Mental illness

MBBS Yr 4 Psychiatry Rotation

What We’ll Cover
• Abnormality vs Normality
• Statistical Infrequency Model
• Cultural Factors
• Religious Factors
• Social Factors
• Mental illness:
▪ A clinical-level disturbance of behaviour, cognition, emotions, performance
and/or relationships (WHO)
▪ “An illness characterized by the presence of mental pathology (i.e. disturbances
in mental functioning) analogous to disturbances of bodily functioning” (The
Oxford dictionary of sociology).

• Mental health problem: not meeting criteria for a clinical diagnosis

but having significant impact on functioning.

• Mental health: refers not only to the absence of psychological illness,

but also to the perception and experience of personal wellbeing,
autonomy, competence, self-efficacy and achievement of potential
 How do We Conceptualize It?

Medical model:
❑A disease, or a disease like entity, with a
psychological, genetic or chemical base
that can be treated through medical means

❑Also, a chemical imbalance within our brain

Or:
Social model:
❑A social dysfunction/deviation from the normal life of an individual
and inability to perform the expected and prescribed social roles.
STRESS MANAGEMENT FOR OPTIMAL FUNCTIONING 6
The Mental Health Continuum
• We are all affected – life circumstances determines
position
❑mental illness represents the biggest economic
burden of any health issue in the world,
❑Around 450 million people currently suffer from
such conditions, placing mental disorders among
the leading causes of ill-health and
disability worldwide
❑60% do not receive any form of care,
❑90% of people in developing countries receive no
form of care.
▪ Source: World Health Organization (WHO), World Economic Forum
(WEF)
Aim of MH
interventions =
to move people
up the continuum
so that they live
satisfying lives
What Mental Health
Feels & Looks Like
• Feeling in control

• Being confident

• Being resilient and able to cope

• Feeling good about yourself

• Building and maintaining good relationships

• Managing and expressing your emotions

 What Does Poor MH Look Like?
OBVIOUS
• Frequent Conflict
• Detachment from reality
• Poor Performance
• Substance Misuse
• Other abnormal behaviours
• Blunted Affect
• Emotional exhaustion,
• Fragility,
LESS OBVIOUS
• Cynicism,
• Suicidal ideation,
• Poor concentration,
• Feelings of not coping,
• Muscle tension,
• Pessimistic thinking
• Irritability
• Insomnia/Hypersomnia
13
What Do You Think?
Understanding the experience of living with a
mental illness
The following audio mimics the
symptoms of schizophrenia.

Medford police use the

recordings in crisis-intervention
training designed to help
officers understand and work
with the mentally ill.
 Abnormal vs
Normal

• Abnormal: how do you decide if someone’s

behaviour is abnormal?

• Normal: what factors would you consider when

making a decision about normalcy?
Abnormal vs Normal
• Involves a series of value judgments based on subjective
impressions

❖ Of pt: Subjective experience of feeling “not normal”(e.g. feeling

intense anxiety, unhappiness, distress)

❖ Of dr: Might consider

whether behaviour violates
social norms or makes
others uncomfortable
7 criteria to decide normality
1. Suffering: is the pt experiencing distress and discomfort?

2. Maladaptiveness: are they behaving in ways that make things difficult for themselves,
rather than better?

3. Irrationality: are they incomprehensible? Lack reason?

4. Unpredictability: unexpected (impulsive, dangerous) actions

5. Vividness and unconventionality: is patient's behaviour substantially different from most

people’s?
6. Observer discomfort: acting in a way that is difficult to watch. Upsets others

7. Violation of moral/ideal standards: Habitually break the accepted ethical/moral

standards?
• Rosenhan and Seligman (1984)
 The 4 Ds of Abnormal Psychology
1. Deviance: any behaviour departing from the cultural norms.
E.g. paedophilia - deviance is the hallmark of the disorder
2. Dysfunction: marked impairment in ability to perform everyday
functions.
3. Distress: The extent to which the issue distresses the individual. A
person can experience a great deal of dysfunction and very
little distress or vice versa. What type of MI might not recognize
distress?
4. Danger: To self and others

Some have suggested a fifth “D”:

• Duration: highlights whether an emotion, cognition or behaviour
is a fleeting symptom or persistent.
• Can also help the clinician differentiate between disorders. E.g.
ASD & PTSD or Brief Psychotic Disorder & Schizophrenia.
 Statistical Infrequency
❑Mathematical method for defining abnormality
❑i.e. human attributes fall into a normal distribution
❑We fall within, above or below a mean/average
❑Works on the idea that abnormality should be based on infrequency;
❑i.e. if it occurs rarely then it is abnormal.
❑Statistical abnormality – when a certain behaviour/characteristic is relevant
to a low percentage of the population.
❑does not necessarily = suffering from mental illness (for example,
statistical abnormalities such as extreme wealth/attractiveness)
❑With this definition it is necessary to be clear about how rare a trait or
behaviour needs to be before we class it as abnormal.
❑For eg. one may say that an individual who has an IQ below or above
the average level of IQ in society is abnormal.
9/3/20XX Presentation Title 22
❖Strength: The statistical approach helps to address what is meant by normal in
a statistical context. It helps us make cut – off points in terms of diagnosis.

❖Criticism: Definition fails to distinguish between desirable and undesirable

behaviour.
• For example, obesity is statistically normal but not associated with good
health or desirable.
• Conversely high IQ is statistically abnormal, but regarded as highly
desirable.
• Additionally, many rare behaviours or characteristics (e.g. left handedness)
have no bearing on normality or abnormality.
• Some characteristics are regarded as abnormal even though they are quite
frequent. Depression may affect 27% of elderly people (NIMH, 2001). This
would make it common but that does not mean it isn’t a problem
 Factors influencing mental health and mental
llness

• SOCIAL
• CULTURAL
• STIGMA
• RELIGION
Social
“Mental or psychological well-being is influenced not
only by individual characteristics or attributes, but
also by the socioeconomic circumstances in which
persons find themselves and the broader
environment in which they live”

9/3/20XX Presentation Title 25

Factors associated with worse mental health
• low income • financial strain
• marital status/not living • perceived discrimination
with a partner • negative subjective health
• lack of emotional/social • loneliness
support
• low subjective social status
• female gender
• deteriorated housing
• low level of education
• higher age
• low socioeconomic status
• negative life events
• unemployment

Silva et al, 2016: Social determinants of mental health: A review of the evidence
9/3/20XX Presentation Title 26
CULTURE
• The concept and distinction between mental
health and mental illness and the distinction
between physical and mental illness are highly
variable across cultures.
& Coping Styles
• Culture relates to how people cope with everyday
problems and more extreme types of adversity.

• E.g. Some Asian groups tend not to dwell on

upsetting thoughts (avoidance is better than
outward expression)

• African cultures tend to rely more on spirituality to

cope with adversity and symptoms of mental illness
 Culture
❖Refers to a group’s shared set of beliefs, norms, and values

❖Concepts of abnormality vary between cultures

❖Culture-bound syndromes: disorders that are thought to be culturally specific

▪ E.g. – Neurasthenia is common in China, but not even listed in the Western DSM-IV
▪ Culture-bound syndromes are now included in a special section of the DSM

❖Cultural and religious teachings often influence beliefs about the origins and nature of
mental illness, and shape attitudes towards the mentally ill.

❖Influences whether mentally ill individuals experience social stigma

▪ Can affect patients’ readiness and willingness to seek and adhere to treatment
 Cultural Outlooks
• India & Africa: mentally ill people are cursed and looked down on (Cohen,
1988)
• China only label individuals out of contact with reality as mentally ill because
of the stigma (Rack, 1982)
• Trinidad?
• Depression takes a primarily affective form in individualistic cultures –
Feelings of loneliness and isolation dominate these cultures (Marsella, 2003)
• Somatic symptoms are more dominant in collectivist cultures
• Cultural blindness: Difficulty ID-ing symptoms of a psychological disorder if
they are not the norm in the clinician’s own culture
• How to Avoid Cultural Bias
• Make efforts to learn about the culture of the people being assessed
• Bilingual patients should be assessed in both languages
• Symptoms of disorders should be discussed with practitioners of that culture
Significant Ways That Culture Influences
Mental Health
1. The individual’s own personal experience of the
illness and associated symptoms;
2. How they express their experience or describe
symptoms within the context of their cultural
norms
3. The meaning they impart on the illness
4. How the mental illness is treated and ultimately the
outcome of this treatment
Stigma
❑One of the most significant problems encountered by
people with mental health problems.

❑Discrimination may be obvious and direct or

unintentional/subtle

❑Makes learning to live with MHPs more difficult

❑Can lead to discrimination.

 The Harmful Effects Of Stigma

▪ Reluctance to seek help or treatment

▪ Lack of understanding by family, friends, co-workers or
others
▪ Fewer opportunities for work, school or social activities
▪ Trouble finding housing
▪ Bullying, physical violence or harassment
▪ Health insurance that doesn't adequately cover your
mental illness treatment
▪ -ve core beliefs regarding ability to succeed and thrive &
improve your health
Where it begins
Childhood references of “crazy” or
“weird”

Negative terms used commonly

throughout adulthood as well.

Negative stereotypes often

involve beliefs that MI people are
dangerous.

Fuelled by media stories without context

of the broad spectrum of mental illness.

Results in social distancing → social

isolation or loneliness
Self-Stigma or Internalised stigma
“occurs when a person cognitively or emotionally absorbs
stigmatizing assumptions and stereotypes about mental illness and
comes to believe and apply them to him- or herself”
Associated with negative outcomes:
• increased depression
• avoidant coping
• social avoidance
• decreased hope and self-esteem
• worsening psychiatric symptoms
• decreased persistence in accessing mental health services and
other supports
 Ways to challenge self stigma
• ͞Identify people who are positive and supportive in your life
and spend more time with them.
• ͞Take less notice of those who run ͞you down. ͞Make an effort to
notice and value your strengths.
• Do things that help you feel good about yourself. ͞
• Notice your negative internal voice or feelings and challenge
them with positive ones. ͞
• Voice your positive feelings. E.g. “I am a worthwhile person!” ͞
• Further educate yourself about self stigma. “Education is
argued to be helpful in reducing as well as preventing, self
stigma” (Watson and Corrigan 2001).
https://www.mentalhealth.org.nz/assets/ResourceFinder/individual-self-stigma-resource-card-4.pdf
9/3/20XX Presentation Title 36
 RELIGION and MENTAL HEALTH

• Complex
connection
between
religion
and mental
health

https://www.psychiatrictimes.com/view/religion-spirituality-and-mental-health
 Mental health
benefits of religion • Gives people something to believe in / Provides a sense of structure /
Offers a group of people to connect with over similar beliefs.

• Initiates social connections with other members

Community • Creates a sense of belonging to a group
• Offers trustworthy and safe social engagement

• Helps people to cope with difficult life situations (i.e. a ceremony for the
loss of a loved one)
Ritual • Provides structure, regularity and predictability
• Allows for time to rest as well as holidays and other special times of the
year

• Provides guidelines to live by (i.e. the importance of doing the right thing)
Teachings • Teaches compassion, forgiveness and gratitude
• Identifies life lessons, even from challenging situations
 Adverse Consequences of Religiosity
• Many outmoded rituals and belief
systems might inhibit positive growth
and may lead to mental ill-health

• Positive religious coping:

• Negative religious
coping:
– Passive waiting for God to
control the situation,
– Redefining the stressor as a
punishment from God or as
an act of the devil
– Questioning God's love
• Trying to find a lesson from God in the stressing
event,
• Doing what one can do and leave the rest in
God's hands,
• Seeking support from clergy/church members,
• Thinking about how one's life is part of a larger
spiritual force,
• Looking to religion for assistance to find a new
direction for living when the old one may no
longer be viable,
• Attempting to provide spiritual support and
comfort to others.