more frequently

• there are concerns about the side effects like retrograde amnesia, and anterograde amnesia

Psychosurgery

• selective destruction of part of the brain to change behavior or ideas. Is not neurosurgery because it does not fix anything.

• Moniz and the prefrontal lobotomy

  • began to drill holes in the top of people’s heads and inject alcohol into the brain while people were awake to fix what he thought was stickiness in the brain when neural impulses get stuck

  • After this was unsuccessful, he made the leucotomy Where he inserted two poles with a wire into the brain to remove brain matter and claimed that 7 out of 20 patients recovered

  • By the early 1940s there were warnings against this procedure and calls to take away his Nobel prize

• After Moniz, Freeman and the prefrontal lobotomy

  • Found the leukotomy left many patient relapsing or unable to recover so he used a blade instead

  • Tried to drill holes in the side of the head, but there were too many relapses and infections so he went through the eye orbit

  • Inserted ice picks above the eye by hammering. 

  • problems came when he advocated for the usage of the surgery on children who were acting in a normal child like way

• Tardive dyskinesia 

• Side effect of antipsychotic drugs, causing involuntary muscle reactions, eye movement, and jolting 

• Approximately half of the people with this can improve overtime, but there is a market for drugs to treat the side effect of another drug

• Iatrogenic- condition caused by drugs

• Risk rises with long term use

• This was at first considered to be a symptom of the disorder until they found out that it was from a drug

  • Can be controlled with more drugs

• 4-5% incidence rate

• Creating a market for antidepressants in Japan (Watters)

• Prof Kirmayer approached by a drug company to talk about the role of culture and shaping illness, thinking that it was the drug companies way of being proactive and progressive when in reality they were just looking to manipulate culture to sell their drug

• Japan had no antidepressant market because they conceived depression a lot more severe, debilitating, and something that requires hospitalization

  • less severe forms were considered normal day-to-day feelings or “walking worries”

• GlaxoKlineSmith the drug company redefined depression in Japan by running a marketing campaign referring to depression as “cold of the soul” to make it seem less debilitating

• This was effective because it seemed like something that was treatable, and that everyone experienced something that could get worse left untreated like a cold

  • played into Japan’s concerns about increasing suicide rates and decreasing productivity leading to a recession

• they created a market for their drug

• Direct-to-consumer drug advertising

• Previously drugs could only be marketed to doctors, but now companies have gotten FDA approval to advertise directly to consumers leading to a steady increase of ad spending yearly by drug companies

  • Most drug companies spend more on advertisements than research

• there is a lot of opposition to this because it inflates the demand for the drugs because the messaging is able to convince people that they need the drugs

• One strategy utilized is comparing one drug to another. Another strategy is condition branding where the company informs the public about and creates a disorder for them to buy into.

  • Example: binge eating disorder was manufactured through celebrity, marketing, social media, campaigns, and ads, giving people ways to strike up the conversation with their doctor. It became the most commonly diagnosed eating disorder, only 10 years into its existence

  • Example: social anxiety disorder has increased as awareness campaigns have increased, and the diagnostic category has widened

• primary concern is that these campaigns lead to over prescription

• Off-label prescriptions

• when drugs are prescribed for purpose, other than their intended purpose

• Drug companies cannot advertise for that reason until they do tests about that

• Kramer discusses one of his patients who is on Prozac, although they did not have depression and then herself back sliding when she was off of it. Even without present symptoms, he prescribed it to her anyway.

• Cosmetic psychopharmacology (Kramer)

• The usage of a prescription drug to create change in someone who is not clinically diagnosed

• Altering your personality or brain functioning with drugs to bring out more desirable traits 

• “Better than well” (Kramer)

• Drugs utilized for enhancement. Not just to get back to the point of well but beyond that.

• meant to exceed one’s own norm

• Julia was placed on Prozac with the intention of weaning her off after 5 to 6 months. During the time she was on medication, she requested a promotion at work, applied for jobs. She was overqualified for, and was working a job that normally required a masters degree. When she was weaned off, she said that she felt like a witch, pessimistic, angry, lousy, and unlike herself.

• Formes frustes (Kramer)

• incomplete disorder

  • People do not exhibit all the symptoms of a disorder

• Antidepressants as feminist drugs (Kramer)

• drugs that can make a woman feel more confident in male dominated areas

• The drugs made Tess confident. She was less conciliatory, firmer, unafraid of confrontation.

• In Julia’s relationship, prozac allowed her to fix the gender role related issues in her marriage. It tipped the balance in favor of assertiveness, allowing julia to make it clear to her husband what she need and why. At the same time, it made her less urgent, which allowed her husband to do things at his own pace a condition under which he appeared competent.

  • julia’s social worker found this change concerning because it came about without any increase in self knowledge on Julia's part. She believes that medication induced change unaccompanied by growth and self understanding was inferior to what psychotherapy had to offer. Kramer believed that insight was not necessary as long as the outcome is desirable.

• Liberating and empowering?

• Makes women be more assertive

• Kramer implying women cannot do it without the drug

• Psychotherapies

• Using interpersonal connection as your approach to dealing with mental health challenges

• typically include everything of a non-medical nature and are referred to as talking cures

• can be practiced by anyone, including social workers, therapists, spiritual healers, clergy, etc. it does not require medical professional

• not under the same level of scrutiny as drugs, which gives people the false idea that they do not come with risk

• Not all types are proven and tested

• The goal is to reduce symptoms, change behavior, cope with the future, and provide insight and understanding into why the difficulties are occurring

• Principle of Rumpelstiltskin 

• The importance of naming things

• The magic of the right word or the right answer is being able to feel a sense of legitimacy for your own illness

• cleansing is to have the right label

• the identification of a problem can help a patient feel understood and less alone