Section Learning Objectives
- Define and exemplify classification.
- Define nomenclature.
- Define epidemiology.
- Define presenting problem and clinical description.
- Differentiate prevalence and incidence and subtypes of prevalence.
- Define comorbidity.
- Define etiology.
- Define course.
- Define prognosis.
- Define treatment.
- Explain the concept of stigma and its three forms.
- Define courtesy stigma.
- Describe what the literature shows about stigma.
1.2.1. Classification and Definitions
Classification is not a foreign concept and as a student, you have likely taken at least one biology class that discussed the taxonomic classification system of Kingdom, Phylum, Class, Order, Family, Genus, and Species revolutionized by Swedish botanist, Carl Linnaeus. You probably even learned a witty mnemonic such as ‘King Phillip, Come Out For Goodness Sake’ to keep the order straight. The Library of Congress uses classification to organize and arrange their book collections and includes such categories as B – Philosophy, Psychology, and Religion; H – Social Sciences; N – Fine Arts; Q – Science; R – Medicine; and T – Technology.
Simply, classification is the way in which we organize or categorize things. The second author’s wife has been known to color code her DVD collection by genre, movie title, and at times release date. It is useful for us to do the same with abnormal behavior and classification provides us with a nomenclature, or naming system, to structure our understanding of mental disorders in a meaningful way. Of course, we want to learn as much as we can about a given disorder so we can understand its cause, predict its future occurrence, and develop ways to treat it.
Epidemiology is the scientific study of the frequency and causes of diseases and other health-related states in specific populations such as a school, neighborhood, a city, country, or the entire world. Psychiatric or mental health epidemiology refers to the study of the frequency of occurrence of mental disorders in a population. In mental health facilities, we say that a patient presents with a specific problem, or the presenting problem, and we give a clinical description of it which includes information about the thoughts, feelings, and behaviors that constitute that mental disorder. We also seek to gain information about the occurrence of the disorder, its cause, course, and treatment possibilities.
Occurrence can be investigated in several ways. First, prevalence is the percentage of people in a population that has a mental disorder. It can also be conceptualized as the number of cases of the disorder per some number of people (usually 100). For instance, if 1 person out of 100 has schizophrenia, then the prevalence rate is 1% (or 1 in 100). Prevalence can be measured in several ways:
- Point prevalence indicates the percentage of a population that has the disorder at a specific point in time. In other words, it is the number of active cases at a given point in time.
- Period prevalence indicates the percentage of a population that has the disorder at any point during a given period of time, typically the past year (Note: when it is the past year it may also be referred to as the one-year prevalence).
- Lifetime prevalence indicates the percentage of a population that has had the disorder at any time during their lives.
According to the National Survey on Drug Use and Health (NSDUH), in 2015 there was an estimated 9.8 million U.S. adults aged 18 years or older with a serious mental illness, or 4% of all U.S. adults, and 43.4 million adults aged 18 years or older with any mental illness, or 17.9% of all U.S. adults.
Incidence indicates the number of new cases in a population over a specific period of time. This measure is usually lower since it does not include existing cases as prevalence does. If you wish to know the number of new cases of social phobia during the past year (going from say Aug 21, 2015 to Aug 20, 2016), you would only count cases that began during this time and ignore cases that emerged before the start date, even if people are currently afflicted with the mental disorder. Incidence is often studied by medical and public health officials so that causes can be identified and future cases prevented.
Comorbidity describes when two or more mental disorders are occurring at the same time and in the same person. The National Comorbidity Survey Replication (NCS-R) study conducted by the National Institute of Mental Health (NIMH) and published in the June 6, 2005 issue of the Archives of General Psychiatry, sought to discover trends in prevalence, impairment, and service use during the 1990s. It revealed that 45% of those with one mental disorder met the diagnostic criteria for two or more disorders. The authors also found that the severity of mental illness, in regards to disability, is strongly related to comorbidity and that substance use disorders often result from disorders such as anxiety and bipolar mood disorders. The implications of this are substantial as services to treat substance abuse and mental disorders are often separate, despite their appearing together.
The etiology is the cause of the disorder. As you will see later in this textbook, there is no single cause of any mental disorder. Rather, there are multiple factors that contribute to increase a person’s susceptibility to developing a mental disorder. These factors include social, biological, or psychological explanations which need to be understood to identify the appropriate treatment. Likewise, the effectiveness of a treatment may give some hint at the cause of the mental disorder. More on this later.
The course of the disorder is its particular pattern. A disorder may be chronic, meaning it lasts a long period of time, episodic, meaning the disorder comes and goes (i.e., individuals tend to recover only to have later reoccurrences). Disorders can also be classified as time-limited, meaning that recovery will occur in a short period of time regardless of whether any treatment occurs.
Prognosis is the anticipated course the mental disorder will take. A key factor in determining the course is age, with some disorders presenting differently in childhood than adulthood.
Finally, we will discuss several treatment strategies in this book in relation to specific disorders, and in a general fashion in Module 3. Treatment is any procedure intended to modify abnormal behavior into normal behavior. The person with the mental disorder seeks the assistance of a trained professional to provide some degree of relief over a series of therapy sessions. The trained mental health professional may utilize psychotherapy and/or medication may be prescribed to bring about this change. Treatment may be sought from the primary care provider (e.g., medical doctor), in an outpatient fashion with a clinical psychologist or psychiatrist, or through inpatient care or hospitalization with at a mental hospital or psychiatric unit of a general hospital.
1.2.2. The Stigma of Mental Disorders
In the previous section, we indicated that care can be sought out in a variety of ways. The problem is that many people who need care never seek it out. Why is that? We already know that society dictates what is considered abnormal behavior through culture and social norms, and you can likely think of a few implications of that. But to fully understand society’s role in why people do not seek care, we need to consider the stigma that is often attached to the label mental disorder.
Stigma refers to when negative stereotyping, labeling, rejection, and loss of status occur. Stigma often takes on three forms as described below:
- Public stigma – when members of a society endorse negative stereotypes of people with a mental disorder and discriminate against them. They might avoid them altogether resulting in social isolation. An example is when an employer intentionally does not hire a person because their mental illness is discovered.
- Label avoidance – In order to avoid being labeled as “crazy” people needing care may avoid seeking it all together or stop care once started. Due to these labels, funding for mental health services could be restricted and instead, physical health services funded.
- Self-stigma – When people with mental illnesses internalize the negative stereotypes and prejudice, and in turn, discriminate against themselves. They may experience shame, reduced self-esteem, hopelessness, low self-efficacy, and a reduction in coping mechanisms. An obvious consequence of these potential outcomes is the why try effect, or the person saying, ‘Why should I try and get that job? I am not unworthy of it’ (Corrigan, Larson, & Rusch, 2009; Corrigan, et al., 2016).
Another form of stigma that is worth noting is that of courtesy stigma or when stigma affects people associated with the person with a mental disorder. Karnieli-Miller et. al. (2013) found that families of the afflicted were often blamed, rejected, or devalued when others learned that one of their family members had a serious mental illness. Due to this, they felt hurt and betrayed and an important source of social support during the difficult time had been removed, resulting in greater levels of stress. To cope, they had decided to conceal their relative’s illness and some parents struggled to decide whether it was their place to disclose information about their child’s mental illness or their child’s place to do so. Others fought with the issue of confronting the stigma through attempts at education or to just ignore it due to not having enough energy or a desire to maintain personal boundaries. There was also a need to understand responses of others and to attribute those responses to a lack of knowledge, experience, and/or media coverage. In some cases, the reappraisal allowed family members to feel compassion for others rather than feeling put down or blamed. The authors concluded that each family “develops its own coping strategies which vary according to its personal experiences, values, and extent of other commitments” and that the “coping strategies families employ change over-time.”
Other effects of stigma include experiencing work-related discrimination resulting in higher levels of self-stigma and stress (Rusch et al., 2014), higher rates of suicide especially when treatment is not available (Rusch, Zlati, Black, and Thornicroft, 2014; Rihmer & Kiss, 2002), and a decreased likelihood of future help-seeking (Lally et al., 2013). The results of the latter study also showed that personal contact with someone with a history of mental illness led to a decreased likelihood of seeking help. This is important because 48% of the sample stated that they needed help for an emotional or mental health issue during the past year but did not seek help. Similar results have been reported in other studies (Eisenberg, Downs, Golberstein, & Zivin, 2009). It is important to also point out that social distance, a result of stigma, has also been shown to increase throughout the lifespan, suggesting that anti-stigma campaigns should focus primarily on older people (Schomerus, et al., 2015).
One potentially disturbing trend is that mental health professionals have been shown to hold negative attitudes toward the people they serve. Hansson et al. (2013) found that staff members at an outpatient clinic in the southern part of Sweden held the most negative attitudes about whether an employer would accept an applicant for work, willingness to date a person who had been hospitalized, and hiring a patient to care for children. Attitudes were stronger when staff treated patients with psychosis or in inpatient settings. In a similar study, Martensson, Jacobsson, and Engstrom (2014) found that staff had more positive attitudes towards persons with mental illness if their knowledge of such disorders is less stigmatized, their workplaces were in the county council – as they were more likely to encounter patients who recover and return to normal life in society compared to municipalities where patients have long-term and recurrent mental illness -, and they have or had one close friend with mental health issues.
To help deal with stigma in the mental health community, Papish et al. (2013) investigated the effect of a one-time contact-based educational intervention compared to a four-week mandatory psychiatry course on the stigma of mental illness among medical students at the University of Calgary. The course included two methods involving contact with people who had been diagnosed with a mental disorder – patient presentations or two, one-hour oral presentations in which patients shared their story of having a mental illness; and “clinical correlations” in which students are mentored by a psychiatrist while they directly interacted with patients with a mental illness in either inpatient or outpatient settings. Results showed that medical students did hold stigmatizing attitudes towards mental illness and that comprehensive medical education can reduce this stigma. As the authors stated, “These results suggest that it is possible to create an environment in which medical student attitudes towards mental illness can be shifted in a positive direction.” That said, the level of stigma was still higher for mental illness than it was for a stigmatized physical illness, type 2 diabetes mellitus.
What might happen if mental illness is presented as a treatable condition? McGinty, Goldman, Pescosolido, and Barry (2015) found that portraying schizophrenia, depression, and heroin addiction as untreated and symptomatic increased negative public attitudes towards people with these conditions but when the same people were portrayed as successfully treated, the desire for social distance was reduced, there was less willingness to discriminate against them, and belief in treatment’s effectiveness increased.
Self-stigma has also been shown to affect self-esteem, which then affects hope, which then affects the quality of life of people with serious mental illnesses. As such, hope should play a central role in recovery (Mashiach-Eizenberg et al., 2013). Narrative Enhancement and Cognitive Therapy (NECT) is an intervention designed to reduce internalized stigma and targets both hope and self-esteem (Yanos et al., 2011). The intervention replaces stigmatizing myths with facts about the illness and recovery which leads to hope in clients and greater levels of self-esteem. This may then reduce susceptibility to internalized stigma.
Stigma has been shown to lead to health inequities (Hatzenbuehler, Phelan, & Link, 2013) prompting calls for change in stigma. Targeting stigma leads to two different agendas. The services agenda attempts to remove stigma so the person can seek mental health services while the rights agenda tries to replace discrimination that “robs people of rightful opportunities with affirming attitudes and behavior” (Corrigan, 2016). The former is successful when there is evidence that people with mental illness are seeking services more or becoming better engaged, while the latter is successful when there is an increase in the number of people with mental illnesses in the workforce and receiving reasonable accommodations. The federal government has tackled this issue with landmark legislation such as the Patient Protection and Affordable Care Act of 2010, Mental Health Parity and Addiction Equity Act of 2008, and the Americans with Disabilities Act of 1990. However, protections are not uniform across all subgroups due to “1) explicit language about inclusion and exclusion criteria in the statute or implementation rule, 2) vague statutory language that yields variation in the interpretation about which groups qualify for protection, and 3) incentives created by the legislation that affect specific groups differently” (Cummings, Lucas, and Druss, 2013).