Incidence and Diagnosis

It is often said that the stress of modern living is responsible for the large number of mentally disordered people seen in families, clinics, institutions, and in the streets. Because of poor record keeping in previous times, growth of the general population, and changes in diagnostic criteria, it is difficult to determine if and by how much the incidence of mental disorders has risen over the years. Available statistics do indicate that mental disorders associated with old age have increased during this century, but most of these conditions are organic disorders due to an increase in the population of older adults. Concerning the percentage of mentally disordered persons in the population as a whole, Adelson (1985) estimated that approximately 20% of the population manifest at least moderately severe symptoms of mental disorders.

My Life 5-1

Breakdowns in the Family

I don't recall that any member of my extended family was ever judged insane, but there were a few nervous breakdowns. That's what we called mental disorders in those days. People also got "hysterical," were occasionally "beside themselves," had "spells," and even "went off the deep end,"but they weren't insane. The term insanity conjured up fears of hereditary taints and violence that kept a family from holding up their collective heads in public.

Some of the incidents in which members of my family lost control of themselves were exciting to a young boy. I remember the time when an inebriated aunt cavorted on our front lawn in the nude during the wee hours ofthe morning. On another occasion, a great aunt was sitting in a rocking chair by a burning fireplace and disposed of herself by rocking into the fire. For the most part, however, when a family member started behaving irrationally, it was due either to old demon Rum, frustration and anger, or a combination of these. In such a state the person would yell, break things, run around the house, and eventually doze off. I knew enough to stay out of the way when someone was in such a fix, and things soon returned to normal.

To my knowledge, no one in our family was ever carted off to an insane asylum (mental hospital), but that isn't to say that a brief stay wouldn't have done several of them somegood. Years later, when I worked in a mental hospital in North Carolina, I met a patient who voluntarily admitted himself for a 2-week sequestration every summer when his problems became insurmountable. According to this patient, the mental hospital was the best hotel he had ever been in and was also priced quite reasonably. Sometimes I think that is exactly what a certain uncle of mine should have done. One time, suffering from depression due to the departure of his wife, he was drinking and driving at 90 miles per hour. Actually, the car was mine, which made it even more frightening to me. Both an open bottle of liquor and a loaded gun were on the seat beside him when he was stopped by a highway patrolman. The patrolman, who apparently had some knowledge of psychology, asked my uncle what his problem was and if he could help. My uncle responded that the patrolman didn't want to hear about it, but the latter assured my uncle that he did. On being told that the problem was "family trouble," the patrolman admitted that my uncle was right: He didn't want to hear about it. Because the patrolman apparently did not see the open liquor bottle or the loaded gun,my uncle avoided a stay in jail on that occasion. However, he made up for the oversight in later years.

Though not strictly insanity, there was a case of apparent fugue—amnesia accompanied by actual physical flight—in our family. Another one of my uncles walked off one fine day and disappeared without a trace. My grandmother hired detectives to search for him, but the trail ran cold in San Francisco. It was widely believed in our family that he had either been shanghaied or voluntarily signed on to a ship going to the Far East. Whether he fell, jumped, or was pushed off the ship, or whether he converted to Orientalism, remains a mystery. Frankly, I've always believed that he found a better life somewhere else, a place where people were less exhibitionistic in responding to their troubles than some of the members of our family.

Determining the nature and extent of a mental disorder, that is, arriving at a diagnosis, involves careful observation of the patient, interviewing the patient and those close to him or her, and conducting medical and psychological examinations. The patient's symptoms are then compared with standard descriptions of various diagnostic categories, such as those listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994). The major diagnostic categories in DSM-IV are given in Table 5-3. These categories are purely descriptive, in that they are not based on any particular theory of personality or abnormal behavior. Mental disorders are grouped according to similar symptoms, with no specification of causation or recommended treatment.

The DSM-IV diagnostic system is multiaxial, classifying each patient on five axes referring to different kinds of patient information:

• Axis I: Clinical Disorders

• Axis 11: Personality Disorders

• Mental Retardation

• Axis III: General Medical Conditions

• Axis IV: Psychosocial and Environmental Problems

• Axis V Global Assessment of Functioning

Each disorder is labeled and numbered with a five-digit code on Axes I and II and its severity is specified as "mild, moderate, or severe." Accompanying physical disorders and conditions are classified on Axis III, the severity of psychosocial stressors is classified on Axis IV, and a global assessment of the patient's functioning (GAF) is indicated on Axis V.

Patients admitted to state and country mental hospitals, private psychi-

Table 5-3 Major Diagnostic Categories in DSM-IV

Delirium, Dementia, and Amnesic and Other Cognitive Disorders

Mental Disorders Due to a General Medical Condition

Substance-Related Disorders

Schizophrenia and Other Psychotic Disorders

Mood Disorders

Anxiety Disorders

Somatoform Disorders

Factitious Disorders

Dissociative Disorders

Sexual and Gender Identity Disorders

Eating Disorders

Sleep Disorders

Impulse-Control Disorders Not Elsewhere Classified Adjustment Disorders Personality Disorders

Other Conditions That May Be a Focus of Clinical Attention

Source: American Psychiatric Association (1994).

□ Alcohol Related . Drug Related HOrganic Disorders H Affective Disorders ■ Schizophrenia

□ Alcohol Related . Drug Related HOrganic Disorders H Affective Disorders ■ Schizophrenia

Under 25 25-44 45-64 65+

Chronological Age Range

Figure 5-1 Average rates for inpatient psychiatric diagnoses in state and county mental hospitals and private psychiatric hospitals during 1986. (Based on data from National Center for Health Statistics, 1995.)

Under 25 25-44 45-64 65+

Chronological Age Range

Figure 5-1 Average rates for inpatient psychiatric diagnoses in state and county mental hospitals and private psychiatric hospitals during 1986. (Based on data from National Center for Health Statistics, 1995.)

atric hospitals, nonfederal general hospitals, and other inpatient psychiatric organizations are diagnosed on admission. Figure 5-1 provides an indication of the frequency of five diagnostic categories by age group. Note that the most common diagnoses are "affective disorders" and "schizophrenia," but that the frequency of a particular disorder varies with chronological age. Organic disorders are, as expected, more common in patients over age 65, whereas schizophrenia is more common in patients in their late twenties to early forties.

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