Mental Disorders: Understanding their Complexity and Impact

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and its successor, the Fifth Edition (DSM-V), have faced criticism for creating an excessive number of diagnostic categories that blur the line between psychopathology and normal psychological phenomena. Both manuals emphasize the inherent challenges in distinguishing normality from psychopathology. The DSM-IV defines mental disorders as: A) a clinically significant behavioral or psychological syndrome or pattern occurring in an individual; B) associated with distress, disability, or a significantly increased risk of suffering death, pain, disability, or important loss of freedom; C) not merely an expectable and culturally sanctioned response to a particular event; D) a manifestation of behavioral, psychological, or biological dysfunction; and E) not solely deviant behavior or conflicts primarily between the individual and society, unless symptomatic of a dysfunction in the individual.

The DSM-V refines this definition, describing a mental or psychiatric disorder as: A) a behavioral or psychological syndrome or pattern occurring in an individual; B) causing clinically significant distress or disability; C) not merely an expectable response to common stressors or a culturally sanctioned event; D) reflecting an underlying psychobiological dysfunction; E) not solely a result of social deviance or conflicts with society; F) having diagnostic validity using one or more sets of diagnostic validators; and G) possessing clinical utility. Despite these detailed criteria, ambiguity remains regarding the classification of certain disorders as mental diseases and their distinguishing characteristics. This paper delves into the nature of mental disorders, with a focus on specific disorders such as anxiety, obsessive-compulsive disorder (OCD), and related conditions.

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder (OCD) is characterized by obsessions, which are persistent thoughts, urges, or images experienced repeatedly, intrusively, and anxiously, and compulsions, which are repetitive, rigid behaviors or mental acts performed to prevent or reduce anxiety. A global survey among OCD experts, using the email addresses of 303 corresponding authors of OCD-related papers published between 1996 and 2006, sought expert consensus on the classification of OCD. Approximately 60 percent agreed that OCD should be removed from the category of anxiety disorders, while 40 percent disagreed. If a new OCD Spectrum Disorders category were created, experts favored a narrow inclusion of Body Dysmorphic Disorder (72% agreement), Trichotillomania (70% agreement), Tic Disorders (61% agreement), and Hypochondriasis (57% agreement).

Cognitive assessments of OCD highlight the importance of beliefs, appraisals, and cognitive processes in its etiology and maintenance. Various assessment methods, including idiographic techniques, information processing paradigms, and self-report measures, suggest that six belief domains are critical in OCD: inflated responsibility, over-importance of thoughts, excessive concern about controlling thoughts, overestimation of threat, intolerance of uncertainty, and perfectionism. OCD and related disorders are prevalent in Western society, often manifesting in childhood or adolescence, with a higher diagnosis rate in women than men at a 2:1 ratio. To be classified as having OCD, individuals must experience recurrent obsessions, compulsions, or both, consuming significant time and causing distress or impairment. Adherence to routines provides comfort for many sufferers, with 40 percent reporting irritation if routines are disrupted.

Freud's psychodynamic theory suggested that OCD is expressed through overt thoughts and actions, with "Id impulses" equating to obsessive thoughts and "Ego defenses" to compulsive actions, linking OCD to the anal stage of development. However, not all psychodynamic theorists agree. Psychodynamic therapies aim to uncover and resolve underlying conflicts through techniques like free association and interpretation. Behaviorists focus on treating compulsions through exposure and response prevention, where clients face anxiety-inducing thoughts or situations and are prevented from performing compulsive acts.

Cognitive theorists propose that everyone experiences unwanted, intrusive thoughts, but individuals with OCD may blame themselves, fearing disastrous consequences. They often hold high moral standards, equating thoughts with actions, and believe in perfect control over thoughts and behaviors. Therapy may include psychoeducation and efforts to help clients identify, challenge, and change distorted cognitions. Research suggests that combining cognitive and behavioral models is more effective than either approach alone.

Biologically, OCD involves abnormal serotonin activity and brain structure/functioning. OCD is linked to structures like the orbitofrontal cortex, caudate nuclei, thalamus, amygdala, and cingulate cortex. Some structures may be overactive in people with OCD, with serotonin and other neurotransmitters (glutamate, GABA, dopamine) playing key roles. Abnormal neurotransmitter activity could contribute to circuit dysfunction. Serotonin-based antidepressants can help rebalance brain circuitry, improving symptoms in 50-80 percent of those with OCD, though relapse may occur if medication is stopped. Combination therapy (medication and cognitive-behavioral therapy) is often most effective.

Paul M. Salkovskis, in "Understanding and Treating Obsessive and Compulsive Disorder," argues that cognitive theory developments suggest the key to understanding obsessional problems lies in interpreting intrusive thoughts, images, impulses, and doubts. Negative interpretations, involving fears of harm resulting from actions or inactions, can lead to neutralizing behavior, increased selective attention, and negative moods, reinforcing obsessive and compulsive problems.

Anxiety Disorders

Fear and anxiety are differentiated by their responses: fear is a response to a serious threat, while anxiety is a response to a vague sense of danger. Both share physiological features, preparing individuals for action through increased respiration, perspiration, and muscle tension. In some, discomfort may be too severe, frequent, prolonged, or easily triggered. According to the DSM-V, 18 percent of U.S. adults experience an anxiety disorder annually, with close to 29 percent developing one at some point, though only one-fifth seek treatment.

The DSM-V includes generalized anxiety disorder (GAD), specific phobias, agoraphobia, social anxiety disorder, and panic disorder. GAD is characterized by: 1) disproportionate, uncontrollable, ongoing anxiety and worry about multiple topics for six months or more; 2) symptoms including edginess, fatigue, poor concentration, irritability, muscle tension, and sleep problems; 3) significant distress or impairment. GAD is more likely in individuals facing dangerous societal conditions, poverty, discrimination, low income, and reduced job opportunities. According to the 2015 Children Mind Institute Children’s Mental Health Report, anxiety and depression are treatable, but 80 percent of kids with diagnosable anxiety and 60 percent with depression do not receive treatment. The National Comorbidity Survey Adolescent Supplement estimates 31.9% of adolescents have an anxiety disorder, with higher prevalence in females (38.0%) than males (26.1%).

The Psychodynamic Perspective posits untreated childhood anxiety progresses to more difficult stages. Psychodynamic therapies use techniques like free association, transference, resistance, and dreams, with object relations therapies helping patients resolve early relationship problems. Child Psychologist Sigmund Freud emphasized control over the "id," with research suggesting people with GAD use defense mechanisms, particularly repression, and adults punished for expressing "id impulses" as children have higher anxiety levels later in life. The humanistic perspective sees GAD arising when individuals stop viewing themselves honestly and acceptingly. Carl Rogers' humanistic therapy, involving acceptance, accurate empathy, and genuineness, is effective for treating GAD.

The cognitive perspective supports that people with GAD hold maladaptive assumptions about danger. When applied to everyday situations and events, GAD may develop. Another overlooked disorder is worrying. In a survey, 62 percent of college students spent less than 10 minutes worrying, while 20 percent worried for more than an hour. Cognitive therapists guide GAD clients to recognize and change dysfunctional worrying, using "mindfulness-based acceptance therapy" to help clients accept streams of thoughts as mind events. Clients learn to observe bodily arousal and cognitive responses, becoming skilled at recognizing reactions.

The biological perspective identifies a brain circuit involving the amygdala, prefrontal cortex, and anterior cingulate cortex in anxiety reactions. Biological theorists attribute GAD to biological factors, with benzodiazepines (e.g., Valium, Xanax) reducing anxiety by affecting gamma-aminobutyric acid (GABA) receptors, inhibiting neuron firing and reducing fear or anxiety. Malfunctions in this feedback system, due to too few or ineffective receptors, may cause GAD.

In conclusion, mental disorders encompass a wide range of conditions affecting mood, thinking, and behavior, including clinical depression, bipolar disorder, dementia, attention-deficit/hyperactivity disorder, schizophrenia, autism, post-traumatic stress disorder, and more. Mental health concerns may arise occasionally, but become illnesses when signs and symptoms persist, frequently causing stress and impairing daily functioning. Symptoms vary by disorder and other factors, affecting thoughts, behavior, and emotions. Treatment, involving consultation with doctors, therapists, or loved ones, can prevent worsening of the illness over time.

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