Mental disorder

• 1. Introduction

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  A mental disorder carries many names. It is also called a mental illness, a mental health condition, or a psychiatric disability. At its core it is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. The disturbance touches a person's cognition, emotional regulation, or behavior, often inside a social context. Such disturbances may arrive as single episodes. They may persist. They may relapse and remit in turns. Worldwide, more than one in three people in most countries meet the criteria for at least one such condition at some point in their life. In the United States, that figure reaches 46 percent. Yet the causes are often unclear, and the very definition has been fought over for centuries. How does a society decide where ordinary suffering ends and disorder begins? Who holds the authority to draw that line? And what happens to the people standing on the wrong side of it?

• 2. Drawing The Line

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  The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1994, conceded that mental disorder "lacks a consistent operational definition that covers all situations". That admission sits at the heart of a long debate. For a mental state to count as a disorder, it generally needs to cause dysfunction. The DSM-IV definition tied disorder to distress, disability, increased risk of death, or significant loss of autonomy. It deliberately excluded normal grief from the loss of a loved one. It also excluded deviant behavior arising from political, religious, or societal reasons rather than from dysfunction in the individual. In 2013 the American Psychiatric Association redefined the term in the DSM-5 as a syndrome reflecting dysfunction in the psychological, biological, or developmental processes underlying mental functioning. The final draft of ICD-11 offered a very similar definition. Scholars still split into camps. One extreme holds that disorder is entirely a matter of value judgements about what is normal. Another proposes it could be entirely objective and scientific. Common hybrid views call the concept a "fuzzy prototype" that can never be precisely defined. Edward Shorter, a professor of psychiatry and the history of medicine, argued in 2013 for reviving the old idea of nervous illness, writing that "the nervous patients of yesteryear are the depressives of today".

• 3. The Manuals And The Map

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  The International Classification of Diseases places mental disorders in Chapter 06, covering mental, behavioural or neurodevelopmental disorders. The latest edition, ICD-11, has been in effect since the 1st of January 2022. The American Psychiatric Association has produced its rival manual since 1952, with the DSM-5-TR released in 2022. Both list categories of disorder and provide standardized criteria, and recent revisions deliberately converged their codes so the manuals are often broadly comparable. The categorical approach has critics. The high degree of comorbidity between disorders, where one person meets the criteria for several, pushed some researchers toward dimensional models instead. Studies of comorbidity revealed two latent dimensions: internalizing disorders such as mood or anxiety symptoms, and externalizing disorders such as behavioral or substance use symptoms. A single general factor of psychopathology, similar to the g factor for intelligence, has been empirically supported. The p factor model adds a third dimension of thought disorders such as schizophrenia. A leading dimensional framework is the Hierarchical Taxonomy of Psychopathology. Some neurologists argue that classification will only be reliable and valid when based on neurobiological features rather than clinical interview.

• 4. The Many Faces

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  Anxiety disorders are anxiety or fear that interferes with normal functioning, spanning specific phobias, generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, and post-traumatic stress disorder. Obsessive-compulsive disorder was filed among anxiety disorders in DSM-III, published in 1980, then moved to its own section in DSM-5. Mood disorders gather their own family. Major depression involves unusually intense and sustained sadness, while a milder but prolonged version is diagnosed as dysthymia. Bipolar disorder, also known as manic depression, swings between mania or hypomania and normal or depressed moods. Psychotic disorders such as schizophrenia and delusional disorder dysregulate belief, language, and perception of reality. Schizoaffective disorder captures people showing aspects of both schizophrenia and affective disorders. The catalogue runs far wider. Sleep disorders include insomnia, narcolepsy, and sleep apnea, the last diagnosed at home or with polysomnography at a sleep center. Impulse control disorders include kleptomania and pyromania. Dissociative disorders include dissociative identity disorder, once called multiple personality disorder. A run of uncommon syndromes carries the names of those who first described them, among them Capgras syndrome, Cotard delusion, Othello syndrome, and Ganser syndrome.

• 5. The Weight Of Disability

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  Unipolar depressive disorder ranks as the third leading cause of disability worldwide, of any condition mental or physical, accounting for 65.5 million years lost. Disability-adjusted life years measure how many years of life are lost to premature death or to poor health, and psychiatric disabilities rank among the most disabling conditions by that yardstick. Alcohol-use disorder follows at 23.7 million years, schizophrenia at 16.8 million, and bipolar disorder at 14.4 million. The first systematic description of global disability arising in youth, in 2011, found that among 10- to 24-year-olds nearly half of all disability was due to psychiatric conditions, including substance use and self-harm. Accidental injuries, mainly traffic collisions, came second at 12 percent. In high-income countries, unipolar major depression accounted for 20 percent of that youth disability and alcohol use disorder for 11 percent. Suicide, often attributed to an underlying mental disorder, is a leading cause of death among teenagers and adults under 35. There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide. Disability here is not purely negative. Some traits labeled as psychiatric disabilities can also involve above-average creativity, non-conformity, goal-striving, meticulousness, or empathy.

• 6. Roots And Triggers

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  Twin studies have revealed a very high heritability for many mental disorders, especially autism and schizophrenia. The predominant view is that genetic, psychological, and environmental factors all contribute, with risk reaching as early as the prenatal period. Decades of searching have not yet yielded specific genetic biomarkers that might sharpen diagnosis or treatment. Statistical research on eleven disorders found widespread assortative mating, meaning people with a disorder were two to three times more likely than the general population to have a partner with a mental disorder. People with autism were 10 times more likely to have a spouse with the same condition. Environment leaves its own marks. Unwanted pregnancy, maternal stress, birth complications, abuse, neglect, bullying, and traumatic events all raise risk. For schizophrenia and psychosis, the listed factors include migration, discrimination, childhood trauma, bereavement, recreational drug use, and urbanicity. Drug use threads through the picture, with cannabis, cocaine, and amphetamines linked to the development of psychosis and schizophrenia. Adolescents face heightened risk, and peer pressure is the main reason they start using substances. People living with chronic conditions like HIV and diabetes also stand at higher risk. The biopsychosocial model, drawing on biological, psychological, and social factors, is said to be the primary paradigm of contemporary mainstream Western psychiatry.

• 7. Doubt Within The Profession

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  Since the 1980s, Paula Caplan has warned about the subjectivity of psychiatric diagnosis and people being arbitrarily "slapped with a psychiatric label". Because the practice is unregulated, she argues, doctors are not required to spend much time interviewing patients or to seek a second opinion. The challenges run deeper than one critic. In 2013 the psychiatrist Allen Frances wrote a paper titled "The New Crisis of Confidence in Psychiatric Diagnosis", arguing that diagnosis "still relies exclusively on fallible subjective judgments rather than objective biological tests". For years, figures like Peter Breggin and Thomas Szasz accused psychiatry of the systematic medicalization of normality. A 2002 editorial in the British Medical Journal warned of inappropriate medicalization leading to disease mongering, where the boundaries of illness expand to swallow personal problems. The term anti-psychiatry itself was coined by the psychiatrist David Cooper in 1967. The most influential figure in that movement was R.D. Laing, author of The Divided Self, while Thomas Szasz wrote The Myth of Mental Illness. Some ex-patient groups turned militantly anti-psychiatric, often calling themselves survivors. In 2018 the American Psychological Association commissioned a review on whether modern MRI and fMRI could diagnose mental health disorders, requiring any biomarker to show at least 80 percent sensitivity and 80 percent specificity. The review concluded that the necessary large studies were not yet available.

• 8. Stigma And The Self

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  In 1999 the US Surgeon General declared that "Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others". The history behind that warning is brutal. In 2016 the researcher Wulf Rössler wrote that for millennia society did not treat sufferers of depression, autism, or schizophrenia much better than slaves or criminals, often imprisoning, torturing, or killing them. Perceptions still vary sharply across cultures. Most Africans view mental disturbance as an external spiritual attack, and the WHO estimated that fewer than 10 percent of mentally ill Nigerians have access to a psychiatrist or health worker in a country of 200 million people. In Latin American communities, especially among older people, discussing mental health can bring embarrassment and shame to the family, which lowers the number seeking treatment. In Taiwan, the public often attributes mental health issues to excessive worry, too much free time, or mental weakness. Employment discrimination drives high unemployment among those diagnosed, and an Australian study found psychiatric disability a bigger barrier to work than physical disability. To counter the silence, the Carter Center created fellowships for journalists in South Africa, the United States, and Romania, an effort begun by former US First Lady Rosalynn Carter to train reporters to discuss mental illness sensitively and to multiply the stories told.