mental disorder


mental disorder
Any illness with a psychological origin, manifested either in symptoms of emotional distress or in abnormal behaviour.

Most mental disorders can be broadly classified as either psychoses or neuroses (see neurosis; psychosis). Psychoses (e.g., schizophrenia and bipolar disorder) are major mental illnesses characterized by severe symptoms such as delusions, hallucinations, and an inability to evaluate reality in an objective manner. Neuroses are less severe and more treatable illnesses, including depression, anxiety, and paranoia as well as obsessive-compulsive disorders and post-traumatic stress disorders. Some mental disorders, such as Alzheimer disease, are clearly caused by organic disease of the brain, but the causes of most others are either unknown or not yet verified. Schizophrenia appears to be partly caused by inherited genetic factors. Some mood disorders, such as mania and depression, may be caused by imbalances of certain neurotransmitters in the brain; they are treatable by drugs that act to correct these imbalances (see psychopharmacology). Neuroses often appear to be caused by psychological factors such as emotional deprivation, frustration, or abuse during childhood, and they may be treated through psychotherapy. Certain neuroses, particularly the anxiety disorders known as phobias, may represent maladaptive responses built up into the human equivalent of conditioned reflexes.

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Introduction

      any illness with significant psychological or behavioral manifestations that is associated with either a painful or distressing symptom or an impairment in one or more important areas of functioning.

      Mental disorders, in particular their consequences and their treatment, are of more concern and receive more attention now than in the past. Mental disorders have become a more prominent subject of attention for several reasons. They have always been common, but, with the eradication or successful treatment of many of the serious physical illnesses that formerly afflicted humans, mental illness has become a more noticeable cause of suffering and accounts for a higher proportion of those disabled by disease. Moreover, the public has come to expect the medical and mental health professions to help it obtain an improved quality of life in its mental as well as physical functioning. And indeed, there has been a proliferation of both pharmacological and psychotherapeutic treatments. The transfer of many psychiatric patients, some still showing conspicuous symptoms, from mental hospitals into the community has also increased the public's awareness of the importance and prevalence of mental illness.

      There is no simple definition of mental disorder that is universally satisfactory. This is partly because mental states or behaviour that are viewed as abnormal in one culture may be regarded as normal or acceptable in another, and in any case it is difficult to draw a line clearly demarcating healthy from abnormal mental functioning.

      A narrow definition of mental illness would insist upon the presence of organic disease of the brain, either structural or biochemical. An overly broad definition would define mental illness as simply being the lack or absence of mental health—that is to say, a condition of mental well-being, balance, and resilience in which the individual can successfully work and function and in which the individual can both withstand and learn to cope with the conflicts and stresses encountered in life. A more generally useful definition ascribes mental disorder to psychological, social, biochemical, or genetic dysfunctions or disturbances in the individual.

      A mental illness can have an effect on every aspect of a person's life, including thinking, feeling, mood, and outlook and such areas of external activity as family and marital life, sexual activity, work, recreation, and management of material affairs. Most mental disorders negatively affect how individuals feel about themselves and impair their capacity for participating in mutually rewarding relationships.

       psychopathology is the systematic study of the significant causes, processes, and symptomatic manifestations of mental disorders. The meticulous study, observation, and inquiry that characterize the discipline of psychopathology are, in turn, the basis for the practice of psychiatry (i.e., the science and practice of diagnosing and treating mental disorders as well as dealing with their prevention). Psychiatry, psychology, and related disciplines such as clinical psychology and counseling embrace a wide spectrum of techniques and approaches for treating mental illnesses. These include the use of psychoactive drugs to correct biochemical imbalances in the brain or otherwise to relieve depression, anxiety, and other painful emotional states.

      Another important group of treatments is the psychotherapies, which seek to treat mental disorders by psychological means and which involve verbal communication between the patient and a trained person in the context of a therapeutic interpersonal relationship between them. Different modes of psychotherapy focus variously on emotional experience, cognitive processing, and overt behaviour.

      This article discusses the types, causes, and treatment of mental disorders. Neurological diseases (see neurology) with behavioral manifestations are treated in nervous system disease. Alcoholism and other substance use disorders are discussed in alcoholism and drug use. Disorders of sexual functioning and behaviour are treated in sexual behaviour, human. Tests used to evaluate mental health and functioning are discussed in psychological testing. The various theories of personality structure and dynamics are treated in personality, while human emotion and motivation are discussed in emotion and motivation. See also personality disorder; psychopharmacology; psychotherapy.

Types and causes of mental disorders

Classification and epidemiology
      Psychiatric classification attempts to bring order to the enormous diversity of mental symptoms, syndromes, and illnesses that are encountered in clinical practice. epidemiology is the measurement of the prevalence, or frequency of occurrence, of these psychiatric disorders in different human populations.

       diagnosis is the process of identifying an illness by studying its signs and symptoms and by considering the patient's history. Much of this information is gathered by the mental health practitioner (e.g., psychiatrist, psychotherapist, psychologist, social worker, or counselor) during initial interviews with the patient, who describes the main complaints and symptoms and any past ones and briefly gives a personal history and current situation. The practitioner may administer any of several psychological tests to the patient and may supplement these with a physical and a neurological examination. These data, along with the practitioner's own observations of the patient and of the patient's interaction with the practitioner, form the basis for a preliminary diagnostic assessment. For the practitioner, diagnosis involves finding the most prominent or significant symptoms, on the basis of which the patient's disorder can be assigned to a category as a first stage toward treatment. Diagnosis is as important in mental health treatment as it is in medical treatment.

      Classification systems in psychiatry aim to distinguish groups of patients who share the same or related clinical symptoms in order to provide an appropriate therapy and accurately predict the prospects of recovery for any individual member of that group. Thus, a diagnosis of depression, for example, would lead the practitioner to consider antidepressant drugs when preparing a course of treatment.

      The diagnostic terms of psychiatry have been introduced at various stages of the discipline's development and from very different theoretical standpoints. Sometimes two words with quite different derivations have come to mean almost the same thing—for example, dementia praecox and schizophrenia. Sometimes a word, such as hysteria (conversion disorder), carries many different meanings depending on the psychiatrist's theoretical orientation.

      Psychiatry is hampered by the fact that the cause of many mental illnesses is unknown, and so convenient diagnostic distinctions cannot be made among such illnesses as they can, for instance, in infectious medicine, where infection with a specific type of bacterium (bacteria) is a reliable indicator for a diagnosis of tuberculosis. But the greatest difficulties presented by mental disorders as far as classification and diagnosis are concerned are that the same symptoms are often found in patients with different or unrelated disorders and a patient may show a mix of symptoms properly belonging to several different disorders. Thus, although the categories of mental illness are defined according to symptom patterns, course, and outcome, the illnesses of many patients constitute intermediate cases between such categories, and the categories themselves may not necessarily represent distinct disease entities and are often poorly defined.

      The two most frequently used systems of psychiatric classification are the International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), produced by the American Psychiatric Association. The 10th revision of the former, published in 1992, is widely used in western Europe and other parts of the world for epidemiological and administrative purposes. Its nomenclature is deliberately conservative in conception so that it can be used by clinicians and mental health care systems in different countries.

      This article, however, will follow the DSM-IV-TR (2000), which is a text revision (TR) of the fourth edition, the DSM-IV (1994). The DSM differs from the ICD in its introduction of precisely described criteria for each diagnostic category; its categorizations are usually based upon the detailed description of symptoms.

      The DSM-IV has been widely used, especially in the United States, and its detailed descriptions of diagnostic criteria have been useful in eradicating the inconsistencies of earlier classifications. However, there are still some major problems in its everyday clinical use. Chief among them is the DSM's innovative and controversial abandonment of the general categories of psychosis and neurosis in its classificatory scheme. These terms have been and still are widely used to distinguish between classes of mental disorders, though there are various mental illnesses, such as personality disorders (personality disorder), that cannot be classified as either psychoses or neuroses.

Psychoses (psychosis)
      Psychoses are major mental illnesses that are characterized by severe symptoms such as delusions (delusion), hallucinations (hallucination), disturbances of the thinking process, and defects of judgment and insight. Persons with psychoses exhibit a disturbance or disorganization of thought, emotion, and behaviour so profound that they are often unable to function in everyday life and may be incapacitated or disabled. Such individuals are often unable to realize that their subjective perceptions and feelings do not correlate with objective reality, a phenomenon evinced by persons with psychoses who do not know or will not believe that they are ill despite the distress they feel and their obvious confusion concerning the outside world. Traditionally, the psychoses have been broadly divided into organic and functional psychoses. Organic psychoses were believed to result from a physical defect of or damage to the brain. Functional psychoses were believed to have no physical brain disease evident upon clinical examination. Much recent research suggests that this distinction between organic and functional is probably inaccurate. Most psychoses are now believed to result from some structural or biochemical change in the brain.

Neuroses (psychoneurosis)
      Neuroses, or psychoneuroses (psychoneurosis), are less-serious disorders in which people may experience negative feelings such as anxiety or depression. Their functioning may be significantly impaired, but personality remains relatively intact, the capacity to recognize and objectively evaluate reality is maintained, and they are basically able to function in everyday life. In contrast to people with psychoses, neurotic patients know or can be made to realize that they are ill, and they usually want to get well and return to a normal state. Their chances for recovery are better than those of persons with psychoses. The symptoms of neurosis may sometimes resemble the coping mechanisms used in everyday life by most people, but in neurotics these defensive reactions are inappropriately severe or prolonged in response to an external stress. anxiety disorders, phobic disorder (exhibited as unrealistic fear or dread), conversion disorder (formerly known as hysteria (conversion disorder)), obsessive-compulsive disorder, and depressive disorders have been traditionally classified as neuroses.

      Epidemiology is the study of the distribution of disease in different populations. Prevalence denotes the number of cases of a condition present at a particular time or over a specified period, while incidence denotes the number of new cases occurring in a defined time period. Epidemiology is also concerned with the social, economic, or other contexts in which mental illnesses arise.

      The understanding of mental disorders is aided by knowledge of the rate and frequency with which they occur in different societies and cultures. Looking at the worldwide prevalence of mental disorders reveals many surprising findings. It is remarkable, for instance, that the lifetime risk of developing schizophrenia, even in widely different cultures, is approximately 1 percent.

      Gradual historical changes in the incidence and prevalence of particular disorders have often been described, but it is very difficult to obtain firm evidence that such changes have actually occurred. On the other hand, prevalence has been seen to increase for a few syndromes because of general changes in living conditions over time. For example, dementia inevitably develops in some 20 percent of those persons over age 80 (old age), so, with the increase in life expectancy common to developed countries, the number of people with dementia is bound to increase. There also seems to be some evidence of an increased prevalence of mood disorders over the past century.

      Several large-scale epidemiological studies have been conducted to determine the incidence and prevalence of mental disorders in the general population. Simple statistics based on those people actually under treatment for mental disorders cannot be relied upon in making such a determination, because the number of those who have sought treatment is substantially smaller than the actual number of people afflicted with mental disorders, many of whom do not seek professional treatment. Moreover, surveys to determine incidence and prevalence depend for their statistics on the clinical judgment of the survey takers, which can always be fallible because there are no objective tests for the assessment of mental illness. Given such objections, one ambitious study conducted by the National Institute of Mental Health in the United States examined thousands of persons in several American localities and yielded the following results concerning the prevalence of mental disorders in the general population. About 1 percent of those surveyed were found to have schizophrenia, more than 9 percent had depression, and about 13 percent had phobias (phobia) or other anxiety disorders.

      There is a relatively strong epidemiological association between socioeconomic class and the occurrence of certain types of mental disorders and of general patterns of mental health. One study found that the lower the socioeconomic class, the greater the prevalence of psychotic disorders; schizophrenia was found to be 11 times more frequent among the lowest of the five classes surveyed (unskilled manual workers) than among the highest class (professionals). (Anxiety disorders were found to be more common among the middle class, however.) Two possible explanations for the elevated frequency of schizophrenia among the poor would be that persons with schizophrenia “drift downward” to the lowest socioeconomic class because they are impaired by their illness or alternatively that unfavourable sociocultural conditions create circumstances that help induce the illness.

      The manifestation of particular psychiatric symptoms is sometimes closely associated with particular epochs or periods in life. The symptoms of autism are usually evident by early childhood, for example. Childhood and adolescence may produce a variety of psychiatric symptoms peculiar to those periods of life. anorexia nervosa, several types of schizophrenia, drug abuse, and bipolar disorder often first appear during adolescence or in young adult life. Alcohol dependence and its consequences, paranoid schizophrenia, and repeated attacks of depression are more likely to occur in middle age. Involutional melancholia and presenile dementias typically occur in late middle age, while senile and arteriosclerotic dementias are characteristic of the elderly.

      There are also marked sex differences in the incidence of certain types of mental illness. For instance, anorexia nervosa is 20 times more common in girls than in boys; men tend to develop schizophrenia at a younger age than women; depression is more common in women than in men; and many sexual deviations occur almost exclusively in men.

Theories of causation
      Very often the etiology, or cause, of a particular type of mental disorder is unknown or is understood only to a very limited extent. The situation is complicated by the fact that a mental disorder such as schizophrenia may be caused by a combination and interaction of several factors, including a probable genetic predisposition to develop the disease, a postulated biochemical imbalance in the brain, and a cluster of stressful (stress) life events that help to precipitate the actual onset of the illness. The predominance of these and other factors probably varies from person to person in schizophrenia. A similarly complex interaction of constitutional, developmental, and social factors can influence the formation of mood and anxiety disorders.

      No single theory of causation can explain all mental disorders or even all those of a particular type. Moreover, the same type of disorder may have different causes in different persons: e.g., an obsessive-compulsive disorder may have its origins in a biochemical imbalance, in an unconscious emotional conflict, in faulty learning processes, or in a combination of these. The fact that quite different therapeutic approaches can produce equal improvements in different patients with the same type of disorder underscores the complex and ambiguous nature of the causes of mental illness. The major theoretical and research approaches to the causation of mental disorders are treated below.

Organic and hereditary etiologies
      Organic explanations of mental illness have usually been genetic, biochemical, neuropathological, or a combination of these.

      The study of the genetic causes of mental disorders involves both the laboratory analysis of the human genome and the statistical analysis of the frequency of a particular disorder's occurrence among individuals who share related genes (gene)—i.e., family members and particularly twins. Family risk studies compare the observed frequency of occurrence of a mental illness in close relatives of the patient with its frequency in the general population. First-degree relatives (parents, siblings, and children) share 50 percent of their genetic material with the patient, and higher rates of the illness in these relatives than expected indicate a possible genetic factor. In twin studies the frequency of occurrence of the illness in both members of pairs of identical (monozygous) twins is compared with its frequency in both members of a pair of fraternal (dizygous) twins. A higher concordance for disease among the identical than the fraternal twins suggests a genetic component. Further information on the relative importance of genetic and environmental factors accrues from comparing identical twins reared together with those reared apart. Adoption studies comparing adopted children whose biological parents had the illness with those whose parents did not can also be useful in separating biological from environmental influences.

      Such studies have demonstrated a clear role for genetic factors in the causation of schizophrenia. When one parent is found to have the disorder, the probability of that person's children developing schizophrenia is at least 10 times higher (about a 12 percent risk probability) than it is for children in the general population (about a 1 percent risk probability). If both parents have schizophrenia, the probability of their children developing the disorder is anywhere from 35 to 65 percent. If one member of a pair of fraternal twins develops schizophrenia, there is about a 12 percent chance that the other twin will too. If one member of a pair of identical twins has schizophrenia, the other identical twin has at least a 40 to 50 percent chance of developing the disorder. Although genetic factors seem to play a less significant role in the causation of other psychotic and personality disorders, studies have demonstrated a probable role for genetic factors in the causation of many mood disorders and some anxiety disorders.

      If a mental disease is caused by a biochemical abnormality, investigation of the brain at the site where the biochemical imbalance occurs should show neurochemical differences from normal. In practice such a simplistic approach is fraught with practical, methodological, and ethical difficulties. The living human brain is not readily accessible to direct investigation, and the dead brain undergoes chemical change; moreover, findings of abnormalities in cerebrospinal fluid, blood, or urine may have no relevance to the question of a presumed biochemical imbalance in the brain. It is difficult to study human mental illnesses using animals as analogs, because most mental disorders either do not occur or are not recognizable in animals. Even when biochemical abnormalities have been found in persons with mental disorders, it is difficult to know whether they are the cause or the result of the illness, or of its treatment, or of other consequences. Despite these problems, progress has been made in unraveling the biochemistry of mood disorders, schizophrenia, and some of the dementias.

      Certain drugs (drug) have been demonstrated to have beneficial effects upon mental illnesses. Antidepressant, antipsychotic (therapeutics), and antianxiety (therapeutics) drugs are thought to achieve their therapeutic results by the selective inhibition or enhancement of the quantities, action, or breakdown of neurotransmitters (neurotransmitter) in the brain. Neurotransmitters are a group of chemical agents that are released by neurons (neuron) (nerve cells) to stimulate neighbouring neurons, thus allowing impulses to be passed from one cell to the next throughout the nervous system. Neurotransmitters play a key role in transmitting impulses across the microscopic gap (synaptic cleft) that exists between neurons. The release of such neurotransmitters is stimulated by the electrical activity of the cell. Norepinephrine (epinephrine and norepinephrine), dopamine, acetylcholine, and serotonin are among the principal neurotransmitters. Some neurotransmitters excite or activate neurons, while others act as inhibiting substances. Abnormally low or high concentrations of neurotransmitters at sites in the brain are thought to change the synaptic activities of neurons, thus ultimately leading to the disturbances of mood, emotion, or thought found in various mental disorders.

      In the past the postmortem study of the brain revealed information upon which great advances in understanding the etiology of neurological and some mental disorders were based, leading to the German psychiatrist Wilhelm Griesinger's postulate: “all mental illness is disease of the brain.” The application of the principles of pathology to general paresis, one of the most common conditions found in mental hospitals in the late 19th century, resulted in the discovery that this was a form of neurosyphilis and was caused by infection with the spirochete bacterium Treponema pallidum. The examination of the brains of patients with other forms of dementia has given useful information concerning other causes of this syndrome—for example, Alzheimer disease and arteriosclerosis. The pinpointing of abnormalities of specific areas of the brain has aided understanding of some abnormal mental functions, such as disturbances of memory and speech disorders (speech disorder). Recent advances in neuroimaging techniques have expanded the ability to investigate brain abnormalities in patients with a wide variety of mental illnesses, eliminating the need for postmortem studies.

Psychodynamic etiologies
 In the first half of the 20th century, theories of the etiology of mental disorders, especially of neuroses and personality disorders, were dominated in the United States by Freudian (Freud, Sigmund) psychoanalysis and the derivative theories of the post-Freudians (see Freud, Sigmund). In western Europe the influence of Freudian theory upon psychiatric theory diminished after World War II.

Theories of personality development
      Freudian and other psychodynamic theories view neurotic symptoms as arising from intrapsychic conflict—i.e., the existence of conflicting motives, drives, impulses, and feelings held within various components of the mind. Central to psychoanalytic theory is the postulated existence of the unconscious, which is that part of the mind whose processes and functions are inaccessible to the individual's conscious awareness or scrutiny. One of the functions of the unconscious is thought to be that of a repository for traumatic memories, feelings, ideas, wishes, and drives that are threatening, abhorrent, anxiety-provoking, or socially or ethically unacceptable to the individual. These mental contents may at some time be pushed out of conscious awareness but remain actively held in the unconscious. This process is a defense mechanism for protecting the individual from the anxiety or other psychic pain associated with those contents and is known as repression. The repressed mental contents held in the unconscious retain much of the psychic energy or power that was originally attached to them, however, and they can continue to influence significantly the mental life of the individual even though (or because) a person is no longer aware of them.

      The natural tendency for repressed drives or feelings, according to this theory, is to reach conscious awareness so that the individual can seek the gratification, fulfillment, or resolution of them. But this threatened release of forbidden impulses or memories provokes anxiety and is seen as threatening, and a variety of defense mechanisms may then come into play to provide relief from the state of psychic conflict. Through reaction formation, projection, regression, sublimation, rationalization, and other defense mechanisms (defense mechanism), some component of the unwelcome mental contents can emerge into consciousness in a disguised or attenuated form, thus providing partial relief to the individual. Later, perhaps in adult life, some event or situation in the person's life triggers the abnormal discharge of the pent-up emotional (emotion) energy in the form of neurotic symptoms in a manner mediated by defense mechanisms. Such symptoms can form the basis of neurotic disorders such as conversion and somatoform disorders (see below somatoform disorders (mental disorder)), anxiety disorders, obsessional disorders, and depressive disorders. Since the symptoms represent a compromise within the mind between letting the repressed mental contents out and continuing to deny all conscious knowledge of them, the particular character and aspects of an individual's symptoms and neurotic concerns bear an inner meaning that symbolically represents the underlying intrapsychic conflict. Psychoanalysis and other dynamic therapies help a person achieve a controlled and therapeutic recovery that is based on a conscious awareness of repressed mental conflicts along with an understanding of their influence on past history and present difficulties. These steps are associated with the relief of symptoms and improved mental functioning.

      Freudian theory views childhood as the primary breeding ground of neurotic conflicts. This is because children are relatively helpless and are dependent on their parents for love, care, security, and support and because their psychosexual, aggressive, and other impulses are not yet integrated into a stable personality framework. The theory posits that children lack the resources to cope with emotional traumas, deprivations, and frustrations; if these develop into unresolved intrapsychic conflicts that the young person holds in abeyance through repression, there is an increased likelihood that insecurity, unease, or guilt will subtly influence the developing personality, thereby affecting the person's interests, attitudes, and ability to cope with later stresses.

Non-Freudian psychodynamics
 Psychoanalytic theory's emphasis on the unconscious mind and its influence on human behaviour resulted in a proliferation of other, related theories of causation incorporating—but not limited to—basic psychoanalytic precepts. Most subsequent psychotherapies have stressed in their theories of causation aspects of earlier, maladaptive psychological development that had been missed or underemphasized by orthodox psychoanalysis, or they have incorporated insights taken from learning theory. Swiss psychiatrist Carl Jung (Jung, Carl), for instance, concentrated on the individual's need for spiritual development and concluded that neurotic symptoms could arise from a lack of self-fulfillment in this regard. Austrian psychiatrist Alfred Adler (Adler, Alfred) emphasized the importance of feelings of inferiority and the unsatisfactory attempts to compensate for it as important causes of neurosis. Neo-Freudian authorities such as Harry Stack Sullivan (Sullivan, Harry Stack), Karen Horney (Horney, Karen), and Erich Fromm (Fromm, Erich) modified Freudian theory by emphasizing social relationships and cultural and environmental factors as being important in the formation of mental disorders.

      More-modern psychodynamic theories have moved away from the idea of explaining and treating neurosis on the basis of a defect in a single psychological system and have instead adopted a more complex notion of multiple causes, including emotional, psychosexual, social, cultural, and existential ones. A notable trend was the incorporation of approaches derived from theories of learning. Such psychotherapies emphasized the acquired, faulty mental processes and maladaptive behavioral responses that act to sustain neurotic symptoms, thereby directing interest toward the patient's extant circumstances and learned responses to those conditions as a causative factor in mental illness. These approaches marked a convergence of psychoanalytic theory and behavioral theory, especially with regard to each school's view of disease causation.

 Behavioral theories for the causation of mental disorders, especially neurotic symptoms, are based upon learning theory, which was in turn largely derived from the study of the behaviour of animals in laboratory settings. Most important theories in this area arose out of the work of the Russian physiologist Ivan Pavlov (Pavlov, Ivan Petrovich) and several American psychologists, such as Edward L. Thorndike (Thorndike, Edward L.), Clark L. Hull (Hull, Clark L.), John B. Watson (Watson, John B.), Edward C. Tolman (Tolman, Edward C.), and B.F. Skinner (Skinner, B.F.). In the classical Pavlovian model of conditioning, an unconditioned stimulus is followed by an appropriate response; for example, food placed in a dog's mouth is followed by the dog salivating. If a bell is rung just before food is offered to a dog, eventually the dog will salivate at the sound of the bell only, even though no food is offered. Because the bell could not originally evoke salivation in the dog (and hence was a neutral stimulus) but came to evoke salivation because it was repeatedly paired with the offering of food, it is called a conditioned stimulus. The dog's salivation at the sound of the bell alone is called a conditioned response. If the conditioned stimulus (the bell) is no longer paired with the unconditioned stimulus (the food), extinction of the conditioned response gradually occurs (the dog ceases to salivate at the sound of the bell alone).

      Behavioral theories for the causation of mental disorders rest largely upon the assumption that the symptoms or symptomatic behaviour found in persons with various neuroses (particularly phobias (phobia) and other anxiety disorders) can be regarded as learned behaviours that have been built up into conditioned responses. In the case of phobias, for example, a person who has once been exposed to an inherently frightening situation afterward experiences anxiety even at neutral objects that were merely associated with that situation at the time but that should not reasonably produce anxiety. Thus, a child who has had a frightening experience with a bird may subsequently have a fear response to the sight of feathers. The neutral object alone is enough to arouse anxiety, and the person's subsequent effort to avoid that object is a learned behavioral response that is self-reinforcing, since the person does indeed procure a reduction of anxiety by avoiding the feared object and is thus likely to continue to avoid it in the future. It is only by confronting the object that the individual can eventually lose the irrational, association-based fear of it.

Major diagnostic categories
Organic mental disorders
      This category includes both those psychological or behavioral abnormalities that arise from structural disease of the brain and also those that arise from brain dysfunction caused by disease outside the brain. These conditions differ from those of other mental illnesses in that they have a definite and ascertainable cause—i.e., brain disease. However, the importance of the distinction (between organic and functional) has become less clear as research has demonstrated that brain abnormalities are associated with many psychiatric illnesses. When possible, treatment is aimed at both the symptoms and the underlying physical dysfunction in the brain.

      There are several types of psychiatric syndromes that clearly arise from organic brain disease, the chief among them being dementia and delirium. Dementia is a gradual and progressive loss of intellectual abilities such as thinking, remembering, paying attention, judging, and perceiving, without an accompanying disturbance of consciousness. The syndrome may also be marked by the onset of personality changes. Dementia usually manifests as a chronic condition that worsens over the long term. delirium is a diffuse or generalized intellectual impairment marked by a clouded or confused state of consciousness, an inability to attend to one's surroundings, difficulty in thinking coherently, a tendency to perceptual disturbances such as hallucinations, and difficulty in sleeping. Delirium is generally an acute condition. amnesia (a gross loss of recent memory and of time sense without other intellectual impairment) is another specific psychological impairment associated with organic brain disease.

      Steps toward the diagnosis of suspected organic disorders include obtaining a full history of the patient followed by a detailed examination of the patient's mental state, with additional tests for particular functions as necessary. A physical examination is also performed with special attention to the central nervous system (nervous system, human). In order to determine whether a metabolic or other biochemical imbalance is causing the condition, blood and urine tests, liver function tests, thyroid function tests, and other evaluations may be performed. Chest and skull X-rays (X-ray) may be taken, and computed tomography (CT) scanning or magnetic resonance imaging (MRI) may be used to reveal focal or generalized brain disease. electroencephalography (EEG) may show localized abnormalities in the electrical conduction of the brain caused by a lesion. Detailed psychological testing may reveal more-specific perceptual, memory, or other disabilities.

Senile and presenile dementia
      In these dementias there is a progressive intellectual impairment that proceeds to lethargy, inactivity, and gross physical deterioration and eventually to death within a few years. Presenile dementias are arbitrarily defined as those that begin in persons under the age of 65. In old age the most common causes of dementia are Alzheimer disease and cerebral arteriosclerosis. Dementia from Alzheimer disease usually begins in people over age 65 and is more common in women than in men. It begins with incidences of forgetfulness, which become more frequent and serious; the disturbances of memory, personality, and mood progress steadily toward physical deterioration and death within a few years. In dementia caused by cerebral arteriosclerosis, multiple areas of destruction of the brain (infarcts) are caused by pieces of damaged arteries outside the skull lodging in the small arteries of the brain. The course of the illness is rapid, with periods of deterioration followed by periods of slight improvement. Death may be delayed slightly longer than with dementia from Alzheimer disease and often occurs from ischemic heart disease, causing a heart attack, or from massive cerebral infarction, causing a stroke.

      Other causes of dementia include Pick disease, a rare inherited condition that occurs in women twice as often as in men, usually between the ages of 50 and 60; Huntington chorea, an inherited disease that usually begins at about age 40 with involuntary movements and proceeds to dementia and death within 15 years; and Creutzfeldt-Jakob disease, a rare brain condition that is caused by an abnormal form of protein called a prion. Dementia may also result from head injury, infection—e.g., with syphilis or encephalitis—various tumours (tumour), toxic conditions such as chronic alcoholism or heavy-metal poisoning, metabolic illnesses such as liver failure (digestive system disease), reduced oxygen to the brain due to anemia or carbon monoxide poisoning, and the inadequate intake or metabolism of certain vitamins (vitamin).

      There is no specific treatment for the symptoms of dementia; the underlying physical cause needs to be identified and treated when possible. The goals of care of the individual with dementia are to relieve distress, prevent behaviour that might result in injury, and optimize remaining physical and psychological faculties.

Other organic syndromes
      Damage to different areas of the brain may cause particular psychological symptoms. Damage to the frontal lobe of the brain may manifest itself in such disturbances of behaviour as loss of inhibitions, tactlessness, and overtalkativeness. Lesions of the parietal lobe may result in difficulties of speech and language or of the perception of space. Lesions of the temporal lobe may lead to emotional instability, aggressive behaviour, or difficulty with learning new information.

      Delirium occurs secondarily to many other physical conditions such as drug intoxication or withdrawal, metabolic disorders (metabolic disease) (for example, liver failure or low blood sugar), infections such as pneumonia or meningitis, head injuries, brain tumours, epilepsy, or nutritional or vitamin deficiency. Clouding or confusion of consciousness and disturbances of thinking, behaviour, perception, and mood occur, with disorientation being prominent. Treatment is aimed at the underlying physical condition.

Substance abuse disorders
      Substance abuse and substance dependence are two distinct disorders associated with the regular nonmedical use of psychoactive drugs. Substance abuse implies a sustained pattern of use resulting in impairment of the person's social or occupational functioning. Substance dependence implies that a significant portion of a person's activities are focused on the use of a particular drug or alcohol. Substance dependence likely leads to tolerance, in which markedly increased amounts of a drug (or other addictive substance) must be taken to achieve the same effect. Dependence is also characterized by withdrawal symptoms such as tremors, nausea, and anxiety, any of which might follow decreases in the dose of the substance or the cessation of drug use. (See chemical dependency.)

      A variety of psychiatric conditions can result from the use of alcohol (alcohol consumption) or other drugs (drug abuse). Mental states resulting from the ingestion of alcohol include intoxication, withdrawal, hallucinations, and amnesia. Similar syndromes may occur following the use of other drugs that affect the central nervous system (see drug use). Other drugs commonly used nonmedically to alter mood are barbiturates (barbiturate), opioids (e.g., heroin), cocaine, amphetamines (amphetamine), hallucinogens (hallucinogen) such as LSD (lysergic acid diethylamide), marijuana, and tobacco. Treatment is directed at alleviating symptoms and preventing the patient's further abuse of the substance.

      The term schizophrenia was introduced by Swiss psychiatrist Eugen Bleuler (Bleuler, Eugen) in 1911 to describe what he considered to be a group of severe mental illnesses with related characteristics; it eventually replaced the earlier term dementia praecox, which the German psychiatrist Emil Kraepelin (Kraepelin, Emil) had first used in 1899 to distinguish the disease from what is now called bipolar disorder. Individuals with schizophrenia exhibit a wide variety of symptoms; thus, although different experts may agree that a particular individual suffers from the condition, they might disagree about which symptoms are essential in clinically defining schizophrenia.

      The annual prevalence of schizophrenia—the number of cases, both old and new, on record in any single year—is between two and four per 1,000 persons. The lifetime risk of developing the illness is between seven and nine per 1,000. Schizophrenia is the single largest cause of admissions to mental hospitals, and it accounts for an even larger proportion of the permanent populations of such institutions. It is a severe and frequently chronic illness that typically first manifests itself during the teen years or early adulthood. More severe levels of impairment and personality disorganization occur in schizophrenia than in almost any other mental disorder.

Clinical features
      The principal clinical signs of schizophrenia may include delusions, hallucinations, a loosening or incoherence of a person's thought processes and train of associations, deficiencies in feeling appropriate or normal emotions, and a withdrawal from reality. A delusion is a false or irrational belief that is firmly held despite obvious or objective evidence to the contrary. The delusions of individuals with schizophrenia may be persecutory, grandiose, religious, sexual, or hypochondriacal in nature, or they may be concerned with other topics. Delusions of reference, in which the person attributes a special, irrational, and usually negative significance to other people, objects, or events, are common in the disease. Especially characteristic of schizophrenia are delusions in which the individual believes his thinking processes, body parts, or actions or impulses are controlled or dictated by some external force.

      Hallucinations (hallucination) are false sensory perceptions that are experienced without an external stimulus but that nevertheless seem real to the person who is experiencing them. Auditory hallucinations, experienced as “voices” and characteristically heard commenting negatively about the affected individual in the third person, are prominent in schizophrenia. Hallucinations of touch, taste, smell, and bodily sensation may also occur. Disorders of thinking vary in nature but are quite common in schizophrenia. thought disorders may consist of a loosening of associations, so that the speaker jumps from one idea or topic to another, unrelated one in an illogical, inappropriate, or disorganized way. At its most serious, this incoherence of thought extends into pronunciation itself, and the speaker's words become garbled or unrecognizable. speech may also be overly concrete and inexpressive; it may be repetitive, or, though voluble, it may convey little or no real information. Usually individuals with schizophrenia have little or no insight into their own condition and realize neither that they are suffering from a mental illness nor that their thinking is disordered.

      Among the so-called negative symptoms of schizophrenia are a blunting or flattening of the person's ability to experience (or at least to express) emotion, indicated by speaking in a monotone and by a peculiar lack of facial expressions. The person's sense of self (i.e., of who he is) may be disturbed. A person with schizophrenia may be apathetic and may lack the drive and ability to pursue a course of action to its logical conclusion, may withdraw from society, become detached from others, or become preoccupied with bizarre or nonsensical fantasies. Such symptoms are more typical of chronic rather than of acute schizophrenia.

      Experts have recognized different types of schizophrenia as well as intermediate stages between the disease and other conditions. Five major types of schizophrenia are recognized by the DSM-IV: the disorganized type, the catatonic type, the paranoid type, the undifferentiated type, and the residual type. Disorganized schizophrenia is characterized by inappropriate emotional responses, delusions or hallucinations, uncontrolled or inappropriate laughter, and by incoherent thought and speech. Catatonic schizophrenia is marked by striking motor behaviour, such as remaining motionless in a rigid posture for hours or even days, and by stupor, mutism, or agitation. Paranoid schizophrenia is characterized by the presence of prominent delusions of a persecutory or grandiose nature; some patients can be argumentative or violent. The undifferentiated type combines symptoms from the above three categories, while the residual type is marked by the absence of these distinct features; moreover, the residual type, in which the major symptoms have abated, is a less severe diagnosis.

Course and prognosis
      The course of schizophrenia is variable. Some individuals with schizophrenia continue to function fairly well and are able to live independently, some have recurrent episodes of the illness with some negative effect on their overall level of function, and some deteriorate into chronic schizophrenia with severe disability. The prognosis for individuals with schizophrenia has improved owing to the development of antipsychotic drugs and the expansion of community supportive measures.

      About 10 percent of individuals with schizophrenia commit suicide. The prognosis for those with schizophrenia is poorer when the onset of the disease is gradual rather than sudden, when the affected individual is quite young at the onset, when the individual has suffered from the disease for a long time, when the individual exhibits blunted feelings or has displayed an abnormal personality previous to the onset of the disease, and when such social factors as never having been married, poor sexual adjustment, a poor employment record, or social isolation exist in the individual's history.

      An enormous amount of research has been performed to try to determine the causes of schizophrenia. Family, twin, and adoption studies provide strong evidence to support an important genetic contribution. Several studies in the early 21st century have found that children born to men older than age 50 are nearly three times more likely to have schizophrenia than those born to younger men. Stressful life events are known to trigger or quicken the onset of schizophrenia or to cause relapse. Some abnormal neurological signs have been found in individuals with schizophrenia, and it is possible that brain damage, perhaps occurring at birth, may be a cause in some cases. Other studies suggest that schizophrenia is caused by a virus or by abnormal activity of genes that govern the formation of nerve fibres in the brain. Various biochemical abnormalities also have been reported in persons with schizophrenia. There is evidence, for example, that the abnormal coordination of neurotransmitters such as dopamine, glutamate, and serotonin may be involved in the development of the disease.

      Research also has been performed to determine whether the parental care used in the families of individuals with schizophrenia contributes to the development of the disease. There has also been extensive interest in such factors as social class, place of residence, migration, and social isolation. Neither family dynamics nor social disadvantage have been proved to be causative agents.

      The most-successful treatment approaches combine the use of medications with supportive therapy. New “atypical” antipsychotic medications such as clozapine, risperidone, and olanzapine have proved effective in relieving or eliminating such symptoms as delusions, hallucinations, thought disorders, agitation, and violent behaviour. These medications also have fewer side effects than the more-traditional antipsychotic medications. Long-term maintenance on such medications also reduces the rate of relapse. Psychotherapy, meanwhile, may help the affected individual to relieve feelings of helplessness and isolation, reinforce healthy or positive tendencies, distinguish psychotic perceptions from reality, and explore any underlying emotional conflicts that might be exacerbating the condition. occupational therapy and regular visits from a social worker or psychiatric nurse may be beneficial. In addition, it is sometimes useful to counsel the live-in relatives of individuals with schizophrenia. Support groups for persons with schizophrenia and their families have become extremely important resources for dealing with the disorder.

Mood disorders (affective disorder)
      Mood disorders include characteristics of either depression or mania or both, often in a fluctuating pattern. In their severer forms, these disorders include the bipolar disorders (bipolar disorder) and major depressive disorder.

Major mood disorders
      The DSM-IV-TR defines two major, or severe, mood disorders: bipolar disorder and major depression.

       mania, or bipolar disorder (previously known as manic-depressive disorder), is characterized by an elated or euphoric mood, quickened thought and accelerated, loud, or voluble speech, overoptimism and heightened enthusiasm and confidence, inflated self-esteem, heightened motor activity, irritability, excitement, and a decreased need for sleep. Depressive mood swings typically occur more often and last longer than manic ones, though there are persons who have episodes only of mania. Individuals with bipolar disorder frequently also show psychotic symptoms such as delusions, hallucinations, paranoia, or grossly bizarre behaviour. These symptoms are generally experienced as discrete episodes of depression and then of mania that last for a few weeks or months, with intervening periods of complete normality. The sequence of depression and mania can vary widely from person to person and within a single individual, with either mood abnormality predominating in duration and intensity. Manic individuals may injure themselves, commit illegal acts, or suffer financial losses because of the poor judgment and risk-taking behaviour they display when in the manic state.

      There are two types of bipolar disorders. The first, commonly known as bipolar 1, has several variations but is characterized primarily by mania, with or without depression. Its most common form involves recurrent episodes of mania and depression, often separated by relatively asymptomatic periods. The second type of bipolar disorder, typically called bipolar 2, is characterized primarily by depression accompanied—often right before or right after an episode of depression—by a condition known as hypomania, which is a milder form of mania that is less likely to interfere with routine activities.

      The lifetime risk for developing bipolar disorder is about 1 percent and is about the same for men and women. The onset of the illness often occurs at about age 30, and the illness persists over a long period. The predisposition to develop bipolar disorder is partly genetically inherited. Antipsychotic medications are used for the treatment of acute or psychotic mania. Mood-stabilizing agents such as lithium and several antiepileptic medications have proved effective in both treating and preventing recurrent attacks of mania.

      Major depressive disorder is characterized by depression without manic symptoms. Episodes of depression in this disorder may or may not be recurrent. In addition, the depression can take on a number of different characteristics in different people, such as catatonic features, which include unusual motor or vocal behaviour, or melancholic features, which include profound lack of responsiveness to pleasure. People with major depression are considered to be at high risk of suicide.

      Symptoms of major depressive disorder include a sad or hopeless mood, pessimistic thinking, a loss of enjoyment and interest in one's usual activities and pastimes, reduced energy and vitality, increased fatigue, slowness of thought and action, change of appetite, and disturbed sleep. Depression must be distinguished from the grief and low spirits felt in reaction to the death of a loved one or some other unfortunate circumstance. The most dangerous consequence of severe depression is suicide. Depression is a much more common illness than mania, and there are indeed many sufferers from depression who have never experienced mania.

      Major depressive disorder may occur as a single episode, or it may be recurrent. It may also exist with or without melancholia and with or without psychotic features. Melancholia implies the biological symptoms of depression: early-morning waking, daily variations of mood with depression most severe in the morning, loss of appetite and weight, constipation, and loss of interest in love and sex. Melancholia is a particular depressive syndrome that is relatively more responsive to somatic treatments such as medications (e.g., Prozac, Paxil, and Zoloft) and electroconvulsive therapy (shock therapy) (ECT).

      It is estimated that women experience depression about twice as often as men. While the incidence of major depression in men increases with age, the peak for women is between ages 35 and 45. There is a serious risk of suicide with the illness; of those who have a severe depressive disorder, about one-sixth eventually kill themselves. Childhood traumas or deprivations, such as the loss of one's parents while young, can increase a person's vulnerability to depression later in life, and stressful life events, especially where some type of loss is involved, are, in general, potent precipitating causes. Both psychosocial and biochemical mechanisms can be causative factors in depression. The best-supported hypotheses, however, suggest that the basic cause is faulty regulation of the release of one or more neurotransmitters (e.g., serotonin, dopamine, and norepinephrine), with a deficiency of neurotransmitters resulting in depression and an excess causing mania. The treatment of major depressive episodes usually requires antidepressant medications. Electroconvulsive therapy may also be helpful, as may cognitive, behavioral, and interpersonal psychotherapies.

      The characteristic symptoms and patterns of depression differ with age. Depression may appear at any age, but its most common period of onset is in young adulthood. Bipolar disorders also tend to appear first in young adulthood.

Other mood disorders
      Less-severe forms of mental disorder include dysthymic disorder (also known as dysthymia), a chronically depressed mood accompanied by one or more other symptoms of depression, and cyclothymic disorder (also known as cyclothymia), marked by chronic, yet not severe, mood swings.

      Dysthmic disorder, or depressive neurosis, may occur on its own but more commonly appears along with other neurotic symptoms such as anxiety, phobia, and hypochondriasis. It includes some, but not all, of the symptoms of depression. Where there are clear external grounds for a person's unhappiness, a dysthymic disorder is considered to be present when the depressed mood is disproportionately severe or prolonged, when there is a preoccupation with the precipitating situation, when the depression continues even after removal of the provocation, and when it impairs the individual's ability to cope with the specific stress. Although dysthymia tends to be a milder form of depression, it is nevertheless persistent and distressing to the person experiencing it, especially when it interferes with the person's ability to conduct normal social or work activities. In cases of cyclothymic disorder, the prevailing mood swings are established in adolescence and continue throughout adult life.

      At any time, depressive symptoms may be present in one-sixth of the population. Loss of self-esteem, feelings of helplessness and hopelessness, and loss of cherished possessions are commonly associated with minor depression. Psychotherapy is the treatment of choice for both dysthymic disorder and cyclothymic disorder, although antidepressant medications or mood-stabilizing agents are often beneficial. Symptoms must be present for at least two years in order for a diagnosis of dysthymic or cyclothymic disorder to be made.

      Major depressive disorder and dysthymic disorder are much more prevalent than the bipolar disorders and cyclothymic disorder. The former disorders, which feature depressive symptoms exclusively, are also diagnosed more frequently in women than in men, whereas the latter tend to be diagnosed to about the same extent in women and men. DSM-IV-TR indicates the lifetime prevalence of major depression to be well over 10 percent for women and 5 percent for men. The prevalence for dysthymic disorder is 6 percent among the general population in the United States, but it is at least twice as common in women as in men. Lifetime prevalence rates reported for the bipolar disorders and cyclothymic disorder are roughly 1 percent or less.

Anxiety disorders
       anxiety has been defined as a feeling of fear, dread, or apprehension that arises without a clear or appropriate justification. It thus differs from true fear, which is experienced in response to an actual threat or danger. Anxiety may arise in response to apparently innocuous situations or may be out of proportion to the actual degree of the external stress. Anxiety also frequently arises as a result of subjective emotional conflicts of whose nature the affected person may be unaware. Generally, intense, persistent, or chronic anxiety that is not justified in response to real-life stresses and that interferes with the individual's functioning is regarded as a manifestation of mental disorder. Although anxiety is a symptom of many mental disorders (including schizophrenia, obsessive-compulsive disorders, and post-traumatic stress disorders), in the anxiety disorders proper it is the primary and frequently the only symptom.

      The symptoms of anxiety disorders are emotional, cognitive, behavioral, and psychophysiological. Anxiety disorder can manifest itself in a distinctive set of physiological signs that arise from overactivity of the sympathetic nervous system (nervous system, human) or from tension in skeletal muscles. The sufferer experiences palpitations, dry mouth, dilatation of the pupils, shortness of breath, sweating, abdominal pain, tightness in the throat, trembling, and dizziness. Aside from the actual feelings of dread and apprehension, the emotional and cognitive symptoms include irritability, worry, poor concentration, and restlessness. Anxiety may also be manifested in avoidance behaviour.

      Anxiety disorders are distinguished primarily in terms of how they are experienced and to what type of anxiety they respond. For example, panic disorder is characterized by the occurrence of panic attacks, which are brief periods of intense anxiety. Panic disorder may occur with agoraphobia, which is a fear of being in certain public locations from which it could be difficult to escape.

      Specific phobias are unreasonable fears of specific stimuli; common examples are a fear of heights and a fear of dogs. Social phobia is an unreasonable fear of being in social situations or in situations in which one's behaviour is likely to be evaluated, such as in public speaking.

       obsessive-compulsive disorder is characterized by the presence of obsessions, compulsions, or both. Obsessions are persistent unwanted thoughts that produce distress. Compulsions are repetitive rule-bound behaviours that the individual feels must be performed in order to ward off distressing situations. Obsessions and compulsions are often linked; for example, obsessions about contamination may be accompanied by compulsive washing.

       post-traumatic stress disorder is characterized by a set of symptoms that are experienced persistently following one's involvement, either as a participant or as a witness, in an intensely negative event, usually experienced as a threat to life or well-being. Some of these symptoms include reexperiencing of the event, avoidance of stimuli associated with the event, emotional numbing, and hyperarousal. Finally, generalized anxiety disorder involves a pervasive sense of worry accompanied by other symptoms of anxiety.

      In general, anxiety, like depression, is one of the most common psychological problems people experience and for which they seek treatment. While panic disorder and some phobias, such as agoraphobia, are diagnosed much more commonly in women than in men, there is little gender difference for the other anxiety disorders. The anxiety disorders tend to appear relatively early in life (i.e., in childhood, adolescence, or young adulthood). As with the mood disorders, a variety of psychopharmacological and psychotherapeutic treatments can be used to help resolve anxiety disorders.

Somatoform disorders
      In these conditions, psychological distress is manifested through physical symptomatology (combined symptoms of a disease) or other physical concerns, but distress can occur in the absence of a medical condition. Even when a medical condition is present, it may not fully account for the symptoms. In such cases there may be positive evidence that the symptoms are caused by psychological factors. According to the DSM-IV-TR, the lifetime prevalence of the somatoform disorders is relatively low (1 to 5 percent of the population) or has yet to be established. These disorders tend to be lifelong conditions that initially appear in adolescence or young adulthood.

      This type of somatoform disorder, formerly known as Briquet's syndrome (after the French physician Paul Briquet), is characterized by multiple, recurrent physical complaints involving a wide range of bodily functions. The complaints, which usually extend over the course of many years, cannot be explained fully by the person's medical history or current condition and are therefore attributed to psychological problems. The individual demands medical attention, but no organic cause (i.e., a relevant medical condition) is found. The symptoms invariably occur in many different bodily systems—for instance, back pain, dizziness, indigestion, difficulty with vision, and partial paralysis—and may follow trends in health concerns among the public.

      The condition is relatively common and occurs in about 1 percent of adult women. Males rarely exhibit this disorder. There are no clear etiological factors. Treatment involves not agreeing with the person's inclination to attribute organic causes to the symptoms and ensuring that physicians and surgeons do not cooperate with the person in seeking excessive diagnostic procedures or surgical remedies for the complaints.

      This disorder was previously labeled hysteria. Its symptoms are a loss of or an alteration in physical functioning, which may include paralysis. The physical symptoms occur in the absence of organic pathology and are thought to stem instead from an underlying emotional conflict. The characteristic motor symptoms of conversion disorder include the paralysis of the voluntary muscles of an arm or leg, tremor, tics (tic), and other disorders of movement or gait. The neurological symptoms may be widely distributed and may not correlate with actual nerve distribution. Blindness, deafness, loss of sensation in arms or legs, the feeling of “pins and needles,” and an increased sensitivity to pain in a limb may also be present.

      Symptoms usually appear suddenly and occur in a setting of extreme psychological stress. The course of the disorder is variable, with recovery often occurring in a few days but with symptoms persisting for years or decades in chronic cases that remain untreated.

      The causation of conversion disorder has been linked with fixations (i.e., arrested stages in the individual's early psychosexual development). Freud's theory that threatening or emotionally charged thoughts are repressed out of consciousness and converted into physical symptoms is still widely accepted. The treatment of conversion disorder thus requires psychological rather than pharmacological methods, notably the exploration of the individual's underlying emotional conflicts. Conversion disorder can also be considered as a form of “illness behaviour”; i.e., the person uses the symptoms to gain a psychological advantage in social relationships, either by gathering sympathy or by being relieved of burdensome or stressful obligations and withdrawing from emotionally disturbing or threatening situations. Thus, the symptoms of conversion disorder may be advantageous, in a psychological sense, to the person who experiences them.

      Hypochondriasis is a preoccupation with physical signs or symptoms that the person unrealistically interprets as abnormal, leading to the fear or belief that he is seriously ill. There may be fears about the future development of physical or mental symptoms, a belief that actual but minor symptoms are of dire consequence, or an experience of normal bodily sensations as threatening symptoms. Even when a thorough physical examination finds no organic cause for the physical signs the individual is concerned about, the examination may nonetheless fail to convince the person that no serious disease is present. The symptoms of hypochondriasis may occur with mental illnesses other than anxiety, such as depression or schizophrenia.

      The onset of this disorder may be associated with precipitating factors such as an actual organic disease with physical and psychological aftereffects—e.g., coronary thrombosis in a previously fit man. Hypochondriasis often begins during the fourth and fifth decades of life but is also common at other times, such as during pregnancy. Treatment aims to provide understanding and support and to reinforce healthy behaviour; antidepressant medications may be used to relieve depressive symptoms.

Psychogenic pain disorder
      In psychogenic pain disorder the main feature is a persistent complaint of pain in the absence of organic disease and with evidence of a psychological cause. The pattern of pain may not conform to the known anatomic distribution of the nervous system. Psychogenic pain may occur as part of hypochondriasis or as a symptom of a depressive disorder. Appropriate treatment depends on the context of the symptom.

Dissociative disorders
      Dissociation is said to occur when one or more mental processes (such as memory or identity) are split off, or dissociated, from the rest of the psychological apparatus so that their function is lost, altered, or impaired. Although the DSM-IV-TR reports no lifetime prevalence rates for the dissociative disorders, both dissociative identity disorder and depersonalization disorder are more commonly diagnosed in women than in men.

      The symptoms of dissociative disorders have often been regarded as the mental counterparts of the physical symptoms displayed in conversion disorders. Since the dissociation may be an unconscious mental attempt to protect the individual from threatening impulses or repressed emotions, the conversion into physical symptoms and the dissociation of mental processes can be seen as related defense mechanisms arising in response to emotional conflict. Dissociative disorders are marked by a sudden, temporary alteration in the person's consciousness, sense of identity, or motor behaviour. There may be an apparent loss of memory (memory abnormality) of previous activities or important personal events, with amnesia for the episode itself after recovery. These are rare conditions, however, and it is important to rule out organic causes first.

Dissociative amnesia
      In dissociative amnesia there is a sudden loss of memory which may appear total; the individual can remember nothing about his previous life or even his name. The amnesia may be localized to a short period of time associated with a traumatic event or it may be selective, affecting the person's recall of some, but not all, of the events during a particular time. In psychogenic fugue the individual typically wanders away from home or from work and assumes a new identity, cannot remember his previous identity, and, upon recovering, cannot recall the events that occurred during the fugue state. In many cases the disturbance lasts only a few hours or days and involves only limited travel. Severe stress is known to trigger this disorder.

       dissociative identity disorder, previously called multiple personality disorder, is a rare and remarkable condition in which two or more distinct and independent personalities develop in a single individual. Each of these personalities inhabits the person's conscious awareness to the exclusion of the others at particular times. This disorder frequently arises as a result of traumas suffered during childhood and is best treated by psychotherapy, which seeks to reunite the various personalities into a single, integrated personality.

      In depersonalization, one feels or perceives one's body or self as being unreal, strange, altered in quality, or distant. This state of self-estrangement may take the form of feeling as if one is machinelike, is living in a dream, or is not in control of one's actions. Derealization, or feelings of unreality concerning objects outside oneself, often occurs at the same time. Depersonalization may occur alone in neurotic persons but is more often associated with phobic, anxiety, or depressive symptoms. It most commonly occurs in younger women and may persist for many years. Persons find the experience of depersonalization intensely difficult to describe and often fear that others will think them insane. Organic conditions, especially temporal lobe epilepsy, must be excluded before making a diagnosis of neurosis when depersonalization occurs. As with other neurotic syndromes, it is more common to see many different symptoms than depersonalization alone.

      The causes of depersonalization are obscure, and there is no specific treatment for it. When the symptom arises in the context of another psychiatric condition, treatment is aimed at that illness.

      Two of the more common eating disorders involve not only abnormalities of eating behaviour but also distortions in body perception. anorexia nervosa consists of a considerable loss in body weight, refusal to gain weight, and a fear of becoming overweight that is dramatically at odds with reality. People with anorexia often become grotesquely thin in the eyes of everyone but themselves, and they manifest the physical symptoms of starvation. Bulimia (bulimia nervosa) nervosa is characterized by impulsive or “binge” eating, alternating with maladaptive (and ineffective) efforts to lose weight, such as by purging (e.g., vomiting or using laxatives) or fasting. People with bulimia are also preoccupied with body weight and shape, but they do not exhibit the weight loss apparent in anorexia patients.

      Anorexia and bulimia are contrasting disorders with respect to self-control; those with anorexia apply excessive control over their eating behaviour, while those with bulimia exhibit a loss of control at some times with attempts to compensate for this at other times. DSM-IV-TR reports lifetime prevalence rates of 0.5 percent for anorexia nervosa and between 1 percent and 3 percent for bulimia nervosa. The typical age of onset for both disorders is mid- to late adolescence. The disorders are diagnosed far more frequently in girls than in boys.

      Misperceptions of one's appearance can also be manifested as body dysmorphic disorder, in which an individual magnifies the negative aspects of a perceived flaw to such a degree that the person shuns social settings or embarks compulsively upon a series of appearance-augmenting procedures, such as dermatological treatments and plastic surgery, in an attempt to remove the perceived defect.

Personality disorders (personality disorder)
      Personality is the characteristic way in which an individual thinks, feels, and behaves; it accounts for the ingrained behaviour patterns of the individual and is the basis for predicting how the individual will act in particular circumstances. Personality embraces a person's moods, attitudes, and opinions and is most clearly expressed in interactions with other people. A personality disorder is a pervasive, enduring, maladaptive, and inflexible pattern of thinking, feeling, and behaving that either significantly impairs an individual's social or occupational functioning or causes the person distress.

      Theories of personality disorder, including their descriptive features, etiology, and development, are as various as theories of personality itself. For example, in trait theory (an approach toward the study of personality formation), personality disorders are viewed as rigid exaggerations of particular traits. Psychoanalytic theorists (Freudian psychologists) explain the genesis of the disorders in terms of markedly negative childhood experiences, such as abuse, that significantly alter the course of normal personality development. Still others in fields such as social learning and sociobiology focus on the maladaptive coping and interactional strategies embodied in the disorders.

      The DSM-IV-TR recognizes 10 personality disorders, each of which is discussed below. It is important to note that the mere presence of the trait, even having it to an abnormal extent, is not enough to constitute disorder; rather, the abnormality must also cause disturbance to the individual or to society. It is also common for personality disorders to co-occur with other psychological symptoms, including those of depression, anxiety, and substance use disorders. Because personality traits are by definition virtually permanent, these disorders are only partially, if at all, amenable to treatment. The most effective treatment (mental disorder) combines various types of group, behavioral, and cognitive psychotherapy. The behavioral manifestations of personality disorders often tend to diminish in their intensity in middle and old age.

Paranoid (paranoia) personality disorder
      Marked by a pervasive suspiciousness and unjustified mistrust of others, this disorder is apparent when the individual misinterprets words and actions as having a special significance for him or as being directed against him. Sometimes such people are guarded, secretive, hostile, quarrelsome, and litigious, and they are excessively sensitive to the implied criticism of others. The disorder may develop over a lifetime, sometimes beginning in childhood or adolescence. It is more common in males.

Schizoid personality disorder
      In this disorder there is a disinclination to interact with others; the individual appears passive, aloof, and withdrawn, and there is a notable lack of interest in and responsiveness to interpersonal relationships. Such a person leads a solitary existence and may appear cold or unemotional. Some theorists hypothesize an underlying fear of connecting with others in a close relationship. The disorder may appear in childhood or adolescence as a tendency toward solitariness. Although it is much discussed in the psychoanalytic literature, it is nonetheless rare.

Schizotypal personality disorder
      This disorder is characterized by notable oddities or eccentricities of thought, speech, perception, or behaviour that may be marked by social withdrawal, delusions of reference (beliefs that things unrelated to the individual refer to or have a personal significance for him), paranoid ideation (the belief that others are intent on harming or insulting the individual), and magical thinking, as well as bizarre fantasies or persecutory delusions. Eccentricities alone do not justify the diagnosis of this (or any) disorder; instead, the characteristic features of schizotypal personality disorder are of such severity that they cause interpersonal deficiencies and considerable emotional distress. Some features may even resemble symptoms of schizophrenia, but, unlike schizophrenia, the personality disorder is stable and enduring, developing as early as childhood or adolescence and lasting throughout life, yet only rarely progressing into schizophrenia.

Antisocial personality disorder
      Those who are diagnosed with this disorder typically exhibit a personal history of chronic and continuous antisocial behaviour that involves violating the rights of others. Job performance is poor or nonexistent. The disorder is associated with actions such as persistent criminality, sexual promiscuity or aggressive sexual behaviour, and drug use. There is evidence of conduct disorder (mental disorder) in childhood and antisocial behaviour in mid-adolescence. People with this disorder typically have problems with the law, and they are often deceitful, aggressive, impulsive, irresponsible, and remorseless. As with borderline personality disorder (discussed below), the features of antisocial personality disorder tend to fade in middle age, but there remains a high risk of suicide, accidental death, drug or alcohol abuse, and a tendency toward interpersonal problems. The disorder occurs more commonly in men.

Borderline personality disorder
      Borderline personality disorder is characterized by an extraordinarily unstable mood and self-image. Individuals with this disorder may exhibit intense episodes of anger, depression, or anxiety. This is a disorder of personality instability—such as unstable emotionality, unstable interpersonal relationships, unstable sense of self—as well as impulsivity. People with this disorder often have “emotional roller-coaster” relationships, in which they experience a desperate fear of abandonment and exhibit alternating extremes of positive and negative affect toward the other person. They may engage in a variety of reckless behaviours, including sexual risk-taking, substance abuse, self-mutilation, and attempts at suicide. They may exhibit cognitive problems as well, particularly regarding their physical and psychological sense of self. The disorder, which occurs more commonly in women, often appears in early adulthood and tends to fade by middle age.

Histrionic personality disorder
      People with this disorder are overly dramatic and intensely expressive, egocentric, highly reactive, and excitable. The characteristic behaviour seems to have the purpose of calling attention to oneself. Other features of this disorder may include emotional and interpersonal superficiality as well as socially inappropriate interpersonal behaviour. Although clinical tradition has tended to associate it more frequently with women, the disorder occurs in both women and men, and it tends to take on characteristics of stereotypical sex roles.

Narcissistic personality disorder
      A person with this disorder has a grandiose sense of self-importance and a preoccupation with fantasies of success, power, and achievement. The essential characteristic of this disorder is an exaggerated sense of self-importance that is reflected in a wide variety of situations. The sense of self-worth exceeds the individual's actual accomplishments. People with this disorder are typically egocentric and are often insensitive to the perspectives and needs of others. They are likely to be seen as arrogant. The disorder is more common in men, and it tends to be apparent by early adulthood. Both narcissistic and histrionic personality disorders are described largely in terms of common personality characteristics, albeit in exaggerated form; what makes each a disorder, however, is not the exaggerated characteristics alone but the distress and dysfunction they produce.

Avoidant personality disorder
      People with this disorder feel personally inadequate and fear that others judge them to be so in social situations. They show extreme sensitivity to rejection and may lead socially withdrawn lives, tending to avoid social situations for fear of being evaluated negatively by others. When they do participate in social situations, they often appear inhibited. They are not asocial, however; they show a great desire for companionship but need unusually strong guarantees of uncritical acceptance. Persons with this disorder are commonly described as having an “ inferiority complex.” Although avoidant personality disorder often appears in childhood or adolescence (first as shyness), it tends to diminish somewhat in adulthood.

Dependent personality disorder
      This disorder is identified in individuals who subordinate their own needs, as well as responsibility over major areas of their lives, to the control of others. In other words, people with this disorder feel personally inadequate, and they exhibit this in their reluctance to take responsibility for themselves, such as in everyday decision making and long-term planning. Instead, they turn to others for these things, creating relationships in which others essentially take care of them. Their own relationship behaviour is likely to be clinging, deferent, eager to please, and self-abasing, and they may exhibit an excessive fear of abandonment. This is one of the most common personality disorders. Persons with this disorder lack self-confidence and may experience intense discomfort when alone. (Compare codependency.)

Obsessive-compulsive personality disorder
      A person with this disorder shows prominent overscrupulous, perfectionistic traits that are expressed in feelings of insecurity, self-doubt, meticulous conscientiousness, indecisiveness, excessive orderliness, and rigidity of behaviour. The person is preoccupied with rules and procedures as ends in themselves. Such persons tend to show a great concern for efficiency, are overly devoted to work and productivity, and are usually deficient in the ability to express warm or tender emotions (emotion). They may also exhibit a high degree of moral rigidity that is not explained by upbringing alone. This disorder is more common in men and is in many ways the antithesis of antisocial personality disorder.

      The causes of personality disorders are obscure and, in many cases, difficult to study empirically. There is, however, a constitutional and therefore hereditary element in determining personality characteristics generally and so in determining personality disorders as well. Psychological and environmental factors are also important in causation. For example, many authorities believe there is a link between childhood sexual abuse and the development of borderline personality disorder or between harsh, inconsistent punishment in childhood and the development of antisocial personality disorder. However, it is extremely difficult to establish the validity of these links through systematic scientific inquiry, and, in any case, such environmental factors are not always associated with the disorders.

Psychosexual disorders
      The following section discusses disorders of gender identity and preferences for unusual or bizarre sexual practices (sexual behaviour, human) or objects.

Gender identity disorder
      In gender identity disorder a person feels a discrepancy between his anatomical sex and the gender that he ascribes to himself. This disorder is much more common in males than females. The individual claims that he is a member of the opposite sex—“a female mind trapped in a male body.” An individual with gender identity disorder may assume the dress and behaviour and participate in activities commonly associated with the opposite sex and may even use hormones and surgery to achieve the physical characteristics of the opposite sex. The cause of the condition is unknown. Individuals with this disorder have a significant risk of developing depression and an increased risk of suicide. Psychiatric treatment is generally supportive in type. Persons with gender identity disorder may choose to have sex reassignment surgery, a procedure in which the body, including the genitals, is surgically altered to look like that of the opposite sex.

Paraphilias
      Paraphilias, or sexual deviations, are defined as unusual fantasies, urges, or behaviours that are recurrent and sexually arousing. These urges must occur for at least six months and cause distress to the individual in order to be classified as a paraphilia. In fetishism, inanimate objects (e.g., shoes) are the person's sexual preference and means of sexual arousal. In transvestism, the recurrent wearing of clothes of the opposite sex is performed to achieve sexual excitement. In pedophilia, an adult has sexual fantasies about or engages in sexual acts with a prepubertal child of the same or opposite sex. In exhibitionism, repeated exposure of the genitals to an unsuspecting stranger is used to achieve sexual excitement. In voyeurism, observing the sexual activity of others repeatedly is the preferred means of sexual arousal. In sadomasochism (masochism), the individual achieves sexual excitement as either the recipient or the provider of pain, humiliation, or bondage.

      The causes of these conditions are generally not known. Behavioral, psychodynamic, and pharmacological methods have been used with varying efficacy to treat these disorders.

Disorders usually first evident in infancy, childhood (childhood disease and disorder), or adolescence
      Children are usually referred to a psychiatrist or therapist because of complaints or concern about their behaviour or development expressed by a parent or some other adult. Family problems, particularly difficulties in the parent-child relationship, are often an important causative factor in the symptomatic behaviour of the child. For a child psychiatrist, the observation of behaviour is especially important, as children may not be able to express their feelings in words. Isolated psychological symptoms are extremely common in children. Boys are affected twice as often as girls.

Attention-deficit disorders
      Children with these disorders show a degree of inattention (attention) and impulsiveness that is markedly inappropriate for their stage of development. Gross overactivity in children can have many causes, including anxiety, conduct disorder (discussed below), or the stresses associated with living in institutions. Learning difficulties and antisocial behaviour may occur secondarily. This syndrome is 10 times more common in boys than in girls.

Conduct disorders
      These are the most common psychiatric disorders in older children and adolescents, accounting for nearly two-thirds of disorders in those of age 10 or 11. Abnormal conduct more serious than ordinary childlike mischief persistently occurs; lying, disobedience, aggression, truancy, delinquency, and deterioration of work may occur at home or at school. Vandalism, drug and alcohol abuse, and early sexual promiscuity may also occur. The most important causative factors are the family background; broken homes, unstable and rejecting families, institutional care in childhood, and a poor social environment are frequently present in such cases.

Anxiety disorders
      Neurotic or emotional disorders in children are similar to the adult conditions except that they are often less clearly differentiated. In anxiety disorders of childhood, the child is fearful, timid with other children, and overdependent and clinging toward the parents. Physical symptoms, sleep disturbance, and nightmares occur. Separation from the parent or from the home environment is a major cause of this anxiety.

       anorexia nervosa usually starts in late adolescence and is about 20 times more common in girls than in boys. This disorder is characterized by a failure to maintain normal body weight for an individual's age and height; weight loss is at least 15 percent of the ideal body weight. Weight loss occurs because of an intense desire to be thin, a fear of gaining weight, or a disturbance in the way in which the individual sees her body weight or shape. Postmenarchal females with anorexia nervosa usually experience amenorrhea (i.e., the absence of at least three consecutive menstrual periods). Medical complications of anorexia nervosa can be life-threatening.

      The condition appears to start with an individual's voluntary control of food intake in response to social pressures such as peer conformity. The disorder is exacerbated by troubled relations within the family. It is much more common in developed, wealthy societies and in girls of higher socioeconomic class. Treatment includes persuading the person to accept and cooperate with medical therapy, achieving weight gain, and helping the person maintain weight by psychological and social therapy.

      Bulimia (bulimia nervosa) nervosa is characterized by excessive overeating binges combined with inappropriate methods of stopping weight gain such as self-induced vomiting or the use of laxatives (laxative) or diuretics (diuretic).

Autistic (autism) disorder
      Psychotic disorders are very rare in childhood, and of these about one-half are cases of autistic disorder. Boys are affected three times as often as girls. As the most severe form of autism, autistic disorder begins in the first two years of life and is more common in the upper socioeconomic classes. The child exhibits an inability to make warm emotional relationships, has severe language and speech disorders, and exhibits a desire for routine to the extent of showing distress if thwarted from the stereotyped behaviour. There is some evidence to support genetic and organic factors in the causation of autistic disorder. Treatment involves management of the abnormal behaviour, training in life skills and occupational activities, and counseling for the family.

Other childhood disorders
      Stereotyped movement disorders involve the exhibition of tics (tic) in differing patterns. A tic is an involuntary, purposeless jerking movement of a group of muscles or the involuntary production of noises or words. Tics may affect the face, head, and neck or, less commonly, the limbs or trunk. Tourette syndrome is typified by multiple tics and involuntary vocalization, which sometimes includes the uttering of obscenities.

      Other physical symptoms that are often listed among psychiatric disorders of childhood include stuttering, enuresis (the repeated involuntary emptying of urine from the bladder during the day or night), encopresis (the repeated voiding of feces into inappropriate places), sleepwalking, and night terror. These symptoms are not necessarily evidence of emotional disturbance or of some other mental illness. Behavioral methods of treatment are usually effective.

Other mental disorders

Factitious disorders
      Factitious disorders are characterized by physical or psychological symptoms that are voluntarily self-induced; they are distinguished from conversion disorder, in which the physical symptoms are produced unconsciously. In factitious disorders, although the person's attempts to create or exacerbate the symptoms of an illness are voluntary, such behaviour is neurotic in that the individual is unable to refrain from it—i.e., the person's goals, whatever they may be, are involuntarily adopted. In malingering, by contrast, the person stimulates or exaggerates an illness or disability to obtain some kind of discernible personal gain or to avoid an unpleasant situation; e.g., a prison inmate may simulate madness to obtain more-comfortable living conditions. It is important to recognize factitious disorders as evidence of psychological disturbance.

Impulse-control disorders
      Persons with these conditions demonstrate a failure to resist desires, impulses, or temptations to perform an act that is harmful to themselves or to others. The individual experiences a feeling of tension before committing the act and a feeling of release or gratification upon completing it. The behaviours involved include pathological gambling, pathological setting of fires ( pyromania), pathological stealing ( kleptomania), and recurrent pulling of hair (trichotillomania).

adjustment disorders
      These are conditions in which there is an inappropriate reaction to an external stress occurring within three months of the stress. The symptoms may be out of proportion to the degree of stress, or they may be maladaptive in the sense that they prevent an individual from coping adequately in normal social or occupational settings. These disorders are often associated with other mood or anxiety disorders.

Andrew C.P. Sims Linda Andrews Charles D. Claiborn Stuart C. Yudofsky Ed.

Treatment of mental disorders

Historical overview
Early history
 References to mental disorders in early Egyptian, Indian, Greek, and Roman writings show that the physicians and philosophers who contemplated problems of human behaviour regarded mental illnesses as a reflection of the displeasure of the gods or as evidence of demoniac possession. Only a few realized that individuals with mental illnesses should be treated humanely rather than exorcised, punished, or banished. Certain Greek medical writers, however, notably Hippocrates (flourished 400 BC), regarded mental disorders as diseases to be understood in terms of disturbed physiology. He and his followers emphasized natural causes, clinical observation, and brain pathology. Later Greek (ancient Greek civilization) medical writers, including those who practiced in imperial Rome (ancient Rome), prescribed treatments for mental illness, including a quiet environment, work, and the use of drugs such as the purgative hellebore. It is probable that most people with psychoses during ancient times were cared for by their families and that those who were thought to be dangerous to themselves or others were detained at home by relatives or by hired keepers.

      During the early Middle Ages in Europe, primitive thinking about mental illness reemerged, and witchcraft and demonology were invoked to account for the symptoms and behaviour of people with psychoses. At least some of those who were deemed insane were looked after by the religious orders, who offered care for the sick generally. The empirical and quasi-scientific Greek tradition in medicine was maintained not by the Europeans but by the Muslim (Islāmic world) Arabs, who are usually credited with the establishment of asylums for the mentally ill in the Middle East as early as the 8th century. In medieval Europe in general it seems that the mentally ill were allowed their freedom, provided they were not regarded as dangerous. The founding of the first hospital in Europe devoted entirely to the care of the mentally ill probably occurred in Valencia, Spain, in 1407–09, though this has also been said of a hospital established in Granada in 1366–67.

      From the 17th century onward in Europe, there was a growing tendency to isolate deviant people, including the mentally ill, from the rest of society. Thus, the mentally ill were confined together with the disabled, vagrants, and delinquents. Those regarded as violent were often chained to the walls of prisons and were treated in a barbarous and inhumane way.

  In the 17th and 18th centuries the development of European medicine and the rise of empirical methods of medical-scientific inquiry were paralleled by an improvement in public attitudes toward the mentally ill. By the end of the 18th century, concern over the care of the mentally ill had become so great among educated people in Europe and North America that governments were forced to act. After the French Revolution the physician Philippe Pinel (Pinel, Philippe) was placed in charge of the Bicêtre, the hospital for the mentally ill in Paris. Under Pinel's supervision a completely new approach to the care of mental patients was introduced. Chains and shackles were removed, and dungeons were replaced by sunny rooms; patients were also permitted to exercise on the hospital grounds. Among other reformers were the British Quaker layman William Tuke, who established the York Retreat for the humane care of the mentally ill in 1796, and the physician Vincenzo Chiarugi, who published a humanitarian regime for his hospital in Florence in 1788. In the mid-19th century Dorothea Dix (Dix, Dorothea Lynde) led a campaign to increase public awareness of the inhumane conditions that prevailed in American mental hospitals. Her efforts led to widespread reforms both in the United States and elsewhere.

The mental hospital era
      Many hospitals for the mentally ill were built in the latter half of the 18th century. Some of them, like the York Retreat in England, were run on humane and enlightened principles, while others, like the York Asylum, gave rise to great scandal because of their brutal methods and filthy conditions. In the mid-19th century an extensive program of mental hospital building was carried out in North America, Britain, and many of the countries of continental Europe. The hospitals housed poor mental patients, and their aim was to care for these individuals humanely and to relieve their families of the burden. The approach represented an attempt toward respectful treatment (as opposed to neglect or brutality), including work, the avoidance of physical methods of restraint, and respect for the individual patient. A widespread belief in the curability of mental illness at this time was a principal motivating factor behind such reform.

      The mental hospital era was an age of reform, and there is no doubt that patients were treated much more humanely than in earlier times. The era produced a large number of segregated institutions in which a much-higher proportion of the mentally ill was confined than previously. But the medical reformers' early hopes of successful cures were not vindicated, and by the end of the 19th century the hospitals had become overcrowded, and custodial care had replaced moral treatment.

The biological movement
      Along with humanitarian reforms in hospital practice and treatment methods during the late 18th and 19th centuries, there was a resurgence of medical and scientific interest in psychiatric theory and practice. Fundamental strides were made during this period in establishing a scientific basis for the study of mental disorders. A long series of observations by clinicians in France, Germany, and England culminated in 1883 in a comprehensive classification of mental disorders by the German psychiatrist Emil Kraepelin (Kraepelin, Emil). His classification system served as the basis for all subsequent ones, and the cardinal distinction he made between schizophrenia and bipolar disorder still stands.

      Rapid advances in various branches of medicine led in the later 19th century to the expectation of discovering specific brain lesions that were thought to cause the various forms of mental disorder. While this research did not attain the results that were expected, the scientific emphasis was productive in that it did elucidate the gross and microscopic pathology of many brain disorders that can produce psychiatric disabilities. Nevertheless, many of the psychotic disorders, notably schizophrenia and bipolar disorder, frustrated the effort to find causative agents in cellular pathology. It became apparent that other explanations had to be found for the many puzzling aspects of mental disorders in general, and they emerged in a wave of psychological rather than physical theories.

Development of psychotherapy
  Foremost among these approaches was psychoanalysis, which originated in the work of the Viennese neurologist Sigmund Freud (Freud, Sigmund). Having studied under the French neurologist Jean-Martin Charcot (Charcot, Jean-Martin), Freud originally used well-known techniques of hypnosis to treat patients suffering from what was then called hysterical paralysis and other neurotic syndromes. Freud and his colleague Josef Breuer (Breuer, Josef) observed that their patients tended to relive earlier life experiences that could be associated with the symptomatic expression of their illnesses. When these memories and the emotions associated with them were brought to consciousness during the hypnotic state, the patients showed improvement. Observing that most of his patients proved able to talk about such memories without being under hypnosis, Freud developed a means of access to the unconscious based on the technique of free association—the production by the patients, aloud and without suppression or self-censorship of any kind, of the thoughts and feelings about whatever was uppermost in their minds. From this beginning Freud gradually developed what became known as psychoanalysis. Other features of the new procedure included the study of dreams, the interpretation of “resistances” on the part of the patient, and the handling of the patient's “transference” (the patient's feelings toward the analyst that reflect previously experienced feelings toward parents and other important figures in the patient's early life). Freud's work, though complex and controversial in many of its aspects, laid the basis for modern psychotherapy in its use of free association and its emphasis on unconscious and irrational mental processes as causative factors in mental illness. This emphasis on purely psychological factors as a basis for both causation and treatment was to become the cornerstone of most subsequent psychotherapies. For a fuller discussion of resistance and transference, see below Psychoanalytic psychotherapy (mental disorder).

      Variations of the original psychoanalytic technique were introduced by several of Freud's colleagues who parted company with him. analytic psychology, devised by Carl Jung (Jung, Carl), placed less emphasis on free association and more on the interpretation of dreams and fantasies. Special importance was given to the collective unconscious, a reservoir of shared unconscious wisdom and ancestral experience that entered consciousness only in symbolic form to influence thought and behaviour. Jungian analysts sought clues to their patients' problems in the archetypal nature of myths, stories, and dreams. Individual psychology, devised by Alfred Adler (Adler, Alfred), emphasized the importance of the individual's drive toward power and of the individual's unconscious feelings of inferiority. The therapist was concerned with the patient's compensations for inferiority as well as with the patient's social relationships.

Development of physical and pharmacological treatments
 During the early decades of the 20th century, the principal approaches to the treatment of mental disorders were psychoanalytically derived psychotherapies, used to treat people with neuroses, and custodial care in mental hospitals, for those with psychoses. But, beginning in the 1930s, these methods began to be supplemented by physical approaches using drugs, electroconvulsive therapy, and surgery. The first successful physical treatment in psychiatry was the induction of malaria in patients with a fatal form of neurosyphilis called general paresis. The malarial treatment stemmed from the observation that some psychotic patients improved during febrile illnesses. In 1933 the Polish psychiatrist Manfred Sakel (Sakel, Manfred J.) reported that psychotic symptoms of patients with schizophrenia were improved by repeated insulin-induced comas. (Neither of these treatments is in use today.) The treatment of symptoms of schizophrenia by convulsions (convulsion), originally induced by the injection of camphor, was reported in 1935 by the psychiatrist Ladislaus Joseph von Meduna in Budapest. An improvement in this approach was the induction of convulsions by the passage of an electrical current through the brain, a technique introduced by Italian psychiatrists Ugo Cerletti and Lucio Bini in 1938. Electroconvulsive treatment (shock therapy) was more successful in alleviating states of severe depression than in treating symptoms of schizophrenia. psychosurgery, or surgery performed to treat mental illness, was introduced by the Portuguese neurologist António Egas Moniz (Egas Moniz, António) in the 1930s. The procedure Moniz originated—leucotomy, or lobotomy—was widely performed during the next two decades in the treatment of patients with schizophrenia, intractable depression, and severe obsessional states. The procedure was later abandoned, however, largely because its therapeutic effects could be better obtained by the use of newly developed medications.

      The decades after World War II were marked by the first safe and effective applications of medications in the treatment of mental disorders. Prior to the 1950s, sedative compounds such as bromides and barbiturates had been used to quiet or sedate patients, but these drugs were general in their effect and did not target specific symptoms of mood disturbances or psychotic disorders. Many of the medications that subsequently proved effective in treating such conditions were recognized serendipitously—i.e., when researchers administered them to patients just to see what would happen or when they were administered to treat one medical condition and were instead found to be helpful in alleviating the symptoms of a mental disorder.

      The first effective pharmacological treatment of psychosis was the treatment of mania with lithium, introduced by the Australian psychiatrist J.F.J. Cade in 1949. Lithium, however, generated little interest until its dramatic effectiveness in the maintenance treatment of bipolar disorder was reported in the mid-1960s. chlorpromazine, the first of a long series of highly successful antipsychotic drugs, was synthesized in France in 1950 during work on antihistamines (antihistamine). It was used in anesthesia before its antipsychotic and tranquilizing effects were reported in France in 1952. The first tricyclic (so called because of its three-ringed chemical structure) antidepressant drug, imipramine, was originally designed as an antipsychotic drug and was investigated by the Swiss psychiatrist Roland Kuhn. He found it ineffective in treating symptoms of schizophrenia but observed its antidepressant effect, which he reported in 1957. A drug used in the treatment of tuberculosis, iproniazid, was found to be effective as an antidepressant in the mid-1950s. It was the first monoamine oxidase inhibitor to be used in psychiatry. The first modern anxiety-relieving drug was meprobamate, which was originally introduced as a muscle relaxant. It was soon overtaken by the pharmacologically rather similar but clinically more effective chlordiazepoxide, which was synthesized in 1957 and marketed as Librium in 1960. This drug was the first of the extensively used benzodiazepines. These and other drugs had a revolutionary impact not only on psychiatry's ability to relieve the symptoms and suffering of people with a wide range of mental disorders but also on the institutional care of the mentally ill.

      Between about 1850 and 1950 there was a steady increase in the number of patients staying in mental hospitals. In England and Wales, for example, there were just over 7,000 such patients in 1850, nearly 120,000 in 1930, and nearly 150,000 in 1954. Thereafter the number steadily declined, reaching just over 100,000 in 1970 and 75,000 in 1980, a decrease of almost 50 percent. The same process began in the United States in 1955 but continued at a more rapid rate. The decrease, from just under 560,000 in 1955 to just over 130,000 in 1980, was more than 75 percent. In both countries it became official policy to replace mental hospital treatment with community care, involving district general hospital psychiatric units in Britain and local mental health centres in the United States. This dramatic change can be partly attributed to the introduction of antipsychotic medications, which drastically changed the atmosphere of mental hospital wards. With the recovery of lucidity and calmness, many psychotic patients could return to their homes and live at least a partially normal existence. The wholesale release of mental patients into the community was not without problems, however, since many areas lacked the facilities to support and maintain such patients, many of whom thus received inadequate care.

Development of behaviour therapy
      In the 1950s and '60s a new type of therapy, called behaviour therapy, was developed. In contrast to the existing psychotherapies, its techniques were based on theories of learning derived from research on classical conditioning by Ivan Pavlov (Pavlov, Ivan Petrovich) and others and from the work of such American behaviourists as John B. Watson (Watson, John B.) and B.F. Skinner (Skinner, B.F.). Behavioral therapy arose when the theoretical principles that were originally developed from experiments with animals were applied to the treatment of patients.

      In 1920 Watson experimentally induced a phobia of rats in a small boy, and in 1924 Mary Cover Jones reported the extinction of phobias in children by gradual desensitization. Modern behaviour therapy began with the description by the South African psychiatrist Joseph Wolpe of his technique of systematically desensitizing patients with phobias, beginning by exposing them to the least-feared object or situation and gradually progressing to the most-feared. Behavioral therapies were more quickly adopted in Europe than in the United States, where psychoanalytic precepts had exercised a particular dominance over psychiatry, but by the 1980s behavioral therapies were also well established in the United States.

Further developments in the mental health profession
      There has been a great increase in the number of mental health professionals since World War II. In the United States the number of psychiatrists was 3,000 in 1939 but had increased to more than 50,000 by the early 1990s. Nonmedical mental health professionals have also increased substantially in number. Clinical (clinical psychology) psychologists, who at one time largely administered psychometric tests, now also provide psychotherapy and behaviour therapy. Psychiatric social workers also have become psychotherapists and play prominent roles in mental health centres. There are new roles for nurses (nursing), including behaviour therapy and the management of chronic mental illness in the community.

      Psychotherapy retains a major role in the mental health profession. Subsequent to the development of psychoanalysis, the varieties of psychotherapy have increased and multiplied to more than 250 different therapies. The repertoire of medications used in the treatment of mental illness has continued to grow as new drugs are developed or new applications of existing ones are discovered. Research on the biochemical and genetic causes of mental disease continues to make headway. The triad of psychotherapy, medication, and counseling affords an unprecedented array of approaches, techniques, and procedures for alleviating the symptoms of people with mental disorders.

Physiological treatments
Pharmacological treatments

Antipsychotic agents
      Antipsychotic medications, which are also known as neuroleptics and major tranquilizers (tranquilizer), belong to several different chemical groups but are similar in their therapeutic effects. These medications have a calming effect that is valuable in the relief of agitation, excitement, and violent behaviour in persons with psychoses. The drugs are quite successful in reducing the symptoms of schizophrenia, mania, and delirium, and they are used in combination with antidepressants to treat psychotic depression. The drugs suppress hallucinations and delusions, alleviate disordered or disorganized thinking, improve the patient's lucidity, and generally make an individual more receptive to psychotherapy. Patients who have previously been agitated, intractable, or grossly delusional become noticeably calmer, quieter, and more rational when maintained on these drugs. The medications have enabled many patients with episodic psychoses to have shorter stays in hospitals and have allowed many other patients who would have been permanently confined to institutions to live in the outside world. The antipsychotics differ in their unwanted effects: some are more likely to make the patient drowsy; some to alter blood pressure or heart rate; and some to cause tremor or slowness of movement.

      In the treatment of schizophrenia, antipsychotic drugs partially or completely control such symptoms as delusions and hallucinations. They also protect the patient who has recovered from an acute episode of the mental illness from suffering a relapse. The newer antipsychotic medications also treat social withdrawal, apathy, blunted emotional capacity, and the other psychological deficits characteristic of the chronic stage of the illness.

      No single drug seems to be outstanding in the treatment of schizophrenia. In an individual patient, one drug may be preferred to another because it produces less-severe unwanted effects, and the dose of any one drug needed to produce a therapeutic effect varies widely from patient to patient. Because of these individual differences, it is common for psychiatrists to substitute a drug of a different chemical group when one drug has been shown to be ineffective despite its use in adequate dosage for several weeks.

      In an acute psychotic episode, a drug such as chlorpromazine, olanzepine, or haloperidol usually has a calming effect within a day or two. The control of psychotic symptoms such as hallucinations or disordered thinking may take weeks. The appropriate dosage has to be determined for each patient by cautiously increasing the dose until a therapeutic effect is achieved without unacceptable side effects.

      It is not known exactly how antipsychotic medications work. One theory is that they block dopamine receptors in the brain. Dopamine is a neurotransmitter—i.e., a chemical messenger produced by certain nerve cells that influence the function of other nerve cells by interacting with receptors in their cell membranes. Since schizophrenia may be caused by either the excessive release of or an increased sensitivity to dopamine in the brain, the effects of antipsychotic drugs may be due to their ability to block or inhibit dopamine transmission.

      Dopamine-receptor blockade is certainly responsible for the main side effects of first-generation antipsychotic medications. These symptoms, which are termed extrapyramidal symptoms (EPS), resemble those of Parkinson disease (human disease) and include tremor of the limbs; bradykinesia (slowness of movement with loss of facial expression, absence of arm-swinging during walking, and a general muscular rigidity); dystonia (sudden, sustained contraction of muscle groups causing abnormal postures); akathisia (a subjective feeling of restlessness leading to an inability to keep still); and tardive dyskinesia (involuntary movements, particularly involving the lips and tongue). Most extrapyramidal symptoms disappear when the drug is withdrawn. Tardive dyskinesia occurs late in the drug treatment and in about half of the cases persists even after the drug is no longer used. There is no satisfactory treatment for severe tardive dyskinesia.

Antianxiety agents
      The drugs most commonly used in the treatment of anxiety are the benzodiazepines, which have replaced the barbiturates because of their vastly greater safety. Benzodiazepines differ from each other in duration of action rather than effectiveness. Smaller doses have a calming effect and alleviate both the physical and psychological symptoms of anxiety. Larger doses induce sleep, and some benzodiazepines are marketed as hypnotics. The benzodiazepines have become among the most widely prescribed drugs in the developed world, and controversy has arisen over their excessive use by the public.

      The side effects of these medications are usually few—most often drowsiness and unsteadiness. Benzodiazepines are not lethal even in very large overdoses, but they increase the sedative effects of alcohol and other drugs. The benzodiazepines are basically intended for short- or medium-term use, since the body develops a tolerance to them that reduces their effectiveness and necessitates the use of progressively larger doses. Dependence on them may also occur, even in moderate dosages, and withdrawal symptoms have been observed in those who have used the drugs for only four to six weeks. In patients who have taken a benzodiazepine for many months or longer, withdrawal symptoms occur in 15 to 40 percent of the cases and may take weeks or months to subside.

      Withdrawal symptoms from benzodiazepines are of three kinds. Such severe symptoms as delirium or convulsions are rare. Frequently the symptoms involve a renewal or increase of the anxiety itself. Many patients also experience other symptoms such as hypersensitivity to noise and light as well as muscle twitching. As a result, many long-term users continue to take the drug not because of persistent anxiety but because the withdrawal symptoms are too unpleasant.

      Because of the danger of dependence, benzodiazepines should be taken in the lowest possible dose for no more than a few weeks. For longer periods they should be taken intermittently, and only when the anxiety is severe.

      Benzodiazepines act on specialized receptors in the brain that are adjacent to receptors for a neurotransmitter called gamma-aminobutyric acid (GABA), which inhibits anxiety. It is possible that the interaction of benzodiazepines with these receptors facilitates the inhibitory (anxiety-suppressing) action of GABA within the brain.

      Many persons suffering from depression gain symptomatic relief from treatment with an antidepressant. There are several classes of antidepressant drugs, which vary in their mechanism of action and side effects. Successful treatment with such drugs relieves all the symptoms of depression, including disturbances of sleep and appetite, loss of sexual desire, and decreased energy, interest, and concentration. It usually takes two to three weeks for an antidepressant to improve a person's depressed mood significantly. Once a good response has been achieved, the drug should be continued for a further six months to reduce the risk of relapse. Antidepressants are also effective in treating other mental disorders such as panic disorder, agoraphobia, obsessive-compulsive disorder, and bulimia nervosa.

      It is widely theorized that depression is partly caused by reduced quantities or reduced activity of one or more neurotransmitters in the brain. Selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac) and sertraline (Zoloft), are thought to act by inhibiting the reabsorption of the neurotransmitter serotonin. As a result, there is an accumulation of serotonin in the brain, a change that may be important in elevating mood. Because SSRIs interfere with only one neurotransmitter system, they have fewer, and less-severe, side effects than other classes of antidepressants, which inhibit the action of several neurotransmitters. Common side effects of SSRIs include decreased sexual drive or ability, diarrhea, insomnia, headache, and nausea.

      Tricyclic antidepressants interfere with the reuptake of norepinephrine, serotonin, and dopamine. The side effects of these drugs are mostly due to their interference with the function of the autonomic nervous system and may include dryness of the mouth, blurred vision, constipation, and difficulty urinating. Weight gain can be a distressing side effect in persons taking a tricyclic for a long period of time. In elderly persons these drugs can cause delirium. Certain tricyclics interfere with conduction in heart muscle, and so they are best avoided in individuals with heart disease. Drug interactions occur with tricyclics, the most important being their interference with the action of certain drugs used in the treatment of high blood pressure.

      Monoamine oxidase inhibitors (MAOIs) interfere with the action of monoamine oxidase, an enzyme involved in the breakdown of norepinephrine and serotonin. As a result, these neurotransmitters accumulate within nerve cells and presumably leak out onto receptors. The side effects of these drugs include daytime drowsiness, insomnia, and a fall in blood pressure when changing position. The MAOIs interact dangerously with various other drugs, including narcotics and some over-the-counter drugs used in treating colds. Persons taking an MAOI must avoid certain foods containing tyramine or other naturally occurring amines (amine), which can cause a severe rise in blood pressure leading to headaches and even to stroke. Tyramine occurs in cheese, Chianti and other red wines, well-cured meats, and foods that contain monosodium glutamate (MSG).

      Newer antidepressants, such as buproprion (Wellbutrin), have been recently introduced. These drugs are chemically unrelated to the other classes of antidepressants.

Mood-stabilizing drugs
       lithium, usually administered as its carbonate in several small doses per day, is effective in the treatment of an episode of mania. It can drastically reduce the elation, overexcitement, grandiosity, paranoia, irritability, and flights of ideas typical of people in the manic state. It has little or no effect for several days, however, and a therapeutic dose is rather close to a toxic dose. In severe episodes antipsychotic drugs may also be used. Lithium also has an antidepressant action in some patients with melancholia.

      The most important use of lithium is in the maintenance treatment of patients with bipolar disorder or with recurrent depression. When given while the patient is well, lithium may prevent further mood swings, or it may reduce either their frequency or their severity. Its mode of action is unknown. Treatment begins with a small dose that is gradually increased until a specified concentration of lithium in the blood is reached. Blood tests to determine this are carried out weekly in the early stages of treatment and later every two to three months. It may take as long as a year for lithium to become fully effective.

      The toxic effects of lithium, which usually occur when there are high concentrations of it in the blood, include drowsiness, coarse tremors, vomiting, diarrhea, incoordination of movement, and, with still higher blood concentrations, convulsions, coma, and death. At therapeutic blood concentrations, lithium's side effects include fine tremors (which can be alleviated by propranolol), weight gain, passing increased amounts of urine with consequent increased thirst, and reduced thyroid function.

      Carbamazepine, an anticonvulsant drug, has been shown to be effective in the treatment of mania and in the maintenance treatment of bipolar disorder. It may be combined with lithium in patients with bipolar disorder who fail to respond to either drug alone. Divalproex, another anticonvulsant, is also used in the treatment of mania.

Electroconvulsive treatment (shock therapy)
      In electroconvulsive therapy (ECT), also called shock therapy, a seizure is induced in a patient by passing a mild electric current through the brain. The mode of action of ECT is not understood. Several studies have shown that ECT is effective in treating patients with severe depression, acute mania, and some types of schizophrenia. However, the procedure remains controversial and is used only if all other methods of treatment have failed.

      Prior to the administration of ECT, the patient is given an intravenous injection of an anesthetic in order to induce sleep and then is administered an injection of a muscle relaxant in order to reduce muscular contractions during the treatment. The electrical current is then applied to the brain. In bilateral ECT this is done by applying an electrode to each side of the head; in unilateral ECT both electrodes are placed over the nondominant cerebral hemisphere—i.e., the right side of the head in a right-handed person. Unilateral ECT produces noticeably less confusion and memory impairment (memory abnormality) in patients, but more treatments may be needed. Patients recover consciousness rapidly after the treatment but may be confused and may experience a mild headache for an hour or two.

      ECT treatments are normally given two or three times a week in the treatment of patients with depression. The number of electroconvulsive treatments required to treat depression is usually between six and 12. Some patients improve after the first treatment, others only after several. Once a program of ECT has been successfully completed, maintenance treatment with an antidepressant significantly decreases the patient's risk of relapse.

      ECT is often considered for cases of severe depression when the patient's life is endangered because of refusal of food and fluids or because of serious risk of suicide, as well as in cases of postpartum depression, when it is desirable to reunite the mother and baby as soon as possible. ECT is often used in treating patients whose depression has not responded to adequate dosages of antidepressants.

      The chief unwanted effect of ECT is impairment of memory. Some patients report memory gaps covering the period just before treatment, but others lose memories from several months before treatment. Many patients have memory difficulties for a few days or even a few weeks after completion of the treatment so that they forget appointments, phone numbers, and the like. These difficulties are transient and disappear rapidly in the vast majority of patients. Occasionally, however, patients complain of permanent memory impairment after ECT.

      Psychosurgery is the destruction of groups of nerve cells or nerve fibres in the brain by surgical techniques in an attempt to relieve severe psychiatric symptoms. The removal of a brain tumour that is causing psychiatric symptoms is not an example of psychosurgery.

      The classical technique of bilateral prefrontal leucotomy (lobotomy) is no longer performed because of its frequent undesirable effects on physical and mental health, in particular the development of epilepsy and the appearance of permanent, undesirable changes in personality. The latter include increased apathy and passivity, lack of initiative, and a generally decreased depth and intensity of the person's emotional responses to life. The procedure was used to treat chronically self-destructive, delusional, agitated, or violent psychotic patients. Stereotaxic surgical techniques (therapeutics) have been developed that enable the surgeon to insert metal probes in specific parts of the brain; small areas of nerve cells or fibres are then destroyed by the implantation of a radioactive substance (usually yttrium) or by the application of heat or cold.

      Proponents of psychosurgery claim that it is effective in treating some patients with severe and intractable obsessive-compulsive disorder and that it may improve the behaviour of abnormally aggressive patients. However, many of the therapeutic effects that were claimed for psychosurgery by its adherents are now attainable by the use of antipsychotic and antidepressant medications. Today psychosurgery has a very small part to play in psychiatric treatment when the prolonged use of other forms of treatment has been unsuccessful and the patient is chronically and severely distressed or tormented by psychiatric symptoms. Whereas ECT is a routine treatment in certain specified conditions, psychosurgery is, at best, a last resort.

The psychotherapies (psychotherapy)
       psychotherapy involves treating mental disorders, adjustment problems, or psychological distress through psychological techniques, any of which is employed by a trained therapist who adheres to a particular theory of both symptom causation and symptom relief. American psychiatrist Jerome D. Frank classified psychotherapies into “religio-magical” and “empirico-scientific” categories, with religio-magical approaches relying on the shared beliefs of the therapist and client in spiritual or other supernatural processes or powers. This article is concerned, however, with the latter forms of psychotherapy—those that have been developed through scientific psychology and are implemented by a member of one of the mental health professions, such as a psychiatrist or a clinical psychologist. As Frank pointed out, however, the processes underlying religio-magical and empirico-scientific forms of psychotherapy are often quite similar. In addition, the seemingly different forms of scientific psychotherapy have a great deal in common with each other with respect to the factors responsible for their effectiveness. This point of view is called the “common factors” perspective on psychotherapy.

Psychotherapeutic approaches
      The many forms of psychotherapy may be conveniently grouped into a few theoretical “families.” These include dynamic, humanistic and existential, behavioral, cognitive, and interpersonal psychotherapies. Dynamic therapy, based on psychoanalysis, concentrates on understanding the meaning of symptoms and understanding the emotional conflicts within the patient that may be causing them. Humanistic and existential therapies use as their primary tool the current relationship between therapist and patient to explore emotional issues in an atmosphere of empathy and support. Behaviour therapy uses a variety of interventions based on learning theory to alter the overt symptoms (e.g., undesirable behaviour) of the patient. Cognitive therapy uses logical analysis to identify and alter the maladaptive thinking underlying the symptoms. Interpersonal therapy focuses on problems that occur in one's interaction with others, and it often studies symptoms in a specific social context, such as the couple or the family.

Dynamic psychotherapies
      There are many variants of dynamic psychotherapy, most of which ultimately derive from the basic precepts of psychoanalysis. The fundamental approach of most dynamic psychotherapies can be traced to three basic theoretical principles or assertions: (1) human behaviour is prompted chiefly by emotional considerations, but insight and self-understanding are necessary to modify and control such behaviour and its underlying aims; (2) a significant proportion of human emotion is not normally accessible to one's personal awareness or introspection, being rooted in the unconscious, those portions of the mind beneath the level of consciousness; and (3) any process that makes available to a person's conscious awareness the true significance of emotional conflicts and tensions that were hitherto held in the unconscious will thereby produce heightened awareness and increased stability and emotional control. The classic dynamic psychotherapies are relatively intensive talking treatments that are aimed at providing patients with insight into their own conscious and unconscious mental processes, with the ultimate goal of enabling them to achieve better self-understanding.

      Dynamic psychotherapy attempts to enhance the patient's personality growth as well as to alleviate symptoms. The main therapeutic forces are activated in the relationship between patient and therapist and depend not only upon the empathy, understanding, integrity, and concern demonstrated by the therapist but also upon the motivation, intelligence, and capacity for achieving insight exhibited by the patient. The attainment of a therapeutic alliance—i.e., a working relationship between patient and therapist that is based on mutual respect, trust, and confidence—provides the context in which the patient's problems can be worked through and resolved. Several of the most important forms are treated below.

      Classical psychoanalysis is the most intensive of all psychotherapies in terms of time, cost, and effort. It is conducted with the patient lying on a couch and with the analyst seated out of sight but close enough to hear what the patient says. The treatment sessions last 50 minutes and are usually held four or five times a week for at least three years. The primary technique used in psychoanalysis and in other dynamic psychotherapies to enable unconscious material to enter the patient's consciousness is that of “free association.” (See association test.) In free association, according to Freud, the patient

is to tell us not only what he can say intentionally and willingly, what will give him relief like a confession, but everything else as well that his self-observation yields him, everything that comes into his head, even if it is disagreeable for him to say it, even if it seems to him unimportant or actually nonsensical.

      Such a procedure is rendered difficult, first because the voicing of one's innermost (and often socially unacceptable) thoughts is a departure from years of experience spent carefully selecting what will be said to others. Free association is also difficult because the patient might resist recalling repressed experiences or feelings that are connected with intense or conflicting emotions the patient has never resolved or settled. Such repressed emotions or memories usually revolve around the patient's important personal relationships and innermost feelings of self; consequently, the release or recollection of such emotions in the course of treatment can be intensely disturbing.

      Through attentive listening and empathy, the therapist helps the patient express thoughts and feelings that in turn permit the unearthing of underlying emotional conflicts. In the course of treatment, however, there likely will be many points at which the patient seems to block progress—for example, by forgetting, growing confused, becoming overly compliant or noncompliant, intellectualizing, and so on. This is called resistance. Another phenomenon, known as transference, occurs when the patient projects (attributes to someone or something else) onto the therapist feelings that the patient has experienced in earlier significant relationships—e.g., love or hatred, dependence or rebellion, and rivalry or rejection. These feelings may include the disturbing emotions felt in the therapeutic process of recollection and free association, with the psychoanalyst almost invariably becoming the focus of such projection; that is, the patient is likely to blame any immediate emotional distress on the analyst. To facilitate the development of transference, the analyst endeavours to maintain a neutral stance toward the patient, becoming an effective “blank screen” onto which the patient can project inner feelings. The analyst's handling of the transference situation is of vital importance in psychoanalysis—or, indeed, in any form of dynamic psychotherapy. It is through such resistance and transference that the patient discovers the nature of unconscious feelings and then becomes able to acknowledge them. Once this has been done, the person is often able to regard these inner feelings in a far more dispassionate and tolerant light and can experience a sense of liberation from their influence on future behaviour.

      A major therapeutic tool in the course of treatment is interpretation. This technique helps patients become aware of any previously repressed aspect of emotional conflict (as reflected in resistance) and to uncover the meaning of uncomfortable feelings evoked by transference. Interpretation is also used to determine the underlying psychological meaning of a patient's dreams, which are held to have a hidden or latent content that may symbolize and indirectly express aspects of emotional conflict.

Individual dynamic psychotherapy
      Although the influence of psychoanalysis, particularly on American psychiatry, was profound, it began to wane in the 1970s. Since then, those seeking treatment have tended to choose short-term individual dynamic therapy over psychoanalysis. This form of therapy is usually more accessible and less costly than psychoanalysis, and it typically requires no more than a series of weekly sessions (lasting approximately one hour) over the course of several months. The aim of treatment, as in psychoanalysis, is to increase the patient's insight (self-understanding), to relieve symptoms, and to improve psychological functioning. Additionally, the therapist provides the patient with a sense of support and a structured means of identifying problems and achieving solutions. Suitable patients include those who experience any of a wide range of psychological and personality disorders or adjustment problems and who wish to change; the patients must, however, be able to view their problems in psychological terms.

      As in psychoanalysis, patients learn to trust the therapist so that they are able to speak candidly and honestly about their most intimate thoughts and feelings. The treatment setting, however, is, less formal than that of psychoanalysis, and it more closely resembles arrangements used in other forms of psychotherapy (e.g., with the therapist and patient seated so that eye contact can be achieved if desired).

      Therapists use treatment techniques such as free association and interpretation to analyze a patient's resistances, transference, and dreams. As opposed to classical psychoanalysis, the focus of interpretation is much more likely to be on resistance than on transference. The therapist directs the patient's attention to meaningful yet unconscious links between present and past experiences, as well as to seemingly unrelated aspects of the patient's current life patterns. The overall treatment goal, as in psychoanalysis proper, is the achievement of increased insight and rational control over previously unconscious aspects of the patient's life and the accompanying relief of symptoms.

Brief focal psychotherapy
      This is a form of short-term dynamic therapy in which a time limit to the duration of the therapy is often established at the outset. Sessions lasting 30 to 60 minutes are held weekly for, typically, five to 15 weeks. At the beginning of treatment the therapist helps identify the patient's problem or problems, and these are made the focus of the treatment. The problem should be an important source of distress to the patient and should be modifiable within the time limit. The therapist is more active, directive, and confrontational than in long-term dynamic therapy and ensures that the patient keeps to the focus of treatment and is not diverted by subsidiary problems or concerns.

Humanistic and existential psychotherapies
 In contrast to dynamic psychotherapy, humanistic and existential psychotherapies focus on the current experience of the patient in resolving problems. Humanistic therapy is represented primarily by the person-centred approach of American psychologist Carl R. Rogers (Rogers, Carl R.), who held that the essential features of therapy are the characteristics of the relationship created by the therapist (as opposed to the therapist's specific interventions). In Rogers's view, these characteristics—empathy, warmth, and a nonjudgmental attitude—are sufficient to produce therapeutic change, given the patient's natural propensity for personal growth and healthy functioning. This belief in the patient's inherent capacity for growth is the basic tenet of humanistic psychology.

      Existential therapies are various in style, although each is concerned in one way or another with the meaning of the patient's current experience and larger existence. In addition, all existential therapies emphasize the importance of the therapeutic relationship as an authentic, “real” medium in which patients can discover themselves. Approaches such as the Gestalt therapy of the German American psychiatrist Frederick S. Perls involve confronting the patient's behaviour in the immediate here and now of the patient's experience. Others, such as the existential approach of the Austrian American psychiatrist Viktor Frankl, appear more intellectually inquisitive regarding meaning and values, though they are still directed toward the patient's immediate experience. Rather than use interpretation in the psychoanalytic sense to uncover unconscious material and supply meaning for the patient, humanistic and existential therapies seek to help patients discover their own meanings through collaborative effort with a supportive, yet often bluntly candid, therapist.

Behavioral psychotherapy
      This approach to the treatment of mental disorders draws upon principles derived from experimental psychology—mainly learning theory. As described by Joseph Wolpe in The Practice of Behavior Therapy (1973),

behavior therapy, or conditioning therapy, is the use of experimentally established principles of learning for the purpose of changing unadaptive behavior. Unadaptive habits are weakened and eliminated; adaptive habits are initiated and strengthened.

      In the treatment of phobias (phobia), behavioral therapists seek to modify and eliminate the avoidance response that patients manifest when confronted with a phobic object or situation. Such confrontation is in fact crucial; although a person's avoidance of the anxiety-producing situation does indeed reduce anxiety, the conditioned association of the phobic situation with the experience of anxiety remains unchallenged and therefore persists, often to the point of limiting normal activity. Behaviour therapy interrupts this self-reinforcing pattern of avoidance behaviour by presenting the feared situation to the patient in a controlled manner such that it eventually ceases to produce anxiety. In this way the patient's associative links between the feared situation, the experience of anxiety, and subsequent avoidance behaviour will be broken down and replaced by a more favourable set of responses.

      The behavioral therapist is concerned with the forces and mechanisms that perpetuate the patient's present symptoms or abnormal behaviours—not with any past experiences that may have caused them nor with any postulated intrapsychic conflict. Behavioral therapy concentrates on observable phenomena—i.e., what is done and what is said rather than what must be inferred (such as unconscious motives and processes and symbolic meanings).

      The behavioral therapist carries out a detailed analysis of the patient's behaviour problems, paying particular attention to the circumstances in which they occur, to the patient's attempts to cope with symptoms, and to the patient's desire for change. The goals of treatment are precisely defined as symptomatic change and usually do not include aims such as personal growth or personality change. The relationship between patient and therapist is sometimes said to be unimportant in behaviour therapy. For instance, a patient may achieve successful results through a behavioral therapeutic program learned from a book or a computer program. Nevertheless, patients are more likely to complete an arduous program when working with a therapist who has won their trust and respect.

      Behaviour therapy has become the preferred treatment for phobic states and for some obsessive-compulsive disorders, and it is effective in many cases of sexual dysfunction and deviation. It also performs an important role in the rehabilitation of patients with chronic, disabling disorders. The essence of the treatment of phobias (phobia) is the controlled exposure of the patient to the very objects or situations that are feared. Behaviour therapy tries to eliminate the phobia by teaching the patient how to face those situations that clearly trigger discomfort. The exposure of the patient to the feared situation can be gradual (sometimes called desensitization) or rapid (sometimes known as flooding). Contrary to popular belief, the anxiety that is produced during such controlled exposure is not usually harmful. Even if severe panic initially strikes the sufferer, it will gradually diminish and will be less likely to return in the future.

      Effective exposure treatments were developed as therapists learned that the patient's endurance of phobic anxiety in a controlled situation is much more likely to be helpful than harmful. The important point in this therapy is to persevere until the phobic anxiety starts to lessen. In general, the more rapidly and directly the worst fears are embraced by the patient, the more quickly the phobic terror fades to a tolerable mild tension.

      In the technique of desensitization, the patient is first taught how to practice muscular relaxation. The patient then reviews the situations that are feared and lists them in order of increasing dread, called a “hierarchy.” Finally, the patient faces the various fear-producing situations in ascending order by means of vividly imagining them, countering any resulting anxiety with relaxation techniques. This treatment is prolonged, and its use is restricted to feared situations that patients cannot regularly confront in real life, such as fear of lightning.

      One of the most common phobic disorders treated by exposure techniques is agoraphobia (fear of open or public places). The patient is encouraged to practice exposure daily, staying in a phobic situation for at least an hour so that anxiety has time to reach a peak and then subside. The patient must be determined to get the better of the fears and not to run away from them. The patient must instead force himself to engage in activities (shopping, viewing exhibits, speaking to sales representatives) that are normal in that setting. Persistence and patience are essential to conquering phobias in this way.

      There is considerable evidence that exposure techniques work in most cases. Even phobias enduring for as long as 20 years can be overcome in a treatment program requiring no more than three to 15 hours of sessions with a therapist. There is also considerable evidence that people with phobias can treat themselves perfectly adequately without a therapist by using carefully devised self-help manuals.

      Some patients with obsessive-compulsive disorders (obsessive-compulsive disorder) can also be helped by behaviour therapy. Several different techniques may be required. For instance, patients with an obsessional fear of contamination are treated by exposure, being taught to soil their hands with dirt and then to resist washing them for longer and longer periods. Anxiety-management training enables patients to withstand the anxiety triggered by exposure to sensitive or antagonistic situations.

      Many such techniques have been recognized as effective in the treatment of compulsive rituals, with improvement occurring in more than two-thirds of patients. There is also a reduction in the frequency and intensity of obsessional thoughts that accompany the rituals. The treatment of obsessional thoughts that occur alone—that is, without compulsive behaviour—is much less satisfactory, however.

Cognitive psychotherapy
      Cognitive psychotherapy is most associated with the theoretical approaches developed by the American psychiatrist Aaron T. Beck and the American psychologist Albert Ellis. It is often used in combination with behavioral techniques, with which it shares the primary aim of ridding patients of their symptoms rather than providing insight into the unconscious or facilitating personal growth. Cognitive therapy is also commonly used alone in treating a variety of psychological problems; it is especially associated with the treatment of depression and anxiety, since these disorders were the primary focus of Beck's theory and research.

      Cognitive therapy is based on the premise that maladaptive thinking causes and maintains emotional problems. Maladaptive thinking may refer to a belief that is false and rationally unsupported, what Ellis called an “irrational belief.” An example of such a belief is that one must be loved and approved of by everyone in order to be happy or to have a sense of self-worth. This is irrational first because it cannot possibly be achieved—no one is loved or approved of by everyone—and second because believing it removes the conditions of happiness and self-worth from the individual's control, placing them instead in the control of other people. Cognitive therapy seeks to identify such beliefs, help the patient connect them to emotional problems, and guide the patient toward adopting more-rational versions.

      Maladaptive thinking may also refer to faulty cognitive processes. These include inappropriate generalization, “catastrophizing” (expecting or recalling the worst of any event), and selective attention. For example, a patient may generalize from one experience or failure that he is likely (or “doomed”) to fail in future situations regardless of how those situations may differ from the past situation or regardless of how he himself may have changed in the interim. When receiving feedback from others, a patient may focus selectively and perhaps catastrophically on a single negative aspect rather than consider it on balance with several positive aspects.

      Such maladaptive cognitive processes not only promote negative emotions in patients but also discourage adaptive behavioral reactions. Why should one learn from the past if one is doomed to fail in the future? By helping patients alter their cognitive experience, cognitive therapists increase the likelihood of more-positive, or at least more-reasonable, emotional reactions, as well as more-adaptive behaviour. Cognitive therapies typically supplement cognitive retraining with behavioral practice so that the adaptive cognitions can be firmly established and linked with adaptive behaviour.

Interpersonal psychotherapy
      Interpersonal therapies help patients understand their symptoms in terms of the impact they have on others (and, in turn, on themselves); they also help patients develop interpersonal styles and communication behaviours that are more direct and effective. In this regard, interpersonal therapies are quite behavioral in focus, even though they do not rely as explicitly on learning theory as the behavioral therapies do.

      The treatment series, which usually lasts less than one year, begins with the identification of interpersonal problems that are likely to be related to a patient's current experience of depression. Problems are typically categorized as stemming from grief, conflicts, major life transitions, or personality problems relating to social skills. Once these areas are identified, treatments focus on therapeutic interventions.

      In interpersonal psychotherapy, symptomatic behaviours are often viewed as maladaptive strategies for meeting one's own needs through the manipulation of others (although the patient is not considered to be intentionally manipulative). Symptoms might also be considered in terms of their communicational impact or in their role as influential messages. Such messages are symptomatic when they are characteristically confusing, contradictory, and deceptive. Interpersonal therapists, regardless of their field of specialization, view psychological problems within their social or interpersonal context. Interpersonal concepts receive wide use in psychotherapy, sometimes within a dynamic framework (as in the approaches espoused by the German psychoanalyst Karen Horney (Horney, Karen) and the American psychiatrist Harry Stack Sullivan (Sullivan, Harry Stack)), sometimes within a personality-trait framework (such as the interpersonal diagnostic and treatment system developed by the American psychologist Lorna Smith Benjamin), and sometimes within schools of couple and family therapy, in which the “patient” is defined as a dysfunctional communication system of several people, rather than a single person with a mental disorder.

Group psychotherapy (group therapy)
      Many types of psychological treatment may be provided for groups of patients who have psychiatric disorders. This is true, for example, of relaxation training and anxiety-management training. There are also self-help groups, of which Alcoholics Anonymous is perhaps the best known. A considerable number of group experiences have been devised for people who are not suffering from any psychiatric disorder; encounter groups are a well-known example. This discussion, however, is concerned with long-term dynamic group therapy, in which six to 10 psychiatric patients meet with a trained group therapist, or sometimes two therapists, usually for 60 to 90 minutes a week for several months or even years. Often the group is closed—i.e., confined to the original group membership, even if one or more members drop out before the treatment ends. In an open group, patients who have stopped attending, whether by default or because of the relief of symptoms, are replaced by new members.

      The types of mental disorders considered suitable for group therapy are much the same as those suitable for individual therapy. Patients with disorders that render them vulnerable in the face of interpersonal feedback, however, are not good candidates for group therapy. It is also important for patients not to think of group therapy as a poor or second alternative to individual therapy.

      There are many varieties of dynamic group therapy, and they differ in their theoretical background and technique. The influential model of the American psychiatrist Irvin D. Yalom provides a good example of such therapies. In this approach the therapist continually encourages the patients to direct their attention to the personal interactions occurring within the group rather than to what happened in the past to individual members or events currently taking place outside the group, although both of these areas may be considered when they are relevant. Throughout these sessions the therapist draws attention to what is happening among members of the group as they learn more about themselves and test out different ways of behaving with one another. The goal in group therapy is to create a climate in which the participants can shed their inhibitions. When the members come to trust one another, they are able to provide feedback and to respond to other group members in ways that might not be possible in ordinary social interactions.

      Several factors contribute to effective group therapy. The most important is group cohesion, which gives patients a feeling of belonging, identification, and security, thereby enabling them to be frank and open and to take risks without the danger of rejection. Another is universality, which refers to the patient's realization that he is not uniquely troubled and that all the other group members have problems, some of which are similar. Optimism about what can be achieved in the group, fostered by the perception of change in others, combats demoralization. Guidance, the giving of advice and explanation, is important in the early meetings of the group and is largely a function of the therapist. What has been called vicarious learning later becomes more important; through this the patient observes how other group members reach solutions to common problems and then emulates the desirable qualities seen in fellow members. Catharsis, or the release of highly charged emotion, occurs within the group setting and can be helpful, provided that the patient is able to understand it and appreciate its significance. Another factor that is helpful in improving self-esteem is altruism, the opportunity to give assistance to another group member.

      Family therapists view the family as the “patient” or “client” and as more than the sum of its members. The family as a focus for treatment usually comprises the members who live under the same roof, sometimes supplemented by relatives who live elsewhere or by nonrelatives who share the family home. Therapy with couples may be considered as a special type of family therapy. Family therapy may be appropriate when the person referred for treatment has symptoms clearly related to such disturbances in family function as marital discord, distorted family roles, and parent-child conflict or when the family as a unit asks for help. It is not appropriate when a single individual has a severe disorder needing specific treatment in its own right.

      The many theoretical approaches include psychoanalytic, systems-theory, and behavioral models. In the first approach the analyst is concerned with the family's past as the cause of the present and pays attention to psychodynamic aspects of the individual members and of the family as a whole. The analyst also makes numerous interpretations while attempting to increase the insight of the members.

      The systems therapist, by comparison, is interested in the present rather than the past and is often not concerned with promoting insight, working instead to change the family system, perhaps by altering the implicit and fixed rules under which it functions so that it can do so more effectively.

      Finally, the behaviour therapist is concerned with behaviour patterns—especially those that pinpoint reinforcements of behaviour seen as undesirable by other family members. Members specify the changes in behaviour that they wish to see in each other, and strategies are devised to reinforce the desired behaviours. This approach has been shown to be effective in work with couples, when one partner promises some particular change on the condition that the other reciprocates.

      Treatment sessions in family therapy are rarely held more often than once a week and often take place only once every three or four weeks. Termination commonly occurs when the therapist considers that treatment has succeeded—or failed irretrievably—or when the family firmly decides to withdraw from treatment. There seems no doubt that family therapy can produce marked change within a family.

James L. Gibbons Stuart C. Yudofsky Charles D. Claiborn

Additional Reading

General works
The following works provide descriptions of the syndromes, causes, epidemiology, and methods of treatment of mental disorders: Harold I. Kaplan and Benjamin J. Sadock, Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry, 8th ed. (1998); Robert E. Hales and Stuart C. Yudofsky (eds.), Essentials of Clinical Psychiatry (1999), based on the following: Robert E. Hales, Stuart C. Yudofsky, and John A. Talbott (eds.), The American Psychiatric Press Textbook of Psychiatry, 3rd ed. (1999); Stuart C. Yudofsky and Robert E. Hales (eds.), The American Psychiatric Press Textbook of Neuropsychiatry, 3rd ed. (1997); and Harold I. Kaplan and Benjamin J. Sadock (eds.), Comprehensive Textbook of Psychiatry/VI, 6th ed., 2 vol. (1995).

Classification and epidemiology
The two classificatory systems mentioned in the text are detailed in American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. (1994); and World Health Organization, International Statistical Classification of Diseases and Related Health Problems, 10th revision, 3 vol. (1992–94).

Causation
Different aspects and theories of causation are considered in Glen O. Gabbard, Psychodynamic Psychiatry in Clinical Practice, 3rd ed. (2000); Robert B. White and Robert M. Gilliland, Elements of Psychopathology: The Mechanisms of Defense (1975); Frederick K. Goodwin and Kay Redfield Jamison, Manic-Depressive Illness (1990); and Nancy C. Andreasen (ed.), Schizophrenia: From Mind to Molecule (1994).

Treatment
A work concerned with the theoretical concepts underlying psychotherapy is Charles Brenner, An Elementary Textbook of Psychoanalysis, rev. ed. (1973, reissued 1990). A good account of the main forms of psychological treatment is given in Sidney Bloch (ed.), An Introduction to the Psychotherapies, 3rd ed. (1996). Also of interest are Peter E. Sifneos, Short-Term Dynamic Psychotherapy: Evaluation and Technique, 2nd ed. (1987); Irvin D. Yalom, The Theory and Practice of Group Psychotherapy, 4th ed. (1995); and John C. Masters et al., Behavior Therapy: Techniques and Empirical Findings, 3rd ed. (1987).Pharmacological and physical methods of treatment are dealt with in Alan F. Schatzberg and Charles B. Nemeroff (eds.), The American Psychiatric Press Textbook of Psychopharmacology, 2nd ed. (1998); Ross J. Baldessarini, Chemotherapy in Psychiatry: Principles and Practice, rev. and enlarged ed. (1985); Steven E. Hyman and Eric J. Nestler, The Molecular Foundations of Psychiatry (1993); and Stuart C. Yudofsky, Robert E. Hales, and Tom Ferguson, What You Need to Know About Psychiatric Drugs (1991). Elliot S. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (1986), presents a history of the methods and personalities involved.James L. Gibbons Andrew C.P. Sims

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Universalium. 2010.

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