Mental Health Illness and Recovery
14.10.2022 uni
Severe Mental Illness (SMI)
o Definition of SMI: the NIMH defined SMI using the following criteria:
(a) A major diagnosis of non-organic psychosis or personality disorder
(b) Duration of at least 2 years
(c) Patients should meet at least 2 out of 5 categories of mental disability
(d) Diagnosis: a major affective, non-organic psychotic disorder that may
lead to a chronic disability such as borderline personality disorder.
o Duration: treatment history meets one or both of the following:
- has undergone psychiatric treatment, more intensive than outpatient care more
than once in a lifetime or
- has experienced an episode of continuous supportive residential care, or other
than hospitalization, for a period long enough to have significantly disrupted
the normal living situation.
o Disability: results in functional limitation in major life activities (they must meet
at least 2/5 of the following criteria on a continuing or intermittent basis:
-poor work history
-public financial assistance
-personal social support system
-basic living skills
-inappropriate social behavior
*We should not see people with SMI like they are something different,
because it is not about THEM, it is something that is here, it is us, on a daily
life basis, it is not something separated from us. → this should be our
perception of mental illness, otherwise “stigma”.
“Difficult to treat patients”:
Students said in the lecture: complexity, puts a lot of pressure on you, some students
said anxious, as it sounds like a battle.
Actually: By choosing these words as a professional you are stigmatizing. It will have
an effect on how much hope you have about the treatment.
(if the therapy is hopeless there is not much chance for the patient to get something)
As a therapist, you might feel helpless because you might not have the tools, places,
or money to help as you want. And that’s something normal. However, you always
have you, so you can always find a way when feeling helpless, even with no financial
recourses.
Contextual Factors:
- Poverty dept
- Low social economic status
- Unemployment
- Homelessness
- Criminal/inappropriate social behavior
Difficult to treat patients →Less understood or Non-understood behavior
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, A little bit of history:
- At first, they used to “lock people” in Tertiary care or high-intensity
secondary care
- From care to cure. If you have psychosis and you cure it, you hope to make the
psychosis disappear. (e.g., you have a tumor, do surgery, take it out, and you
have cured it – making it go away)
- The drug-based treatment. The pills are going to eliminate the disease, the
psychosis, etc.
- So, we start to understand severe mental illness as a disease (disease
model). Like it is something external that gets into your body. It is like either
you have it and you are sick, or you don’t have it and you are happy. In this
way, it sounds abnormal, not normal.
- The disease is understood as a sickness, something bad that makes you not
function right and feel bad.
- Causal= (A) causes (B). so, you have something underly and it causes
something else (symptoms)
- The term implies medical discourse of cure
- We have to make distinctions between the symptoms and the disease. (e.g.
Headache and tumor = tumor is the disease, headache is the symptom. If you
take paracetamol, JUST the symptom is going to disappear)
- Nomothetic approach: explanation of symptoms by underlying diseases (“if it
rains everything gets wet” (or) “if the sun is out, it is day”) nomothetic
approach is about laws, but we also apply it medical field “if you have this
particular disease you will have this particular symptom”
*(A nomothetic approach involves the study of groups of people or cases for the purpose
of discovering those general and universally valid laws or principles that characterize
the average person or case)
- Focus on universal/lawful disease states ||| when person X has disease Y, the
disease cause symptoms x, y, and z.
Major depressive disorder:
depressed mood suicidal behavior weight loss loss of sleepiness
interests
- The term symptoms come from this model. Symptoms mean that there are
sings of something.
The Cure-Paradigm in psychiatry
Ontology (theory of being): causal disease model. (our assumption on what is real, a
theory of what is “being” what is real)
• We assume that the symptoms made up from diseases are caused by
the underlying diseases
• Symptoms: observable signs of the underlying cause
• Treatment goal: eliminate the cause
• Treatment outcome monitoring: observe the reduction of symptoms as
signs of elimination of the cause
• End result: No symptom we assume there is no disease anymore
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,*The first branch is ontology, or the 'study of being', which is concerned with what
actually exists in the world about which humans can acquire knowledge. Ontology
helps researchers recognize how certain they can be about the nature and existence of
objects they are researching.= Ο πρώτος κλάδος είναι η οντολογία, ή η «μελέτη της ύπαρξης», η
οποία ασχολείται με το τι πραγματικά υπάρχει στον κόσμο για το οποίο οι άνθρωποι μπορούν να
αποκτήσουν γνώση. Η οντολογία βοηθά τους ερευνητές να αναγνωρίσουν πόσο σίγουροι μπορούν να
είναι για τη φύση και την ύπαρξη των αντικειμένων που ερευνούν.
Epistemology (theory of knowledge) describes symptoms as clearly as possible
• Cookbook psychiatry
• Comorbidity as isolated diagnoses
e.g. it's like a cookbook for apple pie: the most essential ingredient is apples → in
depression the most essential “ingredient” is “low mood”. HOWEVER, you can also
have cinnamon or sugar, BUT they are not necessary. The same thing is happening
with the diagnosis of mental health illnesses, like depression
* One goal of epistemology is to determine the criteria for knowledge so that we can
know what can or cannot be known, in other words, the study of epistemology
fundamentally includes the study of meta-epistemology (what we can know about knowledge
itself).= Ένας στόχος της επιστημολογίας είναι να καθορίσει τα κριτήρια για τη γνώση, ώστε να
μπορούμε να γνωρίζουμε τι μπορεί ή δεν μπορεί να γίνει γνωστό, με άλλα λόγια, η μελέτη της
γνωσιολογίας περιλαμβάνει βασικά τη μελέτη της μεταεπιστημολογίας (τι μπορούμε να
γνωρίζουμε για την ίδια τη γνώση).
**Stemming from ontology (what exists for people to know about) and epistemology (how
knowledge is created and what is possible to know) are philosophical perspectives, a system
of generalized views of the world, which form beliefs that guide action.= Πηγές από την
οντολογία (τι υπάρχει για να γνωρίζουν οι άνθρωποι) και την γνωσιολογία (πώς δημιουργείται
η γνώση και τι είναι δυνατό να γνωρίζουμε) είναι φιλοσοφικές προοπτικές
• Evidence-based treatments → predictable illness & treatment diagnoses
- Efficiency & dose-response
- Manualization
- Objective evidence = context-independent (αντικειμενική απόδειξη=ανεξάρτητη από το
πλαίσιο)
*(Therapists who use treatments based on science engage in what is called “evidence-based
practice” (EBP). If the treatments they use have scientific evidence supporting the
effectiveness of the treatments, they are called evidence-based treatments (EBTs).)
***Ontology and Epistemology are very tight together.
Cure as the “Symptom reduction model”
- Evidence-based treatment focused on symptom reduction
- Hyperfocus on diagnosis in diagnosis -disability-duration
- Assumption of malleability (ελαστικότητα | ευπλαστότητα) of symptoms (linear,
causal, predictable)
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, Pitfalls of symptoms-based diagnosis (e.g., DSM) (παγίδες)
- High comorbidity rates
- Many disorders occur dimensionally rather than categorically (→ arbitrary
cut-offs= αυθαίρετες αποκοπές)
- Diagnostic categories are highly heterogeneous (e.g., 256 ways to diagnoses
BPD based on five out of nine criteria)
- Limited predictive validity of diagnoses regarding treatment process and
outcome
- The category Not Otherwise Specified (NOS) often yields large numbers but
lacks clarity
(Opposite effect → listen again the audio, patients cannot fit the system the way the
system it is)
“Saving normal”:
• weak scientific status of DSM (classification ontology |reliability: old wine in
new barrels) |
• diagnostic inflation: overdiagnosis/ overtreatment of mild problems |
undertreatment of complex “difficult” problems
• SMI= messy, complete, multidimensional, contextual→ psychiatrists and
psychologists don’t limit your view to DSM
Alternatives:
1. Research domain criteria (RDoC) & transdiagnostic dimensions (network
theory)
2. From Nomothetic to idiosyncratic, Holistic*
3. Interactional & Person-oriented approaches
*Idiosyncratic individuals are tuned in to and sustained by their own feelings and belief
systems, whether or not others accept or understand their particular worldview or approach
to life. Own world. They are self-directed and independent, requiring few close relationships. Own
thing.
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