Mental disorder

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Mental disorder or mental illness are terms used to refer to a psychological or physiological pattern that occurs in an individual and is usually associated with distress or disability that is not expected as part of normal development or culture. The recognition and understanding of mental disorders has changed over time.

Definitions, assessments, and classifications of mental disorders can vary, but guideline criterion listed in the ICD, DSM and other manuals are widely accepted by mental health professionals. Categories of diagnoses in these schemes may include mood disorders, anxiety disorders, psychotic disorders, eating disorders, developmental disorders, personality disorders, and many other categories. In many cases there is no single accepted or consistent cause of mental disorders, although they are widely understood in terms of a diathesis-stress model and biopsychosocial model. Mental disorders have been found to be common, with over a third of people in most countries reporting sufficient criteria at some point in their life. Mental health services may be based in hospitals or in the community.

Mental health professionals diagnose individuals using different methodologies, often relying on case history and interview. Psychotherapy and psychiatric medication are two major treatment options, as well as supportive interventions.

Treatment may be involuntary where legislation allows. Several movements campaign for changes to mental health services and attitudes, including the Consumer/Survivor Movement. There are widespread problems with stigma and discrimination.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

A number of mental disturbances, such as melancholy, hysteria and phobia, were described long ago in Ancient Greece and Rome, while others such as schizophrenia may not have been recognized.^[1] Hippocrates considered the idea that mental illness may be related to biology.^[2]

Psychiatric theories and treatments for mental illness developed in Muslim psychology and Islamic medicine in the medieval Islamic world from the 8th century, where the first psychiatric hospitals were built.^[3] The Baghdad Hospital was run by the Persian physician Rhazes. Unlike most ancient and medieval societies which believed mental illness to be caused by either demonic possession or as punishment from a God, Islamic neuroethics held a more sympathetic attitude towards the mentally ill, as exemplified in Sura 4:5 of the Qur’an, which considers the mentally ill to be unfit to manage property but must be treated humanely and be kept under care by a guardian.^[4]

Medieval Europe had focused on demonic possession as the explanation of aberrant behavior.^[5] Paracelsus used the word lunatic to describe behavior thought to be caused by the lunar effect.^[6] Many other terms for mental disorder that found their way into everyday use have been traced to initial use in the 16th and 17th centuries. ^[7] Shakespeare and his contemporaries frequently depicted mental disorders in their plays. ^[8] Conditions of “shell shock” came to be recognized in war veterans. From the early study of mental illness through individuals such as Philippe Pinel, Sigmund Freud, and Alois Alzheimer, much has changed in the development and understanding of mental illness and continues to change today.

At the start of the 20th century there were only a dozen officially recognized mental health conditions.. By 1952 there were 192 and the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) today lists 374.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The definition and classification of mental disorder is a key issue for the mental health professions and for users and providers of mental health services. Most international clinical documents use the term “mental disorder” rather than “mental illness”. There is no single definition and the inclusion criteria are said to vary depending on the social, legal and political context. In general, however, a mental disorder has been characterized as a clinically significant behavioral or psychological pattern that occurs in an individual and is usually associated with distress, disability or increased risk of suffering. There is often a criterion that a condition should not be expected to occur as part of a person’s usual culture or religion. The term “serious mental illness” (SMI) is sometimes used to refer to more severe and long-lasting disorder. A broad definition can cover mental disorder, mental retardation, personality disorder and substance dependence. The phrase “mental health problems” may be used to refer only to milder or more transient issues.

There are currently two widely established systems that classify mental disorders – Chapter V of the International Classification of Diseases (ICD-10), produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be in use more locally, for example the Chinese Classification of Mental Disorders. Other manuals may be used by those of alternative theoretical persuasions, for example the Psychodynamic Diagnostic Manual.

Some approaches to classification do not employ distinct categories based on cut-offs separating the abnormal from the normal. They are variously referred to as spectrum, continuum or dimensional systems. There is a significant scientific debate about the relative merits of a categorical or a non-categorical system. There is also significant controversy about the role of science and values in classification schemes, and about the professional, legal and social uses to which they are put.

There are many different categories of mental disorder, and many different facets of human behavior and personality that can become disordered.^[1][2][3][4]

The state of anxiety or fear can become disordered, so that it is unusually intense or generalized over a prolonged period of time. Commonly recognized categories of anxiety disorders include specific phobia, Generalized anxiety disorder, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Post-traumatic stress disorder. Relatively long lasting affective states can also become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia or despair is know as Clinical depression (or Major depression), and may more generally be described as Emotional dysregulation. Milder but prolonged depression can be diagnosed as dysthymia. Bipolar disorder involves abnormally “high” or pressured mood states, known as mania or hypomania, alternating with normal or depressed mood. Whether unipolar and bipolar mood phenomena represent distinct categories of disorder, or whether they usually mix and merge together along a dimension or spectrum of mood, is under debate in the scientific literature.^[5]

Patterns of belief, language use and perception can become disordered. Psychotic disorders centrally involving this domain include Schizophrenia and Delusional disorder. Schizoaffective disorder is a category used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy is a category used for individuals showing some of the traits associated with schizophrenia but without meeting cut-off criteria.

The fundamental characteristics of a person that influence his or her cognitions, motivations, and behaviors across situations and time – can be seen as disordered due to being abnormally rigid and maladaptive. Categorical schemes list a number of different personality disorders, such as those classed as eccentric (e.g. Paranoid personality disorder, Schizoid personality disorder, Schizotypal personality disorder), those described as dramatic or emotional (Antisocial personality disorder, Borderline personality disorder, Histrionic personality disorder, Narcissistic personality disorder) or those seen as fear-related (Avoidant personality disorder, Dependent personality disorder, Obsessive-compulsive personality disorder).

There may be an emerging consensus that personality disorders, like personality traits in the normal range, incorporate a mixture of more acute dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable.^[6] Non-categorical schemes may rate individuals via a profile across different dimensions of personality that are not seen as cut off from normal personality variation, commonly through schemes based on the Big Five personality traits.^[7]

Other disorders may involve other attributes of human functioning. Eating practices can be disordered, at least in relatively rich industrialized areas, with either compulsive over-eating or under-eating or binging. Categories of disorder in this area include Anorexia nervosa and Bulimia nervosa or Binge eating disorder. Sleep disorders such as Insomnia also exist and can disrupt normal sleep patterns. Sexual and gender identity disorders, such as Dyspareunia or Gender identity disorder or ego-dystonic homosexuality. People who are abnormally unable to resist urges, or impulses, to perform acts that could be harmful to themselves or others, may be classed as having an impulse control disorder, including various kinds of Tic disorders such as Tourette’s Syndrome, and disorders such as Kleptomania (stealing) or Pyromania (fire-setting). Substance-use disorders include Substance abuse disorder. Addictive gambling may be classed as a disorder. Inability to sufficiently adjust to life circumstances may be classed as an Adjustment disorder. The category of adjustment disorder is usually reserved for problems beginning within three months of the event or situation and ending within six months after the stressor stops or is eliminated. People who suffer severe disturbances of their self-identity, memory and general awareness of themselves and their surroundings may be classed as having a Dissociative identity disorder, such as Depersonalization disorder or Dissociative Identify Disorder itself (which has also been called multiple personality disorder, or “split personality”.). Factitious disorders, such as Munchausen syndrome, also exist where symptoms are experienced and/or reported for personal gain.

Disorders appearing to originate in the body, but thought to be mental, are known as somatoform disorders, including Somatization disorder. There are also disorders of the perception of the body, including Body dysmorphic disorder. Neurasthenia is a category involving somatic complaints as well as fatigue and low spirits/depression, which is officially recognized by the ICD-10 but not by the DSM-IV.^[8] Memory or cognitive disorders, such as amnesia or Alzheimer’s disease exist.

Some disorders are thought to usually first occur in the context of early childhood development, although they may continue into adulthood. The category of Specific developmental disorder may be used to refer to circumscribed patterns of disorder in particular learning skills, motor skills, or communication skills. Disorder which appears more generalized may be classed as pervasive developmental disorders (PDD) also known as autism spectrum disorders (ASD); these include autism, Asperger’s, Rett syndrome, childhood disintegrative disorder and other types of PDD whose exact diagnosis may not be specified. Other disorders mainly or first occurring in childhood include Reactive attachment disorder; Separation Anxiety Disorder; Oppositional Defiant Disorder; Attention Deficit Hyperactivity Disorder.

In alphabetical order. ^{[9] [10]}

• Acute stress disorder
• Agoraphobia
• Generalized anxiety disorder
• Obsessive compulsive disorder
• Panic disorder
• Posttraumatic Stress Disorder
• Social phobia
• Specific phobia

• Asperger’s disorder
• Attention-Deficit disorder
• Autistic disorder
• Conduct disorder
• Oppositional defiant disorder
• Separation Anxiety Disorder
• Tourette’s syndrome

• Delirium
• Dementia in alcoholism
• Dementia of Alzheimer type
• Multi-infarct dementia
• Other dementia

• Anorexia Nervosa
• Bulimia Nervosa

• Bipolar Disorder
• Cyclothymic disorder
• Dysthymic disorder
• Major depressive disorder

• Antisocial personality
• Borderline personality
• Dependent personality
• Histrionic personality
• Obsessive-compulsive personality

• Brief psychotic disorder
• Delusional disorder
• Psychotic disorders
• Schizoaffective disorder
• Schizophreniform disorder
• Shared psychotic disorder

• Alcoholism
• Amphetamines
• Cannabis
• Cocaine
• Hallucinogens
• Inhalants
• Nicotine
• Opinoids
• Phencyclidines
• Sedatives

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In Chief: Marcelo R. Zacarkim, M.D. [2]

Numerous factors have been linked to the development of mental disorders. In many cases there is no single accepted or consistent cause. A common view is that disorders often result from genetic vulnerabilities combining with environmental stressors (Diathesis-stress model). An eclectic or pluralistic mix of models may be used to explain particular disorders. The primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial (BPS) model – incorporating biological, psychological and social factors – although this may not be applied in practice. Biopsychiatry has tended to follow a biomedical model, focusing on “organic” or “hardware” pathology of the brain. Psychoanalytic theories have been popular but are now less so. Evolutionary psychology may be used as an overall explanatory theory. Attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context for mental disorders. A distinction is sometimes made between a “medical model” or a “social model” of disorder and related disability.

Genetic studies have indicated that genes often play an important role in the development of mental disorders, via developmental pathways interacting with environmental factors. The reliable identification of connections between specific genes and specific categories of disorder has proven more difficult.

Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. There have been some tentative inconsistent links found to certain viral infections, to substance misuse, and to general physical health.

Abnormal functioning of neurotransmitter systems has been implicated, including serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity of certain brains regions in some cases. Psychological mechanisms have also been implicated, such as cognitive and emotional processes, personality, temperament and coping style.

Social influences have been found to be important, including abuse, bullying and other negative or stressful life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated, including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures.

• Anxiety disorders
• Anorexia
• Binge eating disorder
• Bulimia
• Depression
• Environmental stressors
• Eating disorders
• Illicit drugs use (cocaine, heroin, meth)
• Personality disorders
• Traumatic brain injury

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Mental disorder must be differentiated from other diseases such as autism spectrum disorder, communication disorders, and major and mild neurocognitive disorders.^[1]

• Autism spectrum disorder
• Communication disorders
• Major and mild neurocognitive disorders
• Specific learning disorders^[1]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

The prevalence of mental disorder is 1000 per 100,000 (1%) of the overall population.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Risk factors for mental disorder include brain malformation, hypoxic ischemic injury, and infections among others.^[1]

• Inborn errors of metabolism
• Brain malformations
• Maternal disease (including placental disease)
• Environmental influences (e.g., alcohol, other drugs, toxins, teratogens)

• Neonatal encephalopathy

• Hypoxic ischemic injury
• Traumatic brain injury
• Infections
• Demyelinating disorders
• Seizure disorders (e.g., infantile spasms)
• Severe and chronic social deprivation
• Toxic metabolic syndromes and intoxications (e.g., lead, mercury)^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

There is substantial variation over time between disorders, and between individuals. Functional ability may also vary across different domains. There may be remission of symptoms, but also relapse. Rates of recovery vary. A number of individual and social factors have been linked to prognosis.

Despite often being characterized in purely negative terms, mental disorders can involve above-average creativity, non-conformity, goal-striving, meticulousness, or empathy.The public perception of the level of disability associated with mental disorders can change.^[1]

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