In connection with mental health and illness, I want to narrate a short vignette. Recently a young lady, age 28 years, with emotional problems was referred to me in one of my ashrams by a friend. She had post-graduate education and some teaching experience. What struck me most was the fact that she was very heavily medicated with many psychotropic drugs. She was highly sedated. The client or her parents could not give me the diagnosis for which she was treated. As I was not familiar with the brand names of the psychiatric medications in India that she was prescribed by a psychiatrist, I asked my wife who is a registered nurse with over 30 years of experience in mental hospitals to look up for their generic names. We were appalled to see the heavy doses of psychotropics together with medications for side-effects that she was taking. From the medications prescribed, I inferred that she was being treated for moderate to severe bi-polar disorder (previously known as manic-depressive disorder). In my understanding she was having an inadequate personality with some impulse control problems, possibly a condition of cyclothemia or even a very mild variety of bi-polar disorder that could benefit from some mild sedatives. I suggested the young lady's uncle whom I considered to be sufficiently assertive to accompany her and her father on their next visit to the psychiatrist to find out her diagnosis. With difficulty the uncle was able to extract from the psychiatrist the diagnosis of mental imbalance. Interestingly every mental disorder results from mental imbalance. Prescribing medication without a diagnosis would not be considered to be a good practice in the USA. I would like to think the same is true of India. I certainly do not want to interfere with mental health practitioners outside of my field of expertise.
While I am licensed to practise clinical psychology in the USA, I merely provide free psychological consultations/opinions in keeping with ethical guidelines and professional affairs to those who seek my services in India. I strongly believe that the field of mental disorders is overly dependent on the medical model and the psychiatric poly-pharmacy prevalent in the USA has also become the order of the day in India. In India I do not think that psychology has asserted the role it rightly deserves in the field of mental health. The medical model that considers every mental disorder as a chemical imbalance is too quick to prescribe drugs as a solution to every mental disorder. I do not by any means intend to minimize the role of anti-psychotic drugs for stabilization of severe mental disorders as chemical restraints in the place of odious, cruel, and inhuman physical restraints of old. I hope to write about other models to understand psychopathology - the field of psychiatry and psychology. There is some arbitrariness with regard to what constitutes mental health and mental illness. For instance, when I started my doctoral program in Clinical Psychology, homosexuality was considered to be a mental disorder in Diagnostic and Statistical Manual of Mental Disorders – II (DSM – 2), the basic essential reference book for psychiatry and psychology in the USA. Then came DSM III, IV, and IV-R. And DSM IV–R about 900 pages containing classifications of Mental Disorders is still being revised. Most DSM disorders have a numerical International Classification of Diseases (ICD) code. In the coming articles I hope to give important information on mental disorders and their effective treatment, models of psychopathology (diseases of the mind), understanding mental health according to various schools of psychology, and guidelines for mental hygiene as part of holistic living.
Defining Mental Disorders
What is mental health? What is mental illness? What is normality? What is abnormality? What are normal and abnormal behaviors? These are questions that are not settled; they lend to debates and heated discussions in academic circles. Theoretical formulations related to the etiology (origin) of diseases depend on the various schools of psychology one follows or advocates. Etiology and epidemiology (spread and control of diseases in a given society) go hand in hand. Variables such as culture, social class, evolving societal norms, mores, habits, and customs also figure much in the determination of mental disorders. What is normal in one culture may not be so in another culture. For instance, burping or belching especially after a meal may be a sign of contentment or satisfaction and may be acceptable or tolerated in one culture; but the same behavior may be considered to be rude and socially unacceptable especially in western countries. Similarly, washing one's mouth or gargling with clearing one's nasal and throat cavities with all the accompanying unappetitive, obnoxious noises in the public that is not uncommon after a meal in Kerala societies may be rightly confined only to toilet rooms in other cultures. The trend or evolving normative behaviors may be patterned on the most influential persons in society, be they entertainers, sports heroes, singers, writers, politicians, beauty queens, wealthy, and the powerful. What is normal at one period of history may be abnormal at another period. For instance, certain terms used to address certain castes in earlier years in Kerala (India) would be considered to be offensive at the present time. The same is true of certain jokes or sayings. For instance, one of the carpenters in our construction setting used a proverb that is connected with another caste and is offensive was used to indicate his uncertainty on the following day. His conversation unwittingly happened to be in the presence of that other caste lady. I had to personally intervene to diffuse the crisis and tell the offending party not to use such offensive, stereotypical sayings that could demean a whole section of a society. Again, before the civil rights era in the 1960's in the United States of America, the black race would be generally called Negroes; now the term negrowould be considered tobe offensive; they would like to be called African Americans. Normality quite often is useful only as a statistical concept in research that can describe or quantify a certain characteristic or variable in a given population.
In some primitive societies persons with psychotic disorders (major mental problems) would be considered to possess certain unusual or divine powers or abilities. And as such they could be treated with special deference. Homosexuality that was considered a mental disorder in an earlier era (in DSM–II: Diagnostic and Statistical Manual of Mental Disorders–II) is no longer considered to be so (in DSM-IV). With rapid progress in affluence and westernization eating disorders, for example, characterized by severe disturbance in eating behavior are raising their ugly heads in India. More specifically, Anorexia Nervosa and Bulimia Nervosa, the two most common eating disorders (diseases), more commonly seen in women, related to maintaining a minimum body weight in one case and preventing weight gain through binge eating and compensatory methods such as vomiting and purging in the other seen in the west have started manifesting themselves in the affluent sections of India. Indian culture in general, for instance, is more tolerant of mental disorders than the USA culture. Ingestion of psychotomimetic (inducing psychotic behavior and personality) drugs can also alter one's mind and generate psychotic symptoms while under the influence of those substances. A psychotic (someone who is out of touch with reality) person creating nuisance in public might be more likely picked up and committed to a mental hospital in the USA than in India. What does all this mean? Understanding and diagnosing mental disorders are very complex and multi-dimensional. A certain amount of arbitrariness and tentativeness is inevitable. A provisional diagnosis before all the data are in, especially in difficult cases, makes good sense. Many disorders may share similar symptoms. So focus may have to be on syndromes (clusters of symptoms). Many variables need to be taken into account before understanding, classifying, and diagnosing mental disorders. In my next article I plan to deal with some important models of psychopathology (the study/science of mental disorders).
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