LECTURE NOTES - Lesson 9

Mental Disorders

Systems for Classifying Mental Disorders

• There are two key classification schemes for diagnosing mental disorders

  • DSM: 

    • The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) was developed by the American Psychological Association (2013) and is the dominant classification system in North America

  • ICD: 

    • The International Classification of Diseases and Health Related Problems - 10th revision (ICD-10) was developed by the World Health Organization (1992) and is primarily used in other parts of the world such as Europe

• Classification systems such as the DSM can be valuable for mental health experts in identifying a mental disorder that is debilitating for a person, and guiding a course of treatment

• The DSM however, has been criticized for a lack of reliability in diagnosing disorders, socially constructing diagnostic categories, and creating a false dichotomy between “normal” and “abnormal” functioning

Major Mental Disorders

• The term major mental disorders refers to a subset of mental disorders that are more serious and feature incapacitating disturbances of thought feelings and perceptions, such as schizophrenia

• Four major mental disorders reviewed in the textbook are schizophrenia, major depression, bipolar disorder, and psychotic disorders

Schizophrenia

• A persistent condition marked by profound distortions in cognition and emotion, affecting language, thought, perception, affect and send of self

• Facts about Schizophrenia:

  • Affects about 1% of the population

  • Onset is usually gradual, and occurs between late teens and mid-thirties

  • Men and women are affected, though men tend to experience symptoms at an earlier age and are more commonly afflicted

  • There are different forms of schizophrenia, the most common being paranoid schizophrenia in which a person experiences persecutory delusions that focus on the belief that others are planning to hurt them

• Symptoms are commonly categorized into positive, negative and disorganized domains:

  • Positive symptoms: 

    • A set of symptoms characterized by an excess of psychological functioning or distortion 

    • Feelings, thoughts, or behaviours that should not normally be present are experienced

      • Examples:

        • Delusion:

          • A fervently held but false belief that is richly maintained despite contrary evidence, e.g., the false belief that the government has bugged one’s home

        • Hallucination: 

          • A false sensory perception that is experienced without a corresponding external stimulus, affecting any one of the five senses

  • Negative symptoms: 

    • A set of symptoms characterized by a deficit of psychological functioning

    • Normal feelings, thoughts, or behaviors that should be present are absent

      • Examples:

        • Flattened affect:

          • Absence of emotion in an individual’s observable expressions and behaviours 

        • Alogia:

          • Poverty of speech, including absence or reduction in spoken words and a lack of content in verbal communications relative to normal speech

        • Avolition: 

          • Loss of motivation, ability or desire to participate in one's usual activities

  • Disorganized symptoms: 

    • A group of symptoms involving bizarre behaviour or confusing speech that reflect a severe underlying disturbance of thoughts; difficulty formulating or producing goal-directed behavior

      • Examples:

        • Formal thought disorder: 

          • A serious disturbance in the organization, process, or flow of a person's thoughts.

        • Word salad:

          • Unintelligible speech characterized by a series of random, unconnected words and phrases 

        • Loosening of associations:

          • Conversation consisting of a sequence of logically unrelated thoughts 

        • Flight of ideas: 

          • Fragmented ideas in which there are frequent shifts in the topic of conversation

Major Depression

• is a serious mood disturbance characterized by one of two core symptoms and lasting at least several weeks:

  • A persistent feeling of profound sadness;

  • Anhedonia, which refers to a loss of interest and pleasure in taking part in a person's usual social and recreational activities

• Common Symptoms of Depression:

• Major depression is the most common mood disorder and is often triggered by stressful events

• Facts about Major Depression:

  • Affects 5% to 7% of the population

  • Average age of onset is in mid-20s

  • Affects women twice as much as men

  • Can be a single episode, or recurring episodes

Bipolar Disorder

• is a persistent condition characterized by fluctuating periods of mania and depression

• A manic episode is a period that features an unusually elevated mood, racing thoughts, and accelerated physical activity that are not appropriate to the situation

• Facts about bipolar disorder:

  • Affects 1% of the population

  • Onset occurs in late adolescence

  • Both men and women are affected equally

  • Most episodes last for several weeks to a few months

Other Psychotic Disorders (Psychosis)

• describes a cluster of symptoms in which a person “loses touch with reality”, in that they have difficulty distinguishing what is real and what is fantasy

• The hallmarks of psychosis are delusions and hallucinations

• Delusional disorder is “marked by the presence of one or more persistent, non-bizarre delusions, without any other accompanying psychotic symptoms

• There are several subtypes of delusional disorders:

  • Persecutory Delusions:

    • A person’s false belief that they are being stalked, spied upon, obstructed, poisoned, conspired against or harassed by other people or an organization

  • Delusion of Grandeur:

    • A person’s false belief that they are much more gifted, superior, famous, wealthy, or influential, than they actually are

  • Erotomania:

    • A person’s false belief that another person of a higher social, political, or economic status is infatuated with them

  • Delusional jealousy:

    • A person’s unfounded fear or false belief that one’s spouse or partner is being unfaithful

Mental Disorder and Crime

• Researchers have spent much time attempting to uncover whether mental illness causes crime

• The search for evidence of a link between mental disorder and crime has followed three lines of research

  • 1. Mental disorder among criminal offenders: 

    • Compared to the general population, rates of mental disorder are higher among convicted offenders

  • 2. Criminal behaviour among psychiatric patients: 

    • Research consistently shows that arrest and conviction rates among former psychiatric patients are higher than the corresponding levels among the general population

  • 3. Mental disorder and crime in community samples: 

    • Unbiased samples of people from the community collected through random selection or total birth cohorts

• A possible explanation for the link between major mental disorder and crime is the criminalization hypothesis

Making Sense of the Criminalization Hypothesis

• The criminalization of mental disorder refers to the idea that the relatively minor but disruptive behavior of those with mental illness is more likely to result in processing as offenders through the criminal justice system

• Beginning in the 1960's, Canada and other parts of the world implemented deinstitutionalization policies that led to the closure of inpatient psychiatric institutions and large-scale transfer of patients to community-based settings

  • Reasons for deinstitutionalization centered on the advent of new psychotropic medications and findings that patients have better treatment outcomes, freedom and enhanced quality of life if they resided in the community

    • As a result, the number of people with major mental disorder living in the community increased markedly deinstitutionalization

Police Response to People with Mental Illness

• It has been argued that criminalization is evident in the way police use discretion in dealing with suspects with major mental illness

• In Canada, there has been a rise in the number of police encounters with people living with major mental illness 

  • Police officers are likely to use their discretion to arrest a person with mental illness for minor crimes particularly when the person is disrespectful or non-compliant, and the officer is not familiar with symptoms of mental illness in the suspect

• In response to numerous police-involved shootings of people in mental health crisis, Canadian police services have dedicated much time and resources to improving training of frontline officers by enhancing familiarity with symptoms of mental disorder and emphasizing de-escalation strategies

• Mobile crisis teams are a new form of mental health response used by police services in Canada where a police officer is paired with a mental health expert and are dispatched by 911 to respond together to persons in mental health crisis

Apprehension of Mentally Disordered Offenders

• The tendency for offenders with major mental illness to be arrested more than non-disordered offenders supports the Criminalization Hypothesis

• Indeed, suspects are more likely to be detected, arrested, and a case made against them by police when a major mental disorder is present

• This is because perpetrators with a major mental disorder tend to stay at the scene of the crime, admit their involvement, and turn themselves into police at higher rates than perpetrators without a disorder

Symptom-Based Theories of Crime

• Symptom-based theories of crime accredits the criminal behaviour of a person with a major mental illness to the profoundly disrupted thoughts, feelings and perceptions brought about by their disorder

• Symptom-consistent behaviour “refers to conduct that appears to reflect the symptoms of the person's mental disorder and therefore makes it reasonable to infer that the disorder contribute to their behaviour”

• Case reports and research suggest that some of the criminal acts committed by people with major mental disorders are driven by mental disorder, others are driven by material gain or self defence

• Research has consistently shown that psychosis in particular is positively related to violence, especially in those individuals demonstrating positive symptoms.

Delusions and Hallucinations

• Compared to hallucinations, delusions are more common and contribute more to motivating criminal behavior

• Phenomenological qualities of delusions that greatly elevate risk of violence are threefold:

• Command hallucinations – hearing voices that are not real that order a person to act out a behaviour, such as a criminal act, are also related to violence

• Command hallucinations are more likely to be obeyed when they are familiar, caring or trusted by the person hearing them

• The principle of rationality–within–irrationality suggests that violence committed by individuals with psychosis is commonly a logical response to irrational symptoms that are perceived and experienced as real

• Theory and research indicate that psychosis-driven violence is more likely to occur in the context of threat/control override symptoms that involve:

Factors Influencing the Relationship Between Mental Disorder and Crime

• There are a number of factors that appear to influence the relationship between mental disorder and crime:

Tense Situations

• Virginia Hiday(1995, 1997) summarized many of the factors in today’s lesson into a single model

• She proposed that tense situations are created for citizens who are confronted by an individual experiencing threat control override (T/CO) or disorganized symptoms who is behaving in a bizzare or disturbing way

• You might find that you feel uncomfortable or upset

  • Hiday argued that some citizens become very frustrated or try to control or stop such disruptive behaviour, which in turn, leads to a physical confrontation on the part of the person who is ill

Hiday’s model incorporates other factors such as substance abuse and antisocial personality disorders, which are often comorbid with other mental disorders, as contributing to these tense situations