Mental Illness

September 17, 2011

Mental illness can be defined as behavioral, psychological, or biological dysfunction that interferes with an individual’s daily life and ability to cope with normal stressors. A “mental disorder” is differentiated from a “physical disorder” in order to categorize types of problematic symptoms and behaviors and to guide decisions regarding the boundary between normality and pathology. It is recognized, however, that the mind and body are inherently connected to and affected by one another, as psychological symptoms affect physical symptoms and vice versa.

Nearly 25% of women will experience mental illness in their lifetime. There are biological and psychosocial factors that affect women’s mental health differently than men’s mental health. Reproductive health events such as the premenstrual period, pregnancy or postpartum, and the perimenopausal period appear to affect psychological functioning. Gender differences in thyroid function, circadian rhythm patterns (sleep cycles), neurotransmitters (brain chemicals), and hormones may also contribute to higher prevalence rates of some mental disorders in women compared to men. Psychosocial factors such as role identity and conflict (family and work), sexual and physical abuse, discrimination, lack of social support, and poverty also affect women’s mental health.

Some mental disorders occur equally commonly in men and women (schizophrenia and bipolar disorder), while other disorders, such as postpartum depression, occur exclusively in women. Depression is much more common in women than in men, likely a result of biological, psychological, and social factors. In the past, it was often believed that women were subject to emotional instability as a “side effect” of their reproductive functioning. “Hysteria” (based on the Greek word for uterus) was a term used in the past to describe overreactive emotional states occurring in women. In some cases, women were deprived of personal rights and freedoms as it was believed they were incapable of making rational decisions when in the grip of these “female,” overreactive emotional states. While stigma is still a major factor in the lives of both men and women with mental illness, campaigns to improve public awareness of mental disorders and significant developments in understanding and treatments of mental illness have greatly improved conditions for women who experience emotional illness. “Hysteria” is not a term utilized in modern psychiatry.

While mental illness occurs all over the world and prevalence of disorder is remarkably consistent globally (e.g., approximately 1% of the population worldwide has schizophrenia), how illnesses manifest may differ across gender, age, and culture. For example, in cultures where depression is not an “acceptable” illness, individuals with depression are more likely to present with somatic complaints such as fatigue, headache, and pain.

Outcomes of mental illness may differ by gender and culture as well. For example, in most countries suicide attempts more commonly occur in women, while men are more likely to commit suicide. However, in some countries, such as India and China, the reverse is true, with women being more likely to commit suicide as compared to men. It has been speculated that this may be due to differing social roles between men and women, although much more study is needed to better understand how gender and culture affect the causes, presentation, and outcomes of mental illness.

Mental disorders describe, classify, and categorize symptoms rather than people. They are divided into the categories of mood, anxiety, psychotic, somatoform, factitious, dissociative, sexual and gender identity, eating, sleep, impulse control, adjustment, personality, first diagnosed in infancy, childhood, or adolescence, delirium, dementia, amnestic, and other cognitive disorders, mental disorders due to a general medical condition, and substance-related disorders.

Mood disorders include variations of unipolar and bipolar depression. Major depressive disorder is the presence of a major depressive episode, which is sad mood or loss of interest, along with symptoms such as weight loss, sleep difficulty, fatigue, difficulty concentrating, and thoughts of death or suicide. Dysthymic disorder is a chronic depressive symptom that lasts for at least two years. Women are 2-3 times more likely than men to develop unipolar depression and approximately one out of seven women will develop depression in their lifetime. Sixty to eighty percent of women in the postpartum period experience some combination of depressive and anxiety symptoms, 10-20% of new mothers experience more severe symptoms, resulting in a diagnosis of major depressive disorder with postpartum onset (postpartum depression), and in rare cases (0.1%) women who have just given birth will develop psychotic symptoms. It is estimated that approximately 75% of women experience depressive symptoms in the premenstrual period, and that 3% of women experience symptoms severe enough to be diagnosed with premenstrual dysphoric disorder.

Bipolar disorder is characterized by alternating mood changes between severe lows (depressive episodes) and severe highs (manic episodes). A manic episode is elevated or irritable mood, inflated selfesteem, decreased need for sleep, pressured or rapid speech, racing thoughts, and excessive involvement in pleasurable activities such as spending sprees and sexual indiscretions. Women with bipolar disorder tend to experience a depressive episode first, which can be triggered during the postpartum period. Cyclothymic disorder involves 2 years of alternating periods of manic and depressive symptoms that are not as severe as bipolar disorder.

Anxiety disorders are characterized by irrational fear that is usually accompanied by physiological sensations such as palpitations, sweating, shaking, shortness of breath, chest pain, nausea, dizziness, fear of losing control or going crazy, fear of dying, numbness, and chills or hot flashes. Panic disorder is diagnosed when panic attacks (period of intense fear and physiological symptoms) occur along with fear of additional panic attacks and worry about the consequences of having attacks. Agoraphobia is anxiety about being in places or situations where escape might be difficult or help might not be available if a panic attack occurs. Specific phobias are excessive fears of specific objects or situations and are classified by type: animal, natural environment, blood-injection-injury, or situational. social phobia is overwhelming fear of social situations or performance. Obsessive-compulsive disorder (OCD) is the presence of obsessions (persistent ideas, thoughts, impulses, or images that are inappropriate and intrusive) or compulsions (repetitive behaviors or mental acts that a person engages in to prevent or reduce anxiety). Posttraumatic stress disorder (PTSD) is an anxious response to witnessing or experiencing an extremely traumatic or life-threatening event that includes symptoms such as difficulty sleeping, irritability or anger outbursts, difficulty concentrating, hypervigilance, and exaggerated startle response. Acute stress disorder is exposure to a traumatic event combined with dissociative symptoms such as numbing, detachment, or absence of emotional response. Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety about numerous events or activities and is associated with symptoms such as restlessness, fatigue, difficulty concentrating, muscle tension, and sleep disturbance. Anxiety disorders such as GAD, social phobia, and panic disorder are diagnosed up to 2-3 times more often in women than men. PTSD is often diagnosed in women who have been raped, physically or sexually abused, or are victims of domestic violence.

Psychotic disorders are characterized by the presence of psychotic features such as delusions (distorted thoughts or false beliefs) or hallucinations (distortions of perceptions). Schizophrenia includes symptoms such as delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and affective flattening. Schizophreniform disorder is similar to schizophrenia but is less severe and lasts only 1-6 months. Schizoaffective disorder is characterized by the presence of schizophrenia and either a major depressive or manic episode or both. Delusional disorder involves mistaken beliefs about situations that could occur in real life.

Somatoform disorders are characterized by the presence of physical complaints that cannot be explained by a general medical condition, substance use, or another psychological disorder. Somatization disorder is characterized by numerous physical ailments (pain, gastrointestinal, sexual or reproductive, or pseudoneurological symptoms) that result in medical treatment being sought or significant impairment in daily living. Undifferentiated somatoform disorder is similar to somatization disorder but not as severe. Conversion disorder is characterized by unexplained symptoms or problems with voluntary motor or sensory functioning that suggest a neurological or other general medical condition but is judged to be associated with psychological factors. Pain disorder involves pain as the main focus of clinical attention but psychological factors are judged to be significantly related to the pain. Hypochondriasis is characterized by the preoccupation with having a serious illness or disease based on the misinterpretation of bodily symptoms. Body dysmorphic disorder involves a preoccupation with an exaggerated or imagined defect in the individual’s physical appearance. Somatization disorder, conversion disorder, and pain disorder are more common in women than men.

Factitious disorders involve pretending to have physical or psychological symptoms to assume the sick role, without the presence of external incentives for this behavior. Factitious disorder includes subjective complaints, self-inflicted conditions, or exacerbation or exaggeration of an existing general medical condition.

Dissociative disorders are characterized by a change in the usually integrated areas of consciousness, memory, identity, or perception of the environment. Dissociative amnesia is an inability to recall important and traumatic information. Dissociative fugue is sudden travel away from home with an inability to recall the past and confusion about personal identity or the assumption of a new identity. Dissociative identity disorder (previously multiple personality disorder) is two or more distinct identities or personality states that recurrently take control of the individual’s behavior. Depersonalization disorder is characterized by a persistent feeling of being detached from one’s body or mental processes.

Sexual and gender identity disorders include Sexual Dysfunctions such as sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders, Paraphilias such as exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, and voyeurism, and gender identity disorders, which involve crossgender identification and discomfort with one’s assigned sex.

Eating disorders include severe disturbances in eating behaviors. Anorexia Nervosa is a refusal to maintain a minimally normal body weight, Bulimia Nervosa is repeated episodes of binge eating that are followed by inappropriate compensatory behaviors such as abuse of laxatives, self-induced vomiting, fasting, or excessive exercise, and binge-eating disorder is repeated episodes of eating an excessive amount of food without inappropriate compensatory behaviors. It is estimated that 0.5-5% of women suffer from eating disorders, and social factors such as the pressure for women to be attractive and the association of thinness with attractiveness are thought to contribute to these disorders.

Sleep disorders are organized into categories based on the cause of the sleep dysfunction. Primary sleep disorders include dyssomnias (abnormalities in the amount, quality, or timing of sleep: primary insomnia, primary hypersomnia, narcolepsy, breathing-related sleep disorder, and circadian rhythm sleep disorder) and parasomnias (abnormal behavior in relation to sleep: nightmare disorder, sleep terror disorder, and sleepwalking disorder).

Impulse control disorders are characterized by the failure to resist an impulse or temptation to perform an act that is harmful. Intermittent explosive disorder is the failure to resist aggressive impulses that result in serious assaults or destruction of property. Kleptomania is the failure to resist impulses to steal objects that are not needed. Pyromania is a pattern of setting fires for relief of tension, pleasure, or gratification. Pathological

Gambling is maladaptive gambling behavior that is persistent and recurrent. Trichotillomania is recurrent pulling out of one’s hair for relief of tension, pleasure, or gratification and results in noticeable hair loss. Kleptomania and trichotillomania are more common in women than men.

Adjustment disorders are characterized by clinically significant emotional or behavioral symptoms in response to an identifiable stressor and are associated with symptoms such as depressed mood, anxiety, and/or behavior problems.

Personality disorders are patterns of experience and behavior that are inflexible and lead to impairment or distress. Paranoid personality disorder is characterized by excessive suspiciousness and distrust. Schizoid personality disorder is diagnosed in individuals who show a restricted range of emotions and have a history of detachment from social relationships. Schizotypal personality disorder is characterized by acute discomfort in close relationships, eccentricities of behavior, and cognitive or perceptual distortions. Antisocial personality disorder is diagnosed in individuals who show disregard for and violation of the rights of others. Borderline personality disorder is characterized by impulsive behaviors and instability in interpersonal relationships, self-image, and mood. Histrionic personality disorder is characterized by excessive emotionality and attention-seeking behaviors. Avoidant personality disorder is diagnosed in individuals who are socially inhibited, feel inadequate, and are hypersensitive to negative evaluation by others. Dependent personality disorder is characterized by submissive and clinging behavior related to an excessive need to be taken care of. Obsessive-compulsive personality disorder is diagnosed in individuals who are preoccupied with orderliness, perfectionism, and control. Borderline, histrionic, and dependent personality disorders are more common in women than in men.

There are disorders that are usually first diagnosed in infancy, childhood, or adolescence, but there is no clear distinction between childhood and adult disorders. Disorders included in this category are mental retardation, learning disorders, motor skills disorder, communication disorders, pervasive developmental disorders (autistic disorder, Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder), attention-deficit and disruptive behavior disorders (attention-deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder), Feeding and eating disorders of infancy or early childhood (pica, rumination disorder, and feeding disorder of infancy or early childhood), Tic disorders (Tourette’s disorder, chronic motor or vocal tic disorder, and transient Tic disorder), Elimination disorders (Encopresis and enuresis), and other disorders such as separation anxiety disorder, selective mutism, reactive attachment disorder of infancy or early childhood, and stereotypic movement disorder.

Delirium, dementia, amnestic, and other cognitive disorders are characterized by a clinically significant deficit in cognition or memory. Delirium is a disturbance of consciousness that develops over a short period of time, Dementia is multiple cognitive deficits including memory, and an amnestic disorder is memory impairment in the absence of other significant cognitive problems.

Mental disorders due to a general medical condition are psychological symptoms (delirium, dementia, amnestic, psychotic, mood, anxiety, sexual dysfunction, or sleep) that are judged to be the result of a general medical condition.

Substance-related disorders are associated with the taking of a drug of abuse, side effects of medication, and toxin exposure. The two groups of substancerelated disorders are substance use disorders (substance dependence and substance abuse) and substanceinduced disorders (substance intoxication, substance withdrawal, and substance-induced delirium, dementia, amnestic, psychotic, mood, anxiety, sexual dysfunction, or sleep disorders). The 11 classes of substances include alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), and sedatives, hypnotics, and anxiolytics.

Most mental disorders can be successfully treated in a variety of ways. Psychoactive medications are used to modify emotions and behavior in the treatment of mental disorders and include antidepressant, antianxiety, antipsychotic, and antimanic medications. Antidepressants are commonly used to treat unipolar depression and anxiety disorders and include tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors (SSRIs). Antianxiety medications include benzodiazepines, which relieve anxiety symptoms for a short period of time. Antipsychotic medications cannot cure psychosis, but are very effective in treating psychotic symptoms, and antimanic medications stabilize the mood swings in bipolar disorder. Women who are of childbearing age should discuss and carefully weigh the pros and cons of psychotropic medication treatment with their doctors because of the potential risks while taking birth control pills, possible birth defects in the developing fetus, and the passing of medication through breast milk. Psychosocial therapy includes individual psychotherapy (cognitive-behavioral or interpersonal therapy is commonly used), family therapy, psychoeducation, group therapy (supportive or selfhelp), inpatient hospitalization, rehabilitation services, and electroconvulsive treatment (ECT).

The changes in laws and public policy in the United States reflect the ever-evolving feminist movement, and the history of women and mental illness is representative of cultural issues reflected in laws and public policy. One historical example is the story of Elizabeth Packard who, in the mid-1800s, was committed to a state mental hospital simply because her husband asserted that she was insane. When she was released, she won a jury trial, and advocated for laws to be changed. She was responsible for changes to commitment laws in many states and was crucial to raising awareness about the treatment of patients in mental asylums. She also fought for the “Bill for the Protection of Personal Liberty,” which granted the right to a jury trial to individuals committed to an asylum. In the United States during the years of Packard’s story, public policy regarding mental illness also reflected the views regarding women at that time. Women were not yet allowed to vote and husbands were permitted to send their wives to a mental hospital without evidence of insanity.

The “Anti-Psychiatry Movement” that began in the 1960s is another example of the impact of culture on women and mental illness (although criticisms of psychiatry began decades before the 1960s). Much of this movement derived from criticism regarding inhumane treatment of psychiatric patients including lobotomies, ECT, isolation, and restraint. Some also believed that many individuals are misdiagnosed, overdiagnosed, or mistreated. Many people argue against involuntary commitment, coming from a legal or civil liberties perspective. As with Elizabeth Packard, social reform and public policy changes resulted from this movement. Sylvia Plath’s The Bell Jar and Ken Kesey’s One Flew Over the Cuckoo’s Nest are examples of literary efforts at social reform regarding psychiatric treatment. Plath’s work also addressed social and cultural issues related to women and mental illness, including social class and a patriarchal society. More recently, Susanna Kaysen’s Girl, Interrupted also questioned the symptoms for diagnosing borderline personality disorder, implying that social class and a male-dominated society had a significant influence in her diagnosis and experiences in inpatient psychiatric treatment.

It is evident that culture plays a significant role in various aspects of mental illness, including prevalence rates of diagnoses, as well as treatment implications and access to treatment. Research has shown that racial and ethnic minorities are less likely than the general public to receive quality mental health care. Culture also affects how patients communicate and manifest their symptoms, coping styles and skills, willingness to seek treatment, and family and community supports. A history of racism and discrimination in this country often causes mistrust and fear that deters minorities from utilizing services and obtaining mental health care.

Research has shown that there is a disproportionate number of African Americans who are homeless, incarcerated, in the child welfare system, and victims of trauma; these populations have an increased risk for mental illness. Approximately 40% of Hispanic Americans report difficulty speaking English, therefore, many Hispanic Americans have limited access to Spanish-speaking mental health providers. The American Indians/Alaskan Natives population has a suicide rate that is 50% higher than the national average. It appears that co-occurring mental illness and substance abuse are also higher in this population. Asian Americans/Pacific Islanders often present with more severe mental illnesses than other ethnic groups, possibly due to stigma and shame preventing individuals from seeking treatment.

SEE ALSO: Anxiety disorders, Bipolar disorder, Dementia, Depression, Discrimination, Eating disorders, Hysteria, Obsessive-compulsive disorder, Panic attack, Schizophrenia, Sleep disorders, Substance use

Suggested Reading

  • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.

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