Mental Health in Adult Life

(11-11-16)

Attempts to define mental health and mental illness

standards of behavior vary over time and cultures; and what is viewed as well adjusted or disturbed is, to some extend, situational
- Birren and Renner (1980) argued that mentally health people possessed several characteristics:
- positive attitude toward self
- accurate perception of reality
- mastery of the environment
- autonomy
- personality balance
- growth or self-actualization
- note that this view is consistent with a “Western” philosophy with emphasis on the individual; a number of “Eastern” cultures would place more emphasis on successful integration into the group, working toward the wellbeing of the group (family, society), and finding meaning/fulfillment by being a contributing part of the group; i.e., less individual rights and needs and more individual responsibilities and obligations
conceptualizations of mental illness
- Standards of difference: on what basis do we judge someone to be abnormal?
  - Relative standards: vary with culture, society, time
    - Distress–pain & suffering [DSM 5]
      - but, not all deviant behavior causes distress: alcoholic, drug addict, psychopath, delinquent, severe dementia
    - Functional–impairment & limitation [DSM 5]
      - but, who gets to say what’s functional and what’s not (individual, parents, society)
    - Sociological–violating rules (deviance)
    - but, the rules vary from culture to culture
      - but, the rules vary from culture to culture
        
        formal rules (laws, ethical codes)
        
        informal rules (mores, folkways)
    - Mathematical or Statistical–unusual
      - but, what is rare varies from culture to culture
    - Tolerance–bothers us (the audience)
      - Leo Kanner spoke of the “annoyance threshold of the child’s environment; we could extend this to our adult world as well
      - but, some of us are more tolerant than others, and our tolerance may vary toward different groups
  - Absolute standards: universal
    - Idealistic: efforts to define mental health
    - Pathogonomic: behaviors that would always signify psychopathology
- The nature of the abnormality: how are the exceptional different from the rest of us?
  - categorical–qualitative difference (difference is of kind)
  - dimensional–quantitative difference (difference is of degree)
- Level of analysis: what do we pay attention to?
  - symptom or sign: a behavior, an action, a characteristic
  - syndrome: a pattern of symptoms
  - disorder: a syndrome that persists and has negative consequences
  - disease: a disorder that where we fully understand the mechanisms
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM 5) (APA, 2013)
- defines a Mental Disorder as a pattern of behavior that causes either significant “personal distress and suffering” or significant “functional impairment”
- assessment and treatment of serious emotional disturbance remains a major issue for our society, especially in older population groups

Major mental disorders in adults

“medical student’s disease”: hearing about patterns of psychopathology causes us to notice that “I’m just like that, that must be what’s wrong with me [because, of course, there’s always something wrong with you].”
- differences between “life” and “mental illness”
  - intensity, frequency, pervasiveness
  - impact (severity)
- most of you don’t have mental disorders (most of the time)
the CDC (Centers for Disease Control and Prevention) reported that during 2007/2008 approximately 5% of ambulatory care visits in the U.S. involved patients with diagnosis of a mental disorder; most of these were classified with depression, psychosis, or anxiety disorders (Reeves, W.C., et al., 2011)
NIMH prevalence data: http://nimh.nih.gov/statistics/SMI_AASR.shtml
- In a telephone survey of 9,585 respondents older adults (age 65 and older) usually report lower frequencies (8% vs. 15% for each of the younger two groups) of mental disorders than young (18-29) and middle aged (30-64) adults, and also perceived less need for services (Klap, et al., 2003)

Mental Disorders: syndromes and disorders

Substance Use Disorders: difficulties arising from our use or abuse of mood altering substances
- tobacco
- alcohol
- everything else (prescription medications, illicit drugs, hallucinogens, other substances)
  - misuse of prescription medications
    - illicit drugs
  - changing standards: medicinal marijuana
- two conflicting trends can be seen in research on substance abuse across the adult life span:
  - overall rates of substance abuse drop in successive age groups
  - the “baby boom bubble” inflates the prevalence of successive age prevalence figures as this cohort moves through life
Anxiety Disorders: patterns of difficulty related to threats and our sensitivity to threats
- the anxiety response: our response to (perceived) threat
  - physiological aspects of anxiety: arousal of sympathetic branch of autonomic nervous system
  - behavioral aspects of anxiety: escape and avoidance, anxiety is aversive and reduction of anxiety will negatively reinforce behavior
  - cognitive aspects of anxiety: narrowing of cognitive focus, decreased concentration (on nonfeared stimuli), decreased memory, decreased problem solving
  - phenomenological aspects of anxiety: dread, negative evaluation, perceived threat (physiologically fear and excitement are pretty much indistinguishable)
- anxiety diagnoses:
  - Generalized Anxiety Disorder: chronic over arousal
  - Panic Disorders and Agoraphobia: episodic experiences of extreme terror, which may become associated with environmental cues and lead to extreme avoidance behavior
  - Phobias: “a special form of fear” (Isaac Marks)
  - Obsessive-Compulsive Disorder: intrusive thoughts (obsessions) and anxiety reducing actions (compulsive rituals)
  - stress and trauma disorders
    - Adjustment Disorder: transient situational disturbances
    - Posttraumatic Stress Disorder: a characteristic pattern (chronic over arousal, diminished emotional responsiveness, intrusive recollections, and avoidance) seen after catastrophic stress and threats to survival or personal integrity
      - soldier’s heart, shell shock, battle fatigue, combat neurosis, rape survivor syndrome, PTSD
    - elder abuse & caretaker abuse
  - other categories of mental disorder that in the past were grouped with anxiety disorders:
    - Somatoform disorders: fears of illness, preoccupation with bodily features or symptoms, “mind-body” interactions
    - Dissociative disorders: disorders involving a functional impairment of memory or identity
Mood Disorders: discongruiety between our experience of positive/negative emotions and the current circumstances of our life
- depressive disorders: a pattern of symptoms (sustained dysphoric mood or anhedonia plus other characteristics of depressed mood)
- bipolar disorders (mania and depression): periods of abnormally elevated mood, usually alternating with normal mood and with depression
- while anxiety disorders are more common in the general population, more attention is probably focused on mood disorders
  - the balance between functional impairment versus distress: mood disorder may be more debilitating
  - associated risk of suicide is high with both anxiety and mood disorders (and higher with substance abuse disorders) but public perception associates suicide with depression
  - somewhat less problematic pharmacological treatments are available for mood disorders; and behavioral and cognitive treatments are more uniformly successful for mood disorders than many anxiety disorders
  - anxiety disorders are relatively static (except possible OCD) and remission with successful treatment (drug or psychotherapy or combination) is relatively stable; mood disorders tend to be cyclical (which further complicates adjustment) and relapse/reoccurrence prevention is a major challenge
- The rate of severe depression declines from young adulthood to older age (for physically healthy individuals) (Gatz, 2000; NIMH, 2008)
  - in the U.S. fewer than 5% of adults living in the community show signs of depression, but the rate climbs to 13% among those who require home health care (NIMH 2008); depression often occurs in association with other conditions (diabetes, cancer, recent heart attack)
Psychotic Disorders: disturbances in our “higher” perceptual, evaluative, and motivational systems
- Schizophrenia: disturbances in reality testing (positive symptoms such as hallucinations, delusions), disturbances in cognitive processing (positive symptoms such as cognitive disrailments, looseness of associations, impaired attention and memory), disturbances in motivation (negative symptoms such as anhedonia, amotivational syndrome, alogia)
  - schizophrenia usually begins in late adolescence and early adulthood, initial onset after middle age is very unusual
- Delusional Disorder (Paranoia): exaggerated false beliefs
- other psychotic disorders
Cognitive Disorders: disturbances in basic cognitive functions
- Delirium, Dementia, and Depression are sometimes characterized as “the big three” in senior citizens (Cavanaugh & Blanchard-Fields, 2011, p. 367)
- Delirium: change in level of consciousness and cognition developing over a short period of time
- Dementia: loss of higher cognitive functions, usually beginning with memory and at least one other area of cognitive ability
other mental disorders
- Eating disorders
- Sleep disorders: dysomnias and parasomnias
  - insomnia
  - sleep apnea
    - CPAP (continuous positive airway pressure) devices
  - restless leg syndrome
- Sexual disorders
  - sexual dysfunctions
  - sexual paraphias (perversions)
  - gender dysphoria
- Impulse control disorders
- Personality disorders: extreme personality traits that are manifested repeatedly across almost all situations (inflexible, rigid, habitual patterns of thought, feeling, behavior that are excessively employed to deal with life’s challenges)
  - some personality disorder (borderline, antisocial) appear to modulate or become less severe with age, cause or causes are debated
Suicide, a special problem
- On the wisdom of being careful about numbers and the interpretation of numbers
- Suicide is the 10th leading cause of death in the U.S. population
  - Suicide is the 3rd leading cause of death among persons aged 10-14
  - fourth leading cause of death among persons aged 15-34
  - 5th leading cause of death among persons aged 45-54
  - 8th leading cause of death among persons 55-64
  - 17th leading cause of death among person 65 years and older
- Despite this decreasing cause of death rate, risk of death from suicide increases across the life span, until the very end of life where the individual may have decreased power of self-determination (living in a residential care facility, close monitoring by family and/or health care providers, decreased physical and mental capabilities)
- suicide is a broad concept:
  - spectrum of “suicidal” behavior:
  - suicide ideation, planning for suicide (precursor behavior), suicide attempts, and death from suicide
  - in 2015 approximately 8% of full time college students (adults aged 18-22) reported having had suicidal thoughts in the past year
  - in 2015 approximately 0.9% of full time college students (adults aged 18-22) reported having made a suicide attempt in the past year
  - in 2015 approximately 0.3% of full time college students (adults aged 18-22) received medical attention as a result of a suicide attempt in the previous 12 months
  - in 2014 approximately 69 college students died due to suicide (this was the reported figure but not all suicide deaths are reported)
    - an estimated rate of 7 deaths by suicide per 100,000 students is cited
    - a campus of 10,000 students would see a student suicide every 2-3 years (ISU would expect a student suicide approximately every 1 to 1.5 years)
      - (also: what is considered a “full time” college student?; do suicides off campus count?; what about a student who has just dropped out or been expelled?)
  - most suicide attempts and deaths are acts of crisis: escaping from intolerable situation vs. a positive motivation to die
    - versus: “rational suicides”
    - versus: suicide as a terrorist act
    - most individuals who commit suicide have a diagnosable mental health condition (depression, bipolar disorder, anxiety disorder, substance abuse/dependence)
  - suicide intent (motivation) is variable and changeable in most individual who attempt suicide (and we suspect in most individual who die of suicide); intent is difficult to assess but is suspected to be a very powerful predictive variable
    - the population of individuals who attempt suicide may be significantly different than the population of individuals who die due to suicide
    - most individuals who survive a suicide attempt are judged to be nonsuicidal with a short period of time, the majority of individuals who survive a suicide attempt report being content/glad/OK with having survived within 24 hours of being medically stabilized
    - many (some suggest most) who die of suicide do so on their first and only attempt, but–repeated attempts are a risk factor for death
  - access to means, alcohol/drug use, feeling hopeless and helpless, and disruption of important communication/human relationships are proximal predictors of suicide attempts and completed (“successful”) suicides
  - nonsuicidal self-injurious behavior (deliberate self-harm; cutting, burning, hitting walls) is a distal risk factor for suicide attempts (and possible death)
  - many status/demographic variable are distal risk factors for suicide attempts and death (sex, age, occupation, ethnic background, religion of upbring, employment status, medical illness, chronic pain, mental illness)
  - “always remember and never forget”: beware of sweeping generalities, they may be both truthfully by conveying modal generalities and, at the same time, obscure individual truths
    - Is it any of our business to try and prevent suicide in [mentally competent] adults?

Treatment of mental disorders in adults

psychotherapy
- overall there is support for the effectiveness of counseling approaches to many forms of emotional and behavior disturbance in adults
- there remains considerable debate and disagreement on why therapies work
- there are many forms of counseling
- there is limited empirical demonstration of the superiority of particular therapies or the specificity of particular therapies for particular problems (an exception to this may be the necessity and sufficiency of exposure treatments of anxiety, fears, compulsive behavior, severe trauma reactions)
  - behavioral and cognitive-behavioral treatments have the largest body of empirically validated results (but this may reflect more characteristics of these approaches that make them amenable to research)
  - so called “common factors” account for most of the variance in outcome studies
    - warmth, empathy, and support from the therapist; structured/meaningful activity; meaningful reframing of the problem that facilitates resolution
- there is emerging support for the prophylactic usefulness of mindfulness meditation in prevention of major depression relapse (not treatment but prevention/mineralization of future episodes)
pharmacotherapy
- supportive research is strongest for controlling symptoms in severe mental illnesses; research is support is more limited for milder problems and for maintenance
  - neuroleptic (antipsychotic) medications
  - antidepressant medications
  - mood regulating medications
  - anxiolytic (anti-anxiety) medications
  - stimulant medications
- polypharmacy has become the rule rather than the exception
- sensitivity to medications often increase with advancing age
  - side effects
  - drug interactions
  - over the counter medications
- compliance
  - forgetting to take medications
  - failure to follow medical directions
other biological treatments
- electroconvulsive therapy of depression (ECT, EIS, “shock treatment”): uses electrical current to induce seizure activity in the brain to treat severe depression
- transcranial magnetic stimulation (TMS) is a procedure that uses magnetic fields to stimulate nerve cells in the brain to treat depression
- intracranial neurostimulation
- neurosurgery
adjunctive therapies
- exercise
- meditation
- speech and language therapy
- physical therapy
- music therapy
- support groups