A mental or emotional disorder is a condition that is characterized by changes in experience and behavior that are relevant to the disease . It can be accompanied by deviations in perception , thinking, feeling or even self-image ( self-perception ). Mental disorders are typically associated with significant personal distress or stress and problems in several areas of life.
A major component of these disorders is also often a reduced ability to self-regulate . In this case, those affected can only influence their illness with difficulty or not at all, even through increased efforts, self-discipline or willpower . The consequences of psychological symptoms are usually problems coping with everyday life or impaired social relationships (e.g. due to difficulties in fulfilling social roles as before).
Mental health disorders occur in many forms and are among the most widespread diseases: The World Health Organization estimates that around 300 million people worldwide are affected by depression , 47.5 million by dementia and 21 million by schizophrenia .
Mental disorders are treated by psychiatrists , psychotherapists and alternative practitioners . The use of psychotropic drugs and psychotherapy is considered to be standard, whereby their respective importance for the treatment depends on the specific individual case. In addition, psycho-education , occupational therapy and other methods can be used. It is also important for the success of the treatment to take away the patient's feeling of stigmatization . The interplay between the person affected and his environment can also be important so that this can be included in treatment.
What is a mental disorder?
Definition of terms
Human experience includes feelings , thinking , attention, and memory . Mental disorders can affect any of these areas. However, not every deviation from an experience that is regarded as normal is already a disorder with a disease value . Many people experience z. B. slight mood swings over a short period of time, which resolve on their own and are not experienced as an illness. There are also people who experience depressive or psychotic episodes under severe stress and then continue to live in a psychologically stable manner. In addition to an objectively ascertainable deviation from a previously defined norm, the subjective suffering of the person concerned also plays a role.
Behavior can indeed be observed, but one can only gain knowledge of inner (i.e. subjective) experience through information from the person concerned. However, there are characteristic symptoms that examiners can determine with a high degree of agreement - especially in the area of content-related thought disorders , disorders of the ego experience and disorders of perception.
There is no universal, universally accepted definition of what constitutes a mental disorder at its core. Nevertheless, one can name some general characteristics that characterize deviant behavior and experience. This includes:
- Statistical rarity - The extreme symptoms and behaviors that are typical of many mental disorders are either absent in the majority of the population or are significantly less pronounced. This means that they are rare (relatively speaking).
- Violation of social norms - This is about the question of whether social norms are violated and other people are threatened, feared or harassed by the behavior. This can undoubtedly apply to some mental disorders. However, prostitution and crime, for example, are not mental disorders, although both are definitely social norm violations. On the other hand, one can also be mentally ill (e.g. as a very anxious person) without behaving in a conspicuous manner. Another problem is that a violation of social norms is naturally highly culture-dependent.
- Personal suffering - A crucial characteristic of many mental disorders is individual suffering . However, this aspect alone is not sufficient for a definition: there are disorders without psychological stress (such as psychopathy ) and conversely, not every type of psychological suffering is disease-related (such as pain during childbirth or starvation in the event of a food shortage).
- Impairment of lifestyle - Functional restrictions in important areas of life (e.g. conflicts at work or in marriage) are another central consequence of most mental disorders. However, there are also phenomena such as transvestism , which are considered to be a disorder if the patient is suffering, but where the lifestyle is hardly affected.
- Inappropriate behavior - This is understood to be behavior that occurs unexpectedly in response to stress and is incomprehensible or inappropriate to the situation. An example of this would be the sudden, gratuitous, and disproportionately strong panic states that occur in some anxiety disorders.
It is important to note that every single aspect alone is not enough to define. Only all together provide a useful approach to the nature of mental disorders. In most mental disorders, several of these criteria are met at the same time.
"Harmful Dysfunction" approach
The concept of “harmful dysfunction” is another approach to determining when a behavior or mental state reaches the level of a valid mental disorder. This approach was developed by Jerome Wakefield and has greatly influenced the DSM definition of mental disorder . In it he combines knowledge from evolutionary biology with social values. According to Wakefield, the essence of any disorder is that a biological and a social order are always impaired at the same time. All mental disorders must therefore meet two conditions:
First, there must be evidence that the experience or behavior being tested is based on natural dysfunction (i.e., a functional disorder). This is the case when an internal psychological mechanism in a person cannot (no longer) fulfill its functions prescribed by evolution effectively enough. There must be a deficiency in a general psychological mechanism (e.g. perception, language, memory or emotional control ) that is common to all people regardless of culture. Accordingly, it can be assumed from this natural psychological ability that normally everyone has sufficient access to it.
Second, scientific evidence is needed that this deficiency leads to significant harm or disadvantage for those affected. What is considered harmful is determined by the current environment and its cultural values. Harmfulness can e.g. B. be determined by evidence of increased mortality or disease burden (such as self-harming behavior , pointless suffering or increased risk of accident). This also includes restrictions on basic daily activities that all people can usually manage according to their age. These affect areas of life such as family, social relationships, self-sufficiency or training and work.
According to this logic, for example, homosexuality (from a biological point of view) represents a dysfunction, since it is contrary to the evolutionary function of producing offspring. However, it does not constitute a psychological disorder because this dysfunction itself has no direct negative consequences for the people concerned (at most indirectly through discriminatory reactions from the environment). However, critics of this approach doubt that all mental disorders can be interpreted as evolutionary dysfunction. For example, snake phobias, on the contrary, can be seen as adaptive adaptation - depending on the environment in which a person moves. Furthermore, it is often criticized that the theory remains fuzzy because, given the current state of evolutionary psychology, far too little is known about the origin of psychological functions.
Since Wilhelm Griesinger (1817–1868), the roots of traditional psychiatry have been primarily of a biological nature. There, the attempt to objectify psychological symptoms by comparing them with known brain diseases and examining to what extent they represent a deviation from the norm is in the foreground of the classification attempts. Here the mental disorders in the sense used by multifactorial causes understood one hand may be an expression of induced externally detectable physical disorder is a mental disorder (eg. Toxic -induced hallucinations ), on the other hand it also possible internal causes (is endogeneity ) taken into account.
There is already an overlap in terms of symptomatology , which makes an exact diagnosis difficult. Viktor von Weizsäcker spoke in this context of a community of expressions of psychological symptoms. A disorder can therefore be very reminiscent of a physical disorder, without this having yet to be proven with certainty on the basis of endogenous factors (e.g. in the case of schizophrenic psychoses ).
Today's medicine no longer attributes a specific cause to mental disorders that cannot be traced back to a clearly identifiable biological cause. The specific causal chain of body processes (the pathomechanism ) that leads to a certain mental disorder, however, remains mostly unknown. Due to this incomplete knowledge of the causes, one is currently limiting oneself to describing symptoms and symptom combinations ( syndromes ) as precisely as possible . In most cases, a multifactorial causal structure is assumed, which is represented in general, not very detailed models (see diathesis-stress model ). This view corresponds to the current state of science, but is constantly evolving. It can be assumed that this understanding will continue to develop as a result of future research findings on the cause of mental disorders.
The understanding of mental disorders is shaped by many attempts at explanation. Therefore the efforts to order these disturbances systematically always depended on the zeitgeist of the time and the corresponding historical conditions. For a long time, the classification ( classification ) of mental disorders differed greatly depending on the country and region and depended on psychological or medical doctrines . However, success in the detection and treatment of these diseases has remained limited.
In the 19th century, medical diagnostics improved, and in biology and chemistry the importance of scientific classification systems (see periodic table or biological taxonomy ) became apparent in order to make progress. Impressed and encouraged by this, they tried to achieve something similar in the field of mental disorders.
In clinical and scientific use today, two diagnostic and classification systems are of global importance:
- the International Classification of Mental Disorders as part of the ICD-10 of the WHO (aimed at international application)
- the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (mainly used in the USA and in international research)
To this day, individual aspects of the classification are discussed controversially. The two existing systems are always understood as provisional and do not yet represent definitive delimitations in the sense of real medical diseases. While mental disorders were divided into neurotic and psychotic disorders for a long time, these terms are largely dispensed with in the current classification systems. Terms such as illness or “psychogenic” are also deliberately avoided there and instead, disorders are spoken of in a more neutral manner .
The fifth chapter of the ICD-10 contains the International Classification of Mental Disorders . The chapter covers all mental disorders and is divided into a hundred classes (F00 – F99). A key with up to five digits is assigned to each class. The first three digits give a rough description of the diagnosis ("three-digit").
The DSM is mainly used in psychiatric and psychological research. The term " mental disorder " is defined as follows:
“A mental disorder is defined as a syndrome that is characterized by clinically significant disorders in a person's cognition , emotion regulation and behavior .
These disorders are an expression of dysfunctional psychological, biological or developmental processes that underlie psychological and emotional functions.
Mental disorders are typically associated with significant ailments or disabilities in relation to social or occupational / educational and other important activities. "
Mental disorders are one of the most frequent consultation occasions at the family doctor and in general medical practices. First in Europe are anxiety disorders, followed by sleep disorders, depression, somatoform disorders, substance addictions, ADHD in the younger and dementia in the elderly.
In 2005, scientists from the Technical University of Dresden and the Max Planck Institute for Psychiatry in Munich calculated that around every fourth adult EU citizen suffers from a mental illness within a year. In a comprehensive global analysis of data in 2014, it was found that, globally, on average, around one in five suffers from a mental illness within a year.
It is more difficult to give a lifetime prevalence . One-off surveys can lead to a serious underestimation of the incidence rate , since mental illnesses experienced in early adulthood are often no longer remembered later. A longitudinal study showed that over 80% of all those examined between birth and middle age suffered at least briefly from a mental illness. According to the WHO, a good quarter of the world's population suffers from a mental illness that requires treatment at some point in their life. A meta-analysis by the TU Dresden even assumes a lifetime risk of more than 50 percent.
Mental illnesses are particularly characterized by the fact that they often start early and disproportionately affect adolescents and young people. Around 50% of all mental disorders break out before the age of 15 and 75% before the age of 25. This is in stark contrast to other chronic diseases such as cancer , heart disease or Parkinson's , which usually occur at a much later age.
The incidence rates are very different depending on the socio-demographic group:
- Age Distribution - Mental disorders are most commonly diagnosed in younger adults (18–34 years old) and least common in older people (65–79 years old).
- Socio-economic status - On average, mental disorders are diagnosed more frequently in lower socio-economic classes than in higher ones.
- Urbanity - With regard to “urbanization” , a trend towards higher disease rates can be seen in large cities with more than 500,000 inhabitants.
The ratios based on this data are shown in the table below as "Men: Women". For example, 4.7: 1 means that for every 4.7 men with alcohol disorders there is 1 woman with alcohol disorders. Please note the footnotes, as some figures only refer to certain age groups (18 to 79 year olds), from different countries and e.g. B. come from different examination times, etc. In addition, different gender-specific diagnostic assignments can distort the statistics (see gender bias ).
|Men more often affected||no (big) gender difference||Women more often affected|
|" Alcohol Disorders " (4.7: 1)||Obsessive-compulsive disorder (1: 1.2) including compulsive acts (hand washing rituals more common in women, "delaying the course of action without repetition" more often in men)||Anxiety disorder (1: 2.3) including most phobic disorders (including agoraphobia ). See generalized anxiety disorder (GAS) (approx. 1: 2) and panic disorder (approx. 1: 2).|
|Attention Deficit / Hyperactivity Disorder (4: 1)||Bipolar disorder (1: 1.1)||Unipolar depression (1: 2).|
|Early Childhood Autism (3-4: 1)||Schizophrenia , psychotic disorder|
|Social phobia (1: 1.4)||Post Traumatic Stress Disorder (PTSD) (1: 2-3)|
|Conduct disorder (2: 1) (children or adolescents)|
|Asperger's Syndrome (2: 1)||Body Dysmorphic Disorder||Anorexia nervosa (1: 5.5) and bulimia nervosa|
|Tic disorder (2: 1)||Rett syndrome (previously only described in girls)|
Many mental illnesses are now easily treatable. Both psychotherapy and psychotropic drugs are scientifically sound means of treating mental illness. In the case of disorders that do not fall below a value of 40 on the GAF scale , sociotherapy can be used concomitantly.
In the case of a recognizable serious danger to themselves or others and at the same time lacking insight into the need for treatment, people with severe mental disorders can be referred to treatment as a last resort, even against their will. Treatment takes place in a closed psychiatric department. The regulations for acute admission are stipulated by state law. Without an additional judicial order, such compulsory placement may not exceed 24 hours.
Long-term forced treatment can occur in the following contexts:
- After a criminal offense as a measure of reform and protection ( measure execution , also called criminal placement).
- As accommodation according to the respective accommodation law ( mentally ill law ), which is designed differently depending on the federal state (so-called accommodation under public law).
- By order of a legal guardian or authorized representative according to BGB (with the approval of the guardianship court ). Compulsory treatment during an approved (civil) placement is only permitted to a very limited extent according to the decision of the BGH of February 1, 2006 (BGH XII ZB 236/05).
Specific stereotypes and prejudices are essential components of the stigmatization of the mentally ill and can lead to discriminatory treatment of these people. For example, when a person with schizophrenia is classified as incompetent, employers question their ability to perform work ( prejudice ) and avoid employing these people ( discrimination ). The stereotype of incompetence can also lead to enforced behavior, such as B. Forced hospital stays , guardianship or restriction of independent life options.
In addition to incompetence, dangerousness and personal responsibility are among the most common stereotypes about people with mental illness. Media reports that exaggerate the connection between mental disorders and violence "cement" the stereotype of dangerousness and lead to public fear of the mentally ill. These fears lead to behaviors such as isolation in poor neighborhoods, avoidance, or withdrawal. With the stereotype of personal responsibility, people with mental illnesses are made responsible for their own illness. Accordingly, the public believes that affected individuals made poor choices that led to their illness or did not make enough efforts to recover.
Mental illness is the second most common cause of incapacity for work certificates under statutory health insurance . The number of days of incapacity for work due to mental illness has risen steadily since 1976. From 2005 to 2012 the share rose by 97.1 percent. Women were affected significantly more often than men. This is also reflected in the inpatient area ( hospital ): Since 1986, the number of hospital cases has increased from 3.8 cases per 1000 GKV insured persons by 2.5 times to 9.3 cases in 2005. This trend continued until 2017 continued.
Mental health disorders are a major cause of early retirement . The economic burdens caused by this disease are significant because of the combination of high prevalence, early onset and often unfavorable, long disease course. The total annual costs in Europe for 2004 were estimated at € 240 billion. The largest part is attributable to the indirect costs, which can be put at € 132 billion. In Germany, the costs for mental and behavioral disorders were 280 euros per inhabitant in 2002; in 2015 this sum was already 540 euros.
Effects of economic crises
According to a 2016 EPA review, there is broad consensus on the harmful effects of economic crises on mental health, particularly mental well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behavior. Main risk factors are unemployment, indebtedness, precarious working conditions , inequality, a lack of social solidarity and instability in housing. Men of working age may be particularly at risk, as well as groups of the population with previous low socio-economic status or stigmatized populations. General austerity measures and poorly developed welfare systems increase the harmful effects of economic crises on mental health. The few studies dealing with policy countermeasures suggested that the development of social protection programs such as active work programs, welfare systems, protection against unstable housing and better access to psychiatric care (especially at the basic level) is urgently needed.
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