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Medical history

The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the medical diagnosis and proposing efficient medical treatments. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness. The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis. The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical ( the H&P). The history requires that a clinician be skilled in asking appropriate and relevant questions that can provide them with some insight as to what the patient may be experiencing. The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their allergies, and a review of systems (where a comprehensive inquiry of symptoms potentially affecting the rest of the body is briefly performed to ensure nothing serious has been missed). After all of the important history questions have been asked, a focused physical exam (meaning one that only involves what is relevant to the chief concern) is usually done. Based on the information obtained from the H&P, lab and imaging tests are ordered and medical or surgical treatment is administered as necessary. Process A practitioner typically asks questions to obtain the following information about the patient: Identification and demographics: name, age, height, weight. The "chief complaint (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours). History of the present illness (HPI) – details about the complaints, enumerated in the CC (also often called history of presenting complaint or HPC). Past medical history (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as past surgical history or PSH), any current ongoing illness, e.g. diabetes). Review of systems (ROS) Systematic questioning about different organ systems Family diseases – especially those relevant to the patient's chief complaint. Childhood diseases – this is very important in pediatrics. Social history (medicine) – including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets. Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine) Allergies – to medications, food, latex, and other environmental factors Sexual history, obstetric/gynecological history, and so on, as appropriate. Conclusion & closure History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computerized history-taking could be an integral part of clinical decision support systems. A follow-up procedure is initiated at the onset of the illness to record details of future progress and results after treatment or discharge. This is known as a catamnesis in medical terms. Review of systems Whatever system a specific condition may seem restricted to, all the other systems are usually reviewed in a comprehensive history. The review of systems often includes all the main systems in the body that may provide an opportunity to mention symptoms or concerns that the individual may have failed to mention in the history. Health care professionals may structure the review of systems as follows: Cardiovascular system (chest pain, dyspnea, ankle swelling, palpitations) are the most important symptoms and you can ask for a brief description for each of the positive symptoms. Respiratory system (cough, haemoptysis, epistaxis, wheezing, pain localized to the chest that might increase with inspiration or expiration). Gastrointestinal system (change in weight, flatulence and heartburn, dysphagia, odynophagia, hematemesis, melena, hematochezia, abdominal pain, vomiting, bowel habit). Genitourinary system (frequency in urination, pain with micturition (dysuria), urine color, any urethral discharge, altered bladder control like urgency in urination or incontinence, menstruation and sexual activity). Nervous system (Headache, loss of consciousness, dizziness and vertigo, speech and related functions like reading and writing skills and memory). Cranial nerves symptoms (Vision (amaurosis), diplopia, facial numbness, deafness, oropharyngeal dysphagia, limb motor or sensory symptoms and loss of coordination). Endocrine system (weight loss, polydipsia, polyuria, increased appetite (polyphagia) and irritability). Musculoskeletal system (any bone or joint pain accompanied by joint swelling or tenderness, aggravating and relieving factors for the pain and any positive family history for joint disease). Skin (any skin rash, recent change in cosmetics and the use of sunscreen creams when exposed to sun). Inhibiting factors Factors that inhibit taking a proper medical history include a physical inability of the patient to communicate with the physician, such as unconsciousness and communication disorders. In such cases, it may be necessary to record such information that may be gained from other people who know the patient. In medical terms, this is known as a heteroanamnesis, or collateral history, in contrast to a self-reporting anamnesis. Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, they often do not start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health. Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues. When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level. Computer-assisted history taking Computer-assisted history taking or computerized history taking systems have been available since the 1960s. However, their use remains variable across healthcare delivery systems. One advantage of using computerized systems as an auxiliary or even primary source of medically related information is that patients may be less susceptible to social desirability bias. For example, patients may be more likely to report that they have engaged in unhealthy lifestyle behaviors. Another advantage of using computerized systems is that they allow easy and high-fidelity portability to a patient's electronic medical record. Also an advantage is that it saves money and paper. One disadvantage of many computerized medical history systems is that they cannot detect non-verbal communication, which may be useful for elucidating anxieties and treatment plans. Another disadvantage is that people may feel less comfortable communicating with a computer as opposed to a human. In a sexual history-taking setting in Australia using a computer-assisted self-interview, 51% of people were very comfortable with it, 35% were comfortable with it, and 14% were either uncomfortable or very uncomfortable with it. The evidence for or against computer-assisted history taking systems is sparse. As of 2011, there were no randomized control trials comparing computer-assisted versus traditional oral-and-written family history taking to identifying patients with an elevated risk of developing type 2 diabetes mellitus. In 2021, a substudy of a large prospective cohort trial showed that a majority (70%) of patients with acute chest pain could, with computerized history taking, provide sufficient data for risk stratification with a well-established risk score (HEART score). See also Genogram Medical record Medicine Physical examination Psychoanalysis (Freud uses the term anamnesis to describe neurotics' recounting of their symptoms) References Practice of medicine Medical terminology Athletic training History of science by discipline

Psychiatry

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions. These include various matters related to mood, behaviour, cognition, perceptions, and emotions. Initial psychiatric assessment of a person begins with creating a case history and conducting a mental status examination. Physical examinations, psychological tests, and laboratory tests may be conducted. On occasion, neuroimaging or other neurophysiological studies are performed. Mental disorders are diagnosed in accordance with diagnostic manuals such as the International Classification of Diseases (ICD), edited by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The fifth edition of the DSM (DSM-5), published in May 2013, reorganized the categories of disorders and added newer information and insights consistent with current research. Treatment may include psychotropics (psychiatric medicines), interventional approaches and psychotherapy, and also other modalities such as assertive community treatment, community reinforcement, substance-abuse treatment, and supported employment. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or risk to the individual or community. Research within psychiatry is conducted on an interdisciplinary basis with other professionals, such as epidemiologists, nurses, social workers, occupational therapists, and clinical psychologists. Etymology The term psychiatry was first coined by the German physician Johann Christian Reil in 1808 and literally means the 'medical treatment of the soul' (ψυχή psych- 'soul' from Ancient Greek psykhē 'soul'; -iatry 'medical treatment' from Gk. ιατρικός iātrikos 'medical' from ιάσθαι iāsthai 'to heal'). A medical doctor specializing in psychiatry is a psychiatrist (for a historical overview, see: Timeline of psychiatry). Theory and focus Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill. People who specialize in psychiatry often differ from most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. The discipline studies the operations of different organs and body systems as classified by the patient's subjective experiences and the objective physiology of the patient. Psychiatry treats mental disorders, which are conventionally divided into three general categories: mental illnesses, severe learning disabilities, and personality disorders. Although the focus of psychiatry has changed little over time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from other medical fields. Scope of practice Though the medical specialty of psychiatry uses research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. Because psychiatry and neurology are deeply intertwined medical specialties, all certification for both specialties and for their subspecialties is offered by a single board, the American Board of Psychiatry and Neurology, one of the member boards of the American Board of Medical Specialties. Unlike other physicians and neurologists, psychiatrists specialize in the doctor–patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and have post-graduate training called residency (usually four to five years) in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations. As well, some psychiatrists are trained in interventional psychiatry and can deliver interventional treatments such as electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation and ketamine. Ethics The World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists (like other purveyors of professional ethics). The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977 has been expanded through a 1983 Vienna update and in the broader Madrid Declaration in 1996. The code was further revised during the organization's general assemblies in 1999, 2002, 2005, and 2011. The World Psychiatric Association code covers such matters as confidentiality, the death penalty, ethnic or cultural discrimination, euthanasia, genetics, the human dignity of incapacitated patients, media relations, organ transplantation, patient assessment, research ethics, sex selection, torture, and up-to-date knowledge. In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry, for example, surrounding the use of lobotomy and electroconvulsive therapy. Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey, Donald Ewen Cameron, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky. Approaches Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a "biopsychosocial model" is often used to underline the multifactorial nature of clinical impairment. In this notion the word model is not used in a strictly scientific way though. Alternatively, a Niall McLaren acknowledges the physiological basis for the mind's existence but identifies cognition as an irreducible and independent realm in which disorder may occur. The biocognitive approach includes a mentalist etiology and provides a natural dualist (i.e., non-spiritual) revision of the biopsychosocial view, reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn. Once a medical professional diagnoses a patient there are numerous ways that they could choose to treat the patient. Often psychiatrists will develop a treatment strategy that incorporates different facets of different approaches into one. Drug prescriptions are very commonly written to be regimented to patients along with any therapy they receive. There are three major pillars of psychotherapy that treatment strategies are most regularly drawn from. Humanistic psychology attempts to put the "whole" of the patient in perspective; it also focuses on self exploration. Behaviorism is a therapeutic school of thought that elects to focus solely on real and observable events, rather than mining the unconscious or subconscious. Psychoanalysis, on the other hand, concentrates its dealings on early childhood, irrational drives, the unconscious, and conflict between conscious and unconscious streams. Practitioners All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are trained physicians who specialize in psychiatry and are certified to treat mental illness. They may treat outpatients, inpatients, or both; they may practice as solo practitioners or as members of groups; they may be self-employed, be members of partnerships, or be employees of governmental, academic, nonprofit, or for-profit entities; employees of hospitals; they may treat military personnel as civilians or as members of the military; and in any of these settings they may function as clinicians, researchers, teachers, or some combination of these. Although psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis or cognitive behavioral therapy, it is their training as physicians that differentiates them from other mental health professionals. As a career choice in the US Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favorably. This has resulted in a significant shortage of psychiatrists in the United States and elsewhere. Strategies to address this shortfall have included the use of short 'taster' placements early in the medical school curriculum and attempts to extend psychiatry services further using telemedicine technologies and other methods. Recently, however, there has been an increase in the number of medical students entering into a psychiatry residency. There are several reasons for this surge, including the intriguing nature of the field, growing interest in genetic biomarkers involved in psychiatric diagnoses, and newer pharmaceuticals on the drug market to treat psychiatric illnesses. Subspecialties The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology (ABPN). Such subspecialties include: Addiction psychiatry, addiction medicine Brain injury medicine Child and adolescent psychiatry Consultation-liaison psychiatry Forensic psychiatry Geriatric psychiatry Hospice and palliative medicine Sleep medicine Additional psychiatry subspecialties, for which the ABPN does not provide formal certification, include: Biological psychiatry Community psychiatry Cross-cultural psychiatry Emergency psychiatry Evolutionary psychiatry Global mental health Learning disabilities Military psychiatry Neurodevelopmental disorders Neuropsychiatry Interventional Psychiatry Social psychiatry Addiction psychiatry focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders. Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system. Child and adolescent psychiatry is the branch of psychiatry that specializes in work with children, teenagers, and their families. Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services. Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services. Emergency psychiatry is the clinical application of psychiatry in emergency settings. Forensic psychiatry utilizes medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions. Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly. Global mental health is an area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide, although some scholars consider it to be a neo-colonial, culturally insensitive project. Liaison psychiatry is the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry. Military psychiatry covers special aspects of psychiatry and mental disorders within the military context. Neuropsychiatry is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system. Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well-being. In larger healthcare organizations, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization's constituents. For example, the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist, although psychologists occasionally are selected for the position as well. In the United States, psychiatry is one of the few specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine. Research Psychiatric research is, by its very nature, interdisciplinary; combining social, biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision of institutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders. Clinical application Diagnostic systems Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. Some clinicians are beginning to utilize genetics and automated speech assessment during the diagnostic process but on the whole these remain research topics. Potential use of MRI/fMRI in diagnosis In 2018, the American Psychological Association commissioned a review to reach a consensus on whether modern clinical MRI/fMRI will be able to be used in the diagnosis of mental health disorders. The criteria presented by the APA stated that the biomarkers used in diagnosis should: "have a sensitivity of at least 80% for detecting a particular psychiatric disorder" "should have a specificity of at least 80% for distinguishing this disorder from other psychiatric or medical disorders" "should be reliable, reproducible, and ideally be noninvasive, simple to perform, and inexpensive" "proposed biomarkers should be verified by 2 independent studies each by a different investigator and different population samples and published in a peer-reviewed journal" The review concluded that although neuroimaging diagnosis may technically be feasible, very large studies are needed to evaluate specific biomarkers which were not available. Diagnostic manuals Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-11 is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association (APA), is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fifth revised edition and is also used worldwide. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders. The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being atheoretical as regards etiology. However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together. While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries. The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress and financial conflicts of interest, including with the practice of psychiatrists and with the pharmaceutical industry; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement. Treatment General considerations Individuals receiving psychiatric treatment are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in countries such as the UK and Australia, by sectioning under a mental health law. A psychiatrist or medical provider evaluates people through a psychiatric assessment for their mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed. Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts, serum drug levels, renal function, liver function or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious conditions, such as those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs may vary from patient to patient. Inpatient treatment Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Average inpatient psychiatric treatment stay has decreased significantly since the 1960s, a trend known as deinstitutionalization. Today in most countries, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalization. However, in Japan psychiatric hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months. Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the United States and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. People may be admitted voluntarily if the treating doctor considers that safety is not compromised by this less restrictive option. For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Internationally, mental health laws vary significantly but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a significant risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on a treating physician's recommendations, without requiring consent from the patient. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, pharmacists, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision and may be put in physical restraints or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own. In many developed countries there has been a massive reduction in psychiatric beds since the mid 20th century, with the growth of community care. Italy has been a pioneer in psychiatric reform, particularly through the no-restraint initiative that began nearly fifty years ago. The Italian movement, heavily influenced by Franco Basaglia, emphasizes ethical treatment and the elimination of physical restraints in psychiatric care. A study examining the application of these principles in Italy found that 14 general hospital psychiatric units reported zero restraint incidents in 2022. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason. Even in developed countries, programs in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centers or "rehab" as popularly termed. Outpatient treatment Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. During initial appointments, a psychiatrist generally conducts a psychiatric assessment or evaluation of the patient. Follow-up appointments then focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient's mental and emotional functioning, and counseling patients regarding changes they might make to facilitate healing and remission of symptoms. The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person's condition, and depending on what the clinician and patient decide would be best. Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy". This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists. Telepsychiatry History Earliest knowledge The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text, Charaka Samhita. The first hospitals for curing mental illness were established in India during the 3rd century BCE. Greek philosophers, including Thales, Plato, and Aristotle (especially in his De Anima treatise), also addressed the workings of the mind. As early as the 4th century BC, the Greek physician Hippocrates theorized that mental disorders had physical rather than supernatural causes. In 387 BCE, Plato suggested that the brain is where mental processes take place. In 4th to 5th century B.C. Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy. During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, a view which existed throughout ancient Greece and Rome, as well as Egyptian regions. Alcmaeon, believed the brain, not the heart, was the "organ of thought". He tracked the ascending sensory nerves from the body to the brain, theorizing that mental activity originated in the CNS and that the cause of mental illness resided within the brain. He applied this understanding to classify mental diseases and treatments. Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing methods that many consider to be cruel or barbaric methods. Trepanning was one of these methods used throughout history. In the 6th century AD, Lin Xie carried out an early psychological experiment, in which he asked people to draw a square with one hand and at the same time draw a circle with the other (ostensibly to test people's vulnerability to distraction). It has been cited that this was an early psychiatric experiment. The Islamic Golden Age fostered early studies in Islamic psychology and psychiatry, with many scholars writing about mental disorders. The Persian physician Muhammad ibn Zakariya al-Razi, also known as "Rhazes", wrote texts about psychiatric conditions in the 9th century. As chief physician of a hospital in Baghdad, he was also the director of one of the first bimaristans in the world. The first bimaristan was founded in Baghdad in the 9th century, and several others of increasing complexity were created throughout the Arab world in the following centuries. Some of the bimaristans contained wards dedicated to the care of mentally ill patients. During the Middle Ages, Psychiatric hospitals and lunatic asylums were built and expanded throughout Europe. Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders, but were used only as custodial institutions and did not provide any type of treatment. It is the oldest extant psychiatric hospital in the world. An ancient text known as The Yellow Emperor's Classic of Internal Medicine identifies the brain as the nexus of wisdom and sensation, includes theories of personality based on yin–yang balance, and analyzes mental disorder in terms of physiological and social disequilibria. Chinese scholarship that focused on the brain advanced during the Qing Dynasty with the work of Western-educated Fang Yizhi (1611–1671), Liu Zhi (1660–1730), and Wang Qingren (1768–1831). Wang Qingren emphasized the importance of the brain as the center of the nervous system, linked mental disorder with brain diseases, investigated the causes of dreams, insomnia, psychosis, depression and epilepsy. Medical specialty The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century, although its germination can be traced to the late eighteenth century. In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. In 1713, the Bethel Hospital Norwich was opened, the first purpose-built asylum in England. In 1656, Louis XIV of France created a public system of hospitals for those with mental disorders, but as in England, no real treatment was applied. During the Enlightenment, attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment. In 1758, English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Royal Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind. The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke. In 1792, Pinel became the chief physician at the Bicêtre Hospital. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel's student and successor, Jean Esquirol (1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles. Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with—a situation he finally achieved in 1838. In 1839, Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country. The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. In England, the Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. All asylums were required to have written regulations and to have a resident qualified physician. In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened around 1850. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization ran into difficulties. Psychiatrists were pressured by an ever-increasing patient population, and asylums again became almost indistinguishable from custodial institutions. In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality. The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of "nerves", and psychiatry became a rough approximation of neurology and neuropsychiatry. Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. By the 1970s, however, the psychoanalytic school of thought became marginalized within the field. Biological psychiatry reemerged during this time. Psychopharmacology and neurochemistry became the integral parts of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Subsequently, it has been shown that different neurotransmitters have different and multiple functions in regulation of behaviour. In a wide range of studies in neurochemistry using human and animal samples, individual differences in neurotransmitters' production, reuptake, receptors' density and locations were linked to differences in dispositions for specific psychiatric disorders. For example, the discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as a treatment for psychosocial issues. This proved the idea of neurochemical nature of many psychiatric disorders. Another approach to look for biomarkers of psychiatric disorders is Neuroimaging that was first utilized as a tool for psychiatry in the 1980s. In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Centers focus shifted to providing psychotherapy for those with acute but less serious mental disorders. Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals, resulting in a large population of chronically homeless people with mental illness. Controversy and criticism The institution of psychiatry has attracted controversy since its inception. Scholars including those from social psychiatry, psychoanalysis, psychotherapy, and critical psychiatry have produced critiques. It has been argued that psychiatry confuses disorders of the mind with disorders of the brain that can be treated with drugs; that its use of drugs is in part due to lobbying by drug companies resulting in distortion of research; and that the concept of "mental illness" is often used to label and control those with beliefs and behaviours that the majority of people disagree with; and that it is too influenced by ideas from medicine causing it to misunderstand the nature of mental distress. Critique of psychiatry from within the field comes from the critical psychiatry group in the UK. Double argues that most critical psychiatry is anti-reductionist. Rashed argues new mental health science has moved beyond this reductionist critique by seeking integrative and biopsychosocial models for conditions and that much of critical psychiatry now exists with orthodox psychiatry but notes that many critiques remain unaddressed The term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz. The word Antipsychiatrie was already used in Germany in 1904. The basic premise of the anti-psychiatry movement is that psychiatrists attempt to classify "normal" people as "deviant"; psychiatric treatments are ultimately more damaging than helpful to patients; and psychiatry's history involves (what may now be seen as) dangerous treatments, such as psychosurgery an example of this being the frontal lobectomy (commonly called a lobotomy). The use of lobotomies largely disappeared by the late 1970s. See also Glossary of psychiatry Medical psychology Biopsychiatry controversy Child and adolescent psychiatry Telepsychiatry Psychiatry Innovation Lab Anti-psychiatry Controversies about psychiatry Notes References Citations Cited texts Further reading Francis, Gavin, "Changing Psychiatry's Mind" (review of Anne Harrington, Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, Norton, 366 pp.; and Nathan Filer, This Book Will Change Your Mind about Mental Health: A Journey into the Heartland of Psychiatry, London, Faber and Faber, 248 pp.), The New York Review of Books, vol. LXVIII, no. 1 (14 January 2021), pp. 26–29. "[M]ental disorders are different [from illnesses addressed by other medical specialties].... [T]o treat them as purely physical is to misunderstand their nature." "[C]are [needs to be] based on distress and [cognitive, emotional, and physical] need rather than [on psychiatric] diagnos[is]", which is often uncertain, erratic, and unreplicable. (p. 29.) Halpern, Sue, "The Bull's-Eye on Your Thoughts" (review of Nita A. Farahany, The Battle for Your Brain: Defending the Right to Think Freely in the Age of Neurotechnology, St. Martin's, 2023, 277 pp.; and Daniel Barron, Reading Our Minds: The Rise of Big Data Psychiatry, Columbia Global Reports, 2023, 150 pp.), The New York Review of Books, vol. LXX, no. 17 (2 November 2023), pp. 60–62. Psychiatrist Daniel Barron deplores psychiatry's reliance largely on subjective impressions of a patient's condition – on behavioral-pattern recognition – whereas other medical specialties dispose of a more substantial armamentarium of objective diagnostic technologies. A psychiatric patient's diagnoses are arguably more in the eye of the physician: "An anti-psychotic 'works' if a [psychiatric] patient looks and feels less psychotic." Barron also posits that talking – an important aspect of psychiatric diagnostics and treatment – involves vague, subjective language and therefore cannot reveal the brain's objective workings. He trusts, though, that Big Data technologies will make psychiatric signs and symptoms more quantifiably objective. Sue Halpern cautions, however, that "When numbers have no agreed-upon, scientifically-derived, extrinsic meaning, quantification is unavailing." (p. 62.) Singh, Manvir, "Read the Label: How psychiatric diagnoses create identities", The New Yorker, 13 May 2024, pp. 20-24. "[T]he Diagnostic and Statistical Manual of Mental Disorders, or DSM [...] guides how Americans [...] understand and deal with mental illness. [...] The DSM as we know it appeared in 1980, with the publication of the DSM-III [which] favored more precise diagnostic criteria and a more scientific approach [than the first two DSM editions]. [H]owever, the emerging picture is of overlapping conditions, of categories that blur rather than stand apart. No disorder has been tied to a specific gene or set of genes. Nearly [p. 20] all genetic vulnerabilities implicated in mental illness have been associated with many conditions. [...] As the philosopher Ian Hacking observed, labelling people is very different from labelling quarks or microbes. Quarks and microbes are indifferent to their labels; by contrast, human classifications change how 'individuals experience themselves – and may even lead people to evolve their feelings and behavior in part because they are so classified.' Hacking's best-known example is multiple personality disorder [now called dissociative identity disorder]. Between 1972 and 1986, the number of cases of patients with multiple personalities exploded from the double digits to an estimated six thousand. [...] [I]n 1955 [n]o such diagnosis [had] existed. [Similarly, o]ver the past twenty years, the prevalence of autism in the United States has quadrupled [...]. A major driver of this surge has been a broadening of the definition and a lowering of the diagnostic threshold. Among people diagnosed with autism [...] evidence of the psychological and neurological traits associated with the condition declined by up to eighty per cent between 2000 and 2015. Temple Grandin [has commented that] [p. 21] 'The spectrum is so broad it doesn't make much sense.' [Confusion has also surrounded the term "sociopathy", which] was dropped from the DSM-II with the arrival of 'antisocial personality disorder' [...]. Some scholars associated sociopathy with remorseless and impulsive behavior caused by a brain injury. Other people associated it with an antisocial personality. [T]he psychologist Martha Stout used it to mean a lack of conscience." (p. 22.) Yet another confusing nosological entity is borderline personality disorder, "defined by sudden swings in mood, self-image, and perceptions of others. [...] The concept is generally attributed to the psychoanalyst Adolph Stern, who used it in 1937 to describe patients who were neither neurotic nor psychotic and thus [were] 'borderline.' [It has been noted that] key symptoms such as identity disturbance, outbursts of anger, and unstable interpersonal relations also feature in narcissistic and histrionic personality disorders. [Medical sociologist] Allan Horwitz [...] asks why the DSM still treats B.P.D. as a disorder of personality rather than of mood. [p. 23.] [T]he process of labelling reifies categories [that is, endows them with a deceptive quality of "thingness"], especially in the age of the Internet. [...] [P]eople everywhere encounter models of illness that they unconsciously embody. [...] In 2006, a [Mexican] student [...] developed devastating leg pain and had trouble walking; soon hundreds of classmates were afflicted." (p. 24.) Academic disciplines Behavioural sciences Branches of psychology Mental disorders Social sciences

Mental status examination

The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests. The MSE is not to be confused with the mini–mental state examination (MMSE), which is a brief neuropsychological screening test for dementia. Theoretical foundations The MSE derives from an approach to psychiatry known as descriptive psychopathology or descriptive phenomenology, which developed from the work of the philosopher and psychiatrist Karl Jaspers. From Jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives. In practice, the MSE is a blend of empathic descriptive phenomenology and empirical clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient (a synonym for signs and symptoms), is incompatible with the original meaning which was concerned with comprehending a patient's subjective experience. Application The mental status examination is a core skill of qualified (mental) health personnel. It is a key part of the initial psychiatric assessment in an outpatient or psychiatric hospital setting. It is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example, by paramedics or emergency department staff. The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan. Domains The mnemonic ASEPTIC can be used to remember the domains of the MSE: A - Appearance/Behavior S - Speech E - Emotion (Mood and Affect) P - Perception T - Thought Content and Process I - Insight and Judgement C - Cognition Appearance Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. Colorful or bizarre clothing might suggest mania, while unkempt, dirty clothes might suggest schizophrenia or depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture, body modifications, or clothing not typical of the patient's gender, might give clues to personality. Observations of physical appearance might include the physical features of alcoholism or drug abuse, such as signs of malnutrition, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication. Weight loss could also signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety. Attitude Attitude, also known as rapport or cooperation, refers to the patient's approach to the interview process and the quality of information obtained during the assessment. Observations of attitude include whether the patient is cooperative, hostile, open or secretive. Behavior Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait. Abnormal movements, for example choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder. A tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medication. The patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette's syndrome. There are a range of abnormalities of movement which are typical of catatonia, such as echopraxia, catalepsy, waxy flexibility and paratonia (or gegenhalten). Stereotypies (repetitive purposeless movements such as rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism. More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium. An inability to sit still might represent akathisia, a side effect of antipsychotic medication. Similarly, a global decrease in arousal and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression or a medical condition such as Parkinson's disease, dementia or delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient's emotional state). Lack of eye contact may suggest depression or autism. Mood and affect The distinction between mood and affect in the MSE is subject to some disagreement. For example, Trzepacz and Baker (1993) describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims (1995) refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation. Mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may have anhedonia. Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. The intensity of the affect may be described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders. Mobility refers to the extent to which affect changes during the interview: the affect may be described as fixed, mobile, immobile, constricted/restricted or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one's disability may be described as showing la belle indifférence, a feature of conversion disorder, which is historically termed "hysteria" in older texts. Speech Speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions. This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought process and thought content (see below). When observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech. Many acoustic features have been shown to be significantly altered in mental health disorders. A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests also form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see below). Language assessment will allow the recognition of medical conditions presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism spectrum disorders may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another person's words) and palilalia (repetition of the subject's own words) can be heard with patients with autism, schizophrenia or Alzheimer's disease. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them. Speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner. Thought process Thought process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. Form of the thought is captured in this category. One should describe the thought form as thought directed A→B (normal), versus formal thought disorders. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, knight's move thinking. Thought may be described as 'circumstantial' when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders. Regarding the tempo of thought, some people may experience 'flight of ideas' (a manic symptom), when their thoughts are so rapid that their speech seems incoherent, although in flight of ideas a careful observer can discern a chain of poetic, syllabic, rhyming associations in the patient's speech (i.e., "I love to eat peaches, beach beaches, sand castles fall in the waves, braves are going to the finals, fee fi fo fum. Golden egg."). Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and one of the negative symptoms of schizophrenia. It can also be a feature of severe depression or dementia. A patient with dementia might also experience thought perseveration. Thought perseveration refers to a pattern where a person keeps returning to the same limited set of ideas. Thought content A description of thought content would be the largest section of the MSE report. It would describe a patient's suicidal thoughts, depressed cognition, delusions, overvalued ideas, obsessions, phobias and preoccupations. One should separate the thought content into pathological thought, versus non-pathological thought. Importantly one should specify suicidal thoughts as either intrusive, unwanted, and not able to translate in the capacity to act on these thoughts (mens rea), versus suicidal thoughts that may lead to the act of suicide (actus reus). Abnormalities of thought content are established by exploring individuals' thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts. Delusions A delusion has three essential qualities: it can be defined as "a false, unshakeable idea or belief (1) which is out of keeping with the patient's educational, cultural and social background (2) ... held with extraordinary conviction and subjective certainty (3)", and is a core feature of psychotic disorders. For instance an alliance to a particular political party, or sports team would not be considered a delusion in some societies. The patient's delusions may be described within the SEGUE PM mnemonic as: somatic, erotomanic delusions, grandiose delusions, unspecified delusions, envious delusions (c.f. delusional jealousy), persecutory or paranoid delusions, or multifactorial delusions. There are several other forms of delusions, these include descriptions such as: delusions of reference, or delusional misidentification, or delusional memories (e.g., "I was a goat last year") among others. Delusional symptoms can be reported as on a continuum from: full symptoms (with no insight), partial symptoms (where they may start questioning these delusions), nil symptoms (where symptoms are resolved), or after complete treatment there are still delusional symptoms or ideas that could develop into delusions you can characterize this as residual symptoms. Delusions can suggest several diseases such as schizophrenia, schizophreniform disorder, brief psychotic disorder, mania, depression with psychotic features, or delusional disorders. One can differentiate delusional disorders from schizophrenia for example by the age of onset for delusional disorders being older with a more complete and unaffected personality, where the delusion may only partially impact their life and be fairly encapsulated off from the rest of their formed personalityfor example, believing that a spider lives in their hair, but this belief not affecting their work, relationships, or education. Whereas schizophrenia typically arises earlier in life with a disintegration of personality and a failure to cope with work, relationships, or education. Other features differentiate diseases with delusions as well. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychosis, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity. Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychosis. Overvalued Ideas An overvalued idea is an emotionally charged belief that may be held with sufficient conviction to make believer emotionally charged or aggressive but that fails to possess all three characteristics of delusion—most importantly, incongruity with cultural norms. Therefore, any strong, fixed, false, but culturally normative belief can be considered an "overvalued idea". Hypochondriasis is an overvalued idea that one has an illness, dysmorphophobia that a part of one's body is abnormal, and anorexia nervosa that one is overweight or fat. Obsessions An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes). Phobias A phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview. Preoccupations Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortions of anxiety and depression. Suicidal thoughts The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life. The most important questions to ask are: Do you have suicidal feeling now; have you ever attempted suicide (highly correlated with future suicide attempts); do you have plans to commit suicide in the future; and, do you have any deadlines where you may commit suicide (e.g., numerology calculation, doomsday belief, Mother's Day, anniversary, Christmas). Perceptions A perception in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucinations and illusions. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as "voices in my head") and is regarded as akin to fantasy. Other sensory abnormalities include a distortion of the patient's sense of time, for example déjà vu, or a distortion of the sense of self (depersonalization) or sense of reality (derealization). Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations. Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the patient) and hearing one's thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the Schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression or schizophrenia. Visual hallucinations are generally suggestive of organic conditions such as epilepsy, drug intoxication or drug withdrawal. Many of the visual effects of hallucinogenic drugs are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations are suggestive of dissociative disorders. Déjà vu, derealization and depersonalization are associated with temporal lobe epilepsy and dissociative disorders. Cognition This section of the MSE covers the patient's level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation. Alertness is a global observation of level of consciousness, i.e. awareness of and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporous. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by several tests, commonly serial sevens test subtracting 7 from 100 and subtracting 7 from the difference 5 times. Alternatively: spelling a five-letter word backwards, saying the months or days of the week in reverse order, serial threes (subtract three from twenty five times), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. Executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter F, in one minute"). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE. Mild impairment of attention and concentration may occur in any mental illness where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain functioning such as delirium, dementia or intoxication. Specific language abnormalities may be associated with pathology in Wernicke's area or Broca's area of the brain. In Korsakoff's syndrome there is dramatic memory impairment with relative preservation of other cognitive functions. Visuospatial or constructional abnormalities here may be associated with parietal lobe pathology, and abnormalities in executive functioning tests may indicate frontal lobe pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing. The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-rock"). The posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed. A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. Pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. A lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (Parinaud's syndrome). Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders. Insight The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context, insight can be said to have three components: recognition that one has a mental illness, compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively. Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment. Anosognosia is the clinical term for the condition in which the patient is unaware of their neurological deficit or psychiatric condition. Judgment Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. One should frame judgement to the functions or domains that are normal versus impaired (e.g., poor judgement is isolated to petty theft, able to function in relationships, work, academics). Traditionally, the MSE included the use of standard hypothetical questions such as "what would you do if you found a stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual's executive system capacity in terms of impulsiveness, social cognition, self-awareness and planning ability. Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others. Cultural considerations There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations these may seem similar to one who does not understand that they have different roots. Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder. Consultation with cultural leaders in community or clinicians when working with Aboriginal people can help guide if any cultural phenomena has been considered when completing an MSE with Aboriginal patients and things to consider from a cross-cultural context. Children There are particular challenges in carrying out an MSE with young children and others with limited language such as people with intellectual impairment. The examiner would explore and clarify the individual's use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner. In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences. See also Diagnostic classification and rating scales used in psychiatry Diagnostic and Statistical Manual of Mental Disorders DSM-IV Codes Glossary of psychiatry Self-administered Gerocognitive Examination (SAGE) Footnotes References Adams, Yolonda, et al. (2010) Principles of Practice in Mental Health Assessment with Aboriginal Australians. ‌ Further reading External links University of Utah Medical School: Video clips demonstrating cognitive assessment Principles of Practice in Mental Health Assessment with Aboriginal Australians Psychiatric assessment Clinical psychology Medical diagnosis Medical mnemonics

Psychiatric rehabilitation

Psychiatric rehabilitation, also known as psychosocial rehabilitation, and sometimes simplified to psych rehab by providers, is the process of restoration of community functioning and well-being of an individual diagnosed in mental health or emotional disorder and who may be considered to have a psychiatric disability. Society affects the psychology of an individual by setting a number of rules, expectations and laws. Psychiatric rehabilitation work is undertaken by rehabilitation counselors (especially the individuals educated in psychiatric rehabilitation), licensed professional counselors (who work in the mental health field), psych rehab consultants or specialists (in private businesses), university level Masters and PhD levels, classes of related disciplines in mental health (psychiatrists, social workers, psychologists, occupational therapists) and community support or allied health workers represented in the new direct support professional workforce in the United States (e.g., psychiatric aides). These workers seek to effect changes in a person's environment and in a person's ability to deal with his/her environment, so as to facilitate improvement in symptoms or personal distress and life outcomes. These services often "combine pharmacologic treatment (often required for program admission), independent living and social skills training, psychological support to clients and their families, housing, vocational rehabilitation and employment, social support and network enhancement and access to leisure activities." The key role of professionals is to generate insight about the illness with the help of demonstration of symptoms and prognosis to the patients. There is often a focus on challenging stigma and prejudice to enable social inclusion, on working collaboratively in order to empower clients, and sometimes on a goal of full recovery. The latter is now widely known as a recovery approach or model. Recovery is a process rather than an outcome. It is a personal journey that is about the rediscovery of self in the process of learning to live with the debilitations of the illness rather than being defined by illness with hope, planning and community engagement. Yet, new in these fields is a person-centered approach to recovery and client-centered therapy based upon Carl Rogers. and user-service direction (as approved in the U.S. by the Centers for Medicare and Medicaid Services). Definition Psychiatric rehabilitation is not a practice but a field of academic study or discipline, similar to social work or political science; other definitions may place it as a specialty of community rehabilitation or physical medicine and rehabilitation. It is aligned with the community support development of the National Institute on Mental Health begun in the 1970s, and is marked by a rigorous tradition of research, training and technical assistance, and information dissemination regarding a critical population group (e.g., psychiatric disability) in the US and worldwide. The field is responsible for developing and testing new models of community service for this population group. The Psychiatric Rehabilitation Association provides this definition of psychiatric rehabilitation: The term was added to the U.S. National Library of Medicine's Medical Subject Headings in 2016. There, psychiatric rehabilitation is defined as a: History From the 1960s and 1970s, the process of de-institutionalization meant that many more individuals with mental health problems were able to live in their communities rather than being confined to mental institutions. Medication and psychotherapy were the two major treatment approaches, with little attention given to supporting and facilitating daily functioning and social interaction. Therapeutic interventions often had little impact on daily living, socialization and work opportunities. There were often barriers to social inclusion in the form of stigma and prejudice. Psychiatric rehabilitation work emerged with the aim of helping the community integration and independence of individuals with mental health problems. "Psychiatric rehabilitation" and "psychosocial rehabilitation" became used interchangeably, as terms for the same practice. These approaches may merge with or conflict with approaches based in the psychiatric survivors movement, including the concept of user-controlled personal assistance services. In the 1980s, the US Department of Education, National Institute on Disability Research and Rehabilitation, revised a Rehabilitation Research and Training Center program to meet the new needs in the community of special population groups. A priority center, published in the Federal Register, was the Rehabilitation Research and Training Center in Psychiatric Disabilities (awarded to William Anthony's Boston University Center). it remains a priority center, providing nationwide assistance and serving as flagship center internationally. With the founding of Psychosocial Rehabilitation Canada in 2004, the professional organization International Association of Psychosocial Rehabilitation Services (IAPSRS) changed its name to United States Psychiatric Rehabilitation Association (USPRA) and the trend is toward the use of "psychiatric rehabilitation". In 2013, USPRA removed the national designation from its name, becoming the Psychiatric Rehabilitation Association (PRA). Academic discipline In 2012, Temple University was funded in the field of psychiatric disabilities for a national center with the National Institute on Disability and Rehabilitation Research (NIDRR), United States Department of Education, having this population group as a priority. Boston University's Center on Psychiatric Rehabilitation's director is President-Elect of the program and Boston University College of Health and Rehabilitation Sciences (Sargent College) awards a Rehabilitation Science Doctor of Science (ScD) degree in the field in which it awards no separate mental health specialty degree (such as occupational therapy). Master' program in psychiatric rehabilitation was part of an MA degree in rehabilitation counseling in the School of Education, Syracuse University and courses were funded in part through the federal Rehabilitation Research and Training Program (now part of National Institute on Disability, Independent Living and Rehabilitation Research). Theory The theoretical base for psychosocial then psychiatric rehabilitation is community support theory as the foundational theory; it is aligned with integration and community integration theories, psychosocial theories, and the rehabilitation and educational paradigms. Its fluid nature is due to variability in development and integration into other essential fields such as family support theories (for this population group) which has already developed its own evidence-based parent education models. The concept of psychiatric rehabilitation is associated with the field of community rehabilitation and later on social psychiatry and is not based on a medical model of disability or the concept of mental illness which is often associated with the words "mental health". However, it can also incorporate elements of a social model of disability as part of progressive professional community field. The academic field developed concurrently with the formation of new mental health agencies in the US, now often offering supported housing services. The Journal of Psychosocial Rehabilitation, then renamed the Journal of Psychiatric Rehabilitation, traces the development of the field over a period of several decades. The academic discipline psychiatric rehabilitation has contributed new models of services such as supported education, has cross-validated models from other fields (e.g., supported employment), has developed the first university-based community living models for populations with "severe mental illness", developed institutional to community training and technical assistance, developed the degree programs at the university levels, offers leadership institutes, and worked collaboratively to expand and upgrade older models such as clubhouses and transitional employment services, among others. Psychiatric rehabilitation was developed and formulated as a new profession of community workers (not medical psychiatry which is an MD awarded by a Medical School) which could assist both in deinstitutionalization (e.g., systems conversion) and in community development in the US. It represents the first Master's and Ph.D. classes in the US to specialize in a rehabilitation discipline focused on community versus institutions or campuses. In the US, it also represents a movement toward evidence-based practices, critical for the development of viable community support services. Psychosocial services, in contrast, have been associated with the term "mental health" as part of community support movement nationwide since the 1970s which has an academic and political base. These services, which have roots in education, psychology and mental health (and community services) administration, were basic funded services of new community mental health agencies offering community living and professionalized community support since the 1970s. Mental health service agencies or multi-service agencies in the non-profit and voluntary sectors form a critical delivery system for psychosocial services. In the 2000s, a sometime similar but sometimes alternative approach (variability and fidelity of provider implementation in the field) employs the concept of psychosocial recovery. Psychiatric rehabilitation was promulgated in the US through Boston University's Rehabilitation Research and Training Center on Psychiatric Rehabilitation led by Dr. William Anthony and Marianne D. Farkas, as well as other professors and teachers such as Julie Ann Racino, Steve Murphy and Bonnie Shoultz of Syracuse University (1989–1991) who also support a generic community approach to education. The concept has been integrated with a community support approach, including supported housing/housing and support, recreation, employment and support, culture/gender and class, families and survivors, family support, and community and systems change. Problems experienced by people with psychiatric disabilities are thought to include difficulties understanding or dealing with interpersonal situations (e.g., misinterpreting social cues, not knowing how to respond), prejudice or bullying from others because they may seem different, problems coping with stress (including daily hassles such as travel or shopping), difficulty concentrating and finding energy and motivation. People leaving psychiatric centers after long-term hospitalizations, an outdated practice, may also have need to assist with injuries that may have occurred and community integration. Psychiatric rehabilitation is distinct from the concept of independent living and consumer-controlled services which have been written about and promoted by psychiatric survivors. The psychiatric rehabilitation concept is separated from the psychiatric survivor concept, in education and training of individuals with psychiatric disorders, in that psychiatric survivors tend to operate services and control funding. Principles The mission of psychiatric rehabilitation is to enable with best practices of illness management, psychosocial functioning, and personal satisfaction. Treatments and practices towards this is guided by principles. There are seven strategic principles: Enabling a normal life. Advocating structural changes for improved accessibility to pharmacological services and availability of psycho-social services. Person-centered treatment. Actively involving support systems. Coordination of efficient services. Strength-based approach. Rehabilitation is not time specific but goal specific in succeeding. The peer-provider approach is among the psychosocial rehabilitation practices guided by these principles. Recovery through rehabilitation is defined possible without complete remission of their illness, it is geared towards aiding the individual in attaining optimum mental health and well-being. Services Psychiatric rehabilitation services may include: community residential services, workplace accommodations, supported employment or education, social firms, assertive community treatment (or outreach) teams assisting with social service agencies, medication management (e.g., self-medication training and support), housing, programs, employment, family issues, coping skills and activities of daily living and socialising. Traditionally, "24-hour" service programs (supervised and regulated options) were based upon the concept of instrumental and daily living skills as formulated in the World Health Organization (WHO) definition. Psychiatric rehabilitation is illustrated by agency models which are offered by traditional and non-traditional service providers, and may be considered to be integrated (e.g. dispersed sites in the community) or segregated (e.g., campus-based facilities or villages). (e.g. Fountain House Model of New York City, MHA Village in Long Beach, CA)or Transitional Living Services of Buffalo or Transitional Living Services of Onondaga County, New York. Agencies supporting integration may align with normalization or integration philosophy, as opposed to the older sheltered workshop or day care models which have been criticized for underpayment of wages at the US Congressional level in the late 2000s. Agencies may deliver cross-field best practices (e.g., supported work), consumer voices (e.g., Rae Unzicker), multiple disabilities (e.g., chemical dependency), training of its own community residential, employment, education and support service professionals, rehabilitation outcomes, and management and evaluation of its own services. Core principles of effective psychiatric rehabilitation (how services are delivered) must include: providing hope when the client lacks it, respect for the client wherever they are in the recovery process, empowering the client, teaching the client wellness planning, and emphasizing the importance for the client to develop social support networks. Psychiatric rehabilitation (what services are delivered) varies by provider and may consist of eight main areas: Psychiatric (symptom management; relaxation, meditation and massage; support groups and in-home assistance) Health and Medical (maintaining consistency of care; family physician and mental health counseling) Housing (safe environments; supported housing; community residential services; group homes; apartment living) Basic Living Skills (personal hygiene or personal care, preparing and sharing meals, home and travel safety and skills, goal and life planning, chores and group decision-making, shopping and appointments) Social (relationships, recreational and hobby, family and friends, housemates and boundaries, communications and community integration) Vocational and/or Educational (vocational planning, transportation assistance to employment, preparation programs (e.g., calculators), GED classes, televised education, coping skills, motivation) Financial (personal budget), planning for own apartment (startup funds, security deposit), household grocery; social security disability; banking accounts (savings or travel) Community and Legal (resources; health insurance, community recreation, memberships, legal aid society, homeownership agencies, community colleges, houses of worship, ethnic activities and clubs; employment presentations; hobby clubs; special interest stores; summer city schedules) , it is expected that areas such as supported housing, household management, quality medical plans, advocacy for rights, counseling, and community participation be part of the available package of options for services. Modernization in these fields includes better health care, such as women and men's health (e.g., heart disease), public and private counseling services in mental health, integrated services (for dual and multiple diagnoses), new specialized treatments (e.g., eating disorders), and understanding of trauma services and mental health. Psychiatric rehabilitation is typically associated with long term services and supports (LTSS) in the community including post secondary education as supported education. Educational and professional organizations Canada In Canada, Psychosocial Rehabilitation/Réadaptation Psychosociale (PSR/RPS) Canada promotes education, research and knowledge exchange in relation to evidence-based psychosocial rehabilitation and recovery-oriented practices for service-providers and those receiving services for mental health challenges. A framework of competencies for service providers (individuals and organizations) was developed and announced at the 2013 Annual National Conference in Winnipeg, Manitoba. United States Boston University, Center for Psychiatric Rehabilitation Psychiatric Rehabilitation Association, formerly the United States Psychiatric Rehabilitation Association and International Association for Psychosocial Rehabilitation; a professional organization founded in 1975. Rutgers School of Health Related Professions, Department of Psychiatric Rehabilitation and Counseling Professions References Further reading Rehabilitation team Psychiatric rehabilitation Deinstitutionalisation Social work

Occupational therapy

Occupational therapy (OT) is a healthcare profession that involves the use of assessment, intervention, consultation, and coaching to develop, recover, or maintain meaningful occupations of individuals, groups, or communities. The field of OT consists of health care practitioners trained and educated to support mental health and physical performance. Occupational therapists specialize in teaching, educating, and supporting participation in activities that occupy an individual's time. It is an independent health profession sometimes categorized as an allied health profession and consists of occupational therapists (OTs) and occupational therapy assistants (OTAs). OTs and OTAs have different roles, with OTs licensed to complete comprehensive occupational therapy evaluations. Both professionals work with people who want to improve their ability to participate in meaningful occupations. The American Occupational Therapy Association defines an occupational therapist as someone who "helps people across their lifespan participate in the things they want and/or need to do through the therapeutic use of everyday activities (occupations)". Definitions by other professional occupational therapy organizations are similar. Common interventions include: Helping disabled children to participate in meaningful activities at home, school, and within the community (independent mobility is often a central concern) Training in assistive device technology, meaningful and purposeful activities, and life skills. Physical injury rehabilitation Mental dysfunction rehabilitation Support of individuals across the age spectrum experiencing physical and cognitive changes Assessing ergonomics and assistive seating options to maximize independent function, while alleviating the risk of pressure injury Education in the disease and rehabilitation process Advocating for patient health Exploring vocational activities with clients Occupational therapists are university-educated professionals and must pass a licensing exam to practice. Currently, entry level occupational therapists must have a master's degree while certified occupational therapy assistants require a two-year associate degree to practice in the United States. Individuals must pass a national board certification and apply for a state license in most states. Occupational therapists often work closely with professionals in physical therapy, speech–language pathology, audiology, nursing, nutrition, social work, psychology, medicine, and assistive technology. History Early history The earliest evidence of using occupations as a method of therapy can be found in ancient times. In c. 100 BCE, Greek physician Asclepiades treated patients with a mental illness humanely using therapeutic baths, massage, exercise, and music. Later, the Roman Celsus prescribed music, travel, conversation and exercise to his patients. However, by medieval times the use of these interventions with people with mental illness was rare, if not nonexistent. Moral treatment and graded activity In late 18th-century Europe, doctors such as Philippe Pinel and Johann Christian Reil reformed the mental asylum system. Their institutions used rigorous work and leisure activities. This became part of what was known as moral treatment. Although it was thriving in Europe, interest in the reform movement fluctuated in the United States throughout the 19th century. In the late 19th and early 20th centuries, the establishment of public health measures to control infectious diseases included the building of fever hospitals. Patients with tuberculosis were recommended to have a regime of prolonged bed rest followed by a gradual increase in exercise. This was a time in which the rising incidence of disability related to industrial accidents, tuberculosis, and mental illness brought about an increasing social awareness of the issues involved. The Arts and Crafts movement that took place between 1860 and 1910 also impacted occupational therapy. The movement emerged against the monotony and lost autonomy of factory work in the developed world. Arts and crafts were used to promote learning through doing, provided a creative outlet, and served as a way to avoid boredom during long hospital stays. From the late 1870's, Scottish tuberculosis doctor Robert William Philip prescribed graded activity from complete rest through to gentle exercise and eventually to activities such as digging, sawing, carpentry and window cleaning. During this period a farm colony near Edinburgh and a village settlement near Papworth in England were established, both of which aimed to employ people in appropriate long-term work prior to their return to open employment. Development into a health profession In the United States, the health profession of occupational therapy was conceived in the early 1910s as a reflection of the Progressive Era. Early professionals merged highly valued ideals, such as having a strong work ethic and the importance of crafting with one's own hands with scientific and medical principles. American social worker Eleanor Clarke Slagle (1870-1942) is considered to be the "mother" of occupational therapy. Slagle proposed habit training as a primary occupational therapy model of treatment. Based on the philosophy that engagement in meaningful routines shape a person's wellbeing, habit training focused on creating structure and balance between work, rest and leisure. Although habit training was initially developed to treat individuals with mental health conditions, its basic tenets are apparent in modern treatment models that are utilized across a wide scope of client populations. In 1912, she became director of a department of occupational therapy at The Henry Phipps Psychiatric Clinic in Baltimore. World War I In 1915, Slagle opened the first occupational therapy training program, the Henry B. Favill School of Occupations, at Hull House in Chicago. British-Canadian teacher and architect Thomas B. Kidner was appointed vocational secretary of the Canadian Military Hospitals Commission in January 1916. He was given the duty of preparing soldiers returning from World War I to return to their former vocational duties or retrain soldiers no longer able to perform their previous duties. He developed a program that engaged soldiers recovering from wartime injuries or tuberculosis in occupations even while they were still bedridden. Once the soldiers were sufficiently recovered they would work in a curative workshop and eventually progress to an industrial workshop before being placed in an appropriate work setting. He used occupations (daily activities) as a medium for manual training and helping injured individuals to return to productive duties such as work.The entry of the United States into World War I in April 1917 was a crucial event in the history of the profession in that country. Up until this time, the profession had been concerned primarily with the treatment of people with mental illness. U.S. involvement in the war led to an escalating number of injured and disabled soldiers, which presented a daunting challenge to those in command. The US National Society for the Promotion of Occupational Therapy (NSPOT) was founded in October 1917 by Slagle, Kidner and others including American doctor William Rush Denton. The military enlisted the assistance of NSPOT to recruit and train over 1,200 "reconstruction aides" to help with the rehabilitation of those wounded in the war. Denton's 1918 article "The Principles of Occupational Therapy" appeared in the journal Public Health, and laid the foundation for the textbook he published in 1919 entitled Reconstruction Therapy. Denton struggled with "the cumbersomeness of the term occupational therapy", as he thought it lacked the "exactness of meaning which is possessed by scientific terms". Other titles such as "work-cure", "ergo therapy" (ergo being the Greek root for "work"), and "creative occupations" were discussed as substitutes, but ultimately, none possessed the broad meaning that the practice of occupational therapy demanded in order to capture the many forms of treatment that existed from the beginning. NSPOT formally adopted the name "occupational therapy" for the field in 1921. Inter-war period There was a struggle to keep people in the profession during the post-war years. Emphasis shifted from the altruistic war-time mentality to the financial, professional, and personal satisfaction that comes with being a therapist. To make the profession more appealing, practice was standardized, as was the curriculum. Entry and exit criteria were established, and the American Occupational Therapy Association advocated for steady employment, decent wages, and fair working conditions. Via these methods, occupational therapy sought and obtained medical legitimacy in the 1920s. The emergence of occupational therapy challenged the views of mainstream scientific medicine. Instead of focusing purely on the medical model, occupational therapists argued that a complex combination of social, economic, and biological reasons cause dysfunction. Principles and techniques were borrowed from many disciplines—including but not limited to physical therapy, nursing, psychiatry, rehabilitation, self-help, orthopedics, and social work—to enrich the profession's scope. The 1920s and 1930s were a time of establishing standards of education and laying the foundation of the profession and its organization. Eleanor Clarke Slagle proposed a 12-month course of training in 1922, and these standards were adopted in 1923. In 1928, William Denton published another textbook, Prescribing Occupational Therapy. Educational standards were expanded to a total training time of 18 months in 1930 to place the requirements for professional entry on par with those of other professions. By the early 1930s, AOTA had established educational guidelines and accreditation procedures. Margaret Barr Fulton became the first US qualified occupational therapist to work in the United Kingdom in 1925. She qualified at the Philadelphia School in the United States and was appointed to the Aberdeen Royal Hospital for mental patients where she worked until her retirement in 1963. US-style OT was introduced into England by Dr Elizabeth Casson who had visited similar establishments in America. (Casson had also earlier worked under the transformative English social reformer Octavia Hill.) In 1929 she established her own residential clinic in Bristol, Dorset House, for "women with mental disorders", and worked as its medical director. It was here in 1930 that she founded the first school of occupational therapy in the UK. The Scottish Association of Occupational Therapists was founded in 1932. The profession was served in the rest of the UK by the Association of Occupational Therapists from 1936. (The two later merged to form what is today the Royal College of Occupational Therapists in 1974.) World War II With the US entry into World War II and the ensuing skyrocketing demand for occupational therapists to treat those injured in the war, the field of occupational therapy underwent dramatic growth and change. Occupational therapists needed to be skilled not only in the use of constructive activities such as crafts, but also increasingly in the use of activities of daily living. The body that is now Occupational Therapy Australia began in 1944. Post-World War II Another textbook was published in the United States for occupational therapy in 1947, edited by Helen S. Willard and Clare S. Spackman. The profession continued to grow and redefine itself in the 1950s. In 1954, AOTA created the Eleanor Clarke Slagle Lectureship Award in its namesake's honor. Each year, this award recognizes a member of AOTA "who has creatively contributed to the development of the body of knowledge of the profession through research, education, or clinical practice." The profession also began to assess the potential for the use of trained assistants in the attempt to address the ongoing shortage of qualified therapists, and educational standards for occupational therapy assistants were implemented in 1960. The 1960s and 1970s were a time of ongoing change and growth for the profession as it struggled to incorporate new knowledge and cope with the recent and rapid growth of the profession in the previous decades. New developments in the areas of neurobehavioral research led to new conceptualizations and new treatment approaches, possibly the most groundbreaking being the sensory integrative approach developed by A. Jean Ayres. The profession has continued to grow and expand its scope and settings of practice. Occupational science, the study of occupation, was founded in 1989 by Elizabeth Yerxa at the University of Southern California as an academic discipline to provide foundational research on occupation to support and advance the practice of occupation-based occupational therapy, as well as offer a basic science to study topics surrounding "occupation". In addition, occupational therapy practitioner's roles have expanded to include political advocacy (from a grassroots base to higher legislation); for example, in 2010 PL 111-148 titled the Patient Protection and Affordable Care Act had a habilitation clause that was passed in large part due to AOTA's political efforts. Furthermore, occupational therapy practitioners have been striving personally and professionally toward concepts of occupational justice and other human rights issues that have both local and global impacts. The World Federation of Occupational Therapist's Resource Centre has many position statements on occupational therapy's roles regarding their participation in human rights issues. In 2021, U.S. News & World Report ranked occupational therapy as #19 of their list of '100 Best Jobs'. Practice frameworks An occupational therapist works systematically with a client through a sequence of actions called an "occupational therapy process." There are several versions of this process. All practice frameworks include the components of evaluation (or assessment), intervention, and outcomes. This process provides a framework through which occupational therapists assist and contribute to promoting health and ensures structure and consistency among therapists. Occupational Therapy Practice Framework (OTPF, United States) The Occupational Therapy Practice Framework (OTPF) is the core competency of occupational therapy in the United States. The OTPF is divided into two sections: domain and process. The domain includes environment, client factors, such as the individual's motivation, health status, and status of performing occupational tasks. The domain looks at the contextual picture to help the occupational therapist understand how to diagnose and treat the patient. The process is the actions taken by the therapist to implement a plan and strategy to treat the patient. Canadian Practice Process Framework The Canadian Model of Client Centered Enablement (CMCE) embraces occupational enablement as the core competency of occupational therapy and the Canadian Practice Process Framework (CPPF) as the core process of occupational enablement in Canada. The Canadian Practice Process Framework (CPPF) has eight action points and three contextual element which are: set the stage, evaluate, agree on objective plan, implement plan, monitor/modify, and evaluate outcome. A central element of this process model is the focus on identifying both client and therapists strengths and resources prior to developing the outcomes and action plan. International Classification of Functioning, Disability and Health (ICF) The International Classification of Functioning, Disability and Health (ICF) is the World Health Organisation's framework to measure health and ability by illustrating how these components impact one's function. This relates very closely to the Occupational Therapy Practice Framework, as it is stated that "the profession's core beliefs are in the positive relationship between occupation and health and its view of people as occupational beings". The ICF is built into the 2nd edition of the practice framework. Activities and participation examples from the ICF overlap Areas of Occupation, Performance Skills, and Performance Patterns in the framework. The ICF also includes contextual factors (environmental and personal factors) that relate to the framework's context. In addition, body functions and structures classified within the ICF help describe the client factors described in the Occupational Therapy Practice Framework. Further exploration of the relationship between occupational therapy and the components of the ICIDH-2 (revision of the original International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which later became the ICF) was conducted by McLaughlin Gray. It is noted in the literature that occupational therapists should use specific occupational therapy vocabulary along with the ICF in order to ensure correct communication about specific concepts. The ICF might lack certain categories to describe what occupational therapists need to communicate to clients and colleagues. It also may not be possible to exactly match the connotations of the ICF categories to occupational therapy terms. The ICF is not an assessment and specialized occupational therapy terminology should not be replaced with ICF terminology. The ICF is an overarching framework for current therapy practices. Occupations According to the American Occupational Therapy Association's (AOTA) Occupational Therapy Practice Framework: Domain and Process, 4th Edition (OTPF-4), occupations are defined as "everyday activities that people do as individuals, and families, and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do". Occupations are central to a client's (person's, group's, or population's) health, identity, and sense of competence and have particular meaning and value to that client. Occupations include activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure, social participation, rest and sleep. Practice settings According to the 2019 Salary and Workforce Survey by the American Occupational Therapy Association, occupational therapists work in a wide-variety of practice settings including: hospitals (28.6%), schools (18.8%), long-term care facilities/skilled nursing facilities (14.5%), free-standing outpatient (13.3%), home health (7.3%), academia (6.9%), early intervention (4.4%), mental health (2.2%), community (2.4%), and other (1.6%). According to the AOTA, the most common primary work setting for occupational therapists is in hospitals. Also according to the survey, 46% of occupational therapists work in urban areas, 39% work in suburban areas and the remaining 15% work in rural areas. The Canadian Institute for Health Information (CIHI) found that as of 2020 nearly half (46.1%) of occupational therapists worked in hospitals, 43.2% worked in community health, 3.6% work in long-term care (LTC) and 7.1% work in "other", including government, industry, manufacturing, and commercial settings. The CIHI also found that 68% of occupational therapists in Canada work in urban settings and only 3.7% work in rural settings. Areas of practice in the United States Children and youth Occupational therapists work with infants, toddlers, children, youth, and their families in a variety of settings, including schools, clinics, homes, hospitals, and the community. Evaluation assesses the child's ability to engage in daily, meaningful occupations, the underlying skills (or performance components) which may be physical, cognitive, or emotional in nature, and the fit between the client's skills and the environments and contexts in which the client functions. OT intervention and involves evaluating a young person's occupational performance in areas of feeding, playing, socializing which aligns with their neurodiversity, daily living skills, or attending school. In planning treatment, occupational therapists work in collaboration with the children and teens themselves, parents, caregivers, and teachers in order to develop functional goals within a variety of occupations meaningful to the young client. Early intervention addresses daily functioning of a child between the ages of birth to three years old. OTs who practice in early intervention support a family's ability to care for their child with special needs and promote his or her function and participation in the most natural environment. Each child is required to have an Individualized Family Service Plan (IFSP) that focuses on the family's goals for the child. It's possible for an OT to serve as the family's service coordinator and facilitate the team process for creating an IFSP for each eligible child. Objectives that an occupational therapist addresses with children and youth may take a variety of forms. Examples are as follows: Providing rehabilitation activities to children with neuromuscular disabilities such as cerebral palsy Supporting self-regulation within neurodivergent children whose neurobiology does not align with the sensory environment or the contexts in which they function Facilitating coping skills to a child with generalized anxiety disorder. Consulting with teachers, psychologists, social workers, parents/caregivers, and other professionals who work with children regarding modifications, accommodations and supports in a variety of areas, such as sensory processing, motor planning, visual processing, and executive function skills. Providing individualized treatment for sensory processing differences. Providing splinting and caregiver education in a hospital burn unit. Instructing caregivers in regard to mealtime intervention for autistic children who have feeding challenges. Facilitating handwriting development through providing intervention to develop fine motor and writing readiness skills in school-aged children. In the United States, pediatric occupational therapists work in the school setting as a "related service" for children with an Individual Education Plan (IEP). Every student who receives special education and related services in the public school system is required by law to have an IEP, which is a very individualized plan designed for each specific student (U.S. Department of Education, 2007). Related services are "developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education," and include a variety of professions such as speech–language pathology and audiology services, interpreting services, psychological services, and physical and occupational therapy. As a related service, occupational therapists work with children with varying disabilities to address those skills needed to access the special education program and support academic achievement and social participation throughout the school day (AOTA, n.d.-b). In doing so, occupational therapists help children fulfill their role as students and prepare them to transition to post-secondary education, career and community integration (AOTA, n.d.-b). Occupational therapists have specific knowledge to increase participation in school routines throughout the day, including: Modification of the school environment to allow physical access for children with disabilities Provide assistive technology to support student success Helping to plan instructional activities for implementation in the classroom Support the needs of students with significant challenges such as helping to determine methods for alternate assessment of learning Helping students develop the skills necessary to transition to post-high school employment, independent living or further education (AOTA). Other settings, such as homes, hospitals, and the community are important environments where occupational therapists work with children and teens to promote their independence in meaningful, daily activities. Outpatient clinics offer a growing OT intervention referred to as "Sensory Integration Treatment". This therapy, provided by experienced and knowledgeable pediatric occupational therapists, was originally developed by A. Jean Ayres, an occupational therapist. Sensory integration therapy is an evidence-based practice which enables children to better process and integrate sensory input from the child's body and from the environment, thus improving his or her emotional regulation, ability to learn, behavior, and functional participation in meaningful daily activities. Recognition of occupational therapy programs and services for children and youth is increasing worldwide. Occupational therapy for both children and adults is now recognized by the United Nations as a human right which is linked to the social determinants of health. , there are over 500,000 occupational therapists working worldwide (many of whom work with children) and 778 academic institutions providing occupational therapy instruction. Health and wellness According to the American Occupational Therapy Association's (AOTA) Occupational Therapy Practice Framework, 3rd Edition, the domain of occupational therapy is described as "Achieving health, well-being, and participation in life through engagement in occupation". Occupational therapy practitioners have a distinct value in their ability to utilize daily occupations to achieve optimal health and well-being. By examining an individual's roles, routines, environment, and occupations, occupational therapists can identify the barriers in achieving overall health, well-being and participation. Occupational therapy practitioners can intervene at primary, secondary and tertiary levels of intervention to promote health and wellness. It can be addressed in all practice settings to prevent disease and injuries, and adapt healthy lifestyle practices for those with chronic diseases. Two of the occupational therapy programs that have emerged targeting health and wellness are the Lifestyle Redesign Program and the REAL Diabetes Program. Occupational therapy interventions for health and wellness vary in each setting: School Occupational therapy practitioners target school-wide advocacy for health and wellness including: bullying prevention, backpack awareness, recess promotion, school lunches, and PE inclusion. They also heavily work with students with learning disabilities such as those on the autism spectrum. A study conducted in Switzerland showed that a large majority of occupational therapists collaborate with schools, half of them providing direct services within mainstream school settings. The results also show that services were mainly provided to children with medical diagnoses, focusing on the school environment rather than the child's disability. Outpatient Occupational therapy practitioners conduct 1:1 treatment sessions and group interventions to address: leisure, health literacy and education, modified physical activity, stress/anger management, healthy meal preparation, and medication management. Acute care Occupational therapy practitioners in acute care assess whether a patient has the cognitive, emotional and physical ability as well as the social supports needed to live independently and care for themselves after discharge from the hospital. Occupational therapists are uniquely positioned to support patients in acute care as they focus on both clinical and social determinants of health. Services delivered by occupational therapists in acute care include: Direct rehabilitation interventions, individually or in group settings to address physical, emotional and cognitive skills that are required for the patient to perform self-care and other important activities. Caregiver training to assist patients after discharge. Recommendations for adaptive equipment for increased safety and independence with activities of daily living (e.g. aids for getting dressed, shower chairs for bathing, and medication organizers for self-administering medications). They also perform home safety assessments to suggest modifications for improved safety and function after discharge. Occupational therapists use a variety of models, including the Model of Human Occupation, Person, Environment and Occupation, and Canadian Occupational Performance Model to adopt a client centered approach used for discharge planning. Hospital spending on occupational therapy services in acute care was found to be the single most significant spending category in reducing the risk of readmission to the hospital for heart failure, pneumonia, and acute myocardial infarction. Community-based Occupational therapy practitioners develop and implement community wide programs to assist in prevention of diseases and encourage healthy lifestyles by: conducting education classes for prevention, facilitating gardening, offering ergonomic assessments, and offering pleasurable leisure and physical activity programs. Mental health Mental Health Occupational therapy's foundation in mental health is deeply rooted in the moral treatment movement, which sought to replace the harsh treatment of mental disorders with the establishment of healthy routines and engagement in meaningful activities. This movement significantly influenced the development of occupational therapy, particularly through the contributions of early 20th-century practitioners and theorists like Adolph Meyer, who emphasized a holistic approach to mental health care (Christiansen & Haertl, 2014). According to the American Occupational Therapy Association (AOTA), occupational therapy is based on the principle that "active engagement in occupation promotes, facilitates, supports, and maintains health and participation" (AOTA, 2017). Occupations refer to individuals' activities to structure their time and provide meaning. The primary goals of occupational therapy include promoting physical and mental health and well-being and establishing, restoring, maintaining, and improving function and quality of life for individuals at risk of or affected by physical or mental health disorders (AOTA, 2017). Education and Professional Qualifications Occupational therapists require a master's degree or clinical doctorate, while occupational therapy assistants need at least an associate's degree. Their education encompasses extensive mental health-related topics, including biological, physical, social, and behavioral sciences, and supervised clinical experiences culminating in full-time internships. Both must pass national examinations and meet state licensure requirements. Occupational therapists apply mental and physical health knowledge, focusing on participation and occupation, using performance-based assessments to understand the relationship between occupational participation and well-being. Their education covers various aspects of mental health, including neurophysiological changes, human development, historical and contemporary perspectives on mental health, and current diagnostic criteria. This comprehensive training prepares occupational therapy practitioners to address the complex interplay of client variables, activity demands, and environmental factors in promoting health and managing health challenges (Bazyk & Downing, 2017). Occupational therapy role in mental health practice Occupational therapy practitioners play a critical role in mental health by using therapeutic activities to promote mental health and support full participation in life for individuals at risk of or experiencing psychiatric, behavioral, and substance use disorders. They work across the lifespan and in various settings, including homes, schools, workplaces, community environments, hospitals, outpatient clinics, and residential facilities (AOTA,2017). Occupational therapists and occupational therapy assistants assume diverse roles, such as case managers, care coordinators, group facilitators, community mental health providers, consultants, program developers, and advocates. Their interventions aim to facilitate engagement in meaningful occupations, enhance role performance, and improve overall well-being. This involves analyzing, adapting, and modifying tasks and environments to support clients' goals and optimal engagement in daily activities (AOTA, 2017). Occupational therapy practitioners utilize clinical reasoning, informed by various theoretical perspectives and evidence-based approaches, to guide evaluation and intervention. They are skilled in analyzing the complex interplay among client variables, activity demands, and the environments where participation occurs. For individuals experiencing any mental health issues, his or her ability to participate in occupations actively may be hindered. For example, an individual diagnosed with depression or anxiety may experience interruptions in sleep, difficulty completing self-care tasks, decreased motivation to participate in leisure activities, decreased concentration for school or job-related work, and avoidance of social interactions. Occupational therapy utilizes the public health approach to mental health (WHO, 2001) which emphasizes the promotion of mental health as well as the prevention of, and intervention for, mental illness. This model highlights the distinct value of occupational therapists in mental health promotion, prevention, and intensive interventions across the lifespan (Miles et al., 2010). Below are the three major levels of service: Tier 3: intensive interventions Intensive interventions are provided for individuals with identified mental, emotional, or behavioral disorders that limit daily functioning, interpersonal relationships, feelings of emotional well-being, and the ability to cope with challenges in daily life. Occupational therapy practitioners are committed to the recovery model which focuses on enabling persons with mental health challenges through a client-centered process to live a meaningful life in the community and reach their potential (Champagne & Gray, 2011). The focus of intensive interventions (direct–individual or group, consultation) is engagement in occupation to foster recovery or "reclaiming mental health" resulting in optimal levels of community participation, daily functioning, and quality of life; functional assessment and intervention (skills training, accommodations, compensatory strategies) (Brown, 2012); identification and implementation of healthy habits, rituals, and routines to support wellness. Tier 2: targeted services Targeted services are designed to prevent mental health problems in persons who are at risk of developing mental health challenges, such as those who have emotional experiences (e.g., trauma, abuse), situational stressors (e.g., physical disability, bullying, social isolation, obesity) or genetic factors (e.g., family history of mental illness). Occupational therapy practitioners are committed to early identification of and intervention for mental health challenges in all settings. The focus of targeted services (small groups, consultation, accommodations, education) is engagement in occupations to promote mental health and diminish early symptoms; small, therapeutic groups (Olson, 2011); environmental modifications to enhance participation (e.g., create Sensory friendly classrooms, home, or work environments) Tier 1: universal services Universal services are provided to all individuals with or without mental health or behavioral problems, including those with disabilities and illnesses (Barry & Jenkins, 2007). Occupational therapy services focus on mental health promotion and prevention for all: encouraging participation in health-promoting occupations (e.g., enjoyable activities, healthy eating, exercise, adequate sleep); fostering self-regulation and coping strategies (e.g., mindfulness, yoga); promoting mental health literacy (e.g., knowing how to take care of one's mental health and what to do when experiencing symptoms associated with ill mental health). Occupational therapy practitioners develop universal programs and embed strategies to promote mental health and well-being in a variety of settings, from schools to the workplace. The focus of universal services (individual, group, school-wide, employee/organizational level) is universal programs to help all individuals successfully participate in occupations that promote positive mental health (Bazyk, 2011); educational and coaching strategies with a wide range of relevant stakeholders focusing on mental health promotion and prevention; the development of coping strategies and resilience; environmental modifications and supports to foster participation in health-promoting occupations. Productive aging Occupational therapists work with older adults to maintain independence, participate in meaningful activities, and live fulfilling lives. Some examples of areas that occupational therapists address with older adults are driving, aging in place, low vision, and dementia or Alzheimer's disease (AD). When addressing driving, driver evaluations are administered to determine if drivers are safe behind the wheel. To enable independence of older adults at home, occupational therapists perform falls risk assessments, assess clients functioning in their homes, and recommend specific home modifications. When addressing low vision, occupational therapists modify tasks and the environment. While working with individuals with AD, occupational therapists focus on maintaining quality of life, ensuring safety, and promoting independence. Geriatrics/productive aging Occupational therapists address all aspects of aging from health promotion to treatment of various disease processes. The goal of occupational therapy for older adults is to ensure that older adults can maintain independence and reduce health care costs associated with hospitalization and institutionalization. In the community, occupational therapists can assess an older adults ability to drive and if they are safe to do so. If it is found that an individual is not safe to drive the occupational therapist can assist with finding alternate transit options. Occupational therapists also work with older adults in their home as part of home care. In the home, an occupational therapist can work on such things as fall prevention, maximizing independence with activities of daily living, ensuring safety and being able to stay in the home for as long as the person wants. An occupational therapist can also recommend home modifications to ensure safety in the home. Many older adults have chronic conditions such as diabetes, arthritis, and cardiopulmonary conditions. Occupational therapists can help manage these conditions by offering education on energy conservation strategies or coping strategies. Not only do occupational therapists work with older adults in their homes, they also work with older adults in hospitals, nursing homes and post-acute rehabilitation. In nursing homes, the role of the occupational therapist is to work with clients and caregivers on education for safe care, modifying the environment, positioning needs and enhancing IADL skills to name a few. In post-acute rehabilitation, occupational therapists work with clients to get them back home and to their prior level of function after a hospitalization for an illness or accident. Occupational therapists also play a unique role for those with dementia. The therapist may assist with modifying the environment to ensure safety as the disease progresses along with caregiver education to prevent burnout. Occupational therapists also play a role in palliative and hospice care. The goal at this stage of life is to ensure that the roles and occupations that the individual finds meaningful continue to be meaningful. If the person is no longer able to perform these activities, the occupational therapist can offer new ways to complete these tasks while taking into consideration the environment along with psychosocial and physical needs. Not only do occupational therapists work with older adults in traditional settings, they also work in senior centre's and ALFs. Visual impairment Visual impairment is one of the top 10 disabilities among American adults. Occupational therapists work with other professions, such as optometrists, ophthalmologists, and certified low vision therapists, to maximize the independence of persons with a visual impairment by using their remaining vision as efficiently as possible. AOTA's promotional goal of "Living Life to Its Fullest" speaks to who people are and learning about what they want to do, particularly when promoting the participation in meaningful activities, regardless of a visual impairment. Populations that may benefit from occupational therapy includes older adults, persons with traumatic brain injury, adults with potential to return to driving, and children with visual impairments. Visual impairments addressed by occupational therapists may be characterized into two types including low vision or a neurological visual impairment. An example of a neurological impairment is a cortical visual impairment (CVI) which is defined as "...abnormal or inefficient vision resulting from a problem or disorder affecting the parts of brain that provide sight". The following section will discuss the role of occupational therapy when working with the visually impaired. Occupational therapy for older adults with low vision includes task analysis, environmental evaluation, and modification of tasks or the environment as needed. Many occupational therapy practitioners work closely with optometrists and ophthalmologists to address visual deficits in acuity, visual field, and eye movement in people with traumatic brain injury, including providing education on compensatory strategies to complete daily tasks safely and efficiently. Adults with a stable visual impairment may benefit from occupational therapy for the provision of a driving assessment and an evaluation of the potential to return to driving. Lastly, occupational therapy practitioners enable children with visual impairments to complete self care tasks and participate in classroom activities using compensatory strategies. Adult rehabilitation Occupational therapists address the need for rehabilitation following an injury or impairment. When planning treatment, occupational therapists address the physical, cognitive, psychosocial, and environmental needs involved in adult populations across a variety of settings. Occupational therapy in adult rehabilitation may take a variety of forms: Working with adults with autism at day rehabilitation programs to promote successful relationships and community participation through instruction on social skills Increasing the quality of life for an individual with cancer by engaging them in occupations that are meaningful, providing anxiety and stress reduction methods, and suggesting fatigue management strategies Coaching individuals with hand amputations how to put on and take off a myoelectrically controlled limb as well as training for functional use of the limb Pressure sore prevention for those with sensation loss such as in spinal cord injuries. Using and implementing new technology such as speech to text software and Nintendo Wii video games Communicating via telehealth methods as a service delivery model for clients who live in rural areas Working with adults who have had a stroke to regain their activities of daily living Assistive technology Occupational therapy practitioners, or occupational therapists (OTs), are uniquely poised to educate, recommend, and promote the use of assistive technology to improve the quality of life for their clients. OTs are able to understand the unique needs of the individual in regards to occupational performance and have a strong background in activity analysis to focus on helping clients achieve goals. Thus, the use of varied and diverse assistive technology is strongly supported within occupational therapy practice models. Travel occupational therapy Because of the rising need for occupational therapy practitioners in the U.S., many facilities are opting for travel occupational therapy practitioners—who are willing to travel, often out of state, to work temporarily in a facility. Assignments can range from 8 weeks to 9 months, but typically last 13–26 weeks in length. Travel therapists work in many different settings, but the highest need for therapists are in home health and skilled nursing facility settings. There are no further educational requirements needed to be a travel occupational therapy practitioner; however, there may be different state licensure guidelines and practice acts that must be followed. According to Zip Recruiter, , the national average salary for a full-time travel therapist is $86,475 with a range between $62,500 to $100,000 across the United States. Most commonly (43%), travel occupational therapists enter the industry between the ages of 21–30. Occupational justice The practice area of occupational justice relates to the "benefits, privileges and harms associated with participation in occupations" and the effects related to access or denial of opportunities to participate in occupations. This theory brings attention to the relationship between occupations, health, well-being, and quality of life. Occupational justice can be approached individually and collectively. The individual path includes disease, disability, and functional restrictions. The collective way consists of public health, gender and sexual identity, social inclusion, migration, and environment. The skills of occupational therapy practitioners enable them to serve as advocates for systemic change, impacting institutions, policy, individuals, communities, and entire populations. Examples of populations that experience occupational injustice include refugees, prisoners, homeless persons, survivors of natural disasters, individuals at the end of their life, people with disabilities, elderly living in residential homes, individuals experiencing poverty, children, immigrants, and LGBTQI+ individuals. For example, the role of an occupational therapist working to promote occupational justice may include: Analyzing task, modifying activities and environments to minimize barriers to participation in meaningful activities of daily living. Addressing physical and mental aspects that may hinder a person's functional ability. Provide intervention that is relevant to the client, family, and social context. Contribute to global health by advocating for individuals with disabilities to participate in meaningful activities on a global level. Occupation therapists are involved with the World Health Organization (WHO), non-governmental organizations and community groups and policymaking to influence the health and well-being of individuals with disabilities worldwide Occupational therapy practitioners' role in occupational justice is not only to align with perceptions of procedural and social justice but to advocate for the inherent need of meaningful occupation and how it promotes a just society, well-being, and quality of life among people relevant to their context. It is recommended to the clinicians to consider occupational justice in their everyday practice to promote the intention of helping people participate in tasks that they want and need to do. Occupational injustice In contrast, occupational injustice relates to conditions wherein people are deprived, excluded or denied of opportunities that are meaningful to them. Types of occupational injustices and examples within the OT practice include: Occupational deprivation: The exclusion from meaningful occupations due to external factors that are beyond the person's control. For example, a person with difficulties with functional mobility may find it challenging to reintegrate into the community due to transportation barriers. OTs can help in raising awareness and bringing communities together to reduce occupational deprivation OTs can recommend the removal of environmental barriers to facilitate occupation, whilst designing programs that enable engagement. Advocacy by providing information to policy to prevent possible unintended occupational deprivation and increase social cohesion and inclusion Occupational apartheid: The exclusion of a person in chosen occupations due to personal characteristics such as age, gender, race, nationality, or socioeconomic status. An example can be seen in children with developmental disabilities from low socioeconomic backgrounds whose families would opt out of therapy due to financial constraints. OTs providing interventions within a segregated population must focus on increasing occupational engagement through large-scale environmental modification and occupational exploration. OTs can address occupational engagement through group and individual skill-building opportunities, as well as community-based experiences that explore free and local resources Occupational marginalization: Relates to how implicit norms of behavior or societal expectations prevent a person from engaging in a chosen occupation. As an example, a child with physical impairments may only be offered table-top leisure activities instead of sports as an extracurricular activity due to the functional limitations caused by his physical impairments. OTs can design, develop, and/or provide programs that mitigate the negative impacts of occupational marginalization and enhance optimal levels of performance and wellbeing that enable participation Occupational imbalance: The limited participation in a meaningful occupation brought about by another role in a different occupation. This can be seen in the situation of a caregiver of a person with a disability who also has to fulfill other roles such as being a parent to other children, a student, or a worker. OTs can advocate fostering for supportive environments for participation in occupations that promote individuals' well-being and in advocating for building healthy public policy Occupational alienation: The imposition of an occupation that does not hold meaning for that person. In the OT profession, this manifests in the provision of rote activities that do not really relate to the goals or the client's interests. OTs can develop individualized activities tailored to the interests of the individual to maximize their potential. OTs can design, develop and promote programs that can be inclusive and provide a variety of choices that the individual can engage in. Within occupational therapy practice, injustice may ensue in situations wherein professional dominance, standardized treatments, laws and political conditions create a negative impact on the occupational engagement of our clients. Awareness of these injustices will enable the therapist to reflect on his own practice and think of ways in approaching their client's problems while promoting occupational justice. Community-based therapy As occupational therapy (OT) has grown and developed, community-based practice has blossomed from an emerging area of practice to a fundamental part of occupational therapy practice (Scaffa & Reitz, 2013). Community-based practice allows for OTs to work with clients and other stakeholders such as families, schools, employers, agencies, service providers, stores, day treatment and day care and others who may influence the degree of success the client will have in participating. It also allows the therapist to see what is actually happening in the context and design interventions relevant to what might support the client in participating and what is impeding her or him from participating. Community-based practice crosses all of the categories within which OTs practice from physical to cognitive, mental health to spiritual, all types of clients may be seen in community-based settings. The role of the OT also may vary, from advocate to consultant, direct care provider to program designer, adjunctive services to therapeutic leader. Nature-based therapy Nature-based interventions and outdoor activities may be incorporated into occupational therapy practice as they can provide therapeutic benefits in various ways. Examples include therapeutic gardening, animal-assisted therapy (AAT), and adventure therapy. For instance, parents reported improvement in the emotional regulation and social engagement of their children with autism spectrum disorder (ASD) in a study of parental perceptions regarding the outcomes of AAT conducted with trained dogs. They also observed reductions in problematic behaviors. A source cited in the study found similar results with AAT employing horses and llamas. Gardening in a group setting may serve as a complementary intervention in stroke rehabilitation; in addition to being mentally restful and conducive to social connection, it helps patients master skills and can remind them of experiences from their past. Royal Rehab's Productive Garden Project in Australia, managed by a horticultural therapist, allows patients and practitioners to participate in meaningful activity outside the usual healthcare settings. Thus, tending a garden helps facilitate experiential activities, perhaps attaining a better balance between clinical and real-life pursuits during rehabilitation, in lieu of mainly relying on clinical interventions. For adults with acquired brain injury, nature-based therapy has been found to improve motor abilities, cognitive function, and general quality of life. Contributing to a theoretical understanding of such successes in nature-based approaches are: nature's positive impact on problem solving and the refocusing of attention; an innate human connection with, and positive response to, the natural world; an increased sense of well-being when in contact with nature; and the emotional, nonverbal, and cognitive aspects of human-environment interaction. Education Worldwide, there is a range of qualifications required to practice as an occupational therapist or occupational therapy assistant. Depending on the country and expected level of practice, degree options include associate degree, Bachelor's degree, entry-level master's degree, post-professional master's degree, entry-level Doctorate (OTD), post-professional Doctorate (DrOT or OTD), Doctor of Clinical Science in OT (CScD), Doctor of Philosophy in Occupational Therapy (PhD), and combined OTD/PhD degrees. Both occupational therapist and occupational therapy assistant roles exist internationally. Currently in the United States, dual points of entry exist for both OT and OTA programs. For OT, that is entry-level Master's or entry-level Doctorate. For OTA, that is associate degree or bachelor's degree. The World Federation of Occupational Therapists (WFOT) has minimum standards for the education of OTs, which was revised in 2016. All of the educational programs around the world need to meet these minimum standards. These standards are subsumed by and can be supplemented with academic standards set by a country's national accreditation organization. As part of the minimum standards, all programs must have a curriculum that includes practice placements (fieldwork). Examples of fieldwork settings include: acute care, inpatient hospital, outpatient hospital, skilled nursing facilities, schools, group homes, early intervention, home health, and community settings. The profession of occupational therapy is based on a wide theoretical and evidence based background. The OT curriculum focuses on the theoretical basis of occupation through multiple facets of science, including occupational science, anatomy, physiology, biomechanics, and neurology. In addition, this scientific foundation is integrated with knowledge from psychology, sociology and more. In the United States, Canada, and other countries around the world, there is a licensure requirement. In order to obtain an OT or OTA license, one must graduate from an accredited program, complete fieldwork requirements, and pass a national certification examination. Philosophical underpinnings The philosophy of occupational therapy has evolved over the history of the profession. The philosophy articulated by the founders owed much to the ideals of romanticism, pragmatism and humanism, which are collectively considered the fundamental ideologies of the past century. One of the most widely cited early papers about the philosophy of occupational therapy was presented by Adolf Meyer, a psychiatrist who had emigrated to the United States from Switzerland in the late 19th century and who was invited to present his views to a gathering of the new Occupational Therapy Society in 1922. At the time, Dr. Meyer was one of the leading psychiatrists in the United States and head of the new psychiatry department and Phipps Clinic at Johns Hopkins University in Baltimore, Maryland. William Rush Dunton, a supporter of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation is a basic human need, and that occupation is therapeutic. From his statements came some of the basic assumptions of occupational therapy, which include: Occupation has a positive effect on health and well-being. Occupation creates structure and organizes time. Occupation brings meaning to life, culturally and personally. Occupations are individual. People value different occupations. These assumptions have been developed over time and are the basis of the values that underpin the Codes of Ethics issued by the national associations. The relevance of occupation to health and well-being remains the central theme. In the 1950s, criticism from medicine and the multitude of disabled World War II veterans resulted in the emergence of a more reductionistic philosophy. While this approach led to developments in technical knowledge about occupational performance, clinicians became increasingly disillusioned and re-considered these beliefs. As a result, client centeredness and occupation have re-emerged as dominant themes in the profession. Over the past century, the underlying philosophy of occupational therapy has evolved from being a diversion from illness, to treatment, to enablement through meaningful occupation. Three commonly mentioned philosophical precepts of occupational therapy are that occupation is necessary for health, that its theories are based on holism and that its central components are people, their occupations (activities), and the environments in which those activities take place. However, there have been some dissenting voices. Mocellin, in particular, advocated abandoning the notion of health through occupation as he proclaimed it obsolete in the modern world. As well, he questioned the appropriateness of advocating holism when practice rarely supports it. Some values formulated by the American Occupational Therapy Association have been critiqued as being therapist-centric and do not reflect the modern reality of multicultural practice. In recent times occupational therapy practitioners have challenged themselves to think more broadly about the potential scope of the profession, and expanded it to include working with groups experiencing occupational injustice stemming from sources other than disability. Examples of new and emerging practice areas would include therapists working with refugees, children experiencing obesity, and people experiencing homelessness. Theoretical frameworks A distinguishing facet of occupational therapy is that therapists often espouse the use theoretical frameworks to frame their practice. Many have argued that the use of theory complicates everyday clinical care and is not necessary to provide patient-driven care. Note that terminology differs between scholars. An incomplete list of theoretical bases for framing a human and their occupations include the following: Generic models Generic models are the overarching title given to a collation of compatible knowledge, research and theories that form conceptual practice. More generally they are defined as "those aspects which influence our perceptions, decisions and practice". The Person Environment Occupation Performance model (PEOP) was originally published in 1991 (Charles Christiansen & M. Carolyn Baum) and describes an individual's performance based on four elements including: environment, person, performance and occupation. The model focuses on the interplay of these components and how this interaction works to inhibit or promote successful engagement in occupation. Occupation-focused practice models Occupational Therapy Intervention Process Model (OTIPM) (Anne Fisher and others) Occupational Performance Process Model (OPPM) Model of Human Occupation (MOHO) (Gary Kielhofner and others) MOHO was first published in 1980. It explains how people select, organise and undertake occupations within their environment. The model is supported with evidence generated over thirty years and has been successfully applied throughout the world. Canadian Model of Occupational Performance and Engagement (CMOP-E) This framework was originated in 1997 by the Canadian Association of Occupational Therapists (CAOT) as the Canadian Model of Occupational Performance (CMOP). It was expanded in 2007 by Palatjko, Townsend and Craik to add engagement. This framework upholds the view that three components—the person, environment and occupation- are related. Engagement was added to encompass occupational performance. A visual model is depicted with the person located at the center of the model as a triangle. The triangles three points represent cognitive, affective, and physical components with a spiritual center. The person triangle is surrounded by an outer ring symbolizing the context of environment with an inner ring symbolizing the context of occupation. Occupational Performances Model – Australia (OPM-A) (Chris Chapparo & Judy Ranka) The OPM(A) was conceptualized in 1986 with its current form launched in 2006. The OPM(A) illustrates the complexity of occupational performance, the scope of occupational therapy practice, and provides a framework for occupational therapy education. Kawa (River) Model (Michael Iwama) Biopsychosocial models Engel's biopsychosocial model takes into account how disease and illness can be impacted by social, environmental, psychological and body functions. The biopsychosocial model is unique in that it takes the client's subjective experience and the client-provider relationship as factors to wellness. This model also factors in cultural diversity as many countries have different societal norms and beliefs. This is a multifactorial and multi-dimensional model to understand not only the cause of disease but also a person-centered approach that the provider has more of a participatory and reflective role. Other models which incorporate biology (body and brain), psychology (mind), and social (relational, attachment) elements influencing human health include interpersonal neurobiology (IPNB), polyvagal theory (PVT), and the dynamic-maturational model of attachment and adaptation (DMM). The latter two in particular provide detail about the source, mechanism and function of somatic symptoms. Kasia Kozlowska describes how she uses these models to better connect with clients, to understand complex human illness, and how she includes occupational therapists as part of a team to address functional somatic symptoms. Her research indicates children with functional neurological disorders (FND) utilize higher, or more challenging, DMM self-protective attachment strategies to cope with their family environments, and how those impact functional somatic symptoms. Pamela Meredith and colleagues have been exploring the relationship between the attachment system and psychological and neurobiological systems with implications for how occupational therapists can improve their approach and techniques. They have found correlations between attachment and adult sensory processing, distress, and pain perception. In a literature review, Meredith identified a number of ways that occupational therapists can effectively apply an attachment perspective, sometimes uniquely. Frames of reference Frames of reference are an additional knowledge base for the occupational therapist to develop their treatment or assessment of a patient or client group. Though there are conceptual models (listed above) that allow the therapist to conceptualise the occupational roles of the patient, it is often important to use further reference to embed clinical reasoning. Therefore, many occupational therapists will use additional frames of reference to both assess and then develop therapy goals for their patients or service users. Biomechanical frame of reference The biomechanical frame of reference is primarily concerned with motion during occupation. It is used with individuals who experience limitations in movement, inadequate muscle strength or loss of endurance in occupations. The frame of reference was not originally compiled by occupational therapists, and therapists should translate it to the occupational therapy perspective, to avoid the risk of movement or exercise becoming the main focus. Rehabilitative (compensatory) Neurofunctional (Gordon Muir Giles and Clark-Wilson) Dynamic systems theory Client-centered frame of reference This frame of reference is developed from the work of Carl Rogers. It views the client as the center of all therapeutic activity, and the client's needs and goals direct the delivery of the occupational therapy process. Cognitive-behavioural frame of reference Ecology of human performance model The recovery model Sensory integration Sensory integration framework is commonly implemented in clinical, community, and school-based occupational therapy practice. It is most frequently used with children with developmental delays and developmental disabilities such as autism spectrum disorder, Sensory processing disorder and dyspraxia. Core features of sensory integration in treatment include providing opportunities for the client to experience and integrate feedback using multiple sensory systems, providing therapeutic challenges to the client's skills, integrating the client's interests into therapy, organizing of the environment to support the client's engagement, facilitating a physically safe and emotionally supportive environment, modifying activities to support the client's strengths and weaknesses, and creating sensory opportunities within the context of play to develop intrinsic motivation. While sensory integration is traditionally implemented in pediatric practice, there is emerging evidence for the benefits of sensory integration strategies for adults. Global occupational therapy The World Federation of Occupational Therapists is an international voice of the profession and is a membership network of occupational therapists worldwide. WFOT supports the international practice of occupational therapy through collaboration across countries. WFOT currently includes over 100 member country organizations, 550,000 occupational therapy practitioners, and 900 approved educational programs. The profession celebrates World Occupational Therapy Day on the 27th of October annually to increase visibility and awareness of the profession, promoting the profession's development work at a local, national and international platform. WFOT has been in close collaboration with the World Health Organization (WHO) since 1959, working together in programmes that aim to improve world health. WFOT supports the vision for healthy people, in alignment with the United Nations 17 Sustainable Development Goals, which focuses on "ending poverty, fighting inequality and injustice, tackling climate change and promoting health". Occupational therapy is a major player in enabling individuals and communities to engage in "chosen and necessary occupations" and in "the creation of more meaningful lives". Occupational therapy is practiced around the world and can be translated in practice to many different cultures and environments. The construct of occupation is shared throughout the profession regardless of country, culture and context. Occupation and the active participation in occupation is now seen as a human right and is asserted as a strong influence in health and well-being. As the profession grows there is a lot of people who are travelling across countries to work as occupational therapists for better work or opportunities. Under this context, every occupational therapist is required to adapt to a new culture, foreign to their own. Understanding cultures and its communities are crucial to occupational therapy ethos. Effective occupational therapy practice includes acknowledging the values and social perspectives of each client and their families. Harnessing culture and understanding what is important to the client is truly a faster way towards independence. See also Busy work Occupational apartheid Occupational therapy and substance use disorder Occupational therapy in the management of cerebral palsy Occupational therapy in the United Kingdom References American Occupational Therapy Association (2014c). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association (2017). Mental Health Promotion, Prevention, and Intervention in Occupational Therapy Practice. The American Journal of Occupational Therapy. 71(Suppl. 2). https://doi.org/10.5014/ajot.2017.716S03 Christiansen, C. H., & Haertl, K. (2014). A contextual history of occupational therapy. In B. A. B. Schell, G. Gillen, & M. E. Scaffa (Eds.), Willard and Spackman's occupational therapy (12th ed., pp. 9–34).Philadelphia: Lippincott Williams & Wilkins. External links World Federation of Occupational Therapists

Sanism

Sanism, saneism, mentalism, or psychophobia refers to the discrimination and oppression of people based on actual or perceived mental disorder or cognitive impairment. This discrimination and oppression are based on numerous factors such as stereotypes about neurodiversity. Mentalism impacts individuals with autism, learning disorders, attention deficit hyperactivity disorder (ADHD), fetal alcohol spectrum disorder (FASD), bipolar disorder, schizophrenia, personality disorders, stuttering, tics, intellectual disability, and other cognitive impairments. Mentalism may cause harm through a combination of social inequalities, insults, indignities, and overt discrimination. Some examples of these include refusal of service and the denial of human rights. Mentalism does not only describe how individuals are treated by the general public. The concept also encapsulates how individuals are treated by mental health professionals, the legal system and other institutions. The term "sanism" was coined by Morton Birnbaum, a physician, lawyer, and mental health advocate. Judi Chamberlin coined the term "mentalism" in a chapter of the book Women Look at Psychiatry. Definition The terms mentalism, from "mental", and sanism, from "sane", have become established in some contexts, although concepts such as social stigma, and in some cases ableism, may be used in similar but not identical ways. While mentalism and sanism are used interchangeably, sanism is becoming predominant in certain circles, such as academics. Those who identify as mad, mad advocates, and in a socio-political context where sanism is gaining ground as a movement. The movement of sanism is an act of resistance among those who identify as mad, consumer survivors, and mental health advocates. In academia evidence of this movement can be found in the number of recent publications about sanism and social work practice. Etymologies The term "sanism" was coined by Morton Birnbaum during his work representing Edward Stephens, a mental health patient, in a legal case in the 1960s. Birnbaum was a physician, lawyer and mental health advocate who helped establish a constitutional right to treatment for psychiatric patients along with safeguards against involuntary commitment. Since first noticing the term in 1980, New York legal professor Michael L. Perlin subsequently continued its use. In 1975 Judi Chamberlin coined the term mentalism in a book chapter of Women Look at Psychiatry. The term became more widely known when she used it in 1978 in her book On Our Own: Patient Controlled Alternatives to the Mental Health System, which for some time became the standard text of the psychiatric survivor movement in the US. People began to recognize a pattern in how they were treated, a set of assumptions which most people seemed to hold about mental (ex-)patients regardless of whether they applied to any particular individual at any particular time – that they were incompetent, unable to do things for themselves, constantly in need of supervision and assistance, unpredictable, likely to be violent or irrational etc. It was realized that not only did the general public express mentalist ideas, so did ex-patients, a form of internalized oppression. As of 1998 these terms have been adopted by some consumers/survivors in the UK and the US, but had not gained general currency. This left a conceptual gap filled in part by the concept of 'stigma', but this has been criticized for focusing less on institutionalized discrimination with multiple causes, but on whether people perceive mental health issues as shameful or worse than they are. Despite its use, a body of literature demonstrated widespread discrimination across many spheres of life, including employment, parental rights, housing, immigration, insurance, health care and access to justice. However, the use of new "isms" has also been questioned on the grounds that they can be perceived as divisive, out of date, or a form of undue political correctness. The same criticisms, in this view, may not apply so much to broader and more accepted terms like 'discrimination' or 'social exclusion'. There is also the umbrella term ableism, referring to discrimination against those who are (perceived as) disabled. In terms of the brain, there is the movement for the recognition of neurodiversity. The term 'psychophobia' (from psyche and phobia) has occasionally been used with a similar meaning. Social division Mentalism at one extreme can lead to a categorical dividing of people into an empowered group assumed to be normal, healthy, reliable, and capable, and a powerless group assumed to be sick, disabled, crazy, unpredictable, and violent. This divide can justify inconsiderate treatment of the latter group and expectations of poorer standards of living for them, for which they may be expected to express gratitude. Further discrimination may involve labeling some as "high functioning" and some as "low-functioning"; while this may enable the targeting of resources, in both categories human behaviors are recast in pathological terms.According to Coni Kalinowski (a psychiatrist at the University of Nevada and Director of Mojave Community Services) and Pat Risser (a mental health consultant and self-described former recipient of mental health services). The discrimination can be so fundamental and unquestioned that it can stop people truly empathizing (although they may think they are) or genuinely seeing the other point of view with respect. Some mental conditions can impair awareness and understanding in certain ways at certain times, but mentalist assumptions may lead others to erroneously believe that they necessarily understand the person's situation and needs better than they do themselves. Reportedly even within the disability rights movement internationally, "there is a lot of sanism", and "disability organisations don't always 'get' mental health and don't want to be seen as mentally defective." Conversely, those coming from the mental health side may not view such conditions as disabilities in the same way. Some national government-funded charities view the issue as primarily a matter of stigmatizing attitudes within the general public, perhaps due to people not having enough contact with those (diagnosed with) mental illness, and one head of a schizophrenia charity has compared mentalism to the way racism may be more prevalent when people don't spend time together throughout life. A psychologist who runs The Living Museum facilitating current or former psychiatric patients to exhibit artwork, has referred to the attitude of the general public as psychophobia. Clinical terminology Mentalism may be codified in clinical terminology in subtle ways, including in the basic diagnostic categories used by psychiatry (as in the DSM or ICD). There is some ongoing debate as to which terms and criteria may communicate contempt or inferiority, rather than facilitate real understanding of people and their issues. Some oppose the entire process as labeling and some have responded to justifications for it – for example that it is necessary for clinical or administrative purposes. Others argue that most aspects could easily be expressed in a more accurate and less offensive manner. Some clinical terms may be used far beyond the usual narrowly defined meanings, in a way that can obscure the regular human and social context of people's experiences. For example, having a bad time may be assumed to be decompensation; incarceration or solitary confinement may be described as treatment regardless of benefit to the person; regular activities like listening to music, engaging in exercise or sporting activities, or being in a particular physical or social environment (milieu), may be referred to as therapy; all sorts of responses and behaviors may be assumed to be symptoms; core adverse effects of drugs may be termed side effects. The former director of a US-based psychiatric survivors organization focused on rights and freedoms, David Oaks, has advocated the taking back of words like "mad", "lunatic", "crazy" or "bonkers". While acknowledging that some choose not to use such words in any sense, he questions whether medical terms like "mentally ill", "psychotic" or "clinically depressed" really are more helpful or indicative of seriousness than possible alternatives. Oaks says that for decades he has been exploring the depths of sanism and has not yet found an end, and suggests it may be the most pernicious 'ism' because people tend to define themselves by their rationality and their core feelings. One possible response is to critique conceptions of normality and the problems associated with normative functioning around the world, although in some ways that could also potentially constitute a form of mentalism. After his 2012 accident breaking his neck and subsequent retirement, Oaks refers to himself as "PsychoQuad" on his personal blog. British writer Clare Allen argues that even reclaimed slang terms such as "mad" are just not accurate. In addition, she sees the commonplace mis-use of concepts relating to mental health problems – including for example jokes about people hearing voices as if that automatically undermines their credibility – as equivalent to racist or sexist phrases that would be considered obviously discriminatory. She characterises such usage as indicating an underlying psychophobia and contempt. Blame Interpretations of behaviors, and applications of treatments, may be done in an judgmental way because of an underlying mentalism, according to critics of psychiatry. If a recipient of mental health services disagrees with treatment or diagnosis, or does not change, they may be labeled as non-compliant, uncooperative, or treatment-resistant. This is despite the fact that the issue may be healthcare provider's inadequate understanding of the person or their problems, adverse medication effects, a poor match between the treatment and the person, stigma associated with the treatment, difficulty with access, cultural unacceptability, or many other issues. Mentalism may lead people to assume that someone is not aware of what they are doing and that there is no point trying to communicate with them, despite the fact that they may well have a level of awareness and desire to connect even if they are acting in a seemingly irrational or self-harming way. In addition, mental health professionals and others may tend to equate subduing a person with treatment; a quiet client who causes no community disturbance may be deemed improved no matter how miserable or incapacitated that person may feel as a result. Clinicians may blame clients for not being sufficiently motivated to work on treatment goals or recovery, and as acting out when things are not agreed with or are found upsetting. But critics say that in the majority of cases this is actually due to the client having been treated in a disrespectful, judgmental, or dismissive manner. Nevertheless, such behavior may be justified by characterizing the client as demanding, angry or needing limits. To overcome this, it has been suggested that power-sharing should be cultivated and that when respectful communication breaks down, the first thing that needs to be asked is whether mentalist prejudices have been expressed. Neglect Mentalism has been linked to negligence in monitoring for adverse effects of medications (or other interventions), or to viewing such effects as more acceptable than they would be for others. This has been compared to instances of maltreatment based on racism. Mentalism has also been linked to neglect in failing to check for, or fully respect, people's past experiences of abuse or other trauma. Treatments that do not support choice and self-determination may cause people to re-experience the helplessness, pain, despair, and rage that accompanied the trauma, and yet attempts to cope with this may be labeled as acting out, manipulation, or attention-seeking. In addition, mentalism can lead to "poor" or "guarded" predictions of the future for a person, which could be an overly pessimistic view skewed by a narrow clinical experience. It could also be made impervious to contrary evidence because those who succeed can be discounted as having been misdiagnosed or as not having a genuine form of a disorder – the no true Scotsman fallacy. While some mental health problems can involve very substantial disability and can be very difficult to overcome in society, predictions based on prejudice and stereotypes can be self-fulfilling because individuals pick up on a message that they have no real hope, and realistic hope is said to be a key foundation of recovery. At the same time, a trait or condition might be considered more a form of individual difference that society needs to include and adapt to, in which case a mentalist attitude might be associated with assumptions and prejudices about what constitutes normal society and who is deserving of adaptations, support, or consideration. Institutional discrimination This may be apparent in physical separation, including separate facilities or accommodation, or in lower standards for some than others. Mental health professionals may find themselves drawn into systems based on bureaucratic and financial imperatives and social control, resulting in alienation from their original values, disappointment in "the system", and adoption of the cynical, mentalist beliefs that may pervade an organization. However, just as employees can be dismissed for disparaging sexual or ethnic remarks, it is argued that staff who are entrenched in negative stereotypes, attitudes, and beliefs about those labeled with mental disorders need to be removed from service organizations. A related theoretical approach, known as expressed emotion, has also focused on negative interpersonal dynamics relating to care givers, especially within families. However, the point is also made in such views that institutional and group environments can be challenging from all sides, and that clear boundaries and rights are required for everyone. The mental health professions have themselves been criticized. While social work (also known as clinical social work) has appeared to have more potential than others to understand and assist those using services, and has talked a lot academically about anti-oppressive practice intended to support people facing various -isms, it has allegedly failed to address mentalism to any significant degree. The field has been accused, by social work professionals with experience of using services themselves, of failing to help people identify and address what is oppressing them; of unduly deferring to psychiatric or biomedical conventions particularly in regard to those deemed most unwell; and of failing to address its own discriminatory practices, including its conflicts of interest in its official role aiding the social control of patients through involuntary commitment. In the "user/survivor" movement in England, Pete Shaughnessy, a founder of mad pride, concluded that the National Health Service is "institutionally mentalist and has a lot of soul searching to do in the new Millennium", including addressing the prejudice of its office staff. He suggested that when prejudice is applied by the very professionals who aspire to eradicate it, it raises the question of whether it will ever be eradicated. Shaughnessy committed suicide in 2002. The psychiatric survivors movement has been described as a feminist issue, because the problems it addresses are "important for all women because mentalism acts as a threat to all women" and "mentalism threatens women's families and children." A psychiatric survivor and professional has said that "Mentalism parallels sexism and racism in creating an oppressed underclass, in this case of people who have received psychiatric diagnosis and treatment". She reported that the most frequent complaint of psychiatric patients is that nobody listens, or only selectively in the course of trying to make a diagnosis. On a society-wide level, mentalism has been linked to people being kept in poverty as second class citizens; to employment discrimination keeping people living on handouts; to interpersonal discrimination hindering relationships; to stereotypes promoted through the media spreading fears of unpredictability and dangerousness; and to people fearing to disclose or talk about their experiences. Law With regard to legal protections against discrimination, mentalism may only be covered under general frameworks such as the disability discrimination acts that are in force in some countries, and which require a person to say that they have a disability and to prove that they meet the criteria. In terms of the legal system itself, the law is traditionally based on technical definitions of sanity and insanity, and so the term "sanism" may be used in response. The concept is well known in the US legal community, being referred to in nearly 300 law review articles between 1992 and 2013, though is less well known in the medical community. Michael Perlin, Professor of Law at New York Law School, has defined sanism as "an irrational prejudice of the same quality and character as other irrational prejudices that cause and are reflected in prevailing social attitudes of racism, sexism, homophobia, and ethnic bigotry that permeates all aspects of mental disability law and affects all participants in the mental disability law system: litigants, fact finders, counsel, and expert and lay witnesses." Perlin notes that sanism affects the theory and practice of law in largely invisible and socially acceptable ways, based mainly on "stereotype, myth, superstition, and deindividualization." He believes that its "corrosive effects have warped involuntary civil commitment law, institutional law, tort law, and all aspects of the criminal process (pretrial, trial and sentencing)." According to Perlin, judges are far from immune, tending to reflect sanist thinking that has deep roots within our culture. This results in judicial decisions based on stereotypes in all areas of civil and criminal law, expressed in biased language and showing contempt for mental health professionals. Moreover, courts are often impatient and attribute mental problems to "weak character or poor resolve". Sanist attitudes are prevalent in the teaching of law students, both overtly and covertly, according to Perlin. He notes that this impacts on the skills at the heart of lawyering such as "interviewing, investigating, counseling and negotiating", and on every critical moment of clinical experience: "the initial interview, case preparation, case conferences, planning litigation (or negotiation) strategy, trial preparation, trial and appeal." There is also widespread discrimination by jurors, who Perlin characterizes as demonstrating "irrational brutality, prejudice, hostility, and hatred" towards defendants where there is an insanity defense. Specific sanist myths include relying on popular images of craziness; an 'obsession' with claims that mental problems can be easily faked and experts duped; assuming an absolute link between mental illness and dangerousness; an 'incessant' confusion and mixing up of different legal tests of mental status; and assuming that defendants acquitted on insanity defenses are likely to be released quickly. Although there are claims that neuroimaging has some potential to help in this area, Perlin concludes that it is very difficult to weigh the truth or relevance of such results due to the many uncertainties and limitations, and as it may be either disregarded or over-hyped by scientists, lawyers or in the popular imagination. He believes "the key to an answer here is a consideration of sanism", because to a great extent it can "overwhelm all other evidence and all other issues in this conversation". He suggests that "only therapeutic jurisprudence has the potential power to 'strip the sanist facade'." Perlin has suggested that the international Convention on the Rights of Persons with Disabilities is a revolutionary human rights document which has the potential to be the best tool to challenge sanist discrimination. He has also addressed the topic of sanism as it affects which sexual freedoms or protections are afforded to psychiatric patients, especially in forensic facilities. Sanism in the legal profession can affect many people in communities who at some point in their life struggle with some degree of mental health problems, according to Perlin. This may unjustly limit their ability to legally resolve issues in their communities such as: "contract problems, property problems, domestic relations problems, and trusts and estates problems." Susan Fraser, a lawyer in Canada who specializes in advocating for vulnerable people, argues that sanism is based on fear of the unknown, reinforced by stereotypes that dehumanize individuals. She argues that this causes the legal system to fail to properly defend patients' rights to refuse potentially harmful medications; to investigate deaths in psychiatric hospitals and other institutions in an equal way to others; and to fail to properly listen to and respect the voices of mental health consumers and survivors. Education Similar issues have been identified by Perlin in how children are dealt with in regard to learning disabilities, including in special education. In any area of law, he points out, two of the most common sanist myths are presuming that persons with mental disabilities are faking, or that such persons would not be disabled if they only tried harder. In this particular area, he concludes that labeled children are stereotyped in a process rife with racial, class and gender bias. Although intended to help some children, he contends that in reality it can be not merely a double-edged sword but a triple, quadruple or quintuple edged sword. The result of sanist prejudices and misconceptions, in the context of academic competition, is that "we are left with a system that is, in many important ways, stunningly incoherent". Oppression A spiral of oppression experienced by some groups in society has been identified. Firstly, oppressions occur on the basis of perceived or actual differences (which may be related to broad group stereotypes such as racism, sexism, classism, ageism, homophobia etc.). This can have negative physical, social, economic and psychological effects on individuals, including emotional distress and what might be considered mental health problems. Then, society's response to such distress may be to treat it within a system of medical and social care rather than (also) understanding and challenging the oppressions that gave rise to it, thus reinforcing the problem with further oppressive attitudes and practices, which can lead to more distress, and so on in a vicious cycle. In addition, due to coming into contact with mental health services, people may become subject to the oppression of mentalism, since society (and mental health services themselves) have such negative attitudes towards people with a psychiatric diagnosis, thus further perpetuating oppression and discrimination. People suffering such oppression within society may be drawn to more radical political action, but sanist structures and attitudes have also been identified in activist communities. This includes cliques and social hierarchies that people with particular issues may find very difficult to break into or be valued by. There may also be individual rejection of people for strange behavior that is not considered culturally acceptable, or alternatively insensitivity to emotional states including suicidality, or denial that someone has issues if they appear to act normally. See also Disability flag Franco Basaglia List of disability-related terms with negative connotations Mental health stigma Rankism (umbrella term for all forms of hierarchical discrimination) Social Darwinism Social model of disability Supremacism Violent behavior in autistic people References Further reading Ableism Disability rights Neurodiversity Prejudice and discrimination by type

Recovery model

The recovery model, recovery approach or psychological recovery is an approach to mental disorder or substance dependence that emphasizes and supports a person's potential for recovery. Recovery is generally seen in this model as a personal journey rather than a set outcome, and one that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. Recovery sees symptoms as a continuum of the norm rather than an aberration and rejects sane-insane dichotomy. William Anthony, Director of the Boston Centre for Psychiatric Rehabilitation developed a cornerstone definition of mental health recovery in 1993. "Recovery is a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness." The concept of recovery in mental health emerged as deinstitutionalization led to more individuals living in the community. It gained momentum as a social movement in response to a perceived failure by services or wider society to adequately support social inclusion, coupled with studies demonstrating that many people do recover. A recovery-oriented approach has since been explicitly embraced as the guiding principle of mental health and substance dependency policies in numerous countries and states. Practical measures are being implemented in many cases to align services with a recovery model, although various obstacles, concerns, and criticisms have been raised by both service providers and recipients of services. Several standardized measures have been developed to assess different aspects of recovery, although there is some divergence between professionalized models and those originating in the psychiatric survivors movement. According to a study, a combined social and physical environment intervention has the potential to enhance the need for recovery. However, the study's focus on a general healthy and well-functioning population posed challenges in achieving significant impact. The researchers suggested implementing the intervention among a population with higher baseline values on the need for recovery and providing opportunities for physical activity, such as organizing lunchtime walking or yoga classes at work. Additionally, they recommended strategically integrating a social media platform with incentives for regular use, linking it to other platforms like Facebook, and considering more drastic physical interventions, such as restructuring an entire department floor, to enhance the intervention's effectiveness. The study concluded that relatively simple environment modifications, such as placing signs to promote stair use, did not lead to changes in the need for recovery. History In general medicine and psychiatry, recovery has long been used to refer to the end of a particular experience or episode of illness. The broader concept of "recovery" as a general philosophy and model was first popularized in regard to recovery from substance abuse/drug addiction, for example within twelve-step programs or the California Sober method. Mental health recovery emerged in Geel, Belgium in the 13th century. Saint Dymphna—the patron saint of mental illness—was martyred there by her father in the 7th century. The Church of Saint Dymphna (built in 1349) became a pilgrimage destination for those seeking help with their psychiatric conditions. By the late 1400s, so many pilgrims were coming to Geel that the townspeople began hosting them as guests in their homes. This tradition of community recovery continues to this day. More widespread application of recovery models to psychiatric disorders is comparatively recent. The concept of recovery can be traced back as far as 1840, when John Thomas Perceval, son of Prime Minister Spencer Perceval, wrote of his personal recovery from the psychosis that he experienced from 1830 until 1832, a recovery that he obtained despite the "treatment" he received from the "lunatic" doctors who attended him. But by consensus the main impetus for the development came from within the consumer/survivor/ex-patient movement, a grassroots self-help and advocacy initiative, particularly within the United States during the late 1980s and early 1990s. The professional literature, starting with the psychiatric rehabilitation movement in particular, began to incorporate the concept from the early 1990s in the United States, followed by New Zealand and more recently across nearly all countries within the "First World". Similar approaches developed around the same time, without necessarily using the term recovery, in Italy, the Netherlands and the UK. Developments were fueled by a number of long-term outcome studies of people with "major mental illnesses" in populations from virtually every continent, including landmark cross-national studies by the World Health Organization from the 1970s and 1990s, showing unexpectedly high rates of complete or partial recovery, with exact statistics varying by region and the criteria used. The cumulative impact of personal stories or testimony of recovery has also been a powerful force behind the development of recovery approaches and policies. A key issue became how service consumers could maintain the ownership and authenticity of recovery concepts while also supporting them in professional policy and practice. Increasingly, recovery became both a subject of mental health services research and a term emblematic of many of the goals of the Consumer/Survivor/Ex-Patient Movement. The concept of recovery was often defined and applied differently by consumers/survivors and professionals. Specific policy and clinical strategies were developed to implement recovery principles although key questions remained. Elements of recovery It has been emphasized that each individual's journey to recovery is a deeply personal process, as well as being related to an individual's community and society. A number of features or signs of recovery have been proposed as often core elements and comprehensively they have been categorized under the concept of CHIME. CHIME is a mnemonic of connectedness, hope & optimism, identity, meaning & purpose and empowerment. Connectedness and supportive relationships A common aspect of recovery is said to be the presence of others who believe in the person's potential to recover and who stand by them. According to Relational Cultural Theory as developed by Jean Baker Miller, recovery requires mutuality and empathy in relationships. The theory states this requires relationships that embody respect, authenticity, and emotional availability. Supportive relationships can also be made safer through predictability and avoiding shaming and violence. While mental health professionals can offer a particular limited kind of relationship and help foster hope, relationships with friends, family and the community are said to often be of wider and longer-term importance. Case managers can play the role of connecting recovering persons to services that the recovering person may have limited access to, such as food stamps and medical care. Others who have experienced similar difficulties and are on a journey of recovery can also play a role in establishing community and combating a recovering person's feelings of isolation. An example of a recovery approach that fosters a sense of community to combat feelings of isolation is the safe house or transitional housing model of rehabilitation. This approach supports victims of trauma through a community-centered, transitional housing method that provides social services, healthcare, and psychological support to navigate through and past experiences. Safe houses aim to support survivors on account of their individual needs and can effectively rehabilitate those recovering from issues such as sexual violence and drug addiction without criminalization. Additionally, safe houses provide a comfortable space where survivors can be listened to and uplifted through compassion. In practice, this can be accomplished through one on one interviews with other recovering persons, engaging in communal story circles, or peer-led support groups. Those who share the same values and outlooks more generally (not just in the area of mental health) may also be particularly important. It is said that one-way relationships based on being helped can actually be devaluing and potentially re-traumatizing, and that reciprocal relationships and mutual support networks can be of more value to self-esteem and recovery. Hope Finding and nurturing hope has been described as a key to recovery. It is said to include not just optimism but a sustainable belief in oneself and a willingness to persevere through uncertainty and setbacks. Hope may start at a certain turning point, or emerge gradually as a small and fragile feeling, and may fluctuate with despair. It is said to involve trusting, and risking disappointment, failure and further hurt. Identity Recovery of a durable sense of self (if it had been lost or taken away) has been proposed as an important element. A research review suggested that people sometimes achieve this by "positive withdrawal"—regulating social involvement and negotiating public space in order to only move towards others in a way that feels safe yet meaningful; and nurturing personal psychological space that allows room for developing understanding and a broad sense of self, interests, spirituality, etc. It was suggested that the process is usually greatly facilitated by experiences of interpersonal acceptance, mutuality, and a sense of social belonging; and is often challenging in the face of the typical barrage of overt and covert negative messages that come from the broader social context. Being able to move on can mean having to cope with feelings of loss, which may include despair and anger. When an individual is ready for change, a process of grieving is initiated. It may require accepting past suffering and lost opportunities or lost time. Formation of healthy coping strategies and meaningful internal schema The development of personal coping strategies (including self-management or self-help) is said to be an important element. This can involve making use of medication or psychotherapy if the patient is fully informed and listened to, including about adverse effects and about which methods fit with the consumer's life and their journey of recovery. Developing coping and problem solving skills to manage individual traits and problem issues (which may or may not be seen as symptoms of mental disorder) may require a person becoming their own expert, in order to identify key stress points and possible crisis points, and to understand and develop personal ways of responding and coping. Developing a sense of meaning and overall purpose is said to be important for sustaining the recovery process. This may involve recovering or developing a social or work role. It may also involve renewing, finding or developing a guiding philosophy, religion, politics or culture. From a postmodern perspective, this can be seen as developing a narrative. Empowerment and building a secure base Building a positive culture of healing is essential in the recovery approach. Since recovering is a long process, a strong supportive network can be helpful. Appropriate housing, a sufficient income, freedom from violence, and adequate access to health care have also been proposed as important tools to empowering someone and increasing her/his self-sufficiency. Empowerment and self-determination are said to be important to recovery for reducing the social and psychological effects of stress and trauma. Women's Empowerment Theory suggests that recovery from mental illness, substance abuse, and trauma requires helping survivors understand their rights so they can increase their capacity to make autonomous choices. This can mean develop the confidence for independent assertive decision making and help-seeking which translates into proper medication and active self care practices. Achieving social inclusion and overcoming challenging social stigma and prejudice about mental distress/disorder/difference is also an important part of empowerment. Advocates of Women's Empowerment Theory argue it is important to recognize that a recovering person's view of self is perpetuated by stereotypes and combating those narratives. Empowerment according to this logic requires reframing a survivor's view of self and the world. In practice, empowerment and building a secure base require mutually supportive relationships between survivors and service providers, identifying a survivor's existing strengths, and an awareness of the survivor's trauma and cultural context. Concepts of recovery Varied definitions What constitutes 'recovery', or a recovery model, is a matter of ongoing debate both in theory and in practice. In general, professionalized clinical models tend to focus on improvement in particular symptoms and functions, and on the role of treatments, while consumer/survivor models tend to put more emphasis on peer support, empowerment and real-world personal experience. "Recovery from", the medical approach, is defined by a dwindling of symptoms, whereas "recovery in", the peer approach, may still involve symptoms, but the person feels they are gaining more control over their life. Similarly, recovery may be viewed in terms of a social model of disability rather than a medical model of disability, and there may be differences in the acceptance of diagnostic "labels" and treatments. A review of research suggested that writers on recovery are rarely explicit about which of the various concepts they are employing. The reviewers classified the approaches they found in to broadly "rehabilitation" perspectives, which they defined as being focused on life and meaning within the context of enduring disability, and "clinical" perspectives which focused on observable remission of symptoms and restoration of functioning. From a psychiatric rehabilitation perspective, a number of additional qualities of the recovery process have been suggested, including that it: can occur without professional intervention, but requires people who believe in and stand by the person in recovery; does not depend on believing certain theories about the cause of conditions; can be said to occur even if symptoms later re-occur, but does change the frequency and duration of symptoms; requires recovery from the consequences of a psychiatric condition as well as the condition itself; is not linear but does tend to take place as a series of small steps; does not mean the person was never really psychiatrically disabled; focuses on wellness not illness, and on consumer choice. A consensus statement on mental health recovery from US agencies, that involved some consumer input, defined recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. Ten fundamental components were elucidated, all assuming that the person continues to be a "consumer" or to have a "mental disability". Conferences have been held on the importance of the "elusive" concept from the perspectives of consumers and psychiatrists. One approach to recovery known as the Tidal Model focuses on the continuous process of change inherent in all people, conveying the meaning of experiences through water metaphors. Crisis is seen as involving opportunity; creativity is valued; and different domains are explored such as sense of security, personal narrative and relationships. Initially developed by mental health nurses along with service users, Tidal is a particular model that has been specifically researched. Based on a discrete set of values (the Ten Commitments), it emphasizes the importance of each person's own voice, resourcefulness and wisdom. Since 1999, projects based on the Tidal Model have been established in several countries. For many, recovery has a political as well as personal implication—where to recover is to: find meaning; challenge prejudice (including diagnostic "labels" in some cases); perhaps to be a "bad" non-compliant patient and refuse to accept the indoctrination of the system; to reclaim a chosen life and place within society; and to validate the self. Recovery can thus be viewed as one manifestation of empowerment. Such an empowerment model may emphasize that conditions are not necessarily permanent; that other people have recovered who can be role models and share experiences; and that "symptoms" can be understood as expressions of distress related to emotions and other people. One such model from the US National Empowerment Center proposes a number of principles of how people recover and seeks to identify the characteristics of people in recovery. In general, recovery may be seen as more of a philosophy or attitude than a specific model, requiring fundamentally that "we regain personal power and a valued place in our communities. Sometimes we need services to support us to get there". Recovery from substance dependence Particular kinds of recovery models have been adopted in drug rehabilitation services. While interventions in this area have tended to focus on harm reduction, particularly through substitute prescribing (or alternatively requiring total abstinence) recovery approaches have emphasized the need to simultaneously address the whole of people's lives, and to encourage aspirations while promoting equal access and opportunities within society. Some examples of harm reduction services include overdose reversal medications (such as Narcan), substance testing kits, supplies for sterile injections, HIV, HBV, and HCV at-home testing equipment– and trauma-informed care in the form of group therapy, community building/events, case management, and rental assistance services. The purpose of this model is to rehabilitate those experiencing addiction in a holistic way rather than through law enforcement and criminal justice-based intervention which can fail to address victims’ circumstances on a need-by-need basis. From the perspective of services the work may include helping people with "developing the skills to prevent relapse into further illegal drug taking, rebuilding broken relationships or forging new ones, actively engaging in meaningful activities and taking steps to build a home and provide for themselves and their families. Milestones could be as simple as gaining weight, re-establishing relationships with friends, or building self-esteem. What is key is that recovery is sustained.". Key to the philosophy of the recovery movement is the aim for an equal relationship between "Experts by Profession" and "Experts by Experience". Trauma-Informed Recovery Trauma-Informed care is a philosophy for recovery that combines the conditions and needs of people recovering from mental illness and/or substance abuse into one framework. This framework combines all of the elements of the Recovery Approach and adds an awareness of trauma. Advocates of trauma-informed care argue the principles and strategies should be applied to individuals experiencing mental illness, substance dependence, and trauma as these three often occur simultaneously or as result of each other. The paradigms surrounding trauma-informed care began to shift in 1998 and 1999. In 1998, the Center for Mental Health Services, the Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention collaborated to fund 14 sites to develop integrated services in order to address the interrelated effects of violence, mental health, and substance abuse. In 1999, the National Association of State Mental Health Program Directors passed a resolution recognizing the impact of violence and trauma and developed a toolkit of resources for the implementation of trauma services in state mental health agencies. Trauma-informed care has been supported in academia as well. Scholars claim that neglecting the role of trauma in a person's story can interfere with recovery in the form of misdiagnosis, inaccurate treatment, or retraumatization. Some principles of trauma-informed care include validating survivor experiences and resiliency, aiming to increase a survivor's control over her/his/their recovery, creating atmospheres for recovery that embody consistency and confidentiality, minimizing the possibilities of triggering past trauma, and integrating survivors/recovering persons in service evaluation. In practice, trauma-informed care has shown to be most effective when every participant in a service providing context to be committed to following these principles. In addition, these principles can apply to all steps of the recovery process within a service providing context, including outreach and engagement, screening, advocacy, crisis intervention, and resource coordination. The overall goal in trauma-informed care is facilitating healing and empowerment using strengths-based empowerment practices and a comprehensive array of services that integrate co-occurring disorders and the multitude of needs a recovering person might have, such as drug treatment, housing, relationship building, and parenting support. These approaches are in contrast to traditional care systems. Advocates of trauma-informed care critique traditional service delivery systems, such as standard hospitals, for failing to understand the role of trauma in a patient's life. Traditional service delivery systems are also critiqued for isolating the conditions of a recovering person and not addressing conditions such as substance abuse and mental illness simultaneously as part of one source. Specific practices in traditional service delivery systems, such as unnecessary procedures, undressing for examinations, involuntary hospitalizations, crowded emergency rooms, and limited time for providers to meet with patients, have all been critiqued as insensitive to persons recovering from trauma and consequential mental illness or substance abuse. Limited resources and time in the United States healthcare system can make the implementation of trauma-informed care difficult. There are other challenges to trauma-informed care besides limits in the United States healthcare system that can make trauma-informed care ineffective for treating persons recovering from mental illness or substance dependence. Advocates of trauma-informed care argue implementation requires a strong commitment from leadership in an agency to train staff members to be trauma-aware, but this training can be costly and time-consuming. "Trauma-informed care" and "trauma" also have contested definitions and can be hard to measure in a real world service setting. Another barrier to trauma-informed care is the necessity of screening for histories of trauma. While agencies need to screen for histories of trauma in order to give the best care, there can be feelings of shame and fear of being invalidated that can prevent a recovering person from disclosing their personal experiences. Concerns Some concerns have been raised about a recovery approach in theory and in practice. These include suggestions that it: is an old concept; only happens to very few people; represents an irresponsible fad; happens only as a result of active treatment; implies a cure; can only be implemented with new resources; adds to the burden of already stretched providers; is neither reimbursable nor evidence based; devalues the role of professional intervention; and increases providers' exposure to risk and liability. Other criticisms focused on practical implementation by service providers include that: the recovery model can be manipulated by officials to serve various political and financial interests including withdrawing services and pushing people out before they're ready; that it is becoming a new orthodoxy or bandwagon that neglects the empowerment aspects and structural problems of societies and primarily represents a middle class experience; that it hides the continued dominance of a medical model; and that it potentially increases social exclusion and marginalizes those who don't fit into a recovery narrative. There have been specific tensions between recovery models and "evidence-based practice" models in the transformation of US mental health services based on the recommendations of the New Freedom Commission on Mental Health. The commission's emphasis on recovery has been interpreted by some critics as saying that everyone can fully recover through sheer will power and therefore as giving false hope and implicitly blaming those who may be unable to recover. However, the critics have themselves been charged with undermining consumer rights and failing to recognize that the model is intended to support a person in their personal journey rather than expecting a given outcome, and that it relates to social and political support and empowerment as well as the individual. Various stages of resistance to recovery approaches have been identified amongst staff in traditional services, starting with "Our people are much sicker than yours. They won't be able to recover" and ending in "Our doctors will never agree to this". However, ways to harness the energy of this perceived resistance and use it to move forward have been proposed. In addition, staff training materials have been developed by various organisations, for example by the National Empowerment Center. Some positives and negatives of recovery models were highlighted in a study of a community mental health service for people diagnosed with schizophrenia. It was concluded that while the approach may be a useful corrective to the usual style of case management - at least when genuinely chosen and shaped by each unique individual on the ground - serious social, institutional and personal difficulties made it essential that there be sufficient ongoing effective support with stress management and coping in daily life. Cultural biases and uncertainties were also noted in the 'North American' model of recovery in practice, reflecting views about the sorts of contributions and lifestyles that should be considered valuable or acceptable. Assessment A number of standardized questionnaires and assessments have been developed to try to assess aspects of an individual's recovery journey. These include the Milestones of Recovery (MOR) Scale, Recovery Enhancing Environment (REE) measure, Recovery Measurement Tool (RMT), Recovery Oriented System Indicators (ROSI) Measure, Stages of Recovery Instrument (STORI), and numerous related instruments. The data-collection systems and terminology used by services and funders are said to be typically incompatible with recovery frameworks, so methods of adapting them have been developed. It has also been argued that the Diagnostic and Statistical Manual of Mental Disorders (and to some extent any system of categorical classification of mental disorders) uses definitions and terminology that are inconsistent with a recovery model, leading to suggestions that the next version, the DSM-V, requires: greater sensitivity to cultural issues and gender; to recognize the need for others to change as well as just those singled out for a diagnosis of disorder; and to adopt a dimensional approach to assessment that better captures individuality and does not erroneously imply excess psychopathology or chronicity. National policies and implementation United States and Canada The New Freedom Commission on Mental Health has proposed to transform the mental health system in the US by shifting the paradigm of care from traditional medical psychiatric treatment toward the concept of recovery, and the American Psychiatric Association has endorsed a recovery model from a psychiatric services perspective. The US Department of Health and Human Services reports developing national and state initiatives to empower consumers and support recovery, with specific committees planning to launch nationwide pro-recovery, anti-stigma education campaigns; develop and synthesize recovery policies; train consumers in carrying out evaluations of mental health systems; and help further the development of peer-run services. Mental Health service directors and planners are providing guidance to help state services implement recovery approaches. Some US states, such as California (see the California Mental Health Services Act), Wisconsin and Ohio, already report redesigning their mental health systems to stress recovery model values like hope, healing, empowerment, social connectedness, human rights, and recovery-oriented services. At least some parts of the Canadian Mental Health Association, such as the Ontario region, have adopted recovery as a guiding principle for reforming and developing the mental health system. New Zealand and Australia Since 1998, all mental health services in New Zealand have been required by government policy to use a recovery approach and mental health professionals are expected to demonstrate competence in the recovery model. Australia's National Mental Health Plan 2003-2008 states that services should adopt a recovery orientation although there is variation between Australian states and territories in the level of knowledge, commitment and implementation. UK and Ireland In 2005, the National Institute for Mental Health in England (NIMHE) endorsed a recovery model as a possible guiding principle of mental health service provision and public education. The National Health Service is implementing a recovery approach in at least some regions, and has developed a new professional role of Support Time and Recovery Worker. Centre for Mental Health issued a 2008 policy paper proposing that the recovery approach is an idea "whose time has come" and, in partnership with the NHS Confederation Mental Health Network, and support and funding from the Department of Health, manages the Implementing Recovery through Organisational Change (ImROC) nationwide project that aims to put recovery at the heart of mental health services in the UK. The Scottish Executive has included the promotion and support of recovery as one of its four key mental health aims and funded a Scottish Recovery Network to facilitate this. A 2006 review of nursing in Scotland recommended a recovery approach as the model for mental health nursing care and intervention. The Mental Health Commission of Ireland reports that its guiding documents place the service user at the core and emphasize an individual's personal journey towards recovery. See also Addiction recovery groups Anti-psychiatry Clinical psychology Capability approach Celebrate Recovery Critical Psychiatry Critical Psychiatry Network Emotions Anonymous Hearing Voices Movement Hearing Voices Network GROW Mark Ragins Mentalism (discrimination) Physical medicine and rehabilitation Recovery coaching Recovery International Rethinking Madness Self-help groups for mental health Shared decision making Social firm Social psychiatry Social work Soteria (psychiatric treatment) Therapeutic community United States Psychiatric Rehabilitation Association Wellness Recovery Action Plan References Further reading Karasaki et al.,(2013). The Place of Volition in Addiction: Differing Approaches and their Implications for Policy and Service Provision. External links The Strengths Model: A Recovery-Oriented Approach to Mental Health Services, St Vincent's Hospital, Melbourne, 2014. NASW Practice Snapshot: The Mental Health Recovery Model Recovery as a Journey of the Heart (PDF) A Critical Exploration of Social Inequities in the Mental Health Recovery Literature National Resource Center on Psychiatric Advance Directives Treatment of mental disorders Psychiatric rehabilitation Drug rehabilitation Twelve-step programs

Arrested development

The term "arrested development" has had multiple meanings for over 200 years. In the field of medicine, the term "arrested development" was first used, circa 1835–1836, to mean a stoppage of physical development; the term continues to be used in the same way. In literature, Ernest Hemingway used the term in The Sun Also Rises, published in 1926: On page 51, Harvey tells Cohn, "I misjudged you [...] You're not a moron. You're only a case of arrested development." In contrast, the UK's Mental Health Act 1983 used the term "arrested development" to characterize a form of mental disorder comprising severe mental impairment, resulting in a lack of intelligence. However, some researchers have objected to the notion that mental development can be "arrested" or stopped, preferring to consider mental status as developing in other ways in psychological terminology. Consequently, the term "arrested development" is no longer used when referring to a developmental disorder in mental health. In anthropology and archaeology, the term "arrested development" means that a plateau of development in some sphere has been reached. Often it is a technological plateau such as the development of high temperature ceramics, but without glaze because of a lack of materials, or copper smelting without development of bronze because of a lack of tin. Arrested development is key in the insight of self-domestication in the evolution of hominidae where it involves being in an environment that favors reduction in aggression, including interspecific and intraspecific antagonism, for survival, in favor of attitudes that favor living together in a group, social behavior, traits that favor the group as a whole to come to the front stage, elimination of bullies - individuals with an antisocial personality disorder. References Developmental neuroscience Developmental psychology Medical terminology

Mental health nursing

Psychiatric nursing or mental health nursing is the appointed position of a nurse that specialises in mental health, and cares for people of all ages experiencing mental illnesses or distress. These include: neurodevelopmental disorders, schizophrenia, schizoaffective disorder, mood disorders, addiction, anxiety disorders, personality disorders, eating disorders, suicidal thoughts, psychosis, paranoia, and self-harm. Mental health nurses receive specific training in psychological therapies, building a therapeutic alliance, dealing with challenging behaviour, and the administration of psychiatric medication. In most countries, after the 1990s, a psychiatric nurse would have to attain a bachelor's degree in nursing to become a Registered Nurse (RN), and specialise in mental health. Degrees vary in different countries, and are governed by country-specific regulations. In the United States one can become a RN, and a psychiatric nurse, by completing either a diploma program, an associate (ASN) degree, or a bachelor's (BSN) degree. Mental health nurses can work in a variety of services, including: Child and Adolescent Mental Health Services (CAMHS), Acute Medical Units (AMUs), Psychiatric Intensive Care Units (PICUs), and Community Mental Health Services (CMHS). History The history of psychiatry and psychiatric nursing, although disjointed, can be traced back to ancient philosophical thinkers. Marcus Tullius Cicero, in particular, was the first known person to create a questionnaire for the mentally ill using biographical information to determine the best course of psychological treatment and care. Some of the first known psychiatric care centers were constructed in the Middle East during the 8th century. The medieval Muslim physicians and their attendants relied on clinical observations for diagnosis and treatment. In 13th century medieval Europe, psychiatric hospitals were built to house the mentally ill, but there were not any nurses to care for them and treatment was rarely provided. These facilities functioned more as a housing unit for the insane. Throughout the high point of Christianity in Europe, hospitals for the mentally ill believed in using religious intervention. The insane were partnered with "soul friends" to help them reconnect with society. Their primary concern was befriending the melancholy and disturbed, forming intimate spiritual relationships. Today, these soul friends are seen as the first modern psychiatric nurses. In the colonial era of the United States, some settlers adapted community health nursing practices. Individuals with mental defects that were deemed as dangerous were incarcerated or kept in cages, maintained and paid fully by community attendants. Wealthier colonists kept their insane relatives either in their attics or cellars and hired attendants, or nurses, to care for them. In other communities, the mentally ill were sold at auctions as slave labor. Others were forced to leave town. As the population in the colonies expanded, informal care for the community failed and small institutions were established. In 1752 the first "lunatics ward" was opened at the Pennsylvania Hospital which attempted to treat the mentally ill. Attendants used the most modern treatments of the time: purging, bleeding, blistering, and shock techniques. Overall, the attendants caring for the patients believed in treating the institutionalized with respect. They believed if the patients were treated as reasonable people, then they would act as such; if they gave them confidence, then patients would rarely abuse it. The 1790s saw the beginnings of moral treatment being introduced for people with mental distress. The concept of a safe asylum, proposed by Philippe Pinel and William Tuke, offered protection and care at institutions for patients who had been previously abused or enslaved. In the United States, Dorothea Dix was instrumental in opening 32 state asylums to provide quality care for the ill. Dix also was in charge of the Union Army Nurses during the American Civil War, caring for both Union and Confederate soldiers. Although it was a promising movement, attendants and nurses were often accused of abusing or neglecting the residents and isolating them from their families. The formal recognition of psychiatry as a modern and legitimate profession occurred in 1808. In Europe, one of the major advocates for mental health nursing to help psychiatrists was Dr. William Ellis. He proposed giving the "keepers of the insane" better pay and training so more respectable, intelligent people would be attracted to the profession. In his 1836 publication of Treatise on Insanity, he openly stated that an established nursing practice calmed depressed patients and gave hope to the hopeless. However, psychiatric nursing was not formalized in the United States until 1882 when Linda Richards opened Boston City College. This was the first school specifically designed to train nurses in psychiatric care. The discrepancy between the founding of psychiatry and the recognition of trained nurses in the field is largely attributed to the attitudes in the 19th century which opposed training women to work in the medical field. In 1913 Johns Hopkins University was the first college of nursing in the United States to offer psychiatric nursing as part of its general curriculum. The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey, was not published until 1920. It was not until 1950 when the National League for Nursing required all nursing schools to include a clinical experience in psychiatry to receive national accreditation. The first psychiatric nurses faced difficult working conditions. Overcrowding, under-staffing and poor resources required the continuance of custodial care. They were pressured by an increasing patient population that rose dramatically by the end of the 19th century. As a result, labor organizations formed to fight for better pay and fewer hours. Additionally, large asylums were founded to hold the large number of mentally ill, including the famous Kings Park Psychiatric Center in Long Island, New York. At its peak in the 1950s, the center housed more than 33,000 patients and required its own power plant. Nurses were often called "attendants" to imply a more humanitarian approach to care. During this time, attendants primarily kept the facilities clean and maintained order among the patients. They also carried out orders from the physicians. In 1963, President John F. Kennedy accelerated the trend towards deinstitutionalization with the Community Mental Health Act. In 1964, the Civil Rights Act was passed, which made it illegal for an organization to discriminate if federally funded. Despite this ruling, certain states such as Mississippi and Alabama fought these laws in court, promoting segregation within healthcare. Moreover, since psychiatric drugs were becoming more available allowing patients to live on their own and the asylums were too expensive, institutions began shutting down. Nursing care thus became more intimate and holistic. Expanded roles were also developed in the 1960s allowing nurses to provide outpatient services such as counseling, psychotherapy, consultations, prescribing medications, along with the diagnosis and treatment of mental illnesses. The first developed standard of care was created by the psychiatric division of the American Nurses Association (ANA) in 1973. This standard outlined the responsibilities and expected quality of care of nurses. In 1975, the government published a document called "Better Services for the Mentally Ill" which reviewed the current standards of psychiatric nursing worldwide and laid out better plans for the future of mental health nursing. Global health care underwent huge expansions in the 1980s; this was due to the government's reaction from the fast increasing demand on health care services. The expansion was continued until the economic crisis of the 1970s. In 1982, the Area Health Authorities was terminated. In 1983, better structure of hospitals was implemented. General managers were introduced to make decisions, thus creating a better system of operation. The year 1983 also saw a lot of staff cuts which were heavily felt by all the mental health nurses. However, a new training syllabus was introduced in 1982, which offered suitable knowledgeable nurses. The 2000s have seen major educational upgrades for nurses to specialize in mental health as well as various financial opportunities. Interventions Nursing interventions may be divided into the following categories: Physical and biological interventions Psychiatric medication Psychiatric medication is a commonly used intervention and many psychiatric mental health nurses are involved in the administration of medicines, both in oral (e.g. tablet or liquid) form or by intramuscular injection. Nurse practitioners can prescribe medication. Nurses will monitor for side effects and response to these medical treatments by using assessments. Nurses will also offer information on medication so that, where possible, the person in care can make an informed choice, using the best medical-based evidence available. Electroconvulsive therapy Psychiatric mental health nurses are also involved in the administration of the treatment of electroconvulsive therapy and assist with the preparation and recovery from the treatment, which involves anesthesia. This treatment is only used in a tiny proportion of cases and only after all other possible treatments have been exhausted. Nurses may also be involved in gaining consent for this procedure. However, consent arrangements vary depending on the jurisdiction in which the treatment takes place. Physical care Along with other nurses, psychiatric mental health nurses will intervene in areas of physical need to ensure that people have good levels of personal hygiene, nutrition, sleep, etc., as well as tending to any concomitant physical ailments. In mental health patients, obesity is not rare because some medications can have a side effect of gaining weight which can cause the patient to have low confidence and lead to other health issues. To fix this problem, mental health nurses are urged to encourage patients to get more exercise to enhance their physical health, along with their mental health by improving the patients confidence and lowering stress levels, improving their mental health which has been a focus for mental health nurses because many patients do not get enough exercise. Nurses may also need to help the patients with alcohol or drug abuse because mental health patients are at a higher risk for this behavior. Mental health nurses need to be able to communicate to patients about this. The alcohol and drug abuse could cause the patient to also have a higher risk of sexually transmitted diseases because alcohol and drugs can lead to more sexual behavior. Psychosocial interventions Psychosocial interventions are increasingly delivered by nurses in mental health settings. These include psychotherapy interventions, such as cognitive behavioural therapy, family therapy, and less commonly other interventions, such as milieu therapy or psychodynamic approaches. These interventions can be applied to a broad range of problems including psychosis, depression, and anxiety. Nurses will work with people over a period of time and use psychological methods to teach the person psychological techniques that they can then use to aid recovery and help manage any future crisis in their mental health. In practice, these interventions will be used often, in conjunction with psychiatric medications. Psychosocial interventions are based on evidence-based practice, and therefore the techniques tend to follow set guidelines based upon what has been demonstrated to be effective by nursing research. There has been some criticism that evidence based practice is focused primarily on quantitative research and should reflect also a more qualitative research approach that seeks to understand the meaning of people's experience. Spiritual interventions The basis of this approach is to look at mental illness or distress from the perspective of a spiritual crisis. Spiritual interventions focus on developing a sense of meaning, purpose, and hope for the person in their current life experience. Spiritual interventions involve listening to the person's story and facilitating the person to connect to God, a greater power or greater whole, perhaps by using meditation or prayer. This may be a religious or non-religious experience depending on the individual's own spirituality. Spiritual interventions, along with psychosocial interventions, emphasize the importance of engagement, however, spiritual interventions focus more on caring and 'being with' the person during their time of crisis, rather than intervening and trying to 'fix' the problem. Spiritual interventions tend to be based on qualitative research and share some similarities with the humanistic approach to psychotherapy. Therapeutic relationship As with other areas of nursing practice, psychiatric mental health nursing works within nursing models, utilising nursing care plans, and seeks to care for the whole person. However, the emphasis of mental health nursing is on the development of a therapeutic alliance. In practice, this means that the nurse should seek to engage with the person in care in a positive and collaborative way that will empower the patient to draw on his or her inner resources in addition to any other treatment they may be receiving. Therapeutic relationship aspects of psychiatric nursing The most important duty of a psychiatric nurse is to maintain a positive therapeutic relationship with patients in a clinical setting. The fundamental elements of mental health care revolve around the interpersonal relations and interactions established between professionals and clients. Caring for people with mental illnesses demands an intensified presence and a strong desire to be supportive. Understanding and empathy Understanding and empathy from psychiatric nurses reinforces a positive psychological balance for patients. Conveying an understanding is important because it provides patients with a sense of importance. The expression of thoughts and feelings should be encouraged without blaming, judging, or belittling. Feeling important is significant to the lives of people who live in a structured society, who often stigmatise the mentally ill because of their disorder. Empowering patients with feelings of importance will bring them closer to the normality they had before the onset of their disorder. When subjected to fierce personal attacks, the psychiatric nurse retained the desire and ability to understand the patient. The ability to quickly empathise with unfortunate situations proves essential. Involvedness is also required when patients expect nursing staff to understand even when they are unable to express their needs verbally. When a psychiatric nurse gains understanding of the patient, the chances of improving overall treatment greatly increases. Individuality Individualised care becomes important when nurses need to get to know the patient. To lives this knowledge the psychiatric nurse must see patients as individual people with lives beyond their mental illness. Seeing people as individuals with lives beyond their mental illness is imperative in making patients feel valued and respected. In order to accept the patient as an individual, the psychiatric nurse must not be controlled by his or her own values, or by ideas, and pre-understanding of mental health patients. Individual needs of patients are met by bending the rules of standard interventions and assessment. Psychiatric nurses spoke of the potential to 'bend the rules', which required an interpretation of the unit rules, and the ability to evaluate the risks associated with bending them. Providing support Successful therapeutic relationships between nurses and patients need to have positive support. Different methods of providing patients with support include many active responses. Minor activities, such as shopping, reading the newspaper together, or taking lunch or dinner breaks with patients can improve the quality of support provided. Physical support may also be used and is manifested through the use of touch. Patients described feelings of connection when nurses hugged them or put a hand on their shoulder. Psychiatric nurses in Berg and Hallberg's study described an element of a working relationship as comforting through holding a patient's hand. Patients with depression described relief when the nurse embraced them. Physical touch is intended to comfort and console patients who are willing to embrace these sensations and share mutual feelings with nurses. Being there and being available In order to make patients feel more comfortable, the patient care providers make themselves more approachable, therefore more readily open to multiple levels of personal connections. Such personal connections have the ability to uplift patients' spirits and secure confidentiality. Utilisation of the quality of time spent with the patient proves to be beneficial. By being available for a proper amount of time, patients open up and disclose personal stories, which enable nurses to understand the meaning behind each story. The outcome results in nurses making every effort to attain a non-biased point of view. A combination of being there and being available allows empirical connections to quell any negative feelings within patients. Being genuine The act of being genuine must come from within and be expressed by nurses without reluctance. Genuineness requires the nurse to be natural or authentic in their interactions with the patient. In his article about pivotal moments in therapeutic relationships, Welch found that nurses must be in accordance with their values and beliefs. Along with the previous concept, O'Brien concluded that being consistent and reliable in both punctuality and character makes for genuinity. Schafer and Peternelj-Taylor believe that a nurses 'genuineness' is determined through the level of consistency displayed between their verbal and non-verbal behaviour. Similarly, Scanlon found that genuineness was expressed by fulfilling intended tasks. Self-disclosure proves to be the key to being open and honest. It involves the nurse sharing life experiences and is essential to the development of the therapeutic relationship, because as the relationship grows patients are reluctant to give any more information if they feel the relationship is too one sided. Multiple authors found genuine emotion, such as tearfulness, blunt feedback, and straight talk facilitated the therapeutic relationship in the pursuit of being open and honest. The friendship of a therapeutic relationship is different from a sociable friendship because the therapeutic relationship friendship is asymmetrical in nature. The basic concept of genuineness is centered on being true to one's word. Patients would not trust nurses who fail in complying with what they say or promise. Promoting equality For a successful therapeutic relationship to form, a beneficial co-dependency between the nurse and patient must be established. A derogatory view of the patient's role in the clinical setting dilapidates a therapeutic alliance. While patients need nurses to support their recovery, psychiatric nurses need patients to develop skills and experience. Psychiatric nurses convey themselves as team members or facilitators of the relationship, rather than the leaders. By empowering the patient with a sense of control and involvement, nurses encourage the patient's independence. Sole control of certain situations should not be embedded in the nurse. Equal interactions are established when nurses talk to patients one-on-one. Participating in activities that do not make one person more dominant over the other, such as talking about a mutual interest or getting lunch together strengthen the levels of equality shared between professionals and patients. This can also create the "illusion of choice"; giving the patient options, even if limited or confined within structure. Demonstrating respect To develop a quality therapeutic relationship, nurses need to make patients feel respected and important. Accepting patient faults and problems is vital to convey respect—helping the patient see themselves as worthy and worthwhile. Demonstrating clear boundaries Boundaries are essential for protecting both the patient and the nurse, and maintaining a functional therapeutic relationship. Limit setting helps to shield the patient from embarrassing behaviour, and instills the patient with feelings of safety and containment. Limit setting also protects the nurse from "burnout", preserving personal stability—thus promoting a quality relationship. Demonstrating self-awareness Psychiatric nurses recognise personal vulnerability in order to develop professionally. Humanistic insight, basic human values, and self-knowledge improves the depth of understanding the self. Different personalities affect the way psychiatric nurses respond to their patients. The more self-aware, the more knowledge on how to approach interactions with patients nurses have. Interpersonal skills needed to form relationships with patients were acquired through learning about oneself. Clinical supervision was found to provide the opportunity for nurses to reflect on patient relationships, to improve clinical skills, and to help repair difficult relationships. The reflections articulated by nurses through clinical supervision help foster self-awareness. Pediatric mental health nursing Nurses are vital to the evaluation and treatment of children with mental illness. Pediatric mental health nursing is the treatment/nursing of mental illness in pediatric patients. Family nurse practitioners (FNPs) are typically expected to evaluate and treat pediatric patients struggling with their mental health. One out of five children experience a mental disorder in a given year, but only 20% receive treatment of said disorder. Profession status Canada The registered psychiatric nurse is a distinct nursing profession in all of the four western provinces. Such nurses carry the designation "RPN". In Eastern Canada, an Americanized system of psychiatric nursing is followed. Registered Psychiatric Nurses can also work in all three of the territories in Canada; although, the registration process to work in the territories varies as the psychiatric nurses must be licensed by one of the four provinces. Ireland In Ireland, mental health nurses undergo a 4-year honors degree training programme. Nurses that trained under the diploma course in Ireland can do a post graduation course to bring their status from diploma to degree. New Zealand Mental Health Nurses in New Zealand require a diploma or degree in nursing. All nurses are now trained in both general and mental health, as part of their three-year degree training programme. Mental health nurses are often requested to complete a graduate diploma or a post graduate certificate in mental health, if they are employed by a District Health Board. This gives additional training that is specific to working with people with mental health issues. Sweden In Sweden, to become a registered psychiatric nurse one must first become a registered nurse which requires a BSc. (Bachelor of Science) in Nursing (three years of full-time study, 180 higher education credits). Then, one must complete one year of graduate studies in psychiatric/mental health nursing (60 higher education credits), which also includes writing a MSc. (Master of Science) thesis. The registered psychiatric nurse is an evolving profession in Sweden. However, unlike in countries such as the US, there is no psychiatric-mental health nurse practitioner, so in Sweden, the profession cannot for example prescribe pharmacological treatment. United Kingdom In the UK and Ireland the term psychiatric nurse has now largely been replaced with mental health nurse. Mental health nurses undergo a 3–4 year training programme at bachelor's degree level, or a 2-year training programme at master's degree level, in common with other nurses. However, most of their training is specific to caring for clients with mental health issues. RMNs can continue into further training as Advanced Nurse Practitioners (ANPs): this requires completion of a 9-month Master's programme. The role includes prescribing medications, being on call for hospital wards and delivering psychosocial interventions to clients. United States In North America, there are three levels of psychiatric nursing. The licensed vocational nurse (licensed practical nurse in some states) and the licensed psychiatric technician may dispense medication and assist with data collection regarding psychiatric and mental health clients. The registered nurse or registered psychiatric nurse has the additional scope of performing assessments and may provide other therapies such as counseling and milieu therapy. The advanced practice registered nurse (APRN) either practices as a clinical nurse specialist or a nurse practitioner after obtaining a master's degree in psychiatric-mental health nursing. Psychiatric-mental health nursing (PMHN) is a nursing specialty. The course work in a master's degree program includes specialty practice. APRNs assess, diagnose, and treat individuals or families with psychiatric problems/disorders or the potential for such disorders, as well as performing the functions associated with the basic level. They provide a full range of primary mental health care services to individuals, families, groups and communities, function as psychotherapists, educators, consultants, advanced case managers, and administrators. In many states, APRNs have the authority to prescribe medications. Qualified to practice independently, psychiatric-mental health APRNs offer direct care services in a variety of settings: mental health centers, community mental health programs, homes, offices, HMOs, etc. Psychiatric nurses who earn doctoral degrees (PhD, DNSc, EdD) often are found in practice settings, teaching, doing research, or as administrators in hospitals, agencies or schools of nursing. Australia In Australia, to be a psychiatric nurse a bachelor's degree of nursing need to be obtained in order to become a registered nurse (RN) and this degree takes three years full-time. Then a diploma in mental health or something similar will need to also be obtained, this is an additional year of study. An Australian psychiatric nurse has duties that may include assessing patients who are mentally ill, observation, helping patients take part in activities, giving medication, observing if the medication is working, assisting in behaviour change programs or visiting patients who are at home. Australian nurses can work in public or private hospitals, institutes, correctional institutes, mental care facilities and homes of the patients. See also List of counseling topics Mental health professional Psychiatric and mental health nurse practitioner Tom Main - author of seminal paper on psychiatric nursing Hildegard Peplau - psychiatric nurse theorist Tidal Model - model developed for mental health nursing References External links Psychiatric nursing Counseling

Psychosocial

The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is used in a broad range of helping professions in health and social care settings as well as by medical and social science researchers. Background Adolf Meyer in the late 19th century stated that: "We cannot understand the individual presentation of mental illness, [and perpetuating factors] without knowing how that person functions in the environment." Psychosocial assessment stems from this idea. The relationship between mental and emotional wellbeing and the environment was first commonly applied by Erik Erikson in his description of the stages of psychosocial development. Mary Richmond considered there to be a strict relationship between cause and effect, in a diagnostic process. In 1941 Gordon Hamilton renamed the existing (1917) concept of "social diagnosis" as "psychosocial study". Psychosocial study was further developed by Hollis in 1964 with emphasis on treatment model. It is in tension with diverse social psychology, which attempts to explain social patterns within the individual. Problems that occur in one's psychosocial functioning can be referred to as "psychosocial dysfunction" or "psychosocial morbidity." That refers to the lack of development or diverse atrophy of the psychosocial self, often occurring alongside other dysfunctions that may be physical, emotional, or cognitive in nature. There is now a cross-disciplinary field of study, and organisations such as the Transcultural Psychosocial Organization (United Nations High Commissioner for Refugees), and Association for Psychosocial Studies. Psychosocial assessment and intervention Psychosocial assessment considers several key areas related to psychological, biological, and social functioning and the availability of supports. It is a systematic inquiry that arises from the introduction of dynamic interaction; it is an ongoing process that continues throughout a treatment, and is characterized by the circularity of cause-effect/effect-cause. In assessment, the clinician/health care professional identifies the problem with the client, takes stock of the resources that are available for dealing with it, and considers the ways in which it might be solved from an educated hypothesis formed by data collection. This hypothesis is tentative in nature and goes through a process of elimination, refinement, or reconstruction in the light of newly obtained data. There are five internal steps in assessment: Data collection (relevant and current) of the problem presented. Integrating collected facts with relevant theories. Formulating a hypothesis (case theory) that gives the presented problem more clarity. Hypothesis substantiation through exploration of the problem: life history of the client, etiology, personality, environment, stigmas, etc. Further integration of newer facts identified in the treatment period and preparing a psychosocial report for psychosocial intervention. Assessment includes psychiatric, psychological and social functioning, risks posed to the individual and others, problems required to address from any co-morbidity, personal circumstances including family or other carers. Other factors are the person's housing, financial and occupational status, and physical needs. Assessments when categorized, it particularly includes Life history of the client that include data collection of living situation and finances, social history and supports, family history, coping skills, religious/cultural factors, trauma from systemic issues or abuse and medico-legal factors (assessment of the client's awareness of legal documents, surrogate decision-making, power of attorney and consent). Components include: the resource assessment of psycho-spiritual strengths; substance abuse; coping mechanisms, styles and patterns (individual, family level, workplace, and use of social support systems); sleeping pattern; needs and impacts of the problem etc. Advanced clinicians incorporate individual scales, batteries and testing instruments in their assessments. In the late 1980s Hans Eysenck, in an issue of Psychological Inquiry, raised controversies on then assessment methods and it gave way to comprehensive Bio-Psycho-Social assessment. This theoretical model sees behavior as a function of biological factors, psychological issues and the social context. Qualified healthcare professionals conduct the physiological part of these assessments. This thrust on biology expands the field of approach for the client, with the client, through the interaction of these disciplines in a domain where mental illnesses are physical, just as physical conditions have mental components. Likewise, the emotional is both psychological and physical. The clinician's comprehension and set of judgments about the client's situation, the assessment through a theory of each case, predicts the intervention. Hence a good psychosocial assessment leads to a good psychosocial intervention that aims to reduce complaints and improve functioning related to mental disorders and/or social problems (e.g., problems with personal relationships, work, or school) by addressing the different psychological and social factors influencing the individual. For example, a psychosocial intervention for an older adult client with a mental disorder might include psychotherapy and a referral to a psychiatrist while also addressing the caregiver's needs in an effort to reduce stress for the entire family system as a method of improving the client's quality of life. Treatment for psychosocial disorders in a medical model usually only involve using drugs and talk therapy. Psychosocial adaptation and support Psychosocial adaptation is a process a person experiences in order to achieve good fitness in person-environment congruence known as adjustment, a state of wisdom oriented activities and psychosocial equilibrium. Psychosocial support is the provision of psychological and social resources to a person by a supporter intended for the benefit of the receiver's ability to cope with problems faced. The allocentric principle within social relationships that promote health and well-being moves individuals to aid victims of terminal illness, disaster, war, catastrophe or violence to foster resilience of communities and individuals. It aims at easing resumption of normal life, facilitating affected people's participation to their convalescence and preventing pathological consequences of potentially traumatic situations. This might extend in forms of informational and instrumental support. See also Psychosocial needs Psychological trauma Mental status examination Psychosocial- a song by Slipknot on their 2008 album All Hope Is Gone. References Further reading Haley, J. Problem-solving therapy. New York: Harper & Row. 1978. Edward S. Neukrug, & R. Charles Fawcett (2006). Essentials of Testing and Assessment: A Practical Guide for Counselors, Social Workers, and Psychologists, 3rd Edition. Froggett, Lynn and Richards, Barry (2002). Exploring the Bio-psychosocial. European Journal of Psychotherapy & Counselling, Vol. 5 (3). pp. 321–326. ISSN 1364-2537. DOI: 10.1080/1364253031000140115. Manley, Julian (2010) From Cause and Effect to Effectual Causes: Can we talk of a philosophical background to psycho-social studies?. Journal of Psycho-Social Studies, 4 (1). pp. 65–87. ISSN 1478-6737 Hodge, D. (2001). Spiritual assessment: A review of major qualitative methods and a new framework for assessing spirituality. Social Work, 46(3), 203–214. Karls, J., & Wandrei, K.E. (1992). The person-in-environment system for classifying client problems. Journal of Case Management, 1(3), 90–95. David E. Ross, A Method for Developing a Biopsychosocial Formulation. Journal of Child and Family Studies 9(1):1-6. March 2000. DOI: 10.1023/A:1009435613679. External links Psychosocial assessment - Michigan State University The Journal of Psychosocial Studies Assessment Report Guidelines for Individuals - Veterans Affairs Canada The Science of Success The International Red Cross Reference Center for Psychosocial Support Biopsychosocial Assessment Samples: 1, 2, 3 , 4. Social psychology Social work Conformity

Vocational rehabilitation

Vocational rehabilitation, also abbreviated VR or voc rehab, is a process which enables persons with functional, psychological, developmental, cognitive, and emotional disabilities, impairments or health disabilities to overcome barriers to accessing, maintaining, or returning to employment or other useful occupations. Whilst, traditionally, the focus of vocational rehabilitation was job retention, an increased focus on an all-encompassing approach has become popular in contemporary approaches. Approaches differ between countries, however, due to the differing amounts of financial and political support vocational rehabilitation receives. Summary Vocational rehabilitation varies greatly between countries.  However, it generally focuses on improvements to the socialisation, healthcare and physical and mental wellbeing of the person receiving the services. People eligible for vocational rehabilitation generally include those with long-term sicknesses, mental health disorders, common health problems and severe medical conditions. Services offered to those who are eligible commonly include financial support, psychological support and social support. Commonly, healthcare programs rely on their successes to gain support. However, vocational rehabilitation is unique as it is largely reliant on employer compliance and willingness to involve themselves in the process. Subsequently, it is often marketed in a way that focuses more on the business gains of the program. There is a large amount of research dedicated to the development and improvement of vocational rehabilitation. Contemporary focus on vocational rehabilitation arose from an increased focus on social security systems on a governmental level. It is believed to be beneficial for people to return to work and to experience full integration into society, which is typically assisted by vocational rehabilitation. Moreover, rehabilitation programs encourage fewer people to rely on governmental financial support by facilitating greater movement into jobs for people with disabilities who, typically, are excluded from the workforce. There is a large cultural influence on approaches to disability and subsequently, disability services. Developed countries such as the US, UK and Australia have had systems in place for rehabilitation services for many years. Developing countries, however, have historically been more focused on combatting diseases and thus, have had less resources to dedicate to the development of rehabilitation programs. There is large amounts of stigma surrounding disability in developing countries. As a result, there is a lack of vocational rehabilitation programs in these countries which in turn has consequences on the economic and social development within them. The World Health Organisation, however, have implemented programs within developing countries in order to better establish their rehabilitation plans for people with disabilities. Whilst it is a popularly used form of intervention throughout many countries, vocational rehabilitation is often criticised for being inefficient and unsuccessful. Furthermore, some critics claim that there is not enough emphasis placed on women with disabilities in need of vocational rehabilitation services. Professionals involved Occupational therapistsare the core profession in vocational rehab. The role of occupational therapists in the workplace is to facilitate individuals' ability to return to work. Occupational therapists assist their clients in reaching their maximum level of function with the aim of meeting the physical and emotional demands of their job. Occupational therapists are also qualified to make recommendations to employers on how to adapt job demands to meet the functional status of an employee in order to prevent further injury and enable productivity during occupational rehabilitation. Individual functional capacity evaluations are used to screen for person-environment fit. Industrial occupational therapists use a collaborative approach involving the workers and employers to encourage a supportive work environment that empowers the worker to reach productivity and other work related goals. Occupational therapy interventions in vocational rehabilitation include developing assertiveness; communication and interpersonal skills; controlling anger; and stress management, adapting environment, identification and use of compensatory strategies to enable functions within the job. Other involved professionals may be occupational psychologists, physiotherapists, kinesiologists, occupational physiologists, and occupational physicians. By location Vocational rehabilitation in the United States History The Vocational Rehabilitation Program was created in 1920. This program was created under the supervision of the Rehabilitation Services Administration (RSA) which was formed by the US government to facilitate a variety of programs for vocational rehabilitation. The President's Committee on Employment of the Handicapped was formed in 1945, which later became the President's Committee on Employment of People with Disabilities and today is known as the Office of Disability Employment Policy. By the end of the 20th century, a number of services were created to facilitate support for vocational rehabilitation. In the 1980s, jobs specifically for people with disabilities were created and the idea of ‘equal access’ became more widespread. The ‘Americans with Disabilities Act’ was implemented in 1990 and afforded people with disabilities the same set of rights that had historically been granted to women and marginalised groups. Current Currently, a variety of federal services exist to facilitate vocational rehabilitation in the United States. The Department of Disability Services has a dedicated sect to vocational rehabilitation services where applicants are provided with a counsellor to develop an Individual Plan for Employment. The Office of Disability Employment Policy further facilitates employment opportunities for people with disabilities. The Social Security Administration pays benefits to people with disabilities whilst the Rehabilitation Services Administration (RSA) administers grants to those eligible, although state vocational rehabilitation agencies are able to obtain funding from the Social Security Administration in certain cases (such as via the Ticket to Work program). Eligibility is determined, firstly, by whether an individual's disability is preventative of employment. Furthermore, the individual needs to benefit from vocational rehabilitation services and further be able to succeed in employment goals. Sometimes, for clients where job retention is not a feasible outcome, vocational rehabilitation services are more geared towards proliferating vocational skills. Some programs offer clients education services in conjunction with their rehabilitation, which has been shown to improve their occupational outcomes. Other programs facilitate jobs in mental health services for people with mental health histories as they often prove to be of great use in such job fields. Overall, however, a strong link between successful recovery and maintaining employment has been made. The US Department of Veterans Affairs offers vocational rehabilitation programs specifically for veterans whose disabilities are related to their years in active service. Such programs include employment assistance, business assistance and job retention. All veterans are provided with a Vocational Rehabilitation Counsellor to create a rehabilitation program. These counsellors tend to dictate the success of individual rehabilitation programs, particularly through the relationship developed between the veteran and the counsellor. Criticisms Of people who suffered traumatic brain injury and used vocational rehabilitation services in the state of Missouri, only 17% were successful in their employment at the time of their case closure. Furthermore, 20.5% of people with disabilities enter the United States labour force and on average they are paid about 37% less. Vocational rehabilitation further tends to cater to advantaged communities, with people from disadvantaged backgrounds less likely to reach out for vocational rehabilitation services and are furthermore, less likely to be found to be eligible. State agencies There are different agencies in the US that run VR programs, including the following: Vocational rehabilitation in the United Kingdom History Vocational rehabilitation has been in practice in the UK since the early 1900s. However, initially it was simply seen as a measure taken after the individual had received the necessary medical treatment. In 1946, the ‘Egham Industrial Rehabilitation Centre in Surry’ became open for public use, following the Second World War. In 1951, the National Health Service (NHS) had primary control over rehabilitation services, offering a variety of programs. However, in the 1980s, the recession in the UK saw a decline in focus on vocational rehabilitation. The NHS shut down many of their rehabilitation service centres which consequently led the Department of Employment to take over responsibility for rehabilitation services. From 2000 to 2002 the Vocational Rehabilitation Association led a government funded research project into vocational rehabilitation and how to better improve it in the UK. By 2003 nearly 2.7 million people in the UK were receiving government disability benefits which the government could not sustain. Such large numbers indicated the lack of vocational rehabilitation services throughout the UK. As a result, ‘Jobcentre’ was created to facilitate work services for disability, overseen by the Department for Work & Pensions. Current Currently, a variety of services are in place to facilitate vocational rehabilitation. In 2005, the Department of Health released “The National Service Framework for Long-term Conditions”. The report was a part of a government plan to improve support for those with long-term health conditions and worked closely with improvements to the NHS, who are in part responsible for assisting those in need of vocational rehabilitation. The British Society of Rehabilitation Medicine represents medical professionals involved in vocational rehabilitation services, who are an important part of the rehabilitation process. However, it is widely understood that the responsibility for the success of vocational rehabilitation services is largely with the employer. This includes creating healthy workplace environments, providing mentors, creating stable work hours and providing a large variety of workplace necessities. As a result, the Vocational Rehabilitation Association supports businesses who facilitate vocational rehabilitation for their employees. In 2016, the NHS released “Commissioning Guidance for Rehabilitation” which served as an official document for rehabilitation providers. It outlined clear guidelines on expectations and policies in regard to administering rehabilitation services, including vocational rehabilitation. JobCentre Plus provides people in vocational rehabilitation programs with a variety of services to support their rehabilitation process. Firstly, they provide Disability Employment Advisors which supervise the process of somebody returning to and staying in the workplace. They also provide the Alternative and Augmentative Communication scheme to facilitate those with limited communication skills in the workplace, and the Access to Work Scheme which provides employers of people with disabilities with suitable resources. Criticisms Only 14% of brain injury patients in the UK successfully remain at full-time work 30 months after their injury, even after the use of vocational rehabilitation services. Whilst a large amount of money is put into such services, the average payback period for people who successfully maintain employment is as long as 20 months. Vocational rehabilitation in Australia History The ‘Disability Services Act’ in 1986 created standards for Australians with disabilities and was later amended, in 1993, to include financial support. In 2014, it became the ‘Disability Inclusion Act’ which officially recognised the human rights of people with disabilities. In 2007, the ‘Disability Services (Rehabilitation Services) Guidelines’ was developed to create outlines on how to provide rehabilitation services in Australia. In 2017, it was amended and included further guidelines on the facilitation of rehabilitation processes. In 1990 the Australian government created the ‘Disability Reform Package’ which improved financial support for disability related issues. Vocational rehabilitation is also made available to veterans in Australia, with the ‘Veterans’ Vocational Rehabilitation Scheme’ being created under the ‘Veterans’ Entitlement Act 1986’ which focused on stable employment and further, employment retention for veterans. The importance of recognising not only physical but mental disabilities of veterans, however, is a recent revelation that has led to an increased focused in programs to support such disabilities. Current From 2006, the Australian government introduced a policy where people who were capable of seeking and maintaining employment had an obligation to do so. In return countless services and financial support options are made available to facilitate the return to work. To be eligible for vocational rehabilitation services an individual must have some form of a disability that is preventative of employment retention. Some people may be eligible for counselling services, as well as guidance and rehabilitation services. Financial and housing services and assistants in the workplace are further available to those who qualify for such level of rehabilitation. The differing levels of support offered are determined through a Job Capacity Assessment in which an individual's needs are assessed and then appropriately met. Typically, vocational rehabilitation services are offered through independent organisations associated with workplaces, or individual workplaces themselves with occupational therapists, psychologists, physiotherapists and exercise physiologists often utilised in the process. The National Disability Insurance Scheme was introduced in 2013 as a means of providing better financial support for people with disability. It was an important factor in better improving job security for people with disability by providing them with increased social and economic freedom. The ‘Employer Incentive Scheme’ (Australian Government, 2016) provides financial support to employers who actively participate in vocational rehabilitation; however, such support is only available if employers comply with ‘Disability Services (Rehabilitation Services) Guidelines’. Criticisms In Australia, there has been limited research dedicated to vocational rehabilitation, with most of the research coming from the United States. Furthermore, providers of vocational rehabilitation in Australia are not required to obtain any form of certifications. Resultantly, the teaching of vocational rehabilitation at universities needs to be improved in order to improve the state of vocational rehabilitation in Australia. By disability or condition For common mental disorders Many workers have an increased risk of developing common mental disorders (CMDs) in the workplace due to job stressors such as job insecurity, bullying or psychological harassment, low social support at work, employee perceptions of fairness in the workplace, and an imbalance between job demands and rewards. These CMDs may include anxiety disorders, alcohol dependence, addiction-related disorders, suicidal ideation, and depression A symptom of CMDs is having disorganized and deteriorated habits. Therefore, during work rehabilitation, occupational therapists and/or other rehabilitation professionals often use a graded environment, intentionally eliminating barriers to increase individuals' performance and self-esteem. An integrative approach, based on the three key disciplines of medicine, public health, and psychology, is being utilized by occupational therapists to reduce job stressors and improve the psychological well-being of employees with CMDs. The purpose of an integrative approach is to prevent further harm to the employee and to learn how to manage the illness through health promotion, occupational psychology, positive psychology management, psychiatry, and occupational medicine. Cognitive work hardening programs administered by occupational therapists using the Canadian Model of Client-Centered Enablement (CMCE) improve return to work outcomes of employees who have depression. Cognitive work hardening incorporates meaningful occupations or work tasks that are graded to fit individual needs within an environment that is supportive in order to improve self-worth. Cognitive work hardening programs are individualized to promote interpersonal communication and coping skills within a real-life work setting. The Stimulating Healthy Participation and Relapse Prevention (SHARP) approach is used for individuals with CMDs who experience many sick absences from work. The SHARP approach encompasses five steps including: listing positive and negative situations encountered in the workplace; solutions to negative situations or problems; support need for solutions; planning how to implement solutions; and evaluation of implementation See also European Platform for Rehabilitation Psychiatric rehabilitation Rehabilitation counseling Vocational education Vocational Rehabilitation and Employment (Disabled Persons) Convention, 1983 References Rehabilitation medicine Occupational safety and health Disability Articles containing video clips

Deinstitutionalisation

Deinstitutionalisation (or deinstitutionalization) is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. In the 1950's and 1960's, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses, group homes, and clinics, in regular hospitals, or not at all. Deinstitutionalisation works in two ways. The first focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates. The second focuses on reforming psychiatric care to reduce (or avoid encouraging) feelings of dependency, hopelessness and other behaviors that make it hard for patients to adjust to a life outside of care. The modern deinstitutionalisation movement was made possible by the discovery of psychiatric drugs in the mid-20th century, which could manage psychotic episodes and reduced the need for patients to be confined and restrained. Another major impetus was a series of socio-political movements that campaigned for patient freedom. Lastly, there were financial imperatives, with many governments also viewing it as a way to save costs. The movement to reduce institutionalisation was met with wide acceptance in Western countries, though its effects have been the subject of many debates. Critics of the policy include defenders of the previous policies as well as those who believe the reforms did not go far enough to provide freedom to patients. History 19th century The 19th century saw a large expansion in the number and size of asylums in Western industrialised countries. In contrast to the prison-like asylums of old, these were designed to be comfortable places where patients could live and be treated, in keeping with the movement towards "moral treatment". In spite of these ideals, they became overstretched, non-therapeutic, isolated in location, and neglectful of patients. 20th century By the beginning of the 20th century, increasing admissions had resulted in serious overcrowding, causing many problems for psychiatric institutions. Funding was often cut, especially during periods of economic decline and wartime. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patients; many patients starved to death. The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. Eugenics and Aktion T4 The eugenics movement started in the late 19th century, but reached the height of its influence between the two world wars. One stated aim was to improve the health of the nation by ‘breeding out defects’, isolating people with disabilities and ensuring they could not procreate. Charles Darwin's son lobbied the British government to arrest people deemed as ‘unfit’, then segregate them in colonies or sterilise them. At the same time, in Germany medics and lawyers joined forces to argue for the extermination of people with disabilities. The 1920 essay, “Permitting the Destruction of Life Unworthy of Life” is seen by many as a blueprint for the Nazis’ future crimes against humanity. In 1939, the Nazi regime began ‘Aktion T4’. Through this programme, psychiatric institutions for children and adults with disabilities were transformed into killing centres. The government compelled midwives to report all babies born with disabilities, then coerced parents to place their children in institutions. Visits were discouraged or forbidden. Then medical personnel transformed a programme of institutionalisation into extermination. More than 5,000 children were killed in the network of institutions for children with disabilities, followed by more than 200,000 disabled adults. The medical and administrative teams who developed the first mass extermination programme were transferred – together with their killing technology – to set up and manage the death camps of Treblinka and Sobibor during the Holocaust. The Nazi crimes against people with mental illness and disabilities in institutions was one of the catalysts for moving away from an institutionalised approach to mental health and disability in the second half of the 20th century. Origins of the modern movement The advent of chlorpromazine and other antipsychotic drugs in the 1950s and 1960s played an important role in permitting deinstitutionalisation, but it was not until social movements campaigned for reform in the 1960s that the movement gained momentum. A key text in the development of deinstitutionalisation was Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, a 1961 book by sociologist Erving Goffman. The book is one of the first sociological examinations of the social situation of mental patients, the hospital. Based on his participant observation field work, the book details Goffman's theory of the "total institution" (principally in the example he gives, as the title of the book indicates, mental institutions) and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor", suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Franco Basaglia, a leading Italian psychiatrist who inspired and was the architect of the psychiatric reform in Italy, also defined mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents, and patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. Other critics went further and campaigned against all involuntary psychiatric treatment. In 1970, Goffman worked with Thomas Szasz and George Alexander to found the American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH), who proposed abolishing all involuntary psychiatric intervention, particularly involuntary commitment, against individuals. The association provided legal help to psychiatric patients and published a journal, The Abolitionist, until it was dissolved in 1980. Reform The prevailing public arguments, time of onset, and pace of reforms varied by country. Leon Eisenberg lists three key factors that led to deinstitutionalisation gaining support. The first factor was a series of socio-political campaigns for the better treatment of patients. Some of these were spurred on by institutional abuse scandals in the 1960s and 1970s, such as Willowbrook State School in the United States and Ely Hospital in the United Kingdom. The second factor was new psychiatric medications made it more feasible to release people into the community and the third factor was financial imperatives. There was an argument that community services would be cheaper. Mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation. However, the 20th century marked the development of the first community services designed specifically to divert deinstitutionalization and to develop the first conversions from institutional, governmental systems to community majority systems (governmental-NGO-For Profit). These services are so common throughout the world (e.g., individual and family support services, groups homes, community and supportive living, foster care and personal care homes, community residences, community mental health offices, supported housing) that they are often "delinked" from the term deinstitutionalization. Common historical figures in deinstitutionalization in the US include Geraldo Rivera, Robert Williams, Burton Blatt, Gunnar Dybwad, Michael Kennedy, Frank Laski, Steven J. Taylor, Douglas P. Biklen, David Braddock, Robert Bogdan and K. C. Lakin. in the fields of "intellectual disabilities" (e.g., amicus curae, Arc-US to the US Supreme Court; US state consent decrees). Community organizing and development regarding the fields of mental health, traumatic brain injury, aging (nursing facilities) and children's institutions/private residential schools represent other forms of diversion and "community re-entry". Paul Carling's book, Return to the Community: Building Support Systems for People with Psychiatric Disabilities describes mental health planning and services in that regard, including for addressing the health and personal effects of "long term institutionalization". and the psychiatric field continued to research whether "hospitals" (e.g., forced involuntary care in a state institution; voluntary, private admissions) or community living was better. US states have made substantial investments in the community, and similar to Canada, shifted some but not all institutional funds to the community sectors as deinstitutionalization. For example, NYS Education, Health and Social Services Laws identify mental health personnel in the state of New York, and the two term Obama Presidency in the US created a high-level Office of Social and Behavioral Services. The 20th century marked the growth in a class of deinstitutionalization and community researchers in the US and world, including a class of university women. These women follow university education on social control and the myths of deinstitutionalization, including common forms of transinstitutionalization such as transfers to prison systems in the 21st century, "budget realignments", and the new subterfuge of community data reporting. Consequences Community services that developed include supportive housing with full or partial supervision and specialised teams (such as assertive community treatment and early intervention teams). Costs have been reported as generally equivalent to inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded the community alternatives are). Although deinstitutionalisation has been positive for the majority of patients, it also has shortcomings. Walid Fakhoury and Stefan Priebe suggest that modern day society now faces a new problem of "reinstitutionalisation". and many critics argue that the policy left patients homeless or in prison. Leon Eisenberg has argued that deinstitutionalisation was generally positive for patients, while noting that some were left homeless or without care. Medication There was an increase in prescriptions of psychiatric medication in the years following deinstitutionalization. Although most of these drugs had been discovered in the years before, deinstitutionalisation made it far cheaper to care for a mental health patient and increased the profitability of the drugs. Some researchers argue that this created economic incentives to increase the frequency of psychiatric diagnosis (and related diagnoses, such as ADHD in children) that did not happen in the era of costly hospitalized psychiatry. In most countries (except some countries that are either in extreme poverty or are hindered from importing psychiatric drugs by their customs regulations), more than 10% of the population are now on some form of psychiatric medicine. This increases to more than 15% in some countries such as the United Kingdom. A 2012 study by Kales, Pierce and Greenblatt argued that these medicines were being overprescribed. Victimisation Moves to community living and services have led to various concerns and fears, from both the individuals themselves and other members of the community. Over a quarter of individuals accessing community mental health services in a US inner-city area are victims of at least one violent crime per year, a proportion eleven times higher than the inner-city average. The elevated victim rate holds for every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. Victimisation rates are similar to those with developmental disabilities. Misconceptions There is a common perception by the public and media that people with mental disorders are more likely to be dangerous and violent if released into the community. However, a large 1998 study in Archives of General Psychiatry suggested that discharged psychiatric patients without substance abuse symptoms are no more likely to commit violence than others without substance abuse symptoms in their neighborhoods, which were usually economically deprived and high in substance abuse and crime. The study also reported that a higher proportion of the patients than of the others in the neighborhoods reported symptoms of substance abuse. Findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of more serious offences such as homicide have sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not been increased by deinstitutionalisation. The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers. The argument that deinstitutionalization has led to increases in homelessness can also be viewed a misconception with some suggesting a correlative rather than causative relationship between the two. It has been argued that in United States, loss of low-income housing and disability benefits are the core causes of homelessness historically and placing the blame on deinstitutionalization is an oversimplification which does not take into account the other policy changes which occurred during the same time. Reinstitutionalisation Some mental health academics and campaigners have argued that deinstitutionalisation was well-intentioned for trying to make patients less dependent on psychiatric care, but in practice patients were still left being dependent on the support of a mental healthcare system, a phenomenon known as "reinstitutionalisation" or "transinstitutionalisation". The argument is that community services can leave the mentally ill in a state of social isolation (even if it is not physical isolation), frequently meeting other service users but having little contact with the rest of the public community. Fakhoury and Priebe said that instead of "community psychiatry", reforms established a "psychiatric community". Julie Racino argues that having a closed social circle like this can limit opportunities for mentally ill people to integrate with the wider society, such as personal assistance services. Other criticisms Criticism of deinstitutionalisation takes on a number of forms. Some, like E. Fuller Torrey, defend the use of psychiatric institutions and conclude that deinstitutionalisation was a move in the wrong direction entirely. Torrey has opposed deinstitutionalisation in principle, arguing that people with mental illness will be resistant to medical help due to the nature of their conditions. These views have made him a controversial figure in psychiatry. He believes that reducing psychiatrists' powers to use involuntary commitment led to many patients losing out on treatment, and that many who would have previously lived in institutions are now homeless or in prison. Another form of critique argues that while deinstitutionalization was a move in the right direction and had laudable goals, many shortcomings in the execution stage have made it unsuccessful thus far. New community services developed as alternatives to institutionalization leave patients dependent still on the support of mental healthcare without clear evidence of providing adequate treatment and support. Multiple for-profit businesses, non-profit organizations and multiple levels of government involved have been criticized as being uncoordinated, underfunded and unable to meet complex needs. In a 1998 study of the effects of deinstitutionalisation in the United Kingdom, Means and Smith argue that the program had some successes, such as increasing the participation of volunteers in mental healthcare, but that it was underfunded and let down by a lack of coordination between the health service and social services. Thomas Szasz, a longtime opponent of involuntary psychiatric treatment, argued that the reforms never addressed the aspects of psychiatry that he objected to, particularly his belief that mental illnesses are not true illnesses but medicalized social and personal problems. Worldwide Asia Hong Kong In Hong Kong, a number of residential care services such as halfway houses, long-stay care homes, supported hostels are provided for the discharged patients. In addition, community support services such as rehabilitation day services and mental health care have been launched to facilitate the patients' re-integration into the community. Japan Unlike most developed countries, Japan has not followed a program of deinstitutionalisation. The number of hospital beds has risen steadily over the last few decades. Physical restraints are used far more often. In 2014, more than 10,000 people were restrained–the highest ever recorded, and more than double the number a decade earlier. In 2018, the Japanese Ministry of Health introduced revised guidelines that placed more restrictions against the use of restraints. Africa Uganda has one psychiatric hospital. There are only 40 psychiatrists in Uganda. The World Health Organization estimates that 90% of mentally ill people in the country never get treatment. Australia and Oceania New Zealand New Zealand established a reconciliation initiative in 2005 to address the ongoing compensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. A number of grievances were heard, including: poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate mechanisms for dealing with complaints; pressures and difficulties for staff, within an authoritarian hierarchy based on containment; fear and humiliation in the misuse of seclusion; over-use and abuse of ECT, psychiatric medications, and other treatments as punishments, including group therapy, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice, and emotional distress and trauma. There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, along with advice on their rights, including access to records and legal redress. Europe Republic of Ireland The Republic of Ireland formerly had the highest psychiatric hospitalisation rate of any Western country. The Lunatic (Asylums) Act, 1875, the Criminal Lunatics Act, 1838 and the Private Lunatic Asylums Act of 1842 created a network of large "district asylums". The Mental Treatment Act, 1945 caused some modernisation but by 1958 the Republic of Ireland still had the highest psychiatric hospitalisation rate in the world. In the 1950s and '60s there was a transition to outpatient facilities and care homes. The 1963 Irish Psychiatric Hospital Census noted the extremely high hospitalisation rate of unmarried people; six times the equivalent in England and Wales. In all, about 1% of the population was living in a psychiatric hospital. In 1963–1978, Irish psychiatric hospitalisation rates were times that of England. Health Boards were set up in 1970 and the Health (Mental Services) Act 1981 was passed in order to prevent the wrongful hospitalisation of individuals. In the 1990s, there was still about 25,000 patients in the asylums. In 2009, the government committed to closing two psychiatric hospitals every year; in 2008, there were still 1,485 patients housed in "inappropriate conditions". Today, Ireland's hospitalisation rate to a position of equality with other comparable countries. In the public sector virtually no patients remain in 19th-century mental hospitals; acute care is provided in general hospital units. Acute private care is still delivered in stand-alone psychiatric hospitals. The Central Mental Hospital in Dublin is used as a secure psychiatric hospital for criminal offenders, with room for 84 patients. Italy Italy was the first country to begin the deinstitutionalisation of mental health care and to develop a community-based psychiatric system. The Italian system served as a model of effective service and paved the way for deinstitutionalisation of mental patients. Since the late 1960s, the Italian physician Giorgio Antonucci questioned the basis itself of psychiatry. After working with Edelweiss Cotti in 1968 at the Centro di Relazioni Umane in Cividale del Friuli – an open ward created as an alternative to the psychiatric hospital – from 1973 to 1996 Antonucci worked on the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli of Imola and the liberation – and restitution to life – of the people there secluded. In 1978, the Basaglia Law had started Italian psychiatric reform that resulted in the end of the Italian state mental hospital system in 1998. The reform was focused on the gradual dismantlement of psychiatric hospitals, which required an effective community mental health service. The object of community care was to reverse the long-accepted practice of isolating the mentally ill in large institutions and to promote their integration in a socially stimulating environment, while avoiding subjecting them to excessive social pressures. The work of Giorgio Antonucci, instead of changing the form of commitment from the mental hospital to other forms of coercion, questions the basis of psychiatry, affirming that mental hospitals are the essence of psychiatry and rejecting any possible reform of psychiatry, that must be eliminated. United Kingdom In the United Kingdom, the trend towards deinstitutionalisation began in the 1950s. At the time, 0.4% of the population of England were housed in asylums. The government of Harold Macmillan sponsored the Mental Health Act 1959, which removed the distinction between psychiatric hospitals and other types of hospitals. Enoch Powell, the Minister of Health in the early 1960s, criticized psychiatric institutions in his 1961 "Water Tower" speech and called for most of the care to be transferred to general hospitals and the community. The campaigns of Barbara Robb and several scandals involving mistreatment at asylums (notably Ely Hospital) furthered the campaign. The Ely Hospital scandal led to an inquiry led by Brian Abel-Smith and a 1971 white paper that recommended further reform. The policy of deinstitutionalisation came to be known as Care in the Community at the time it was taken up by the government of Margaret Thatcher. Large-scale closures of the old asylums began in the 1980s. By 2015, none remained. North America United States The United States has experienced two main waves of deinstitutionalisation. The first wave began in the 1950s and targeted people with mental illness. The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability. Loren Mosher argues that deinstitutionalisation fully began in the 1970s and was due to financial incentives like SSI and Social Security Disability, rather than after the earlier introduction of psychiatric drugs. The most important factors that led to deinstitutionalisation were changing public attitudes to mental health and mental hospitals, the introduction of psychiatric drugs and individual states' desires to reduce costs from mental hospitals. The federal government offered financial incentives to the states to achieve this goal. Stroman pinpoints World War II as the point when attitudes began to change. In 1946, Life magazine published one of the first exposés of the shortcomings of mental illness treatment. Also in 1946, Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health (NIMH). NIMH was pivotal in funding research for the developing mental health field. President John F. Kennedy had a special interest in the issue of mental health because his sister, Rosemary, had incurred brain damage after being lobotomised at the age of 23. His administration sponsored the successful passage of the Community Mental Health Act, one of the most important laws that led to deinstitutionalization. The movement continued to gain momentum during the Civil Rights Movement. The 1965 amendments to Social Security shifted about 50% of the mental health care costs from states to the federal government, motivating state governments to promote deinstitutionalization. The 1970s saw the founding of several advocacy groups, including Liberation of Mental Patients, Project Release, Insane Liberation Front, and the National Alliance on Mental Illness (NAMI). The lawsuits these activist groups filed led to some key court rulings in the 1970s that increased the rights of patients. In 1973, a federal district court ruled in Souder v. Brennan that whenever patients in mental health institutions performed activity that conferred an economic benefit to an institution, they had to be considered employees and paid the minimum wage required by the Fair Labor Standards Act of 1938. Following this ruling, institutional peonage was outlawed. In the 1975 ruling O'Connor v. Donaldson, the U.S. Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with the 1978 ruling Addington v. Texas, further restricting states from confining anyone involuntarily for mental illness. In 1975, the United States Court of Appeals for the First Circuit ruled in favour of the Mental Patient's Liberation Front in Rogers v. Okin, establishing the right of a patient to refuse treatment. Later reforms included the Mental Health Parity Act, which required health insurers to give mental health patients equal coverage. Other factors included scandals. A 1972 television broadcast exposed the abuse and neglect of 5,000 patients at the Willowbrook State School in Staten Island, New York. The Rosenhan's experiment in 1973 caused several psychiatric hospitals to fail to notice fake patients who showed no symptoms once they were institutionalized. The pitfalls of institutionalization were dramatized in an award-winning 1975 film, One Flew Over the Cuckoo's Nest. In 1955, for every 100,000 US citizens there were 340 psychiatric hospital beds. In 2005 that number had diminished to 17 per 100,000. South America In several South American countries, such as in Argentina, the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings. In Brazil, there are 6,003 psychiatrists, 18,763 psychologists, 1,985 social workers, 3,119 nurses and 3,589 occupational therapists working for the Unified Health System (SUS). At primary care level, there are 104,789 doctors, 184,437 nurses and nurse technicians and 210,887 health agents. The number of psychiatrists is roughly 5 per 100,000 inhabitants in the Southeast region, and the Northeast region has less than 1 psychiatrist per 100,000 inhabitants. The number of psychiatric nurses is insufficient in all geographical areas, and psychologists outnumber other mental health professionals in all regions of the country. The rate of beds in psychiatric hospitals in the country is 27.17 beds per 100,000 inhabitants. The rate of patients in psychiatric hospitals is 119 per 100,000 inhabitants. The average length of stay in mental hospitals is 65.29 days. See also Homeless dumping Obligatory Dangerousness Criterion Outpatient commitment General Ableism Ankang (asylum) Institutional syndrome Involuntary commitment Inclusion (disability rights) Mental health Public housing Psychiatric survivors movement Right to housing Voluntary commitment References Bibliography Further reading

Mental health

Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. According to the World Health Organization (WHO), it is a "state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community". It likewise determines how an individual handles stress, interpersonal relationships, and decision-making. Mental health includes subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one's intellectual and emotional potential, among others. From the perspectives of positive psychology or holism, mental health may include an individual's ability to enjoy life and to create a balance between life activities and efforts to achieve psychological resilience. Cultural differences, personal philosophy, subjective assessments, and competing professional theories all affect how one defines "mental health". Some early signs related to mental health difficulties are sleep irritation, lack of energy, lack of appetite, thinking of harming oneself or others, self-isolating (though introversion and isolation aren't necessarily unhealthy), and frequently zoning out. Mental disorders Mental health, as defined by the Public Health Agency of Canada, is an individual's capacity to feel, think, and act in ways to achieve a better quality of life while respecting personal, social, and cultural boundaries. Impairment of any of these are risk factor for mental disorders, or mental illnesses, which are a component of mental health. In 2019, about 970 million people worldwide suffered from a mental disorder, with anxiety and depression being the most common. The number of people suffering from mental disorders has risen significantly throughout the years. Mental disorders are defined as health conditions that affect and alter cognitive functioning, emotional responses, and behavior associated with distress and/or impaired functioning. The ICD-11 is the global standard used to diagnose, treat, research, and report various mental disorders. In the United States, the DSM-5 is used as the classification system of mental disorders. Mental health is associated with a number of lifestyle factors such as diet, exercise, stress, drug abuse, social connections and interactions. Psychiatrists, psychologists, licensed professional clinical counselors, social workers, nurse practitioners, and family physicians can help manage mental illness with treatments such as therapy, counseling, and medication. History Early history In the mid-19th century, William Sweetser was the first to coin the term mental hygiene, which can be seen as the precursor to contemporary approaches to work on promoting positive mental health. Isaac Ray, the fourth president of the American Psychiatric Association and one of its founders, further defined mental hygiene as "the art of preserving the mind against all incidents and influences calculated to deteriorate its qualities, impair its energies, or derange its movements". In American history, mentally ill patients were thought to be religiously punished. This response persisted through the 1700s, along with the inhumane confinement and stigmatization of such individuals. Dorothea Dix (1802–1887) was an important figure in the development of the "mental hygiene" movement. Dix was a school teacher who endeavored to help people with mental disorders and to expose the sub-standard conditions into which they were put. This became known as the "mental hygiene movement". Before this movement, it was not uncommon that people affected by mental illness would be considerably neglected, often left alone in deplorable conditions without sufficient clothing. From 1840 to 1880, she won the support of the federal government to set up over 30 state psychiatric hospitals; however, they were understaffed, under-resourced, and were accused of violating human rights. Emil Kraepelin in 1896 developed the taxonomy of mental disorders which has dominated the field for nearly 80 years. Later, the proposed disease model of abnormality was subjected to analysis and considered normality to be relative to the physical, geographical and cultural aspects of the defining group. At the beginning of the 20th century, Clifford Beers founded "Mental Health America – National Committee for Mental Hygiene", after publication of his accounts as a patient in several lunatic asylums, A Mind That Found Itself, in 1908 and opened the first outpatient mental health clinic in the United States. The mental hygiene movement, similar to the social hygiene movement, had at times been associated with advocating eugenics and sterilization of those considered too mentally deficient to be assisted into productive work and contented family life. In the post-WWII years, references to mental hygiene were gradually replaced by the term 'mental health' due to its positive aspect that evolves from the treatment of illness to preventive and promotive areas of healthcare. Deinstitutionalization and transinstitutionalization When US government-run hospitals were accused of violating human rights, advocates pushed for deinstitutionalization: the replacement of federal mental hospitals for community mental health services. The closure of state-provisioned psychiatric hospitals was enforced by the Community Mental Health Centers Act in 1963 that laid out terms in which only patients who posed an imminent danger to others or themselves could be admitted into state facilities. This was seen as an improvement from previous conditions. However, there remains a debate on the conditions of these community resources. It has been proven that this transition was beneficial for many patients: there was an increase in overall satisfaction, a better quality of life, and more friendships between patients all at an affordable cost. This proved to be true only in the circumstance that treatment facilities had enough funding for staff and equipment as well as proper management. However, this idea is a polarizing issue. Critics of deinstitutionalization argue that poor living conditions prevailed, patients were lonely, and they did not acquire proper medical care in these treatment homes. Additionally, patients that were moved from state psychiatric care to nursing and residential homes had deficits in crucial aspects of their treatment. Some cases result in the shift of care from health workers to patients' families, where they do not have the proper funding or medical expertise to give proper care. On the other hand, patients that are treated in community mental health centers lack sufficient cancer testing, vaccinations, or otherwise regular medical check-ups. Other critics of state deinstitutionalization argue that this was simply a transition to "transinstitutionalization", or the idea that prisons and state-provisioned hospitals are interdependent. In other words, patients become inmates. This draws on the Penrose Hypothesis of 1939, which theorized that there was an inverse relationship between prisons' population size and the number of psychiatric hospital beds. This means that populations that require psychiatric mental care will transition between institutions, which in this case, includes state psychiatric hospitals and criminal justice systems. Thus, a decrease in available psychiatric hospital beds occurred at the same time as an increase in inmates. Although some are skeptical that this is due to other external factors, others will reason this conclusion to a lack of empathy for the mentally ill. There is no argument for the social stigmatization of those with mental illnesses, they have been widely marginalized and discriminated against in society. In this source, researchers analyze how most compensation prisoners (detainees who are unable or unwilling to pay a fine for petty crimes) are unemployed, homeless, and with an extraordinarily high degree of mental illnesses and substance use disorders. Compensation prisoners then lose prospective job opportunities, face social marginalization, and lack access to resocialization programs, which ultimately facilitate reoffending. The research sheds light on how the mentally ill—and in this case, the poor—are further punished for certain circumstances that are beyond their control, and that this is a vicious cycle that repeats itself. Thus, prisons embody another state-provisioned mental hospital. Families of patients, advocates, and mental health professionals still call for increase in more well-structured community facilities and treatment programs with a higher quality of long-term inpatient resources and care. With this more structured environment, the United States will continue with more access to mental health care and an increase in the overall treatment of the mentally ill. However, there is still a lack of studies for mental health conditions (MHCs) to raise awareness, knowledge development, and attitudes toward seeking medical treatment for MHCs in Bangladesh. People in rural areas often seek treatment from the traditional healers and MHCs are sometimes considered a spiritual matter. Epidemiology Mental illnesses are more common than cancer, diabetes, or heart disease. As of 2021, over 22 percent of all Americans over the age of 18 meet the criteria for having a mental illness. Evidence suggests that 970 million people worldwide have a mental disorder. Major depression ranks third among the top 10 leading causes of disease worldwide. By 2030, it is predicted to become the leading cause of disease worldwide. Over 700 thousand people commit suicide every year and around 14 million attempt it. A World Health Organization (WHO) report estimates the global cost of mental illness at nearly $2.5 trillion (two-thirds in indirect costs) in 2010, with a projected increase to over $6 trillion by 2030. Evidence from the WHO suggests that nearly half of the world's population is affected by mental illness with an impact on their self-esteem, relationships and ability to function in everyday life. An individual's emotional health can impact their physical health. Poor mental health can lead to problems such as the inability to make adequate decisions and substance use disorders. Good mental health can improve life quality whereas poor mental health can worsen it. According to Richards, Campania, & Muse-Burke, "There is growing evidence that is showing emotional abilities are associated with pro-social behaviors such as stress management and physical health." Their research also concluded that people who lack emotional expression are inclined to anti-social behaviors (e.g., substance use disorder and alcohol use disorder, physical fights, vandalism), which reflects one's mental health and suppressed emotions. Adults and children who face mental illness may experience social stigma, which can exacerbate the issues. Global prevalence Mental health can be seen as a continuum, where an individual's mental health may have many different possible values. Mental wellness is viewed as a positive attribute; this definition of mental health highlights emotional well-being, the capacity to live a full and creative life, and the flexibility to deal with life's inevitable challenges. Some discussions are formulated in terms of contentment or happiness. Many therapeutic systems and self-help books offer methods and philosophies espousing strategies and techniques vaunted as effective for further improving the mental wellness. Positive psychology is increasingly prominent in mental health. A holistic model of mental health generally includes concepts based upon anthropological, educational, psychological, religious, and sociological perspectives. There are also models as theoretical perspectives from personality, social, clinical, health and developmental psychology. The tripartite model of mental well-being views mental well-being as encompassing three components of emotional well-being, social well-being, and psychological well-being. Emotional well-being is defined as having high levels of positive emotions, whereas social and psychological well-being are defined as the presence of psychological and social skills and abilities that contribute to optimal functioning in daily life. The model has received empirical support across cultures. The Mental Health Continuum-Short Form (MHC-SF) is the most widely used scale to measure the tripartite model of mental well-being. Demographics Children and young adults As of 2019, about one in seven of the world's 10–19 year olds experienced a mental health disorder; about 165 million young people in total. A person's teenage years are a unique period where much crucial psychological development occurs, and is also a time of increased vulnerability to the development of adverse mental health conditions. More than half of mental health conditions start before a child reaches 20 years of age, with onset occurring in adolescence much more frequently than it does in early childhood or adulthood. Many such cases go undetected and untreated. In the United States alone, in 2021, at least roughly 17.5% of the population (ages 18 and older) were recorded as having a mental illness. The comparison between reports and statistics of mental health issues in newer generations (18–25 years old to 26–49 years old) and the older generation (50 years or older) signifies an increase in mental health issues as only 15% of the older generation reported a mental health issue whereas the newer generations reported 33.7% (18-25) and 28.1% (26-49). The role of caregivers for youth with mental health needs is valuable, and caregivers benefit most when they have sufficient psychoeducation and peer support. Depression is one of the leading causes of illness and disability among adolescents. Suicide is the fourth leading cause of death in 15-19-year-olds. Exposure to childhood trauma can cause mental health disorders and poor academic achievement. Ignoring mental health conditions in adolescents can impact adulthood. 50% of preschool children show a natural reduction in behavioral problems. The remaining experience long-term consequences. It impairs physical and mental health and limits opportunities to live fulfilling lives. A result of depression during adolescence and adulthood may be substance abuse. The average age of onset is between 11 and 14 years for depressive disorders. Only approximately 25% of children with behavioral problems refer to medical services. The majority of children go untreated. Homeless population Mental illness is thought to be highly prevalent among homeless populations, though access to proper diagnoses is limited. An article written by Lisa Goodman and her colleagues summarized Smith's research into PTSD in homeless single women and mothers in St. Louis, Missouri, which found that 53% of the respondents met diagnostic criteria, and which describes homelessness as a risk factor for mental illness. At least two commonly reported symptoms of psychological trauma, social disaffiliation and learned helplessness are highly prevalent among homeless individuals and families. While mental illness is prevalent, people infrequently receive appropriate care. Case management linked to other services is an effective care approach for improving symptoms in people experiencing homelessness. Case management reduced admission to hospitals, and it reduced substance use by those with substance abuse problems more than typical care. Immigrants and refugees States that produce refugees are sites of social upheaval, civil war, even genocide. Most refugees experience trauma. It can be in the form of torture, sexual assault, family fragmentation, and death of loved ones. Refugees and immigrants experience psychosocial stressors after resettlement. These include discrimination, lack of economic stability, and social isolation causing emotional distress. For example, Not far into the 1900s, campaigns targeting Japanese immigrants were being formed that inhibited their ability to participate in U.S life, painting them as a threat to the American working-class. They were subject to prejudice and slandered by American media as well as anti-Japanese legislation being implemented. For refugees family reunification can be one of the primary needs to improve quality of life. Post-migration trauma is a cause of depressive disorders and psychological distress for immigrants. Cultural and religious considerations Mental health is a socially constructed concept; different societies, groups, cultures (both ethnic and national/regional), institutions, and professions have very different ways of conceptualizing its nature and causes, determining what is mentally healthy, and deciding what interventions, if any, are appropriate. Thus, different professionals will have different cultural, class, political and religious backgrounds, which will impact the methodology applied during treatment. In the context of deaf mental health care, it is necessary for professionals to have cultural competency of deaf and hard of hearing people and to understand how to properly rely on trained, qualified, and certified interpreters when working with culturally Deaf clients. Research has shown that there is stigma attached to mental illness. Due to such stigma, individuals may resist labeling and may be driven to respond to mental health diagnoses with denialism. Family caregivers of individuals with mental disorders may also suffer discrimination or face stigma. Addressing and eliminating the social stigma and perceived stigma attached to mental illness has been recognized as crucial to education and awareness surrounding mental health issues. In the United Kingdom, the Royal College of Psychiatrists organized the campaign Changing Minds (1998–2003) to help reduce stigma, while in the United States, efforts by entities such as the Born This Way Foundation and The Manic Monologues specifically focus on removing the stigma surrounding mental illness. The National Alliance on Mental Illness (NAMI) is a U.S. institution founded in 1979 to represent and advocate for those struggling with mental health issues. NAMI helps to educate about mental illnesses and health issues, while also working to eliminate stigma attached to these disorders. Many mental health professionals are beginning to, or already understand, the importance of competency in religious diversity and spirituality, or the lack thereof. They are also partaking in cultural training to better understand which interventions work best for these different groups of people. The American Psychological Association explicitly states that religion must be respected. Education in spiritual and religious matters is also required by the American Psychiatric Association, however, far less attention is paid to the damage that more rigid, fundamentalist faiths commonly practiced in the United States can cause. This theme has been widely politicized in 2018 such as with the creation of the Religious Liberty Task Force in July of that year. Also, many providers and practitioners in the United States are only beginning to realize that the institution of mental healthcare lacks knowledge and competence of many non-Western cultures, leaving providers in the United States ill-equipped to treat patients from different cultures. Occupations Occupational therapy Occupational therapy practitioners aim to improve and enable a client or group's participation in meaningful, everyday occupations. In this sense, occupation is defined as any activity that "occupies one's time". Examples of those activities include daily tasks (dressing, bathing, eating, house chores, driving, etc.), sleep and rest, education, work, play, leisure (hobbies), and social interactions. The OT profession offers a vast range of services for all stages of life in a myriad of practice settings, though the foundations of OT come from mental health. Community support for mental health through expert-moderated support groups can aid those who want to recover from mental illness or otherwise improve their emotional well-being. OT services focused on mental health can be provided to persons, groups, and populations across the lifespan and experiencing varying levels of mental health performance. For example, occupational therapy practitioners provide mental health services in school systems, military environments, hospitals, outpatient clinics, and inpatient mental health rehabilitation settings. Interventions or support can be provided directly through specific treatment interventions or indirectly by providing consultation to businesses, schools, or other larger groups to incorporate mental health strategies on a programmatic level. Even people who are mentally healthy can benefit from the health promotion and additional prevention strategies to reduce the impact of difficult situations. The interventions focus on positive functioning, sensory strategies, managing emotions, interpersonal relationships, sleep, community engagement, and other cognitive skills (i.e. visual-perceptual skills, attention, memory, arousal/energy management, etc.). Mental health in social work Social work in mental health, also called psychiatric social work, is a process where an individual in a setting is helped to attain freedom from overlapping internal and external problems (social and economic situations, family and other relationships, the physical and organizational environment, psychiatric symptoms, etc.). It aims for harmony, quality of life, self-actualization and personal adaptation across all systems. Psychiatric social workers are mental health professionals that can assist patients and their family members in coping with both mental health issues and various economic or social problems caused by mental illness or psychiatric dysfunctions and to attain improved mental health and well-being. They are vital members of the treatment teams in Departments of Psychiatry and Behavioral Sciences in hospitals. They are employed in both outpatient and inpatient settings of a hospital, nursing homes, state and local governments, substance use clinics, correctional facilities, health care services, private practice, etc. In the United States, social workers provide most of the mental health services. According to government sources, 60 percent of mental health professionals are clinically trained social workers, 10 percent are psychiatrists, 23 percent are psychologists, and 5 percent are psychiatric nurses. Mental health social workers in Japan have professional knowledge of health and welfare and skills essential for person's well-being. Their social work training enables them as a professional to carry out Consultation assistance for mental disabilities and their social reintegration; Consultation regarding the rehabilitation of the victims; Advice and guidance for post-discharge residence and re-employment after hospitalized care, for major life events in regular life, money and self-management and other relevant matters to equip them to adapt in daily life. Social workers provide individual home visits for mentally ill and do welfare services available, with specialized training a range of procedural services are coordinated for home, workplace and school. In an administrative relationship, Psychiatric social workers provides consultation, leadership, conflict management and work direction. Psychiatric social workers who provides assessment and psychosocial interventions function as a clinician, counselor and municipal staff of the health centers. Risk factors and causes of mental health problems There are many things that can contribute to mental health problems, including biological factors, genetic factors, life experiences (such as psychological trauma or abuse), and a family history of mental health problems. Biological factors According to the National Institute of Health Curriculum Supplement Series book, most scientists believe that changes in neurotransmitters can cause mental illnesses. In the section "The Biology of Mental Illnesses" the issue is explained in detail, "...there may be disruptions in the neurotransmitters dopamine, glutamate, and norepinephrine in individuals who have schizophrenia". Demographic factors Gender, age, ethnicity, life expectancy, longevity, population density, and community diversity are all demographic characteristics that can increase the risk and severity of mental disorders. Existing evidence demonstrates that the female gender is connected with an elevated risk of depression at differerent phases of life, commencing in adolescence in different contexts. Females, for example, have a higher risk of anxiety and eating disorders, whereas males have a higher chance of substance abuse and behavioural and developmental issues. This does not imply that women are less likely to suffer from developmental disorders such autism spectrum disorder, attention deficit hyperactivity disorder, Tourette syndrome, or early-onset schizophrenia. Ethnicity and ethnic heterogeneity have also been identified as risk factors for the prevalence of mental disorders, with minority groups being at a higher risk due to discrimination and exclusion. Unemployment has been shown to hurt an individual's emotional well-being, self-esteem, and more broadly their mental health. Increasing unemployment has been shown to have a significant impact on mental health, predominantly depressive disorders. This is an important consideration when reviewing the triggers for mental health disorders in any population survey. According to a 2009 meta-analysis by Paul and Moser, countries with high income inequality and poor unemployment protections experience worse mental health outcomes among the unemployed. Emotional mental disorders are a leading cause of disabilities worldwide. Investigating the degree and severity of untreated emotional mental disorders throughout the world is a top priority of the World Mental Health (WMH) survey initiative, which was created in 1998 by the World Health Organization (WHO). "Neuropsychiatric disorders are the leading causes of disability worldwide, accounting for 37% of all healthy life years lost through disease. These disorders are most destructive to low and middle-income countries due to their inability to provide their citizens with proper aid. Despite modern treatment and rehabilitation for emotional mental health disorders, "even economically advantaged societies have competing priorities and budgetary constraints". Unhappily married couples suffer 3–25 times the risk of developing clinical depression. The World Mental Health survey initiative has suggested a plan for countries to redesign their mental health care systems to best allocate resources. "A first step is documentation of services being used and the extent and nature of unmet treatment needs. A second step could be to do a cross-national comparison of service use and unmet needs in countries with different mental health care systems. Such comparisons can help to uncover optimum financing, national policies, and delivery systems for mental health care." Knowledge of how to provide effective emotional mental health care has become imperative worldwide. Unfortunately, most countries have insufficient data to guide decisions, absent or competing visions for resources, and near-constant pressures to cut insurance and entitlements. WMH surveys were done in Africa (Nigeria, South Africa), the Americas (Colombia, Mexico, United States), Asia and the Pacific (Japan, New Zealand, Beijing and Shanghai in the People's Republic of China), Europe (Belgium, France, Germany, Italy, Netherlands, Spain, Ukraine), and the Middle East (Israel, Lebanon). Countries were classified with World Bank criteria as low-income (Nigeria), lower-middle-income (China, Colombia, South Africa, Ukraine), higher middle-income (Lebanon, Mexico), and high-income. The coordinated surveys on emotional mental health disorders, their severity, and treatments were implemented in the aforementioned countries. These surveys assessed the frequency, types, and adequacy of mental health service use in 17 countries in which WMH surveys are complete. The WMH also examined unmet needs for treatment in strata defined by the seriousness of mental disorders. Their research showed that "the number of respondents using any 12-month mental health service was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care". "High levels of unmet need worldwide are not surprising, since WHO Project ATLAS' findings of much lower mental health expenditures than was suggested by the magnitude of burdens from mental illnesses. Generally, unmet needs in low-income and middle-income countries might be attributable to these nations spending reduced amounts (usually <1%) of already diminished health budgets on mental health care, and they rely heavily on out-of-pocket spending by citizens who are ill-equipped for it". Stress The Centre for Addiction and Mental Health discusses how a certain amount of stress is a normal part of daily life. Small doses of stress help people meet deadlines, be prepared for presentations, be productive and arrive on time for important events. However, long-term stress can become harmful. When stress becomes overwhelming and prolonged, the risks for mental health problems and medical problems increase." Also on that note, some studies have found language to deteriorate mental health and even harm humans. The impact of a stressful environment has also been highlighted by different models. Mental health has often been understood from the lens of the vulnerability-stress model. In that context, stressful situations may contribute to a preexisting vulnerability to negative mental health outcomes being realized. On the other hand, the differential susceptibility hypothesis suggests that mental health outcomes are better explained by an increased sensitivity to the environment than by vulnerability. For example, it was found that children scoring higher on observer-rated environmental sensitivity often derive more harm from low-quality parenting, but also more benefits from high-quality parenting than those children scoring lower on that measure. Poverty Environmental factors Prevention and promotion "The terms mental health promotion and prevention have often been confused. Promotion is defined as intervening to optimize positive mental health by addressing determinants of positive mental health (i.e. protective factors) before a specific mental health problem has been identified, with the ultimate goal of improving the positive mental health of the population. Mental health prevention is defined as intervening to minimize mental health problems (i.e. risk factors) by addressing determinants of mental health problems before a specific mental health problem has been identified in the individual, group, or population of focus with the ultimate goal of reducing the number of future mental health problems in the population." In order to improve mental health, the root of the issue has to be resolved. "Prevention emphasizes the avoidance of risk factors; promotion aims to enhance an individual's ability to achieve a positive sense of self-esteem, mastery, well-being, and social inclusion." Mental health promotion attempts to increase protective factors and healthy behaviors that can help prevent the onset of a diagnosable mental disorder and reduce risk factors that can lead to the development of a mental disorder. Yoga is an example of an activity that calms one's entire body and nerves. According to a study on well-being by Richards, Campania, and Muse-Burke, "mindfulness is considered to be a purposeful state, it may be that those who practice it belief in its importance and value being mindful, so that valuing of self-care activities may influence the intentional component of mindfulness." Akin to surgery, sometimes the body must be further damaged, before it can properly heal Mental health is conventionally defined as a hybrid of the absence of a mental disorder and the presence of well-being. Focus is increasing on preventing mental disorders. Prevention is beginning to appear in mental health strategies, including the 2004 WHO report "Prevention of Mental Disorders", the 2008 EU "Pact for Mental Health" and the 2011 US National Prevention Strategy. Some commentators have argued that a pragmatic and practical approach to mental disorder prevention at work would be to treat it the same way as physical injury prevention. Prevention of a disorder at a young age may significantly decrease the chances that a child will have a disorder later in life, and shall be the most efficient and effective measure from a public health perspective. Prevention may require the regular consultation of a physician for at least twice a year to detect any signs that reveal any mental health concerns. Additionally, social media is becoming a resource for prevention. In 2004, the Mental Health Services Act began to fund marketing initiatives to educate the public on mental health. This California-based project is working to combat the negative perception with mental health and reduce the stigma associated with it. While social media can benefit mental health, it can also lead to deterioration if not managed properly. Limiting social media intake is beneficial. Studies report that patients in mental health care who can access and read their Electronic Health Records (EHR) or Open Notes online experience increased understanding of their mental health, feeling in control of their care, and enhanced trust in their clinicians. Patients' also reported feelings of greater validation, engagement, remembering their care plan, and acquiring a better awareness of potential side effects of their medications, when reading their mental health notes. Other common experiences were that shared mental health notes enhance patient empowerment and augment patient autonomy. Furthermore, recent studies have shown that social media is an effective way to draw attention to mental health issues. By collecting data from Twitter, researchers found that social media presence is heightened after an event relating to behavioral health occurs. Researchers continue to find effective ways to use social media to bring more awareness to mental health issues through online campaigns in other sites such as Facebook and Instagram. Care navigation Mental health care navigation helps to guide patients and families through the fragmented, often confusing mental health industries. Care navigators work closely with patients and families through discussion and collaboration to provide information on best therapies as well as referrals to practitioners and facilities specializing in particular forms of emotional improvement. The difference between therapy and care navigation is that the care navigation process provides information and directs patients to therapy rather than providing therapy. Still, care navigators may offer diagnosis and treatment planning. Though many care navigators are also trained therapists and doctors. Care navigation is the link between the patient and the below therapies. A clear recognition that mental health requires medical intervention was demonstrated in a study by Kessler et al. of the prevalence and treatment of mental disorders from 1990 to 2003 in the United States. Despite the prevalence of mental health disorders remaining unchanged during this period, the number of patients seeking treatment for mental disorders increased threefold. Methods Pharmacotherapy Pharmacotherapy is a therapy that uses pharmaceutical drugs. Pharmacotherapy is used in the treatment of mental illness through the use of antidepressants, benzodiazepines, and the use of elements such as lithium. It can only be prescribed by a medical professional trained in the field of Psychiatry. Physical activity Physical exercise can improve mental and physical health. Playing sports, walking, cycling, or doing any form of physical activity trigger the production of various hormones, sometimes including endorphins, which can elevate a person's mood. Studies have shown that in some cases, physical activity can have the same impact as antidepressants when treating depression and anxiety. Moreover, cessation of physical exercise may have adverse effects on some mental health conditions, such as depression and anxiety. This could lead to different negative outcomes such as obesity, skewed body image and many health risks associated with mental illnesses. Exercise can improve mental health but it should not be used as an alternative to therapy. Activity therapies Activity therapies also called recreation therapy and occupational therapy, promote healing through active engagement. An example of occupational therapy would be promoting an activity that improves daily life, such as self-care or improving hobbies. Each of these therapies have proven to improve mental health and have resulted in healthier, happier individuals. In recent years, for example, coloring has been recognized as an activity that has been proven to significantly lower the levels of depressive symptoms and anxiety in many studies. Expressive therapies Expressive therapies or creative arts therapies are a form of psychotherapy that involves the arts or art-making. These therapies include art therapy, music therapy, drama therapy, dance therapy, and poetry therapy. It has been proven that music therapy is an effective way of helping people with a mental health disorder. Drama therapy is approved by NICE for the treatment of psychosis. Psychotherapy Psychotherapy is the general term for the scientific based treatment of mental health issues based on modern medicine. It includes a number of schools, such as gestalt therapy, psychoanalysis, cognitive behavioral therapy, psychedelic therapy, transpersonal psychology/psychotherapy, and dialectical behavioral therapy. Group therapy involves any type of therapy that takes place in a setting involving multiple people. It can include psychodynamic groups, expressive therapy groups, support groups (including the Twelve-step program), problem-solving and psychoeducation groups. Self-compassion According to Neff, self-compassion consists of three main positive components and their negative counterparts: Self-Kindness versus Self-Judgment, Common Humanity versus Isolation and Mindfulness versus Over-Identification. Furthermore, there is evidence from a study by Shin & Lin suggesting specific components of self-compassion can predict specific dimensions of positive mental health (emotional, social, and psychological well-being). Social-emotional learning The Collaborative for academic, social, emotional learning (CASEL) addresses five broad and interrelated areas of competence and highlights examples for each: self-awareness, self-management, social awareness, relationship skills, and responsible decision-making. A meta-analysis was done by Alexendru Boncu, Iuliana Costeau, & Mihaela Minulescu (2017) looking at social-emotional learning (SEL) studies and the effects on emotional and behavior outcomes. They found a small but significant effect size (across the studies looked into) for externalized problems and social-emotional skills. Meditation The practice of mindfulness meditation has several potential mental health benefits, such as bringing about reductions in depression, anxiety and stress. Mindfulness meditation may also be effective in treating substance use disorders. Lucid Dreaming Lucid dreaming has been found to be associated with greater mental well-being. It also was not associated with poorer sleep quality nor with cognitive dissociation. There is also some evidence lucid dreaming therapy can help with nightmare reduction. Mental fitness Mental fitness is a mental health movement that encourages people to intentionally regulate and maintain their emotional wellbeing through friendship, regular human contact, and activities that include meditation, calming exercises, aerobic exercise, mindfulness, having a routine and maintaining adequate sleep. Mental fitness is intended to build resilience against every-day mental and potentially physical health challenges to prevent an escalation of anxiety, depression, and suicidal ideation. This can help people, including older adults with health challenges, to more effectively cope with the escalation of those feelings if they occur. Spiritual counseling Spiritual counsellors meet with people in need to offer comfort and support and to help them gain a better understanding of their issues and develop a problem-solving relation with spirituality. These types of counselors deliver care based on spiritual, psychological and theological principles. Laws and public health policies There are many factors that influence mental health including: Mental illness, disability, and suicide are ultimately the result of a combination of biology, environment, and access to and utilization of mental health treatment. Public health policies can influence access and utilization, which subsequently may improve mental health and help to progress the negative consequences of depression and its associated disability. United States Emotional mental illnesses is a particular concern in the United States since the U.S. has the highest annual prevalence rates (26 percent) for mental illnesses among a comparison of 14 developing and developed countries. While approximately 80 percent of all people in the United States with a mental disorder eventually receive some form of treatment, on average persons do not access care until nearly a decade following the development of their illness, and less than one-third of people who seek help receive minimally adequate care. The government offers everyone programs and services, but veterans receive the most help, there is certain eligibility criteria that has to be met. Policies Mental health policies in the United States have experienced four major reforms: the American asylum movement led by Dorothea Dix in 1843; the mental hygiene movement inspired by Clifford Beers in 1908; the deinstitutionalization started by Action for Mental Health in 1961; and the community support movement called for by The CMCH Act Amendments of 1975. In 1843, Dorothea Dix submitted a Memorial to the Legislature of Massachusetts, describing the abusive treatment and horrible conditions received by the mentally ill patients in jails, cages, and almshouses. She revealed in her Memorial: "I proceed, gentlemen, briefly to call your attention to the present state of insane persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience...." Many asylums were built in that period, with high fences or walls separating the patients from other community members and strict rules regarding the entrance and exit. In 1866, a recommendation came to the New York State Legislature to establish a separate asylum for chronic mentally ill patients. Some hospitals placed the chronic patients into separate wings or wards, or different buildings. In A Mind That Found Itself (1908) Clifford Whittingham Beers described the humiliating treatment he received and the deplorable conditions in the mental hospital. One year later, the National Committee for Mental Hygiene (NCMH) was founded by a small group of reform-minded scholars and scientists—including Beers himself—which marked the beginning of the "mental hygiene" movement. The movement emphasized the importance of childhood prevention. World War I catalyzed this idea with an additional emphasis on the impact of maladjustment, which convinced the hygienists that prevention was the only practical approach to handle mental health issues. However, prevention was not successful, especially for chronic illness; the condemnable conditions in the hospitals were even more prevalent, especially under the pressure of the increasing number of chronically ill and the influence of the depression. In 1961, the Joint Commission on Mental Health published a report called Action for Mental Health, whose goal was for community clinic care to take on the burden of prevention and early intervention of the mental illness, therefore to leave space in the hospitals for severe and chronic patients. The court started to rule in favor of the patients' will on whether they should be forced to treatment. By 1977, 650 community mental health centers were built to cover 43 percent of the population and serve 1.9 million individuals a year, and the lengths of treatment decreased from 6 months to only 23 days. However, issues still existed. Due to inflation, especially in the 1970s, the community nursing homes received less money to support the care and treatment provided. Fewer than half of the planned centers were created, and new methods did not fully replace the old approaches to carry out its full capacity of treating power. Besides, the community helping system was not fully established to support the patients' housing, vocational opportunities, income supports, and other benefits. Many patients returned to welfare and criminal justice institutions, and more became homeless. The movement of deinstitutionalization was facing great challenges. After realizing that simply changing the location of mental health care from the state hospitals to nursing houses was insufficient to implement the idea of deinstitutionalization, the National Institute of Mental Health (NIMH) in 1975 created the Community Support Program (CSP) to provide funds for communities to set up a comprehensive mental health service and supports to help the mentally ill patients integrate successfully in the society. The program stressed the importance of other supports in addition to medical care, including housing, living expenses, employment, transportation, and education; and set up new national priority for people with serious mental disorders. In addition, the Congress enacted the Mental Health Systems Act of 1980 to prioritize the service to the mentally ill and emphasize the expansion of services beyond just clinical care alone. Later in the 1980s, under the influence from the Congress and the Supreme Court, many programs started to help the patients regain their benefits. A new Medicaid service was also established to serve people who were diagnosed with a "chronic mental illness". People who were temporally hospitalized were also provided aid and care and a pre-release program was created to enable people to apply for reinstatement prior to discharge. Not until 1990, around 35 years after the start of the deinstitutionalization, did the first state hospital begin to close. The number of hospitals dropped from around 300 by over 40 in the 1990s, and finally a Report on Mental Health showed the efficacy of mental health treatment, giving a range of treatments available for patients to choose. However, several critics maintain that deinstitutionalization has, from a mental health point of view, been a thoroughgoing failure. The seriously mentally ill are either homeless, or in prison; in either case (especially the latter), they are getting little or no mental health care. This failure is attributed to a number of reasons over which there is some degree of contention, although there is general agreement that community support programs have been ineffective at best, due to a lack of funding. The 2011 National Prevention Strategy included mental and emotional well-being, with recommendations including better parenting and early intervention programs, which increase the likelihood of prevention programs being included in future US mental health policies. The NIMH is researching only suicide and HIV/AIDS prevention, but the National Prevention Strategy could lead to it focusing more broadly on longitudinal prevention studies. In 2013, United States Representative Tim Murphy introduced the Helping Families in Mental Health Crisis Act, HR2646. The bipartisan bill went through substantial revision and was reintroduced in 2015 by Murphy and Congresswoman Eddie Bernice Johnson. In November 2015, it passed the Health Subcommittee by an 18–12 vote. See also 988 (telephone number) Abnormal psychology Emotional resilience Ethnopsychopharmacology Lifestyle and Mental Health Mental environment Mental health day Mental health during the COVID-19 pandemic Mental health first aid Mental health in education Mental health in the workplace Mental health of Asian Americans Self-help groups for mental health Social determinants of mental health Social stigma Suicide awareness Telemental health World Mental Health Day Well-being References Further reading Online Books by William Sweetser External links Mental Health by WHO The Public Health Agency of Canada National Institute of Mental Health (United States) Health-EU Portal Mental Health in the EU Mental Health Department of Health (United Kingdom)

Personality disorder

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish individual humans. Hence, personality disorders are defined by experiences and behaviors that deviate from social norms and expectations. Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. For psychiatric patients, the prevalence of personality disorders is estimated between 40 and 60%. The behavior patterns of personality disorders are typically recognized by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life. Treatment for personality disorders is primarily psychotherapeutic. Evidence-based psychotherapies for personality disorders include cognitive behavioral therapy, and dialectical behavior therapy especially for borderline personality disorder. A variety of psychoanalytic approaches are also used. Personality disorders are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorize personality disorders, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations. Classification and symptoms The two latest editions of the major systems of classification are: the International Classification of Diseases (11th revision, ICD-11) published by the World Health Organization the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) by the American Psychiatric Association. The ICD is a collection of alpha-numerical codes which have been assigned to all known clinical states, and provides uniform terminology for medical records, billing, statistics and research. The DSM defines psychiatric diagnoses based on research and expert consensus. Both have deliberately aligned their diagnoses to some extent, but some differences remain. For example, the ICD-10 included narcissistic personality disorder in the group of other specific personality disorders, while DSM-5 does not include enduring personality change after catastrophic experience. The ICD-10 classified the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other. Dissociative identity disorder, previously known as multiple personality as well as multiple personality disorder, has always been classified as a dissociative disorder and never was regarded as a personality disorder. DSM-5 The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate 'axis', as previously. DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive–compulsive personality disorder. The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, which nevertheless exhibit characteristics of a personality disorder: Personality change due to another medical conditionpersonality disturbance due to the direct effects of a medical condition Other specified personality disorderdisorder which meets the general criteria for a personality disorder but fails to meet the criteria for a specific disorder, with the reason given Unspecified personality disorderdisorder which meets the general criteria for a personality disorder but is not included in the DSM-5 classification These specific personality disorders are grouped into the following three clusters based on descriptive similarities: Cluster A (odd or eccentric disorders) Cluster A personality disorders are often associated with schizophrenia. People with these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Paranoid personality disorderpattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent Schizoid personality disordercold affect and detachment from social relationships, apathy, and restricted emotional expression Schizotypal personality disorderpattern of extreme discomfort interacting socially, and distorted cognition and perceptions Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder. Cluster B (emotional or erratic disorders) Cluster B personality disorders are characterized by dramatic, impulsive, self-destructive, emotional behavior and sometimes incomprehensible interactions with others. Antisocial personality disorderpervasive pattern of disregard for and violation of the rights of others, lack of empathy, lack of remorse, callousness, bloated self-image, and manipulative and impulsive behavior Borderline personality disorderpervasive pattern of abrupt emotional outbursts, fear of abandonment, unhealthy attachment, altered empathy, and instability in relationships, self-image, identity, behavior and affect, often leading to self-harm and impulsivity Histrionic personality disorderpervasive pattern of attention-seeking behavior, including excessive emotions, an impressionistic style of speech, inappropriate seduction, exhibitionism, and egocentrism Narcissistic personality disorderpervasive pattern of superior grandiosity, haughtiness, need for admiration, deceiving others, and lack of empathy (and, in more severe expressions, criminal behavior remorse) Cluster C (anxious or fearful disorders) Group C personality disorders are characterised by a consistent pattern of anxious thinking or behavior. Avoidant personality disorderpervasive feelings of social inhibition and inadequacy, and extreme sensitivity to negative evaluation Dependent personality disorderpervasive psychological need to be cared for by other people Obsessive–compulsive personality disorderrigid conformity to rules, perfectionism, and control to the point of exclusion of leisurely activities and friendships (distinct from obsessive–compulsive disorder) DSM-5 general criteria Both the DSM-5 and the ICD-11 diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made. The DSM-5 indicates that any personality disorder diagnosis must meet the following criteria: There is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: Cognition (i.e., ways of perceiving and interpreting self, other people, and events) Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) Interpersonal functioning Impulse control The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress, or impairment in functioning, in social, occupational, or other important areas. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma). ICD-11 The ICD-11 personality disorder section differs substantially from the previous edition, ICD-10. All distinct PDs have been merged into one: personality disorder, which can be coded as mild, moderate, severe, or severity unspecified. There is also an additional category called personality difficulty, which can be used to describe personality traits that are problematic, but do not meet the diagnostic criteria for a PD. A personality disorder or difficulty can be specified by one or more prominent personality traits or patterns. The ICD-11 uses five trait domains: Negative affectivity – including anxiety, separation insecurity, distrustfulness, worthlessness and emotional instability Detachment – including social detachment and emotional coldness Dissociality – including grandiosity, egocentricity, deception, exploitativeness and aggression Disinhibition – including risk-taking, impulsivity, irresponsibility and distractibility Anankastia – including rigid control over behaviour and affect and rigid perfectionism Listed directly underneath is borderline pattern, a category similar to borderline personality disorder. This is not a trait in itself, but a combination of the five traits in certain severity. In the ICD-11, any personality disorder must meet all of the following criteria: There is an enduring disturbance characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others' perspectives and to manage conflict in relationships). The disturbance has persisted over an extended period of time (e.g., lasting 2 years or more). The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g., inflexible or poorly regulated). The disturbance is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles), though it may be consistently evoked by particular types of circumstances and not others. The symptoms are not due to the direct effects of a medication or substance, including withdrawal effects, and are not better accounted for by another mental disorder, a disease of the nervous system, or another medical condition. The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. Personality disorder should not be diagnosed if the patterns of behaviour characterizing the personality disturbance are developmentally appropriate (e.g., problems related to establishing an independent self-identity during adolescence) or can be explained primarily by social or cultural factors, including socio-political conflict. ICD-10 The ICD-10 lists these general guideline criteria: Markedly disharmonious attitudes and behavior, generally involving several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others; The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness; The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations; The above manifestations always appear during childhood or adolescence and continue into adulthood; The disorder leads to considerable personal distress but this may only become apparent late in its course; The disorder is usually, but not invariably, associated with significant problems in occupational and social performance. The ICD adds: "For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations." Chapter V in the ICD-10 contains the mental and behavioral disorders and includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others. The specific personality disorders are: paranoid, schizoid, schizotypal, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, narcissistic, anankastic, anxious (avoidant) and dependent. Besides the ten specific PD, there are the following categories: Other specific personality disorders (involves PD characterized as eccentric, haltlose, immature, narcissistic, passive–aggressive, or psychoneurotic.) Personality disorder, unspecified (includes "character neurosis" and "pathological personality"). Mixed and other personality disorders (defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders). Enduring personality changes, not attributable to brain damage and disease (this is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness). Other personality types and Millon's description Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behavior) and self-defeating personality disorder or masochistic personality disorder (characterized by behavior consequently undermining the person's pleasure and goals). They were listed in the DSM-III-R appendix as "Proposed diagnostic categories needing further study" without specific criteria. Psychologist Theodore Millon, a researcher on personality disorders, and other researchers consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses. Millon proposed the following description of personality disorders: Additional factors In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution. Severity This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a "ripple effect" of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk. There are several advantages to classifying personality disorder by severity: It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other. It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality disorder versus personality disorder. This system accommodates the new diagnosis of severe personality disorder, particularly "dangerous and severe personality disorder" (DSPD). Effect on social functioning Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables. The Personality Assessment Schedule gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder. Attribution Many who have a personality disorder do not recognize any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamor for treatment. The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others. Psychoanalytic theory has been used to explain treatment-resistant tendencies as egosyntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are therefore perceived to be appropriate by that individual. In addition, this behavior can result in maladaptive coping skills and may lead to personal problems that induce extreme anxiety, distress, or depression and result in impaired psychosocial functioning. Presentation Comorbidity There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another. Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits. Sites used DSM-III-R criterion sets. Data obtained for purposes of informing the development of the DSM-IV-TR personality disorder diagnostic criteria. Abbreviations used: PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive–Compulsive Personality Disorder, PAPD – Passive–Aggressive Personality Disorder. The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively. But they may also have a spectrum relationship to certain syndromal mental disorders: Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia. Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse-control disorders, eating disorders, ADHD, ASD, or a substance use disorder. Avoidant personality disorder is seen with social anxiety disorder. Impact on functioning It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder. In several studies, higher levels of disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorders. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive–compulsive PD was not related to a reduced QoL or increased impairment. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder. One study investigated some aspects of "life success" (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive–compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success. There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life. Personality disorders – especially dependent, narcissistic, and sadistic personality disorders – also facilitate various forms of counterproductive work behavior, including knowledge hiding and knowledge sabotage. Issues In the workplace Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace—potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can be problematic. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the individual with the condition to exploit their co-workers. In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals: Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence. Obsessive–compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies. According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team. In children Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood. In addition, in Robert F. Krueger's review of their research indicates that some children and adolescents do experience clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases. Versus normal personality The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM-5 and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality. Thomas Widiger and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed the Five Factor Model of personality as an alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e., high neuroticism), impulsivity (i.e., low conscientiousness), and hostility (i.e., low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model. This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within DSM-5. In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time-consuming. Abbreviations used: PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive–Compulsive Personality Disorder, PAPD – Passive–Aggressive Personality Disorder, DpPD – Depressive Personality Disorder, SDPD – Self-Defeating Personality Disorder, SaPD – Sadistic Personality Disorder, and n/a – not available. As of 2002, there were over fifty published studies relating the five factor model (FFM) to personality disorders. Since that time, quite a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains. In her seminal review of the personality disorder literature published in 2007, Lee Anna Clark asserted that "the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits". The five factor model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms. Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled "The five-factor model and personality disorder empirical literature: A meta-analytic review", the authors analyzed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness. Openness to experience At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight (means the ability to recognize one's own mental illness) and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society. High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioral patterns. The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests. Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one's emotional experiences. It is most characteristic of obsessive–compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders. Causes Currently, there are no definitive proven causes for personality disorders. However, there are numerous possible causes and known risk factors supported by scientific research that vary depending on the disorder, the individual, and the circumstance. Overall, findings show that genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders. Child abuse Child abuse and neglect consistently show up as risk factors to the development of personality disorders in adulthood. A study looked at retrospective reports of abuse of participants that had demonstrated psychopathology throughout their life and were later found to have past experience with abuse. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not experience such verbal abuse) to have borderline, narcissistic, obsessive–compulsive or paranoid personality disorders in adulthood. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood. Socioeconomic status Socioeconomic status has also been looked at as a potential cause for personality disorders. There is a strong association with low parental/neighborhood socioeconomic status and personality disorder symptoms. In a 2015 publication from Bonn, Germany, which compared parental socioeconomic status and a child's personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher IQs. These traits correlate with a low risk of developing personality disorders later on in life. In a study looking at female children who were detained for disciplinary actions found that psychological problems were most negatively associated with socioeconomic problems. Furthermore, social disorganization was found to be inversely correlated with personality disorder symptoms. Parenting Evidence shows personality disorders may begin with parental personality issues. These cause the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships. By either genetic or modeling mechanisms, children can pick up these traits. Additionally, poor parenting appears to have symptom elevating effects on personality disorders. More specifically, lack of maternal bonding has also been correlated with personality disorders. In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls). These researchers suggested "Breastfeeding may act as an early indicator of the mother-infant relationship that seems to be relevant for bonding and attachment later in life". Additionally, findings suggest personality disorders show a negative correlation with two attachment variables: maternal availability and dependability. When left unfostered, other attachment and interpersonal problems occur later in life ultimately leading to development of personality disorders. Genetics Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms. Neurobiological correlates – hippocampus, amygdala Research shows that several brain regions are altered in personality disorders, particularly: hippocampus up to 18% smaller, a smaller amygdala, malfunctions in the striatum-nucleus accumbens and the cingulum neural pathways connecting them and taking care of the feedback loops on what to do with all the incoming information from the multiple senses; so what comes out is anti-social – not according to what is the social norm, socially acceptable and appropriate. Management Specific approaches There are many different forms (modalities) of treatment used for personality disorders: Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term (brief) forms. Family therapy, including couples therapy. Group therapy for personality dysfunction is probably the second most used. Psychological-education may be used as an addition. Self-help groups may provide resources for personality disorders. Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions. Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities. The practice of mindfulness that includes developing the ability to be nonjudgmentally aware of unpleasant emotions appears to be a promising clinical tool for managing different types of personality disorders. There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioral techniques. In clinical practice, many therapists use an 'eclectic' approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries). Despite the lack of evidence supporting the benefit of antipsychotics in people with personality disorders, 1 in 4 who do not have a serious mental illness are prescribed them in UK primary care. Many people receive these medication for over a year, contrary to NICE guidelines. Challenges The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organizations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviors. The disruptiveness that people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage. Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient's ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between 'normal' and 'abnormal' personalities. There is substantial social stigma and discrimination related to the diagnosis. The term 'personality disorder' encompasses a wide range of issues, each with a different level of severity or impairment; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterized by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioral addictions. Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be perceived as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defense mechanisms, or deliberate strategies; and in terms of moral judgments or the need to consider underlying motivations for specific behaviors or conflicts. The vulnerabilities of a client, and indeed a therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and views that both the client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. As an example of one extreme, people who may have been exposed to hostility, deceptiveness, rejection, aggression or abuse in their lives, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client's issues. Epidemiology The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of cocaine, is described as a major public health concern requiring attention by researchers and clinicians. The prevalence of individual personality disorders ranges from about 2% to 8% for the more common varieties, such as obsessive-compulsive, schizotypal, antisocial, borderline, and histrionic, to 0.5–1% for the least common, such as narcissistic and avoidant. A screening survey across 13 countries by the World Health Organization using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders. In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM). This statistic has been supported by other studies in the US, with overall global prevalence statistics ranging from 9% to 11%. A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely in need of services was a much smaller group. Personality disorders (especially Cluster A) are found more commonly among homeless people. There are some sex differences in the frequency of personality disorders which are shown in the table below. The known prevalence of some personality disorders, especially borderline PD and antisocial PD are affected by diagnostic bias. This is due to many factors including disproportionately high research towards borderline PD and antisocial PD, alongside social and gender stereotypes, and the relationship between diagnosis rates and prevalence rates. Since the removal of depressive PD, self-defeating PD, sadistic PD and passive-aggressive PD from the DSM-5, studies analysing their prevalence and demographics have been limited. History Diagnostic and Statistical Manual history Before the 20th century Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks. For example, the Greek philosopher Theophrastus described 29 'character' types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen's concept of personality types, which he linked to the four humours proposed by Hippocrates. Such views lasted into the eighteenth century, when experiments began to question the supposed biologically based humours and 'temperaments'. Psychological concepts of character and 'self' became widespread. In the nineteenth century, 'personality' referred to a person's conscious awareness of their behavior, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term 'multiple personality disorder' in the first versions of the DSM. Physicians in the early nineteenth century started to diagnose forms of insanity involving disturbed emotions and behaviors but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as ' manie sans délire ' – mania without delusions – and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. 'Moral' in this sense referred to affect (emotion or mood) rather than simply the ethical dimension, but it was arguably a significant move for 'psychiatric' diagnostic practice to become so clearly engaged with judgments about individual's social behaviour. Prichard was influenced by his own religious, social and moral beliefs, as well as ideas in German psychiatry. These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about 'psychopaths'. Separately, Richard von Krafft-Ebing popularized the terms sadism and masochism, as well as homosexuality, as psychiatric issues. The German psychiatrist Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase 'psychopathic inferiority', theorized to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent "mental retardation" or illness, supposedly without a moral judgment. Described as deeply rooted in his Christian faith, his work established the concept of personality disorder as used today. 20th century In the early 20th century, another German psychiatrist, Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types – excitable, unstable, eccentric, liar, swindler and quarrelsome. The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid vagabonds who wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid, schizotypal; interpretations of earlier (1921) theories of Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder. In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin published his book Manifestations of Psychopathies: Statics, Dynamics, Systematic Aspects, which was one of the first attempts to develop a detailed typology of psychopathies. Regarding maladaptation, ubiquity, and stability as the three main symptoms of behavioral pathology, he distinguished nine clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid. Some elements of Gannushkin's typology were later incorporated into the theory developed by a Russian adolescent psychiatrist, Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called accentuations of character. In 1939, psychiatrist David Henderson published a theory of 'psychopathic states' that contributed to popularly linking the term to anti-social behavior. Hervey M. Cleckley's 1941 text, The Mask of Sanity, based on his personal categorization of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage. Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by Sigmund Freud and others. This included the concept of character disorders, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were often understood as weaknesses of character or willful deviance, and were distinguished from neurosis or psychosis. The term 'borderline' stems from a belief some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive–compulsive and histrionic, the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel William Menninger during World War II in the context of men's reactions to military compliance, which would later be referenced as a personality disorder in the DSM. Otto Kernberg was influential with regard to the concepts of borderline and narcissistic personalities later incorporated in 1980 as disorders into the DSM. Meanwhile, a more general personality psychology had been developing in academia and to some extent clinically. Gordon Allport published theories of personality traits from the 1920s—and Henry Murray advanced a theory called personology, which influenced a later key advocate of personality disorders, Theodore Millon. Tests were developing or being applied for personality evaluation, including projective tests such as the Rorschach test, as well as questionnaires such as the Minnesota Multiphasic Personality Inventory. Around mid-century, Hans Eysenck was analysing traits and personality types, and psychiatrist Kurt Schneider was popularising a clinical use in place of the previously more usual terms 'character', 'temperament' or 'constitution'. American psychiatrists officially recognized concepts of enduring personality disturbances in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate 'axis' along with "mental retardation", intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. 'Inadequate' and 'asthenic' personality disorder' categories were deleted, and others were expanded into more types, or changed from being personality disorders to regular disorders. Sociopathic personality disorder, which had been the term for psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific 'operationalized' definitions, with standard criteria psychiatrists could agree on to conduct research and diagnose patients. In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed 'depressive personality disorder' was added; in addition, the official diagnosis of passive–aggressive personality disorder was dropped, tentatively renamed 'negativistic personality disorder.' International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider argued they were 'abnormal varieties of psychic life' and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviors associated with personality disorders. In the US, the prevailing healthcare system and psychoanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them. See also Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Avoidant personality disorder Dependent personality disorder Obsessive–compulsive personality disorder Depressive personality disorder Passive–aggressive personality disorder Sadistic personality disorder Self-defeating personality disorder Adjustment personality disorder References Further reading External links Personality Disorders Foundation National Mental Health Association personality disorder fact sheet Personality Disorders information leaflet from The Royal College of Psychiatrists Mental disorders Behavioural sciences

Insanity

Insanity, madness, lunacy, and craziness are behaviors caused by certain abnormal mental or behavioral patterns. Insanity can manifest as violations of societal norms, including a person or persons becoming a danger to themselves or to other people. Conceptually, mental insanity also is associated with the biological phenomenon of contagion (that mental illness is infectious) as in the case of copycat suicides. In contemporary usage, the term insanity is an informal, un-scientific term denoting "mental instability"; thus, the term insanity defense is the legal definition of mental instability. In medicine, the general term psychosis is used to include the presence of delusions and/or hallucinations in a patient; and psychiatric illness is "psychopathology", not mental insanity. In English, the word "sane" derives from the Latin adjective sanus, meaning "healthy". Juvenal's phrase mens sana in corpore sano is often translated to mean a "healthy mind in a healthy body". From this perspective, insanity can be considered as poor health of the mind, not necessarily of the brain as an organ (although that can affect mental health), but rather refers to defective function of mental processes such as reasoning. Another Latin phrase related to our current concept of sanity is compos mentis ("sound of mind"), and a euphemistic term for insanity is non compos mentis. In law, mens rea means having had criminal intent, or a guilty mind, when the act (actus reus) was committed. A more informal use of the term insanity is to denote something or someone considered highly unique, passionate or extreme, including in a positive sense. The term may also be used as an attempt to discredit or criticize particular ideas, beliefs, principles, desires, personal feelings, attitudes, or their proponents, such as in politics and religion. Historical views and treatment Madness, the non-legal word for insanity, has been recognized throughout history in every known society. Some traditional cultures have turned to witch doctors or shamans to apply magic, herbal mixtures, or folk medicine to rid deranged persons of evil spirits or bizarre behavior, for example. Archaeologists have unearthed skulls (at least 7000 years old) that have small, round holes bored in them using flint tools. It has been conjectured that the subjects may have been thought to have been possessed by spirits that the holes would allow to escape. More recent research on the historical practice of trepanning supports the hypothesis that this procedure was medical in nature and intended as means of treating cranial trauma. Ancient Greece The Greeks appeared to share something of the modern Western world's secular and holistic view, believing that afflictions of the mind did not differ from diseases of the body. Moreover, they saw mental and physical illness as a result of natural causes and an imbalance in bodily humors. Hippocrates frequently wrote that an excess of black bile resulted in irrational thinking and behavior. Ancient Rome Romans made other contributions to psychiatry, in particular a precursor of some contemporary practice. They put forward the idea that strong emotions could lead to bodily ailments, the basis of today's theory of psychosomatic illness. The Romans also supported humane treatment of the mentally ill, and in so doing, codified into law the principle of insanity as a mitigation of responsibility for criminal acts, although the criterion for insanity was sharply set as the defendant had to be found "non compos mentis", a term meaning "not sound of mind". From the Middle Ages onward The Middle Ages witnessed the end of the progressive ideas of the Greeks and Romans. During the 18th century, the French and the British introduced humane treatment of the clinically insane, though the criteria for diagnosis and placement in an asylum were considerably looser than today, often including such conditions as speech disorder, speech impediments, epilepsy, and depression or being pregnant out of wedlock. Europe's oldest asylum was the precursor of today's Bethlem Royal Hospital in London, known then as Bedlam, which began admitting the mentally ill in 1403 and is mentioned in Chaucer's Canterbury Tales. The first American asylum was built in Williamsburg, Virginia, circa 1773. Before the 19th century, these hospitals were used to isolate the mentally ill or the socially ostracized from society rather than cure them or maintain their health. Pictures from this era portrayed patients bound with rope or chains, often to beds or walls, or restrained in straitjackets. Medicine Insanity is no longer considered a medical diagnosis but is a legal term in the United States, stemming from its original use in common law. The disorders formerly encompassed by the term covered a wide range of mental disorders now diagnosed as bipolar disorder, organic brain syndromes, schizophrenia, and other psychotic disorders. Law In United States criminal law, insanity may serve as an affirmative defense to criminal acts and thus does not need to negate an element of the prosecution's case such as general or specific intent. Each U.S. state differs somewhat in its definition of insanity but most follow the guidelines of the Model Penal Code. All jurisdictions require a sanity evaluation to address the question first of whether or not the defendant has a mental illness. Most courts accept a major mental illness such as psychosis but will not accept the diagnosis of a personality disorder for the purposes of an insanity defense. The second question is whether the mental illness interfered with the defendant's ability to distinguish right from wrong. That is, did the defendant know that the alleged behavior was against the law at the time the offense was committed. Additionally, some jurisdictions add the question of whether or not the defendant was in control of their behavior at the time of the offense. For example, if the defendant was compelled by some aspect of their mental illness to commit the illegal act, the defendant could be evaluated as not in control of their behavior at the time of the offense. The forensic mental health specialists submit their evaluations to the court. Since the question of sanity or insanity is a legal question and not a medical one, the judge and or jury will make the final decision regarding the defendant's status regarding an insanity defense. In most jurisdictions within the United States, if the insanity plea is accepted, the defendant is committed to a psychiatric institution for at least 60 days for further evaluation, and then reevaluated at least yearly after that. Insanity is generally no defense in a civil lawsuit, but an insane plaintiff can toll the statute of limitations for filing a suit until gaining sanity, or until a statute of repose has run. Feigning Feigned insanity is the simulation of mental illness in order to deceive. Amongst other purposes, insanity is feigned in order to avoid or lessen the consequences of a confrontation or conviction for an alleged crime. A number of treatises on medical jurisprudence were written during the nineteenth century, the most famous of which was Isaac Ray in 1838 (fifth edition 1871); others include Ryan (1832), Taylor (1845), Wharton and Stille (1855), Ordronaux (1869), Meymott (1882). The typical techniques as outlined in these works are the background for Dr. Neil S. Kaye's widely recognized guidelines that indicate an attempt to feign insanity. One famous example of someone feigning insanity is Mafia boss Vincent Gigante, who pretended for years to be suffering from dementia, and was often seen wandering aimlessly around his neighborhood in his pajamas muttering to himself. Testimony from informants and surveillance showed that Gigante was in full control of his faculties the whole time, and ruled over his Mafia family with an iron fist. Today feigned insanity is considered malingering. In a 2005 court case, United States v. Binion, the defendant was prosecuted and convicted for obstruction of justice (adding to his original sentence) because he feigned insanity in a Competency to Stand Trial evaluation. Insult In modern times, labeling someone as insane often carries little or no medical meaning and is rather used as an insult or as a reaction to behavior perceived to be outside the bounds of accepted norms. For instance, the definition of insanity is sometimes colloquially purported to be "doing the same thing over and over again and expecting a different result." However, this does not match the legal definition of insanity. See also Rosenhan, David L. References External links "On Being Sane in Insane Places" Obsolete medical terms Pejorative terms for people with disabilities

Idiosyncrasy

An idiosyncrasy is a unique feature of something. The term is often used to express peculiarity. Etymology The term "idiosyncrasy" originates from Greek , "a peculiar temperament, habit of body" (from , "one's own", , "with" and , "blend of the four humors" (temperament)) or literally "particular mingling". Idiosyncrasy is sometimes used as a synonym for eccentricity, as these terms "are not always clearly distinguished when they denote an act, a practice, or a characteristic that impresses the observer as strange or singular." Eccentricity, however, "emphasizes the idea of divergence from the usual or customary; idiosyncrasy implies a following of one's particular temperament or bent especially in trait, trick, or habit; the former often suggests mental aberration, the latter, strong individuality and independence of action". Linguistics The term can also be applied to symbols or words. Idiosyncratic symbols mean one thing for a particular person, as a blade could mean war, but to someone else, it could symbolize a surgery. Idiosyncratic property In phonology, an idiosyncratic property contrasts with a systematic regularity. While systematic regularities in the sound system of a language are useful for identifying phonological rules during analysis of the forms morphemes can take, idiosyncratic properties are those whose occurrence is not determined by those rules. For example, the fact that the English word cab starts with the sound /k/ is an idiosyncratic property; on the other hand that its vowel is longer than in the English word cap is a systematic regularity, as it arises from the fact that the final consonant is voiced rather than voiceless. Medicine Disease Idiosyncrasy defined the way physicians conceived diseases in the 19th century. They considered each disease as a unique condition, related to each patient. This understanding began to change in the 1870s, when discoveries made by researchers in Europe permitted the advent of a "scientific medicine", a precursor to the evidence-based medicine that is the standard of practice today. Pharmacology The term idiosyncratic drug reaction denotes an aberrant or bizarre reaction or hypersensitivity to a substance, without connection to the pharmacology of the drug. It is what is known as a Type B reaction. Type B reactions have the following characteristics: they are usually unpredictable, might not be picked up by toxicological screening, not necessarily dose-related, incidence and morbidity low but mortality is high. Type B reactions are most commonly immunological (e.g. penicillin allergy). Psychiatry and psychology The word is used for the personal way a given individual reacts, perceives and experiences: a certain dish made of meat may cause nostalgic memories in one person and disgust in another. These reactions are called idiosyncratic. Economics In portfolio theory, risks of price changes due to the unique circumstances of a specific security, as opposed to the overall market, are called "idiosyncratic risks". This specific risk, also called unsystematic, can be nulled out of a portfolio through diversification. Pooling multiple securities means the specific risks cancel out. In complete markets, there is no compensation for idiosyncratic risk—that is, a security's idiosyncratic risk does not matter for its price. For instance, in a complete market in which the capital asset pricing model holds, the price of a security is determined by the amount of systematic risk in its returns. Net income received, or losses suffered, by a landlord from renting of one or two properties is subject to idiosyncratic risk due to the numerous things that can happen to real property and variable behavior of tenants. According to one macroeconomic model including a financial sector, hedging idiosyncratic risk can be self-defeating as amid the "risk reduction" experts are encouraged to increase their leverage. This works for small shocks but leads to higher vulnerability for larger shocks and makes the system less stable. Thus, while securitisation in principle reduces the costs of idiosyncratic shocks, it ends up amplifying systemic risks in equilibrium. In econometrics, "idiosyncratic error" is used to describe error—that is, unobserved factors that impact the dependent variable—from panel data that both changes over time and across units (individuals, firms, cities, towns, etc.). See also Humorism Portfolio theory References External links Allergology Deviance (sociology) Inborn errors of metabolism Medical terminology Effects of external causes

Mental disorder

A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior, often in a social context. Such disturbances may occur as single episodes, may be persistent, or may be relapsing–remitting. There are many different types of mental disorders, with signs and symptoms that vary widely between specific disorders. A mental disorder is one aspect of mental health. The causes of mental disorders are often unclear. Theories incorporate findings from a range of fields. Disorders may be associated with particular regions or functions of the brain. Disorders are usually diagnosed or assessed by a mental health professional, such as a clinical psychologist, psychiatrist, psychiatric nurse, or clinical social worker, using various methods such as psychometric tests, but often relying on observation and questioning. Cultural and religious beliefs, as well as social norms, should be taken into account when making a diagnosis. Services for mental disorders are usually based in psychiatric hospitals, outpatient clinics, or in the community, Treatments are provided by mental health professionals. Common treatment options are psychotherapy or psychiatric medication, while lifestyle changes, social interventions, peer support, and self-help are also options. In a minority of cases, there may be involuntary detention or treatment. Prevention programs have been shown to reduce depression. In 2019, common mental disorders around the globe include: depression, which affects about 264 million people; dementia, which affects about 50 million; bipolar disorder, which affects about 45 million; and schizophrenia and other psychoses, which affect about 20 million people. Neurodevelopmental disorders include attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and intellectual disability, of which onset occurs early in the developmental period. Stigma and discrimination can add to the suffering and disability associated with mental disorders, leading to various social movements attempting to increase understanding and challenge social exclusion. Definition The definition and classification of mental disorders are key issues for researchers as well as service providers and those who may be diagnosed. For a mental state to be classified as a disorder, it generally needs to cause dysfunction. Most international clinical documents use the term mental "disorder", while "illness" is also common. It has been noted that using the term "mental" (i.e., of the mind) is not necessarily meant to imply separateness from the brain or body. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published in 1994, a mental disorder is a psychological syndrome or pattern that is associated with distress (e.g., via a painful symptom), disability (impairment in one or more important areas of functioning), increased risk of death, or causes a significant loss of autonomy; however, it excludes normal responses such as the grief from loss of a loved one and also excludes deviant behavior for political, religious, or societal reasons not arising from a dysfunction in the individual. DSM-IV predicates the definition with caveats, stating that, as in the case with many medical terms, mental disorder "lacks a consistent operational definition that covers all situations", noting that different levels of abstraction can be used for medical definitions, including pathology, symptomology, deviance from a normal range, or etiology, and that the same is true for mental disorders, so that sometimes one type of definition is appropriate and sometimes another, depending on the situation. In 2013, the American Psychiatric Association (APA) redefined mental disorders in the DSM-5 as "a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning." The final draft of ICD-11 contains a very similar definition. The terms "mental breakdown" or "nervous breakdown" may be used by the general population to mean a mental disorder. The terms "nervous breakdown" and "mental breakdown" have not been formally defined through a medical diagnostic system such as the DSM-5 or ICD-10 and are nearly absent from scientific literature regarding mental illness. Although "nervous breakdown" is not rigorously defined, surveys of laypersons suggest that the term refers to a specific acute time-limited reactive disorder involving symptoms such as anxiety or depression, usually precipitated by external stressors. Many health experts today refer to a nervous breakdown as a mental health crisis. Nervous illness In addition to the concept of mental disorder, some people have argued for a return to the old-fashioned concept of nervous illness. In How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown (2013), Edward Shorter, a professor of psychiatry and the history of medicine, says: Classifications There are currently two widely established systems that classify mental disorders: ICD-11 Chapter 06: Mental, behavioural or neurodevelopmental disorders, part of the International Classification of Diseases produced by the WHO (in effect since 1 January 2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the APA since 1952. Both of these list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be used in non-western cultures, for example, the Chinese Classification of Mental Disorders, and other manuals may be used by those of alternative theoretical persuasions, such as the Psychodynamic Diagnostic Manual. In general, mental disorders are classified separately from neurological disorders, learning disabilities or intellectual disability. Unlike the DSM and ICD, some approaches are not based on identifying distinct categories of disorder using dichotomous symptom profiles intended to separate the abnormal from the normal. There is significant scientific debate about the relative merits of categorical versus such non-categorical (or hybrid) schemes, also known as continuum or dimensional models. A spectrum approach may incorporate elements of both. In the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms). Common hybrid views argue that the concept of mental disorder is objective even if only a "fuzzy prototype" that can never be precisely defined, or conversely that the concept always involves a mixture of scientific facts and subjective value judgments. Although the diagnostic categories are referred to as 'disorders', they are presented as medical diseases, but are not validated in the same way as most medical diagnoses. Some neurologists argue that classification will only be reliable and valid when based on neurobiological features rather than clinical interview, while others suggest that the differing ideological and practical perspectives need to be better integrated. The DSM and ICD approach remains under attack both because of the implied causality model and because some researchers believe it better to aim at underlying brain differences which can precede symptoms by many years. Dimensional models The high degree of comorbidity between disorders in categorical models such as the DSM and ICD have led some to propose dimensional models. Studying comorbidity between disorders have demonstrated two latent (unobserved) factors or dimensions in the structure of mental disorders that are thought to possibly reflect etiological processes. These two dimensions reflect a distinction between internalizing disorders, such as mood or anxiety symptoms, and externalizing disorders such as behavioral or substance use symptoms. A single general factor of psychopathology, similar to the g factor for intelligence, has been empirically supported. The p factor model supports the internalizing-externalizing distinction, but also supports the formation of a third dimension of thought disorders such as schizophrenia. Biological evidence also supports the validity of the internalizing-externalizing structure of mental disorders, with twin and adoption studies supporting heritable factors for externalizing and internalizing disorders. A leading dimensional model is the Hierarchical Taxonomy of Psychopathology. Disorders There are many different categories of mental disorder, and many different facets of human behavior and personality that can become disordered. Anxiety disorder An anxiety disorder is anxiety or fear that interferes with normal functioning may be classified as an anxiety disorder. Commonly recognized categories include specific phobias, generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, obsessive–compulsive disorder and post-traumatic stress disorder. Mood disorder Other affective (emotion/mood) processes can also become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia, or despair is known as major depression (also known as unipolar or clinical depression). Milder, but still prolonged depression, can be diagnosed as dysthymia. Bipolar disorder (also known as manic depression) involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating with normal or depressed moods. The extent to which unipolar and bipolar mood phenomena represent distinct categories of disorder, or mix and merge along a dimension or spectrum of mood, is subject to some scientific debate. Psychotic disorder Patterns of belief, language use and perception of reality can become dysregulated (e.g., delusions, thought disorder, hallucinations). Psychotic disorders in this domain include schizophrenia, and delusional disorder. Schizoaffective disorder is a category used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy is a category used for individuals showing some of the characteristics associated with schizophrenia, but without meeting cutoff criteria. Personality disorder Personality—the fundamental characteristics of a person that influence thoughts and behaviors across situations and time—may be considered disordered if judged to be abnormally rigid and maladaptive. Although treated separately by some, the commonly used categorical schemes include them as mental disorders, albeit on a separate axis II in the case of the DSM-IV. A number of different personality disorders are listed, including those sometimes classed as eccentric, such as paranoid, schizoid and schizotypal personality disorders; types that have described as dramatic or emotional, such as antisocial, borderline, histrionic or narcissistic personality disorders; and those sometimes classed as fear-related, such as anxious-avoidant, dependent, or obsessive–compulsive personality disorders. Personality disorders, in general, are defined as emerging in childhood, or at least by adolescence or early adulthood. The ICD also has a category for enduring personality change after a catastrophic experience or psychiatric illness. If an inability to sufficiently adjust to life circumstances begins within three months of a particular event or situation, and ends within six months after the stressor stops or is eliminated, it may instead be classed as an adjustment disorder. There is an emerging consensus that personality disorders, similar to personality traits in general, incorporate a mixture of acute dysfunctional behaviors that may resolve in short periods, and maladaptive temperamental traits that are more enduring. Furthermore, there are also non-categorical schemes that rate all individuals via a profile of different dimensions of personality without a symptom-based cutoff from normal personality variation, for example through schemes based on dimensional models. Eating disorder An eating disorder is a serious mental health condition that involves an unhealthy relationship with food and body image. They can cause severe physical and psychological problems. Eating disorders involve disproportionate concern in matters of food and weight. Categories of disorder in this area include anorexia nervosa, bulimia nervosa, exercise bulimia or binge eating disorder. Sleep disorder Sleep disorders are associated with disruption to normal sleep patterns. A common sleep disorder is insomnia, which is described as difficulty falling and/or staying asleep. Other sleep disorders include narcolepsy, sleep apnea, REM sleep behavior disorder, chronic sleep deprivation, and restless leg syndrome. Narcolepsy is a condition of extreme tendencies to fall asleep whenever and wherever. People with narcolepsy feel refreshed after their random sleep, but eventually get sleepy again. Narcolepsy diagnosis requires an overnight stay at a sleep center for analysis, during which doctors ask for a detailed sleep history and sleep records. Doctors also use actigraphs and polysomnography. Doctors will do a multiple sleep latency test, which measures how long it takes a person to fall asleep. Sleep apnea, when breathing repeatedly stops and starts during sleep, can be a serious sleep disorder. Three types of sleep apnea include obstructive sleep apnea, central sleep apnea, and complex sleep apnea. Sleep apnea can be diagnosed at home or with polysomnography at a sleep center. An ear, nose, and throat doctor may further help with the sleeping habits. Sexuality related Sexual disorders include dyspareunia and various kinds of paraphilia (sexual arousal to objects, situations, or individuals that are considered abnormal or harmful to the person or others). Other Impulse control disorder: People who are abnormally unable to resist certain urges or impulses that could be harmful to themselves or others, may be classified as having an impulse control disorder, and disorders such as kleptomania (stealing) or pyromania (fire-setting). Various behavioral addictions, such as gambling addiction, may be classed as a disorder. Obsessive–compulsive disorder can sometimes involve an inability to resist certain acts but is classed separately as being primarily an anxiety disorder. Substance use disorder: This disorder refers to the use of drugs (legal or illegal, including alcohol) that persists despite significant problems or harm related to its use. Substance dependence and substance abuse fall under this umbrella category in the DSM. Substance use disorder may be due to a pattern of compulsive and repetitive use of a drug that results in tolerance to its effects and withdrawal symptoms when use is reduced or stopped. Dissociative disorder: People with severe disturbances of their self-identity, memory, and general awareness of themselves and their surroundings may be classified as having these types of disorders, including depersonalization derealization disorder or dissociative identity disorder (which was previously referred to as multiple personality disorder or "split personality"). Cognitive disorder: These affect cognitive abilities, including learning and memory. This category includes delirium and mild and major neurocognitive disorder (previously termed dementia). Developmental disorder: These disorders initially occur in childhood. Some examples include autism spectrum disorder, oppositional defiant disorder and conduct disorder, and attention deficit hyperactivity disorder (ADHD), which may continue into adulthood. Conduct disorder, if continuing into adulthood, may be diagnosed as antisocial personality disorder (dissocial personality disorder in the ICD). Popular labels such as psychopath (or sociopath) do not appear in the DSM or ICD but are linked by some to these diagnoses. Somatoform disorders may be diagnosed when there are problems that appear to originate in the body that are thought to be manifestations of a mental disorder. This includes somatization disorder and conversion disorder. There are also disorders of how a person perceives their body, such as body dysmorphic disorder. Neurasthenia is an old diagnosis involving somatic complaints as well as fatigue and low spirits/depression, which is officially recognized by the ICD-10 but no longer by the DSM-IV. Factitious disorders are diagnosed where symptoms are thought to be reported for personal gain. Symptoms are often deliberately produced or feigned, and may relate to either symptoms in the individual or in someone close to them, particularly people they care for. There are attempts to introduce a category of relational disorder, where the diagnosis is of a relationship rather than on any one individual in that relationship. The relationship may be between children and their parents, between couples, or others. There already exists, under the category of psychosis, a diagnosis of shared psychotic disorder where two or more individuals share a particular delusion because of their close relationship with each other. There are a number of uncommon psychiatric syndromes, which are often named after the person who first described them, such as Capgras syndrome, De Clerambault syndrome, Othello syndrome, Ganser syndrome, Cotard delusion, and Ekbom syndrome, and additional disorders such as the Couvade syndrome and Geschwind syndrome. Signs and symptoms Course The onset of psychiatric disorders usually occurs from childhood to early adulthood. Impulse-control disorders and a few anxiety disorders tend to appear in childhood. Some other anxiety disorders, substance disorders, and mood disorders emerge later in the mid-teens. Symptoms of schizophrenia typically manifest from late adolescence to early twenties. The likely course and outcome of mental disorders vary and are dependent on numerous factors related to the disorder itself, the individual as a whole, and the social environment. Some disorders may last a brief period of time, while others may be long-term in nature. All disorders can have a varied course. Long-term international studies of schizophrenia have found that over a half of individuals recover in terms of symptoms, and around a fifth to a third in terms of symptoms and functioning, with many requiring no medication. While some have serious difficulties and support needs for many years, "late" recovery is still plausible. The World Health Organization (WHO) concluded that the long-term studies' findings converged with others in "relieving patients, carers and clinicians of the chronicity paradigm which dominated thinking throughout much of the 20th century." A follow-up study by Tohen and coworkers revealed that around half of people initially diagnosed with bipolar disorder achieve symptomatic recovery (no longer meeting criteria for the diagnosis) within six weeks, and nearly all achieve it within two years, with nearly half regaining their prior occupational and residential status in that period. Less than half go on to experience a new episode of mania or major depression within the next two years. Disability Some disorders may be very limited in their functional effects, while others may involve substantial disability and support needs. In this context, the terms psychiatric disability and psychological disability are sometimes used instead of mental disorder. The degree of ability or disability may vary over time and across different life domains. Furthermore, psychiatric disability has been linked to institutionalization, discrimination and social exclusion as well as to the inherent effects of disorders. Alternatively, functioning may be affected by the stress of having to hide a condition in work or school, etc., by adverse effects of medications or other substances, or by mismatches between illness-related variations and demands for regularity. It is also the case that, while often being characterized in purely negative terms, some mental traits or states labeled as psychiatric disabilities can also involve above-average creativity, non-conformity, goal-striving, meticulousness, or empathy. In addition, the public perception of the level of disability associated with mental disorders can change. Nevertheless, internationally, people report equal or greater disability from commonly occurring mental conditions than from commonly occurring physical conditions, particularly in their social roles and personal relationships. The proportion with access to professional help for mental disorders is far lower, however, even among those assessed as having a severe psychiatric disability. Disability in this context may or may not involve such things as: Basic activities of daily living. Including looking after the self (health care, grooming, dressing, shopping, cooking etc.) or looking after accommodation (chores, DIY tasks, etc.) Interpersonal relationships. Including communication skills, ability to form relationships and sustain them, ability to leave the home or mix in crowds or particular settings Occupational functioning. Ability to acquire an employment and hold it, cognitive and social skills required for the job, dealing with workplace culture, or studying as a student. In terms of total disability-adjusted life years (DALYs), which is an estimate of how many years of life are lost due to premature death or to being in a state of poor health and disability, psychiatric disabilities rank amongst the most disabling conditions. Unipolar (also known as Major) depressive disorder is the third leading cause of disability worldwide, of any condition mental or physical, accounting for 65.5 million years lost. The first systematic description of global disability arising in youth, in 2011, found that among 10- to 24-year-olds nearly half of all disability (current and as estimated to continue) was due to psychiatric disabilities, including substance use disorders and conditions involving self-harm. Second to this were accidental injuries (mainly traffic collisions) accounting for 12 percent of disability, followed by communicable diseases at 10 percent. The psychiatric disabilities associated with most disabilities in high-income countries were unipolar major depression (20%) and alcohol use disorder (11%). In the eastern Mediterranean region, it was unipolar major depression (12%) and schizophrenia (7%), and in Africa it was unipolar major depression (7%) and bipolar disorder (5%). Suicide, which is often attributed to some underlying mental disorder, is a leading cause of death among teenagers and adults under 35. There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide. Risk factors The predominant view is that genetic, psychological, and environmental factors all contribute to the development or progression of mental disorders. Different risk factors may be present at different ages, with risk occurring as early as during prenatal period. Genetics A number of psychiatric disorders are linked to a family history (including depression, narcissistic personality disorder and anxiety). Twin studies have also revealed a very high heritability for many mental disorders (especially autism and schizophrenia). Although researchers have been looking for decades for clear linkages between genetics and mental disorders, that work has not yielded specific genetic biomarkers yet that might lead to better diagnosis and better treatments. Statistical research looking at eleven disorders found widespread assortative mating between people with mental illness. That means that individuals with one of these disorders were two to three times more likely than the general population to have a partner with a mental disorder. Sometimes people seemed to have preferred partners with the same mental illness. Thus, people with schizophrenia or ADHD are seven times more likely to have affected partners with the same disorder. This is even more pronounced for people with Autism spectrum disorders who are 10 times more likely to have a spouse with the same disorder. Environment During the prenatal stage, factors like unwanted pregnancy, lack of adaptation to pregnancy or substance use during pregnancy increases the risk of developing a mental disorder. Maternal stress and birth complications including prematurity and infections have also been implicated in increasing susceptibility for mental illness. Infants neglected or not provided optimal nutrition have a higher risk of developing cognitive impairment. Social influences have also been found to be important, including abuse, neglect, bullying, social stress, traumatic events, and other negative or overwhelming life experiences. Aspects of the wider community have also been implicated, including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures. The specific risks and pathways to particular disorders are less clear, however. Nutrition also plays a role in mental disorders. In schizophrenia and psychosis, risk factors include migration and discrimination, childhood trauma, bereavement or separation in families, recreational use of drugs, and urbanicity. In anxiety, risk factors may include parenting factors including parental rejection, lack of parental warmth, high hostility, harsh discipline, high maternal negative affect, anxious childrearing, modelling of dysfunctional and drug-abusing behavior, and child abuse (emotional, physical and sexual). Adults with imbalance work to life are at higher risk for developing anxiety. For bipolar disorder, stress (such as childhood adversity) is not a specific cause, but does place genetically and biologically vulnerable individuals at risk for a more severe course of illness. Drug use Mental disorders are associated with drug use including: cannabis, alcohol and caffeine, use of which appears to promote anxiety. For psychosis and schizophrenia, usage of a number of drugs has been associated with development of the disorder, including cannabis, cocaine, and amphetamines. There has been debate regarding the relationship between usage of cannabis and bipolar disorder. Cannabis has also been associated with depression. Adolescents are at increased risk for tobacco, alcohol and drug use; Peer pressure is the main reason why adolescents start using substances. At this age, the use of substances could be detrimental to the development of the brain and place them at higher risk of developing a mental disorder. Chronic disease People living with chronic conditions like HIV and diabetes are at higher risk of developing a mental disorder. People living with diabetes experience significant stress from the biological impact of the disease, which places them at risk for developing anxiety and depression. Diabetic patients also have to deal with emotional stress trying to manage the disease. Conditions like heart disease, stroke, respiratory conditions, cancer, and arthritis increase the risk of developing a mental disorder when compared to the general population. Personality traits Risk factors for mental illness include a propensity for high neuroticism or "emotional instability". In anxiety, risk factors may include temperament and attitudes (e.g. pessimism). Causal models Mental disorders can arise from multiple sources, and in many cases there is no single accepted or consistent cause currently established. An eclectic or pluralistic mix of models may be used to explain particular disorders. The primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial model which incorporates biological, psychological and social factors, although this may not always be applied in practice. Biological psychiatry follows a biomedical model where many mental disorders are conceptualized as disorders of brain circuits likely caused by developmental processes shaped by a complex interplay of genetics and experience. A common assumption is that disorders may have resulted from genetic and developmental vulnerabilities, exposed by stress in life (for example in a diathesis–stress model), although there are various views on what causes differences between individuals. Some types of mental disorders may be viewed as primarily neurodevelopmental disorders. Evolutionary psychology may be used as an overall explanatory theory, while attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context of mental disorders. Psychoanalytic theories have continued to evolve alongside and cognitive-behavioral and systemic-family approaches. A distinction is sometimes made between a "medical model" or a "social model" of psychiatric disability. Diagnosis Psychiatrists seek to provide a medical diagnosis of individuals by an assessment of symptoms, signs and impairment associated with particular types of mental disorder. Other mental health professionals, such as clinical psychologists, may or may not apply the same diagnostic categories to their clinical formulation of a client's difficulties and circumstances. The majority of mental health problems are, at least initially, assessed and treated by family physicians (in the UK general practitioners) during consultations, who may refer a patient on for more specialist diagnosis in acute or chronic cases. Routine diagnostic practice in mental health services typically involves an interview known as a mental status examination, where evaluations are made of appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of other professionals, relatives, or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in rare specialist cases neuroimaging tests may be requested, but such methods are more commonly found in research studies than routine clinical practice. Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations. It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice. In addition, comorbidity is very common in psychiatric diagnosis, where the same person meets the criteria for more than one disorder. On the other hand, a person may have several different difficulties only some of which meet the criteria for being diagnosed. There may be specific problems with accurate diagnosis in developing countries. More structured approaches are being increasingly used to measure levels of mental illness. HoNOS is the most widely used measure in English mental health services, being used by at least 61 trusts. In HoNOS a score of 0–4 is given for each of 12 factors, based on functional living capacity. Research has been supportive of HoNOS, although some questions have been asked about whether it provides adequate coverage of the range and complexity of mental illness problems, and whether the fact that often only 3 of the 12 scales vary over time gives enough subtlety to accurately measure outcomes of treatment. Criticism Since the 1980s, Paula Caplan has been concerned about the subjectivity of psychiatric diagnosis, and people being arbitrarily "slapped with a psychiatric label." Caplan says because psychiatric diagnosis is unregulated, doctors are not required to spend much time interviewing patients or to seek a second opinion. The Diagnostic and Statistical Manual of Mental Disorders can lead a psychiatrist to focus on narrow checklists of symptoms, with little consideration of what is actually causing the person's problems. So, according to Caplan, getting a psychiatric diagnosis and label often stands in the way of recovery. In 2013, psychiatrist Allen Frances wrote a paper entitled "The New Crisis of Confidence in Psychiatric Diagnosis", which said that "psychiatric diagnosis... still relies exclusively on fallible subjective judgments rather than objective biological tests." Frances was also concerned about "unpredictable overdiagnosis." For many years, marginalized psychiatrists (such as Peter Breggin, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality." More recently these concerns have come from insiders who have worked for and promoted the American Psychiatric Association (e.g., Robert Spitzer, Allen Frances). A 2002 editorial in the British Medical Journal warned of inappropriate medicalization leading to disease mongering, where the boundaries of the definition of illnesses are expanded to include personal problems as medical problems or risks of diseases are emphasized to broaden the market for medications. Gary Greenberg, a psychoanalyst, in his book "the Book of Woe", argues that mental illness is really about suffering and how the DSM creates diagnostic labels to categorize people's suffering. Indeed, the psychiatrist Thomas Szasz, in his book "the Medicalization of Everyday Life", also argues that what is psychiatric illness, is not always biological in nature (i.e. social problems, poverty, etc.), and may even be a part of the human condition. Potential routine use of MRI/fMRI in diagnosis in 2018 the American Psychological Association commissioned a review to reach a consensus on whether modern clinical MRI/fMRI will be able to be used in the diagnosis of mental health disorders. The criteria presented by the APA stated that the biomarkers used in diagnosis should: "have a sensitivity of at least 80% for detecting a particular psychiatric disorder" should "have a specificity of at least 80% for distinguishing this disorder from other psychiatric or medical disorders" "should be reliable, reproducible, and ideally be noninvasive, simple to perform, and inexpensive" proposed biomarkers should be verified by 2 independent studies each by a different investigator and different population samples and published in a peer-reviewed journal. The review concluded that although neuroimaging diagnosis may technically be feasible, very large studies are needed to evaluate specific biomarkers which were not available. Prevention The 2004 WHO report "Prevention of Mental Disorders" stated that "Prevention of these disorders is obviously one of the most effective ways to reduce the [disease] burden." The 2011 European Psychiatric Association (EPA) guidance on prevention of mental disorders states "There is considerable evidence that various psychiatric conditions can be prevented through the implementation of effective evidence-based interventions." A 2011 UK Department of Health report on the economic case for mental health promotion and mental illness prevention found that "many interventions are outstandingly good value for money, low in cost and often become self-financing over time, saving public expenditure". In 2016, the National Institute of Mental Health re-affirmed prevention as a research priority area. Parenting may affect the child's mental health, and evidence suggests that helping parents to be more effective with their children can address mental health needs. Universal prevention (aimed at a population that has no increased risk for developing a mental disorder, such as school programs or mass media campaigns) need very high numbers of people to show effect (sometimes known as the "power" problem). Approaches to overcome this are (1) focus on high-incidence groups (e.g. by targeting groups with high risk factors), (2) use multiple interventions to achieve greater, and thus more statistically valid, effects, (3) use cumulative meta-analyses of many trials, and (4) run very large trials. Management Treatment and support for mental disorders are provided in psychiatric hospitals, clinics or a range of community mental health services. In some countries services are increasingly based on a recovery approach, intended to support individual's personal journey to gain the kind of life they want. There is a range of different types of treatment and what is most suitable depends on the disorder and the individual. Many things have been found to help at least some people, and a placebo effect may play a role in any intervention or medication. In a minority of cases, individuals may be treated against their will, which can cause particular difficulties depending on how it is carried out and perceived. Compulsory treatment while in the community versus non-compulsory treatment does not appear to make much of a difference except by maybe decreasing victimization. Lifestyle Lifestyle strategies, including dietary changes, exercise and quitting smoking may be of benefit. Therapy There is also a wide range of psychotherapists (including family therapy), counselors, and public health professionals. In addition, there are peer support roles where personal experience of similar issues is the primary source of expertise. A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Other psychotherapies include dialectic behavioral therapy (DBT) and interpersonal psychotherapy (IPT). Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of significant others as well as an individual. Some psychotherapies are based on a humanistic approach. There are many specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement. Medication A major option for many mental disorders is psychiatric medication and there are several main groups. Antidepressants are used for the treatment of clinical depression, as well as often for anxiety and a range of other disorders. Anxiolytics (including sedatives) are used for anxiety disorders and related problems such as insomnia. Mood stabilizers are used primarily in bipolar disorder. Antipsychotics are used for psychotic disorders, notably for positive symptoms in schizophrenia, and also increasingly for a range of other disorders. Stimulants are commonly used, notably for ADHD. Despite the different conventional names of the drug groups, there may be considerable overlap in the disorders for which they are actually indicated, and there may also be off-label use of medications. There can be problems with adverse effects of medication and adherence to them, and there is also criticism of pharmaceutical marketing and professional conflicts of interest. However, these medications in combination with non-pharmacological methods, such as cognitive-behavioral therapy (CBT) are seen to be most effective in treating mental disorders. Other Electroconvulsive therapy (ECT) is sometimes used in severe cases when other interventions for severe intractable depression have failed. ECT is usually indicated for treatment resistant depression, severe vegetative symptoms, psychotic depression, intense suicidal ideation, depression during pregnancy, and catatonia. Psychosurgery is considered experimental but is advocated by some neurologists in certain rare cases. Counseling (professional) and co-counseling (between peers) may be used. Psychoeducation programs may provide people with the information to understand and manage their problems. Creative therapies are sometimes used, including music therapy, art therapy or drama therapy. Lifestyle adjustments and supportive measures are often used, including peer support, self-help groups for mental health and supported housing or supported employment (including social firms). Some advocate dietary supplements. Reasonable accommodations (adjustments and supports) might be put in place to help an individual cope and succeed in environments despite potential disability related to mental health problems. This could include an emotional support animal or specifically trained psychiatric service dog. cannabis is specifically not recommended as a treatment. Epidemiology Mental disorders are common. Worldwide, more than one in three people in most countries report sufficient criteria for at least one at some point in their life. In the United States, 46% qualify for a mental illness at some point. An ongoing survey indicates that anxiety disorders are the most common in all but one country, followed by mood disorders in all but two countries, while substance disorders and impulse-control disorders were consistently less prevalent. Rates varied by region. A review of anxiety disorder surveys in different countries found average lifetime prevalence estimates of 16.6%, with women having higher rates on average. A review of mood disorder surveys in different countries found lifetime rates of 6.7% for major depressive disorder (higher in some studies, and in women) and 0.8% for Bipolar I disorder. In the United States the frequency of disorder is: anxiety disorder (28.8%), mood disorder (20.8%), impulse-control disorder (24.8%) or substance use disorder (14.6%). A 2004 cross-Europe study found that approximately one in four people reported meeting criteria at some point in their life for at least one of the DSM-IV disorders assessed, which included mood disorders (13.9%), anxiety disorders (13.6%), or alcohol disorder (5.2%). Approximately one in ten met the criteria within a 12-month period. Women and younger people of either gender showed more cases of the disorder. A 2005 review of surveys in 16 European countries found that 27% of adult Europeans are affected by at least one mental disorder in a 12-month period. An international review of studies on the prevalence of schizophrenia found an average (median) figure of 0.4% for lifetime prevalence; it was consistently lower in poorer countries. Studies of the prevalence of personality disorders (PDs) have been fewer and smaller-scale, but one broad Norwegian survey found a five-year prevalence of almost 1 in 7 (13.4%). Rates for specific disorders ranged from 0.8% to 2.8%, differing across countries, and by gender, educational level and other factors. A US survey that incidentally screened for personality disorder found a rate of 14.79%. Approximately 7% of a preschool pediatric sample were given a psychiatric diagnosis in one clinical study, and approximately 10% of 1- and 2-year-olds receiving developmental screening have been assessed as having significant emotional/behavioral problems based on parent and pediatrician reports. While rates of psychological disorders are often the same for men and women, women tend to have a higher rate of depression. Each year 73 million women are affected by major depression, and suicide is ranked 7th as the cause of death for women between the ages of 20–59. Depressive disorders account for close to 41.9% of the psychiatric disabilities among women compared to 29.3% among men. History Ancient civilizations Ancient civilizations described and treated a number of mental disorders. Mental illnesses were well known in ancient Mesopotamia, where diseases and mental disorders were believed to be caused by specific deities. Because hands symbolized control over a person, mental illnesses were known as "hands" of certain deities. One psychological illness was known as Qāt Ištar, meaning "Hand of Ishtar". Others were known as "Hand of Shamash", "Hand of the Ghost", and "Hand of the God". Descriptions of these illnesses, however, are so vague that it is usually impossible to determine which illnesses they correspond to in modern terminology. Mesopotamian doctors kept detailed record of their patients' hallucinations and assigned spiritual meanings to them. The royal family of Elam was notorious for its members often being insane. The Greeks coined terms for melancholy, hysteria and phobia and developed the humorism theory. Mental disorders were described, and treatments developed, in Persia, Arabia and in the medieval Islamic world. Europe Middle Ages Conceptions of madness in the Middle Ages in Christian Europe were a mixture of the divine, diabolical, magical and humoral, and transcendental. In the early modern period, some people with mental disorders may have been victims of the witch-hunts. While not every witch and sorcerer accused were mentally ill, all mentally ill were considered to be witches or sorcerers. Many terms for mental disorders that found their way into everyday use first became popular in the 16th and 17th centuries. Eighteenth century By the end of the 17th century and into the Enlightenment, madness was increasingly seen as an organic physical phenomenon with no connection to the soul or moral responsibility. Asylum care was often harsh and treated people like wild animals, but towards the end of the 18th century a moral treatment movement gradually developed. Clear descriptions of some syndromes may be rare before the 19th century. Nineteenth century Industrialization and population growth led to a massive expansion of the number and size of insane asylums in every Western country in the 19th century. Numerous different classification schemes and diagnostic terms were developed by different authorities, and the term psychiatry was coined (1808), though medical superintendents were still known as alienists. Twentieth century The turn of the 20th century saw the development of psychoanalysis, which would later come to the fore, along with Kraepelin's classification scheme. Asylum "inmates" were increasingly referred to as "patients", and asylums were renamed as hospitals. Europe and the United States Early in the 20th century in the United States, a mental hygiene movement developed, aiming to prevent mental disorders. Clinical psychology and social work developed as professions. World War I saw a massive increase of conditions that came to be termed "shell shock". World War II saw the development in the U.S. of a new psychiatric manual for categorizing mental disorders, which along with existing systems for collecting census and hospital statistics led to the first Diagnostic and Statistical Manual of Mental Disorders. The International Classification of Diseases (ICD) also developed a section on mental disorders. The term stress, having emerged from endocrinology work in the 1930s, was increasingly applied to mental disorders. Electroconvulsive therapy, insulin shock therapy, lobotomies and the neuroleptic chlorpromazine came to be used by mid-century. In the 1960s there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman who said that mental illness was merely another example of how society labels and controls non-conformists; from behavioral psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science by Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis. Deinstitutionalization gradually occurred in the West, with isolated psychiatric hospitals being closed down in favor of community mental health services. A consumer/survivor movement gained momentum. Other kinds of psychiatric medication gradually came into use, such as "psychic energizers" (later antidepressants) and lithium. Benzodiazepines gained widespread use in the 1970s for anxiety and depression, until dependency problems curtailed their popularity. Advances in neuroscience, genetics, and psychology led to new research agendas. Cognitive behavioral therapy and other psychotherapies developed. The DSM and then ICD adopted new criteria-based classifications, and the number of "official" diagnoses saw a large expansion. Through the 1990s, new SSRI-type antidepressants became some of the most widely prescribed drugs in the world, as later did antipsychotics. Also during the 1990s, a recovery approach developed. Africa and Nigeria Most Africans view mental disturbances as external spiritual attack on the person. Those who have a mental illness are thought to be under a spell or bewitched. Often than usual, People view a mentally ill person as possessed of an evil spirit and is seen as more of sociological perspective than a psychological order. The WHO estimated that fewer than 10% of mentally ill Nigerians have access to a psychiatrist or health worker, because there is a low ratio of mental-health specialists available in a country of 200 million people. WHO estimates that the number of mentally ill Nigerians ranges from 40 million to 60 million. Disorders such as depression, anxiety, schizophrenia, personality disorder, old age-related disorder, and substance-abuse disorder are common in Nigeria, as in other countries in Africa. Nigeria is still nowhere near being equipped to solve prevailing mental health challenges. With little scientific research carried out, coupled with insufficient mental-health hospitals in the country, traditional healers provide specialized psychotherapy care to those that require their services and pharmacotherapy Society and culture Different societies or cultures, even different individuals in a subculture, can disagree as to what constitutes optimal versus pathological biological and psychological functioning. Research has demonstrated that cultures vary in the relative importance placed on, for example, happiness, autonomy, or social relationships for pleasure. Likewise, the fact that a behavior pattern is valued, accepted, encouraged, or even statistically normative in a culture does not necessarily mean that it is conducive to optimal psychological functioning. People in all cultures find some behaviors bizarre or even incomprehensible. But just what they feel is bizarre or incomprehensible is ambiguous and subjective. These differences in determination can become highly contentious. The process by which conditions and difficulties come to be defined and treated as medical conditions and problems, and thus come under the authority of doctors and other health professionals, is known as medicalization or pathologization. Mental illness in the Latin American community There is a perception in Latin American communities, especially among older people, that discussing problems with mental health can create embarrassment and shame for the family. This results in fewer people seeking treatment. Latin Americans from the US are slightly more likely to have a mental health disorder than first-generation Latin American immigrants, although differences between ethnic groups were found to disappear after adjustment for place of birth. From 2015 to 2018, rates of serious mental illness in young adult Latin Americans increased by 60%, from 4% to 6.4%. The prevalence of major depressive episodes in young and adult Latin Americans increased from 8.4% to 11.3%. More than a third of Latin Americans reported more than one bad mental health day in the last three months. The rate of suicide among Latin Americans was about half the rate of non-Latin American white Americans in 2018, and this was the second-leading cause of death among Latin Americans ages 15 to 34. However, Latin American suicide rates rose steadily after 2020 in relation to the COVID-19 pandemic, even as the national rate declined. Family relations are an integral part of the Latin American community. Some research has shown that Latin Americans are more likely rely on family bonds, or familismo, as a source of therapy while struggling with mental health issues. Because Latin Americans have a high rate of religiosity, and because there is less stigma associated with religion than with psychiatric services, religion may play a more important therapeutic role for the mentally ill in Latin American communities. However, research has also suggested that religion may also play a role in stigmatizing mental illness in Latin American communities, which can discourage community members from seeking professional help. Religion Religious, spiritual, or transpersonal experiences and beliefs meet many criteria of delusional or psychotic disorders. A belief or experience can sometimes be shown to produce distress or disability—the ordinary standard for judging mental disorders. There is a link between religion and schizophrenia, a complex mental disorder characterized by a difficulty in recognizing reality, regulating emotional responses, and thinking in a clear and logical manner. Those with schizophrenia commonly report some type of religious delusion, and religion itself may be a trigger for schizophrenia. Movements Controversy has often surrounded psychiatry, and the term anti-psychiatry was coined by the psychiatrist David Cooper in 1967. The anti-psychiatry message is that psychiatric treatments are ultimately more damaging than helpful to patients, and psychiatry's history involves what may now be seen as dangerous treatments. Electroconvulsive therapy was one of these, which was used widely between the 1930s and 1960s. Lobotomy was another practice that was ultimately seen as too invasive and brutal. Diazepam and other sedatives were sometimes over-prescribed, which led to an epidemic of dependence. There was also concern about the large increase in prescribing psychiatric drugs for children. Some charismatic psychiatrists came to personify the movement against psychiatry. The most influential of these was R.D. Laing who wrote a series of best-selling books, including The Divided Self. Thomas Szasz wrote The Myth of Mental Illness. Some ex-patient groups have become militantly anti-psychiatric, often referring to themselves as survivors. Giorgio Antonucci has questioned the basis of psychiatry through his work on the dismantling of two psychiatric hospitals (in the city of Imola), carried out from 1973 to 1996. The consumer/survivor movement (also known as user/survivor movement) is made up of individuals (and organizations representing them) who are clients of mental health services or who consider themselves survivors of psychiatric interventions. Activists campaign for improved mental health services and for more involvement and empowerment within mental health services, policies and wider society. Patient advocacy organizations have expanded with increasing deinstitutionalization in developed countries, working to challenge the stereotypes, stigma and exclusion associated with psychiatric conditions. There is also a carers rights movement of people who help and support people with mental health conditions, who may be relatives, and who often work in difficult and time-consuming circumstances with little acknowledgement and without pay. An anti-psychiatry movement fundamentally challenges mainstream psychiatric theory and practice, including in some cases asserting that psychiatric concepts and diagnoses of 'mental illness' are neither real nor useful. Alternatively, a movement for global mental health has emerged, defined as 'the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide'. Cultural bias Diagnostic guidelines of the 2000s, namely the DSM and to some extent the ICD, have been criticized as having a fundamentally Euro-American outlook. Opponents argue that even when diagnostic criteria are used across different cultures, it does not mean that the underlying constructs have validity within those cultures, as even reliable application can prove only consistency, not legitimacy. Advocating a more culturally sensitive approach, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV. Disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, revealing to Kleinman an underlying assumption that Western cultural phenomena are universal. Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics. Common responses included both disappointment over the large number of documented non-Western mental disorders still left out and frustration that even those included are often misinterpreted or misrepresented. Many mainstream psychiatrists are dissatisfied with the new culture-bound diagnoses, although for partly different reasons. Robert Spitzer, a lead architect of the DSM-III, has argued that adding cultural formulations was an attempt to appease cultural critics, and has stated that they lack any scientific rationale or support. Spitzer also posits that the new culture-bound diagnoses are rarely used, maintaining that the standard diagnoses apply regardless of the culture involved. In general, mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are significant only to specific symptom presentations. Clinical conceptions of mental illness also overlap with personal and cultural values in the domain of morality, so much so that it is sometimes argued that separating the two is impossible without fundamentally redefining the essence of being a particular person in a society. In clinical psychiatry, persistent distress and disability indicate an internal disorder requiring treatment; but in another context, that same distress and disability can be seen as an indicator of emotional struggle and the need to address social and structural problems. This dichotomy has led some academics and clinicians to advocate a postmodernist conceptualization of mental distress and well-being. Such approaches, along with cross-cultural and "heretical" psychologies centered on alternative cultural and ethnic and race-based identities and experiences, stand in contrast to the mainstream psychiatric community's alleged avoidance of any explicit involvement with either morality or culture. In many countries there are attempts to challenge perceived prejudice against minority groups, including alleged institutional racism within psychiatric services. There are also ongoing attempts to improve professional cross cultural sensitivity. Laws and policies Three-quarters of countries around the world have mental health legislation. Compulsory admission to mental health facilities (also known as involuntary commitment) is a controversial topic. It can impinge on personal liberty and the right to choose, and carry the risk of abuse for political, social, and other reasons; yet it can potentially prevent harm to self and others, and assist some people in attaining their right to healthcare when they may be unable to decide in their own interests. Because of this it is a concern of medical ethics. All human rights oriented mental health laws require proof of the presence of a mental disorder as defined by internationally accepted standards, but the type and severity of disorder that counts can vary in different jurisdictions. The two most often used grounds for involuntary admission are said to be serious likelihood of immediate or imminent danger to self or others, and the need for treatment. Applications for someone to be involuntarily admitted usually come from a mental health practitioner, a family member, a close relative, or a guardian. Human-rights-oriented laws usually stipulate that independent medical practitioners or other accredited mental health practitioners must examine the patient separately and that there should be regular, time-bound review by an independent review body. The individual should also have personal access to independent advocacy. For involuntary treatment to be administered (by force if necessary), it should be shown that an individual lacks the mental capacity for informed consent (i.e. to understand treatment information and its implications, and therefore be able to make an informed choice to either accept or refuse). Legal challenges in some areas have resulted in supreme court decisions that a person does not have to agree with a psychiatrist's characterization of the issues as constituting an "illness", nor agree with a psychiatrist's conviction in medication, but only recognize the issues and the information about treatment options. Proxy consent (also known as surrogate or substituted decision-making) may be transferred to a personal representative, a family member, or a legally appointed guardian. Moreover, patients may be able to make, when they are considered well, an advance directive stipulating how they wish to be treated should they be deemed to lack mental capacity in the future. The right to supported decision-making, where a person is helped to understand and choose treatment options before they can be declared to lack capacity, may also be included in the legislation. There should at the very least be shared decision-making as far as possible. Involuntary treatment laws are increasingly extended to those living in the community, for example outpatient commitment laws (known by different names) are used in New Zealand, Australia, the United Kingdom, and most of the United States. The World Health Organization reports that in many instances national mental health legislation takes away the rights of persons with mental disorders rather than protecting rights, and is often outdated. In 1991, the United Nations adopted the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, which established minimum human rights standards of practice in the mental health field. In 2006, the UN formally agreed the Convention on the Rights of Persons with Disabilities to protect and enhance the rights and opportunities of disabled people, including those with psychiatric disabilities. The term insanity, sometimes used colloquially as a synonym for mental illness, is often used technically as a legal term. The insanity defense may be used in a legal trial (known as the mental disorder defence in some countries). Perception and discrimination Stigma The social stigma associated with mental disorders is a widespread problem. The US Surgeon General stated in 1999 that: "Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others." Additionally, researcher Wulf Rössler in 2016, in his article, "The Stigma of Mental Disorders" stated In the United States, racial and ethnic minorities are more likely to experience mental health disorders often due to low socioeconomic status, and discrimination. In Taiwan, people with mental disorders often face misconceptions from the general public. These misconceptions include the belief that mental health issues stem from excessive worry, having too much free time, a lack of progress or ambition, not taking life seriously, neglecting real-life responsibilities, mental weakness, unwillingness to be resilient, perfectionism, or a lack of courage. Employment discrimination is reported to play a significant part in the high rate of unemployment among those with a diagnosis of mental illness. An Australian study found that having a psychiatric disability is a bigger barrier to employment than a physical disability. The mentally ill are stigmatized in Chinese society and can not legally marry. Efforts are being undertaken worldwide to eliminate the stigma of mental illness, although the methods and outcomes used have sometimes been criticized. Media and general public Media coverage of mental illness comprises predominantly negative and pejorative depictions, for example, of incompetence, violence or criminality, with far less coverage of positive issues such as accomplishments or human rights issues. Such negative depictions, including in children's cartoons, are thought to contribute to stigma and negative attitudes in the public and in those with mental health problems themselves, although more sensitive or serious cinematic portrayals have increased in prevalence. In the United States, the Carter Center has created fellowships for journalists in South Africa, the U.S., and Romania, to enable reporters to research and write stories on mental health topics. Former US First Lady Rosalynn Carter began the fellowships not only to train reporters in how to sensitively and accurately discuss mental health and mental illness, but also to increase the number of stories on these topics in the news media. There is also a World Mental Health Day, which in the United States and Canada falls within a Mental Illness Awareness Week. The general public have been found to hold a strong stereotype of dangerousness and desire for social distance from individuals described as mentally ill. A US national survey found that a higher percentage of people rate individuals described as displaying the characteristics of a mental disorder as "likely to do something violent to others", compared to the percentage of people who are rating individuals described as being troubled. In the article, "Discrimination Against People with a Mental Health Diagnosis: Qualitative Analysis of Reported Experiences", an individual who has a mental disorder, revealed that, "If people don't know me and don't know about the problems, they'll talk to me quite happily. Once they've seen the problems or someone's told them about me, they tend to be a bit more wary." In addition, in the article, "Stigma and its Impact on Help-Seeking for Mental Disorders: What Do We Know?" by George Schomerus and Matthias Angermeyer, it is affirmed that "Family doctors and psychiatrists have more pessimistic views about the outcomes for mental illnesses than the general public (Jorm et al., 1999), and mental health professionals hold more negative stereotypes about mentally ill patients, but, reassuringly, they are less accepting of restrictions towards them." Recent depictions in media have included leading characters successfully living with and managing a mental illness, including in bipolar disorder in Homeland (2011) and post-traumatic stress disorder in Iron Man 3 (2013). Violence Despite public or media opinion, national studies have indicated that severe mental illness does not independently predict future violent behavior, on average, and is not a leading cause of violence in society. There is a statistical association with various factors that do relate to violence (in anyone), such as substance use and various personal, social, and economic factors. A 2015 review found that in the United States, about 4% of violence is attributable to people diagnosed with mental illness, and a 2014 study found that 7.5% of crimes committed by mentally ill people were directly related to the symptoms of their mental illness. The majority of people with serious mental illness are never violent. In fact, findings consistently indicate that it is many times more likely that people diagnosed with a serious mental illness living in the community will be the victims rather than the perpetrators of violence. In a study of individuals diagnosed with "severe mental illness" living in a US inner-city area, a quarter were found to have been victims of at least one violent crime over the course of a year, a proportion eleven times higher than the inner-city average, and higher in every category of crime including violent assaults and theft. People with a diagnosis may find it more difficult to secure prosecutions, however, due in part to prejudice and being seen as less credible. However, there are some specific diagnoses, such as childhood conduct disorder or adult antisocial personality disorder or psychopathy, which are defined by, or are inherently associated with, conduct problems and violence. There are conflicting findings about the extent to which certain specific symptoms, notably some kinds of psychosis (hallucinations or delusions) that can occur in disorders such as schizophrenia, delusional disorder or mood disorder, are linked to an increased risk of serious violence on average. The mediating factors of violent acts, however, are most consistently found to be mainly socio-demographic and socio-economic factors such as being young, male, of lower socioeconomic status and, in particular, substance use (including alcohol use) to which some people may be particularly vulnerable. High-profile cases have led to fears that serious crimes, such as homicide, have increased due to deinstitutionalization, but the evidence does not support this conclusion. Violence that does occur in relation to mental disorder (against the mentally ill or by the mentally ill) typically occurs in the context of complex social interactions, often in a family setting rather than between strangers. It is also an issue in health care settings and the wider community. Mental health The recognition and understanding of mental health conditions have changed over time and across cultures and there are still variations in definition, assessment, and classification, although standard guideline criteria are widely used. In many cases, there appears to be a continuum between mental health and mental illness, making diagnosis complex. According to the World Health Organization, over a third of people in most countries report problems at some time in their life which meet the criteria for diagnosis of one or more of the common types of mental disorder. Corey M Keyes has created a two continua model of mental illness and health which holds that both are related, but distinct dimensions: one continuum indicates the presence or absence of mental health, the other the presence or absence of mental illness. For example, people with optimal mental health can also have a mental illness, and people who have no mental illness can also have poor mental health. Other animals Psychopathology in non-human primates has been studied since the mid-20th century. Over 20 behavioral patterns in captive chimpanzees have been documented as (statistically) abnormal for frequency, severity or oddness—some of which have also been observed in the wild. Captive great apes show gross behavioral abnormalities such as stereotypy of movements, self-mutilation, disturbed emotional reactions (mainly fear or aggression) towards companions, lack of species-typical communications, and generalized learned helplessness. In some cases such behaviors are hypothesized to be equivalent to symptoms associated with psychiatric disorders in humans such as depression, anxiety disorders, eating disorders and post-traumatic stress disorder. Concepts of antisocial, borderline and schizoid personality disorders have also been applied to non-human great apes. The risk of anthropomorphism is often raised concerning such comparisons, and assessment of non-human animals cannot incorporate evidence from linguistic communication. However, available evidence may range from nonverbal behaviors—including physiological responses and homologous facial displays and acoustic utterances—to neurochemical studies. It is pointed out that human psychiatric classification is often based on statistical description and judgment of behaviors (especially when speech or language is impaired) and that the use of verbal self-report is itself problematic and unreliable. Psychopathology has generally been traced, at least in captivity, to adverse rearing conditions such as early separation of infants from mothers; early sensory deprivation; and extended periods of social isolation. Studies have also indicated individual variation in temperament, such as sociability or impulsiveness. Particular causes of problems in captivity have included integration of strangers into existing groups and a lack of individual space, in which context some pathological behaviors have also been seen as coping mechanisms. Remedial interventions have included careful individually tailored re-socialization programs, behavior therapy, environment enrichment, and on rare occasions psychiatric drugs. Socialization has been found to work 90% of the time in disturbed chimpanzees, although restoration of functional sexuality and caregiving is often not achieved. Laboratory researchers sometimes try to develop animal models of human mental disorders, including by inducing or treating symptoms in animals through genetic, neurological, chemical or behavioral manipulation, but this has been criticized on empirical grounds and opposed on animal rights grounds. See also 50 Signs of Mental Illness List of mental disorders Mental illness portrayed in media Mental disorders in film Mental illness in fiction Mental illness in American prisons Parity of esteem Psychological evaluation References Further reading Stanford Encyclopedia of Philosophy External links Overcoming Mental Health Stigma in the Latino Community – Consult QD clevelandclinic.org National Institute of Mental Health International Committee of Women Leaders on Mental Health Disability by type Abnormal psychology Psychopathology Psychiatric assessment Suffering

Clinical psychology

Clinical psychology is an integration of human science, behavioral science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession. The field is generally considered to have begun in 1896 with the opening of the first psychological clinic at the University of Pennsylvania by Lightner Witmer. In the first half of the 20th century, clinical psychology was focused on psychological assessment, with little attention given to treatment. This changed after the 1940s when World War II resulted in the need for a large increase in the number of trained clinicians. Since that time, three main educational models have developed in the US—the PhD Clinical Science model (heavily focused on research), the PhD science-practitioner model (integrating scientific research and practice), and the PsyD practitioner-scholar model (focusing on clinical theory and practice). In the UK and the Republic of Ireland, the Clinical Psychology Doctorate falls between the latter two of these models, whilst in much of mainland Europe, the training is at the master's level and predominantly psychotherapeutic. Clinical psychologists are expert in providing psychotherapy, and generally train within four primary theoretical orientations—psychodynamic, humanistic, cognitive behavioral therapy (CBT), and systems or family therapy. History The earliest recorded approaches to assess and treat mental distress were a combination of religious, magical, and/or medical perspectives. In the early 19th century, one approach to study mental conditions and behavior was using phrenology, the study of personality by examining the shape of the skull. Other popular treatments at that time included the study of the shape of the face (physiognomy) and Mesmer's treatment for mental conditions using magnets (mesmerism). Spiritualism and Phineas Quimby's "mental healing" were also popular. While the scientific community eventually came to reject all of these methods for treating mental illness, academic psychologists also were not concerned with serious forms of mental illness. The study of mental illness was already being done in the developing fields of psychiatry and neurology within the asylum movement. It was not until the end of the 19th century, around the time when Sigmund Freud was first developing his "talking cure" in Vienna, that the first scientific application of clinical psychology began. Early clinical psychology By the second half of the 1800s, the scientific study of psychology was becoming well established in university laboratories. Although there were a few scattered voices calling for applied psychology, the general field looked down upon this idea and insisted on "pure" science as the only respectable practice. This changed when Lightner Witmer (1867–1956), a past student of Wundt and head of the psychology department at the University of Pennsylvania, agreed to treat a young boy who had trouble with spelling. His successful treatment was soon to lead to Witmer's opening of the first psychological clinic at Penn in 1896, dedicated to helping children with learning disabilities. Ten years later in 1907, Witmer was to found the first journal of this new field, The Psychological Clinic, where he coined the term "clinical psychology", defined as "the study of individuals, by observation or experimentation, with the intention of promoting change". The field was slow to follow Witmer's example, but by 1914, there were 26 similar clinics in the US. Even as clinical psychology was growing, working with issues of serious mental distress remained the domain of psychiatrists and neurologists. However, clinical psychologists continued to make inroads into this area due to their increasing skill at psychological assessment. Psychologists' reputation as assessment experts became solidified during World War I with the development of two intelligence tests, Army Alpha and Army Beta (testing verbal and nonverbal skills, respectively), which could be used with large groups of recruits. Due in large part to the success of these tests, assessment was to become the core discipline of clinical psychology for the next quarter-century, when another war would propel the field into treatment. Early professional organizations The field began to organize under the name "clinical psychology" in 1917 with the founding of the American Association of Clinical Psychology. This only lasted until 1919, after which the American Psychological Association (founded by G. Stanley Hall in 1892) developed a section on Clinical Psychology, which offered certification until 1927. Growth in the field was slow for the next few years when various unconnected psychological organizations came together as the American Association of Applied Psychology in 1930, which would act as the primary forum for psychologists until after World War II when the APA reorganized. In 1945, the APA created what is now called Division 12, the Society for Clinical Psychology, which remains a leading organization in the field. Psychological societies and associations in other English-speaking countries developed similar divisions, including in Britain, Canada, Australia, and New Zealand. World War II and the integration of treatment When World War II broke out, the military once again called upon clinical psychologists. As soldiers began to return from combat, psychologists started to notice symptoms of psychological trauma labeled "shell shock" (eventually to be termed post-traumatic stress disorder) that were best treated as soon as possible. Because physicians (including psychiatrists) were over-extended in treating bodily injuries, psychologists were called to help treat this condition. At the same time, female psychologists (who were excluded from the war effort) formed the National Council of Women Psychologists with the purpose of helping communities deal with the stresses of war and giving young mothers advice on child rearing. After the war, the Veterans Administration in the US made an enormous investment to set up programs to train doctoral-level clinical psychologists to help treat the thousands of veterans needing care. As a consequence, the US went from having no formal university programs in clinical psychology in 1946 to over half of all PhDs in psychology in 1950 being awarded in clinical psychology. WWII helped bring dramatic changes to clinical psychology, not just in America but internationally as well. Graduate education in psychology began adding psychotherapy to the science and research focus based on the 1947 scientist-practitioner model, known today as the Boulder Model, for PhD programs in clinical psychology. Clinical psychology in Britain developed much like in the US after WWII, specifically within the context of the National Health Service with qualifications, standards, and salaries managed by the British Psychological Society. Development of the Doctor of Psychology degree By the 1960s, psychotherapy had become embedded within clinical psychology, but for many, the PhD educational model did not offer the necessary training for those interested in practice rather than research. There was a growing argument that said the field of psychology in the US had developed to a degree warranting explicit training in clinical practice. The concept of a practice-oriented degree was debated in 1965 and narrowly gained approval for a pilot program at the University of Illinois starting in 1968. Several other similar programs were instituted soon after, and in 1973, at the Vail Conference on Professional Training in Psychology, the practitioner–scholar model of clinical psychology—or Vail Model—resulting in the Doctor of Psychology (PsyD) degree was recognized. Although training would continue to include research skills and a scientific understanding of psychology, the intent would be to produce highly trained professionals, similar to programs in medicine, dentistry, and law. The first program explicitly based on the PsyD model was instituted at Rutgers University. Today, about half of all American graduate students in clinical psychology are enrolled in PsyD programs. A changing profession Since the 1970s, clinical psychology has continued growing into a robust profession and academic field of study. Although the exact number of practicing clinical psychologists is unknown, it is estimated that between 1974 and 1990, the number in the US grew from 20,000 to 63,000. Clinical psychologists continue to be experts in assessment and psychotherapy while expanding their focus to address issues of gerontology, sports, and the criminal justice system to name a few. One important field is health psychology, the fastest-growing employment setting for clinical psychologists in the past decade. Other major changes include the impact of managed care on mental health care; an increasing realization of the importance of knowledge relating to multicultural and diverse populations; and emerging privileges to prescribe psychotropic medication. Professional practice Clinical psychologists engage in a wide range of activities. Some focus solely on research into the assessment, treatment, or cause of mental illness and related conditions. Some teach, whether in a medical school or hospital setting, or in an academic department (e.g., psychology department) at an institution of higher education. The majority of clinical psychologists engage in some form of clinical practice, with professional services including psychological assessment, provision of psychotherapy, development and administration of clinical programs, and forensics (e.g., providing expert testimony in a legal proceeding). In clinical practice, clinical psychologists may work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organizations, schools, businesses, and non-profit agencies. Clinical psychologists who provide clinical services may also choose to specialize. Some specializations are codified and credentialed by regulatory agencies within the country of practice. In the United States, such specializations are credentialed by the American Board of Professional Psychology (ABPP). Training and certification to practice Clinical psychologists study a generalist program in psychology plus postgraduate training and/or clinical placement and supervision. The length of training differs across the world, ranging from four years plus post-Bachelors supervised practice to a doctorate of three to six years which combines clinical placement. The practice of clinical psychology requires a license in the United States, Canada, the United Kingdom, and many other countries. US and Canada In the US, about half of all clinical psychology graduate students are being trained in PhD programs—a model that emphasizes research—with the other half in PsyD programs, which has more focus on practice (similar to professional degrees for medicine and law). Both models are accredited by the American Psychological Association and many other English-speaking psychological societies. A smaller number of schools offer accredited programs in clinical psychology resulting in a master's degree, which usually takes two to three years post-Bachelors. Although each of the US states is somewhat different in terms of requirements and licenses, there are three common elements: Graduation from an accredited school with the appropriate degree Completion of supervised clinical experience or internship Passing a written examination and, in some states, an oral examination All U.S. state and Canadian province licensing boards are members of the Association of State and Provincial Psychology Boards (ASPPB), which created and maintains the Examination for Professional Practice in Psychology (EPPP). Many states require other examinations in addition to the EPPP, such as a jurisprudence (i.e. mental health law) examination and/or an oral examination. Most states also require a certain number of continuing education credits per year in order to renew a license, which can be obtained through various means, such as taking audited classes and attending approved workshops. Clinical psychologists require the psychologist license to practice, although other mental health provider licenses can be obtained with a master's degree, such as Marriage and Family Therapist (MFT), Licensed Professional Counselor (LPC), and Licensed Psychological Associate (LPA). UK In the UK, clinical psychologists undertake a Doctor of Clinical Psychology (DClinPsych), which is a practitioner doctorate with both clinical and research components. This is a three-year full-time salaried program sponsored by the National Health Service (NHS) and based in universities and the NHS. Entry into these programs is highly competitive and requires at least a three-year undergraduate degree in psychology plus some form of experience, usually in either the NHS as an assistant psychologist or in academia as a research assistant. It is not unusual for applicants to apply several times before being accepted onto a training course as only about one-fifth of applicants are accepted each year. These clinical psychology doctoral degrees are accredited by the British Psychological Society and the Health Professions Council (HPC). The HPC is the statutory regulator for practitioner psychologists in the UK. Those who successfully complete clinical psychology doctoral degrees are eligible to apply for registration with the HPC as a clinical psychologist. In the UK, registration as a clinical psychologist with the Health Professions Council (HPC) is necessary. The HPC is the statutory regulator for practitioner psychologists in the UK. In the UK the following titles are restricted by law "registered psychologist" and "practitioner psychologist"; in addition, the specialist title "clinical psychologist" is also restricted by law. India In India, training is through the M.Phil Clinical Psychology, PsyD and Professional diploma in clinical psychology. Assessment An important area of expertise for many clinical psychologists is psychological assessment, and there are indications that as many as 91% of psychologists engage in this core clinical practice. Assessment methods include standardized psychometric tests, semi-structured diagnostic interviews, record review, collateral interviews, and behavioral observation. Measurement domains Psychological measures generally fall within one of several categories, including the following: Intelligence and achievement tests – These tests are designed to measure certain specific kinds of cognitive functioning (often referred to as IQ) in comparison to a norming group. These tests, such as the WISC-IV and the WAIS, attempt to measure such traits as general knowledge, verbal skill, memory, attention span, logical reasoning, and visual/spatial perception. Several tests have been shown to predict accurately certain kinds of performance, especially scholastic. Other tests in this category include the WRAML and the WIAT. Personality tests – Tests of personality aim to describe patterns of behavior, thoughts, and feelings. They generally fall within two categories: objective and projective. Objective measures, such as the MMPI, are based on restricted answers—such as yes/no, true/false, or a rating scale—which allow for the computation of scores that can be compared to a normative group. Projective tests, such as the Rorschach inkblot test, allow for open-ended answers, often based on ambiguous stimuli. Other commonly used personality assessment measures include the PAI and the NEO. Neuropsychological tests – Neuropsychological tests consist of specifically designed tasks used to measure psychological functions known to be linked to a particular brain structure or pathway. They are typically used to assess impairment after an injury or illness known to affect neurocognitive functioning, or when used in research, to contrast neuropsychological abilities across experimental groups. Diagnostic Measurement Tools – Clinical psychologists are able to diagnose psychological disorders and related disorders found in the DSM-5 and ICD-10. Many assessment tests have been developed to complement the clinicians clinical observation and other assessment activities. Some of these include the SCID-IV, the MINI, as well as some specific to certain psychological disorders such as the CAPS-5 for trauma, the ASEBA, and the K-SADS for affective and Schizophrenia in children. Clinical observation – Clinical psychologists are also trained to gather data by observing behavior. The clinical interview is a vital part of the assessment, even when using other formalized tools, which can employ either a structured or unstructured format. Such assessment looks at certain areas, such as general appearance and behavior, mood and affects, perception, comprehension, orientation, insight, memory, and content of the communication. One psychiatric example of a formal interview is the mental status examination, which is often used in psychiatry as a screening tool for treatment or further testing. Diagnostic impressions After assessment, clinical psychologists may provide a diagnosis. Many countries use the International Statistical Classification of Diseases and Related Health Problems (ICD-10) while the US most often uses the Diagnostic and Statistical Manual of Mental Disorders. Both are nosological systems that largely assume categorical disorders diagnosed through the application of sets of criteria including symptoms and signs. Several new models are being discussed, including a "dimensional model" based on empirically validated models of human differences (such as the five factor model of personality) and a "psychosocial model", which would take changing, intersubjective states into greater account. The proponents of these models claim that they would offer greater diagnostic flexibility and clinical utility without depending on the medical concept of illness. However, they also admit that these models are not yet robust enough to gain widespread use, and should continue to be developed. Clinical v. mechanical prediction Clinical assessment can be characterized as a prediction problem where the purpose of assessment is to make inferences (predictions) about past, present, or future behavior. For example, many therapy decisions are made on the basis of what a clinician expects will help a patient make therapeutic gains. Once observations have been collected (e.g., psychological testing results, diagnostic impressions, clinical history, X-ray, etc.), there are two mutually exclusive ways to combine those sources of information to arrive at a decision, diagnosis, or prediction. One way is to combine the data in an algorithmic, or "mechanical" fashion. Mechanical prediction methods are simply a mode of combination of data to arrive at a decision/prediction of behavior (e.g., treatment response). The mechanical prediction does not preclude any type of data from being combined; it can incorporate clinical judgments, properly coded, in the algorithm. The defining characteristic is that, once the data to be combined is given, the mechanical approach will make a prediction that is 100% reliable. That is, it will make exactly the same prediction for exactly the same data every time. Clinical prediction, on the other hand, does not guarantee this, as it depends on the decision-making processes of the clinician making the judgment, their current state of mind, and knowledge base. What has come to be called the "clinical versus statistical prediction" debate was first described in detail in 1954 by Paul Meehl, where he explored the claim that mechanical (formal, algorithmic) methods of data combination could outperform clinical (e.g., subjective, informal, "in the clinician's head") methods when such combinations are used to arrive at a prediction of behavior. Meehl concluded that mechanical modes of combination performed as well or better than clinical modes. Subsequent meta-analyses of studies that directly compare mechanical and clinical predictions have born out Meehl's 1954 conclusions. A 2009 survey of practicing clinical psychologists found that clinicians almost exclusively use their clinical judgment to make behavioral predictions for their patients, including diagnosis and prognosis. Intervention Psychotherapy involves a formal relationship between professional and client—usually an individual, couple, family, or small group—that employs a set of procedures intended to form a therapeutic alliance, explore the nature of psychological problems, and encourage new ways of thinking, feeling, or behaving. Clinicians have a wide range of individual interventions to draw from, often guided by their training—for example, a cognitive behavioral therapy (CBT) clinician might use worksheets to record distressing cognitions, a psychoanalyst might encourage free association, while a psychologist trained in Gestalt techniques might focus on immediate interactions between client and therapist. Clinical psychologists generally seek to base their work on research evidence and outcome studies as well as on trained clinical judgment. Although there are literally dozens of recognized therapeutic orientations, their differences can often be categorized on two dimensions: insight vs. action and in-session vs. out-session. Insight – emphasis is on gaining a greater understanding of the motivations underlying one's thoughts and feelings (e.g. psychodynamic therapy) Action – focus is on making changes in how one thinks and acts (e.g. solution focused therapy, cognitive behavioral therapy) In-session – interventions center on the here-and-now interaction between client and therapist (e.g. humanistic therapy, Gestalt therapy) Out-session – a large portion of therapeutic work is intended to happen outside of session (e.g. bibliotherapy, rational emotive behavior therapy) The methods used are also different in regards to the population being served as well as the context and nature of the problem. Therapy will look very different between, say, a traumatized child, a depressed but high-functioning adult, a group of people recovering from substance dependence, and a ward of the state suffering from terrifying delusions. Other elements that play a critical role in the process of psychotherapy include the environment, culture, age, cognitive functioning, motivation, and duration (i.e. brief or long-term therapy). Four main schools Many clinical psychologists are integrative or eclectic and draw from the evidence base across different models of therapy in an integrative way, rather than using a single specific model.In the UK, clinical psychologists have to show competence in at least two models of therapy, including CBT, to gain their doctorate. The British Psychological Society Division of Clinical Psychology has been vocal about the need to follow the evidence base rather than being wedded to a single model of therapy. In the US, intervention applications and research are dominated in training and practice by essentially four major schools of practice: psychodynamic, humanism, behavioral/cognitive behavioral, and systems or family therapy. Psychodynamic The psychodynamic perspective developed out of the psychoanalysis of Sigmund Freud. The core object of psychoanalysis is to make the unconscious conscious—to make the client aware of his or her own primal drives (namely those relating to sex and aggression) and the various defenses used to keep them in check. The essential tools of the psychoanalytic process are the use of free association and an examination of the client's transference towards the therapist, defined as the tendency to take unconscious thoughts or emotions about a significant person (e.g. a parent) and "transfer" them onto another person. Major variations on Freudian psychoanalysis practiced today include self psychology, ego psychology, and object relations theory. These general orientations now fall under the umbrella term psychodynamic psychology, with common themes including examination of transference and defenses, an appreciation of the power of the unconscious, and a focus on how early developments in childhood have shaped the client's current psychological state. Humanistic/Experiential Humanistic psychology was developed in the 1950s in reaction to both behaviorism and psychoanalysis, largely due to the person-centered therapy of Carl Rogers (often referred to as Rogerian Therapy) and existential psychology developed by Viktor Frankl and Rollo May. Rogers believed that a client needed only three things from a clinician to experience therapeutic improvement—congruence, unconditional positive regard, and empathetic understanding. By using phenomenology, intersubjectivity and first-person categories, the humanistic approach seeks to get a glimpse of the whole person and not just the fragmented parts of the personality. This aspect of holism links up with another common aim of humanistic practice in clinical psychology, which is to seek an integration of the whole person, also called self-actualization. From 1980, Hans-Werner Gessmann integrated the ideas of humanistic psychology into group psychotherapy as humanistic psychodrama. According to humanistic thinking, each individual person already has inbuilt potentials and resources that might help them to build a stronger personality and self-concept. The mission of the humanistic psychologist is to help the individual employ these resources via the therapeutic relationship. Emotion focused therapy/Emotionally focused therapy (EFT), not to be confused with Emotional Freedom Techniques, was initially informed by humanistic–phenomenological and Gestalt theories of therapy. "Emotion Focused Therapy can be defined as the practice of therapy informed by an understanding of the role of emotion in psychotherapeutic change. EFT is founded on a close and careful analysis of the meanings and contributions of emotion to human experience and change in psychotherapy. This focus leads therapist and client toward strategies that promotes the awareness, acceptance, expression, utilization, regulation, and transformation of emotion as well as corrective emotional experience with the therapist. The goals of EFT are strengthening the self, regulating affect, and creating new meaning". Similarly to some Psychodynamic therapy approaches, EFT pulls heavily from attachment theory. Pioneers of EFT are Les Greenberg and Sue Johnson. EFT is often used in therapy with individuals, and may be especially useful for couples therapy. Founded in 1998, Sue Johnson and others lead the International Centre for Excellence in Emotion Focused Therapy (ICEEFT) where clinicians can find EFT training internationally. EFT is also a commonly chosen modality to treat clinically diagnosable trauma. Behavioral and cognitive behavioral Cognitive behavioral therapy (CBT) developed from the combination of cognitive therapy and rational emotive behavior therapy, both of which grew out of cognitive psychology and behaviorism. CBT is based on the theory that how we think (cognition), how we feel (emotion), and how we act (behavior) are related and interact together in complex ways. In this perspective, certain dysfunctional ways of interpreting and appraising the world (often through schemas or beliefs) can contribute to emotional distress or result in behavioral problems. The object of many cognitive behavioral therapies is to discover and identify the biased, dysfunctional ways of relating or reacting and through different methodologies help clients transcend these in ways that will lead to increased well-being. There are many techniques used, such as systematic desensitization, socratic questioning, and keeping a cognition observation log. Modified approaches that fall into the category of CBT have also developed, including dialectic behavior therapy and mindfulness-based cognitive therapy. Behavior therapy is a rich tradition. It is well researched with a strong evidence base. Its roots are in behaviorism. In behavior therapy, environmental events predict the way we think and feel. Our behavior sets up conditions for the environment to feedback back on it. Sometimes the feedback leads the behavior to increase- reinforcement and sometimes the behavior decreases- punishment. Oftentimes behavior therapists are called applied behavior analysts or behavioral health counselors. They have studied many areas from developmental disabilities to depression and anxiety disorders. In the area of mental health and addictions a recent article looked at APA's list for well established and promising practices and found a considerable number of them based on the principles of operant and respondent conditioning. Multiple assessment techniques have come from this approach including functional analysis (psychology), which has found a strong focus in the school system. In addition, multiple intervention programs have come from this tradition including community reinforcement approach for treating addictions, acceptance and commitment therapy, functional analytic psychotherapy, including dialectic behavior therapy and behavioral activation. In addition, specific techniques such as contingency management and exposure therapy have come from this tradition. Systems or family therapy Systems or family therapy works with couples and families, and emphasizes family relationships as an important factor in psychological health. The central focus tends to be on interpersonal dynamics, especially in terms of how change in one person will affect the entire system. Therapy is therefore conducted with as many significant members of the "system" as possible. Goals can include improving communication, establishing healthy roles, creating alternative narratives, and addressing problematic behaviors. Other therapeutic perspectives There exist dozens of recognized schools or orientations of psychotherapy—the list below represents a few influential orientations not given above. Although they all have some typical set of techniques practitioners employ, they are generally better known for providing a framework of theory and philosophy that guides a therapist in his or her working with a client. Existential – Existential psychotherapy postulates that people are largely free to choose who we are and how we interpret and interact with the world. It intends to help the client find deeper meaning in life and to accept responsibility for living. As such, it addresses fundamental issues of life, such as death, aloneness, and freedom. The therapist emphasizes the client's ability to be self-aware, freely make choices in the present, establish personal identity and social relationships, create meaning, and cope with the natural anxiety of living. Gestalt – Gestalt therapy was primarily founded by Fritz Perls in the 1950s. This therapy is perhaps best known for using techniques designed to increase self-awareness, the best-known perhaps being the "empty chair technique." Such techniques are intended to explore resistance to "authentic contact", resolve internal conflicts, and help the client complete "unfinished business". Postmodern – Postmodern psychology says that the experience of reality is a subjective construction built upon language, social context, and history, with no essential truths. Since "mental illness" and "mental health" are not recognized as objective, definable realities, the postmodern psychologist instead sees the goal of therapy strictly as something constructed by the client and therapist. Forms of postmodern psychotherapy include narrative therapy, solution-focused therapy, and coherence therapy. Transpersonal – The transpersonal perspective places a stronger focus on the spiritual facet of human experience. It is not a set of techniques so much as a willingness to help a client explore spirituality and/or transcendent states of consciousness. Transpersonal psychology is concerned with helping clients achieve their highest potential. Multiculturalism – Although the theoretical foundations of psychology are rooted in European culture, there is a growing recognition that there exist profound differences between various ethnic and social groups and that systems of psychotherapy need to take those differences into greater consideration. Further, the generations following immigrant migration will have some combination of two or more cultures—with aspects coming from the parents and from the surrounding society—and this process of acculturation can play a strong role in therapy (and might itself be the presenting problem). Culture influences ideas about change, help-seeking, locus of control, authority, and the importance of the individual versus the group, all of which can potentially clash with certain givens in mainstream psychotherapeutic theory and practice. As such, there is a growing movement to integrate knowledge of various cultural groups in order to inform therapeutic practice in a more culturally sensitive and effective way. Feminism – Feminist therapy is an orientation arising from the disparity between the origin of most psychological theories (which have male authors) and the majority of people seeking counseling being female. It focuses on societal, cultural, and political causes and solutions to issues faced in the counseling process. It openly encourages the client to participate in the world in a more social and political way. Positive psychology – Positive psychology is the scientific study of human happiness and well-being, which started to gain momentum in 1998 due to the call of Martin Seligman, then president of the APA. The history of psychology shows that the field has been primarily dedicated to addressing mental illness rather than mental wellness. Applied positive psychology's main focus, therefore, is to increase one's positive experience of life and ability to flourish by promoting such things as optimism about the future, a sense of flow in the present, and personal traits like courage, perseverance, and altruism. There is now preliminary empirical evidence to show that by promoting Seligman's three components of happiness—positive emotion (the pleasant life), engagement (the engaged life), and meaning (the meaningful life)—positive therapy can decrease clinical depression. Community psychology approaches are often used for psychological prevention of harm and clinical intervention. Integration In the last couple of decades, there has been a growing movement to integrate the various therapeutic approaches, especially with an increased understanding of cultural, gender, spiritual, and sexual-orientation issues. Clinical psychologists are beginning to look at the various strengths and weaknesses of each orientation while also working with related fields, such as neuroscience, behavioural genetics, evolutionary biology, and psychopharmacology. The result is a growing practice of eclecticism, with psychologists learning various systems and the most efficacious methods of therapy with the intent to provide the best solution for any given problem. Professional ethics The field of clinical psychology in most countries is strongly regulated by a code of ethics. In the US, professional ethics are largely defined by the APA Code of Conduct, which is often used by states to define licensing requirements. The APA Code generally sets a higher standard than that which is required by law as it is designed to guide responsible behavior, the protection of clients, and the improvement of individuals, organizations, and society. The Code is applicable to all psychologists in both research and applied fields. The APA Code is based on five principles: Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, and Respect for People's Rights and Dignity. Detailed elements address how to resolve ethical issues, competence, human relations, privacy and confidentiality, advertising, record keeping, fees, training, research, publication, assessment, and therapy. The Canadian Psychological Association ethical code principle's are: Respect for the Dignity of Persons and Peoples, Responsible Caring, Integrity in Relationships, and Responsibility to Society. It is considered very similar to the APA's Code. In the UK the British Psychological Society has published a Code of Conduct and Ethics for clinical psychologists. This has four key areas: Respect, Competence, Responsibility and Integrity. Other European professional organizations have similar codes of conduct and ethics. The Asian Federation for Psychotherapy published a code of ethics in 2008 with the following principles: Beneficence, Responsibility, Integrity, Justices, and Respect. Similar to the APA code, it provides detailed instructions for the conduct of psychologists, specifically psychotherapists. Russia, India, Iran, Kazakhstan, China, Malaysia, and Japan are member countries. The National Latina/o Psychological Association adopted their current ethical guidelines in 2018, stating that "the traditional Eurocentric foundations in mainstream psychology have provided culturally bound knowledge about worldviews, ways of living, and cultural practices." Their principles are: Respect and Responsibility, Ethical Dilemmas, Ethical Decision-Making and Legal Responsibility, Consultation, Justice and Advocacy, Self-Awareness and Social-Consciousness, Action and Accountability, Training and Creating Infrastructure, and Mentorship. Comparison with other mental health professions Psychiatry Although clinical psychologists and psychiatrists can be said to share a same fundamental aim—the alleviation of mental distress—their training, outlook, and methodologies are often quite different. Perhaps the most significant difference is that psychiatrists are licensed physicians. As such, psychiatrists often use the medical model to assess psychological problems (i.e., those they treat are seen as patients with an illness) and can use psychotropic medications as a method of addressing the illness—although some also employ psychotherapy as well. Psychiatrists are able to conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. Conversely, clinical psychologists conduct specialist assessment and psychometric testing. Such assessments and tests would not normally only be administered and interpreted by psychologists due to their advanced training in psychometric assessment. As standard clinical psychologists also usually possess more advanced training and specialist knowledge in psycho-social development and psychological therapies. Clinical psychologists generally do not prescribe medication, although there is a movement for psychologists to have prescribing privileges. These medical privileges require additional training and education. To date, medical psychologists (prescribing psychologists) may prescribe psychotropic medications in Colorado, Guam, Iowa, Idaho, Illinois, New Mexico, Louisiana, the Public Health Service, the Indian Health Service, and the United States Military. Counseling psychology Counseling psychologists undergo the same level of rigor in study and use many of the same interventions and tools as clinical psychologists, including psychotherapy and assessment. Traditionally, counseling psychologists helped people with what might be considered normal or moderate psychological problems—such as the feelings of anxiety or sadness resulting from major life changes or events. However, that distinction has faded over time, and of the counseling psychologists who do not go into academia (which does not involve treatment or diagnosis), the majority of counseling psychologists treat mental illness alongside clinical psychologists. Many counseling psychologists also receive specialized training in career assessment, group therapy, and relationship counseling. Counseling psychology as a field values multiculturalism and social advocacy, often stimulating research in multicultural issues. There are fewer counseling psychology graduate programs than those for clinical psychology and they are more often housed in departments of education rather than psychology. Counseling psychologists tend to be more frequently employed in university counseling centers compared to hospitals and private practice for clinical psychologists. However, counseling and clinical psychologists can be employed in a variety of settings, with a large degree of overlap (prisons, colleges, community mental health, non-profits, corporations, private practice, hospitals and Veterans Affairs). School psychology School psychologists are primarily concerned with the academic, social, and emotional well-being of children and adolescents within a scholastic environment. In the UK, they are known as "educational psychologists". Like clinical (and counseling) psychologists, school psychologists with doctoral degrees are eligible for licensure as health service psychologists, and many work in private practice. Unlike clinical psychologists, they receive much more training in education, child development and behavior, and the psychology of learning. Common degrees include the Educational Specialist Degree (EdS), Doctor of Philosophy (PhD), and Doctor of Education (EdD). Traditional job roles for school psychologists employed in school settings have focused mainly on assessment of students to determine their eligibility for special education services in schools, and on consultation with teachers and other school professionals to design and carry out interventions on behalf of students. Other major roles also include offering individual and group therapy with children and their families, designing prevention programs (e.g. for reducing dropout), evaluating school programs, and working with teachers and administrators to help maximize teaching efficacy, both in the classroom and systemically. Clinical social work Social workers provide a variety of services, generally concerned with social problems, their causes, and their solutions. With specific training, clinical social workers may also provide psychological counseling (in the US and Canada), in addition to more traditional social work. Occupational therapy Occupational therapy—often abbreviated OT—is the "use of productive or creative activity in the treatment or rehabilitation of physically, cognitively, or emotionally disabled people." Most commonly, occupational therapists work with people with disabilities to enable them to maximize their skills and abilities. Occupational therapy practitioners are skilled professionals whose education includes the study of human growth and development with specific emphasis on the physical, emotional, psychological, sociocultural, cognitive and environmental components of illness and injury. They commonly work alongside clinical psychologists in settings such as inpatient and outpatient mental health, pain management clinics, eating disorder clinics, and child development services. OT's use support groups, individual counseling sessions, and activity-based approaches to address psychiatric symptoms and maximize functioning in life activities. Criticisms and controversies Clinical psychology is a diverse field and there have been recurring tensions over the degree to which clinical practice should be limited to treatments supported by empirical research. Despite some evidence showing that all the major therapeutic orientations are about of equal effectiveness, there remains much debate about the efficacy of various forms of treatment in use in clinical psychology. See also Anti-psychiatry Applied psychology Clinical Associate (Psychology) Clinical neuropsychology Clinical trial List of clinical psychologists List of credentials in psychology List of psychotherapies Outline of psychology Psychiatric and mental health nursing Psychoneuroimmunology References External links American Academy of Clinical Psychology American Association for Marriage and Family Therapy American Board of Professional Psychology Annual Review of Clinical Psychology APA Society of Clinical Psychology (Division 12) Association of State and Provincial Psychology Boards (ASPPB) NAMI: National Alliance on Mental Illness National Institute of Mental Health Psychotherapy Health care occupations Behavioural sciences

Ableism

Ableism (; also known as ablism, disablism (British English), anapirophobia, anapirism, and disability discrimination) is discrimination and social prejudice against people with physical or mental disabilities (see also Sanism). Ableism characterizes people as they are defined by their disabilities and it also classifies disabled people as people who are inferior to non-disabled people. On this basis, people are assigned or denied certain perceived abilities, skills, or character orientations. Although ableism and disablism are both terms which describe disability discrimination, the emphasis for each of these terms is slightly different. Ableism is discrimination in favor of non-disabled people, while disablism is discrimination against disabled people. There are stereotypes which are either associated with disability in general, or they are associated with specific impairments or chronic health conditions (for instance the presumption that all disabled people want to be cured, the presumption that wheelchair users also have an intellectual disability, or the presumption that blind people have some special form of insight). These stereotypes, in turn, serve as a justification for discriminatory practices, and reinforce discriminatory attitudes and behaviors toward people who are disabled. Labeling affects people when it limits their options for action or changes their identity. In ableist societies, the lives of disabled people is considered less worth living, or disabled people less valuable, even sometimes expendable. The eugenics movement of the early 20th century is considered an expression of widespread ableism. Ableism can be further understood by reading literature which is written and published by those who experience disability and ableism first-hand. Disability studies is an academic discipline which is also beneficial when non-disabled people pursue it in order to gain a better understanding of ableism. Etymology Originating from -able (in disable, disabled) and -ism (in racism, sexism); first recorded in 1981. History Canada Ableism in Canada refers to a set of discourses, behaviors, and structures that express feelings of anxiety, fear, hostility, and antipathy towards people with disabilities in Canada. The specific types of discrimination that have occurred or are still occurring in Canada include the inability to access important facilities such as infrastructure within the transport network, restrictive immigration policies, involuntary sterilization to stop people with disabilities from having offspring, barriers to employment opportunities, wages that are insufficient to maintain a minimal standard of living, and institutionalization of people with disabilities in substandard conditions. Austerity measures implemented by the government of Canada have also at times been referred to as ableist, such as funding cuts that put people with disabilities at risk of living in abusive arrangements. Nazi Germany In July 1933, Hitler, along with the Nazi Government, implemented the Law for the Prevention of Progeny with Hereditary Diseased Offspring. Essentially, this law implemented sterilization practices for all people who had what were considered hereditary disabilities. For example, disabilities such as mental illness, blindness and deafness were all considered hereditary diseases; therefore, people with these disabilities were sterilized. The law also created propaganda against people with disabilities; people with disabilities were displayed as unimportant towards progressing the Aryan race. In 1939 Hitler signed the secret euthanasia program decree Aktion T4, which authorized the killing of selected patients diagnosed with chronic neurological and psychiatric disorders. This program killed about 70,000 disabled people before it was officially halted by Hitler in 1941 under public pressure, and it was unofficially continued out of the public eye, killing a total of 200,000 or more by the end of Hitler's reign in 1945. United Kingdom In the UK, disability discrimination became unlawful as a result of the Disability Discrimination Act 1995, and the Disability Discrimination Act 2005. These were later superseded, retaining the substantive law, by the Equality Act 2010. The Equality Act 2010 brought together protections against multiple areas of discriminatory behavior (disability, race, religion and belief, sex, sexual orientation, gender identity, age and pregnancy the so-called "protected characteristics"). Under the Equality Act 2010, there are prohibitions addressing several forms of discrimination including direct discrimination (s.13), indirect discrimination (s.6, s.19), harassment (s.26), victimisation (s.27), discrimination arising from disability (s.15), and failure to make reasonable adjustments (s.20). Part 2, chapter 1, section 6, of the Equality Act 2010 states that "A person (P) has a disability if (a) P has a physical or mental impairment, and (b) the impairment has a substantial and long-term adverse effect on P's ability to carry out normal day-to-day activities." United States Much like many minority groups, disabled Americans were often segregated and denied certain rights for a majority of American history. In the 1800s, a shift from a religious view to a more scientific view took place and caused more individuals with disabilities to be examined. Public stigma began to change after World War II when many Americans returned home with disabilities. In the 1960s, following the civil rights movement in America, the world began the disabled rights movement. The movement was intended to give all individuals with disabilities equal rights and opportunities. Until the 1970s, ableism in the United States was often codified into law. For example, in many jurisdictions, so-called "ugly laws" barred people from appearing in public if they had diseases or disfigurements that were considered unsightly. UN Convention on the Rights of Persons with Disabilities In May 2012, the UN Convention on the Rights of Persons with Disabilities was ratified. The document establishes the inadmissibility of discrimination on the basis of disability, including in employment. In addition, the amendments create a legal basis for significantly expanding opportunities to protect the rights of persons with disabilities, including in the administrative procedure and in court. The law defined specific obligations that all owners of facilities and service providers must fulfill to create conditions for disabled people equal to the rest. Workplace In 1990, the Americans with Disabilities Act was put in place to prohibit private employers, state and local government, employment agencies and labor unions from discrimination against qualified disabled people in job applications, when hiring, firing, advancement in workplace, compensation, training, and on other terms, conditions and privileges of employment. The U.S. Equal Employment Opportunity Commission (EEOC) plays a part in fighting against ableism by being responsible for enforcing federal laws that make it illegal to discriminate against a job applicant or an employee because of the person's race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age (40 or older), disability or genetic information. Similarly in the UK, the Equality Act 2010 was put in place and provides legislation that there should be no workplace discrimination. Under the act, all employers have a duty to make reasonable adjustments for their disabled employees to help them overcome any disadvantages resulting from the impairment. Failure to carry out reasonable adjustment amounts to disability discrimination. Employers and managers are often concerned about the potential cost associated with providing accommodations to employees with disabilities. However, many accommodations have a cost of $0 (59% in a survey of employers conducted by the Job Accommodation Network (JAN)), and accommodation costs may be offset by the savings associated with employing people with disabilities (higher performance, lower turnover costs). Moreover, organizational interventions that support workplace inclusion of the most vulnerable, such as neurodivergent individuals, are likely to benefit all employees. Idiosyncratic deals (i-deals), individually negotiated work arrangements (e.g., flexible schedules, working from home), can also serve as an important work accommodation for persons with disabilities. I-deals can create the conditions for long-term employment for people with disabilities by creating jobs that fit each employee's abilities, interests, and career aspirations. Agents can represent people with disabilities and help them negotiate their unique employment terms, but successful i-deals require resources and flexibility on the part of the employer. Healthcare Ableism is prevalent in the many different divisions of healthcare, whether that be in prison systems, the legal or policy side of healthcare, and clinical settings. The following subsections will explore the ways in which ableism makes its way into these areas of focus through the inaccessibility of appropriate medical treatment. Clinical settings Just as in every other facet of life, ableism is present in clinical healthcare settings. A 2021 study of over 700 physicians in the United States found that only 56.5% "strongly agreed that they welcomed patients with disability into their practices." The same study also found that 82.4% of these physicians believed that people with a significant disability had a lower quality of life than those without disabilities. Data from the 1994–1995 National Health Interview Survey-Disability Supplement has shown that those with disabilities have lower life expectancies than those without them. While that can be explained by a myriad of factors, one of the factors is the ableism experienced by those with disabilities in clinical settings. Those with disabilities may be more hesitant to seek care when needed due to barriers created by ableism such as dentist chairs that are not accessible or offices that are filled with bright lights and noises that can be triggering. In June 2020, near the start of the COVID-19 pandemic, a 46-year-old quadriplegic in Austin, Texas named Michael Hickson was denied treatment for COVID-19, sepsis, and a urinary tract infection and died 6 days after treatment was withheld. His physician was quoted as having said that he had a "preference to treat patients who can walk and talk." The physician also had stated that Hickson's brain injury made him have not much of a quality of life. Several complaints have since been filed with the Texas Office of Civil Rights and many disability advocacy groups have become involved in the case. Several states, including Alabama, Arizona, Kansas, Pennsylvania, Tennessee, Utah, and Washington allow healthcare providers, in times of crisis, to triage based on the perceived quality of life of the patients, which tends to be perceived as lower for those with disabilities. In Alabama, a ventilator-rationing scheme put in place during the pandemic enabled healthcare providers to exclude patients with disabilities from treatment; such patients were those who required assistance with various activities of daily living, had certain mental conditions (varying degrees of mental retardation or moderate-to-severe dementia) or other preexisting conditions categorized as disabilities. Criminal justice settings The provision of effective healthcare for people with disabilities in criminal justice institutions is an important issue because the percentage of disabled people in such facilities has been shown to be larger than the percentage in the general population. A lack of prioritization on working to incorporate efficient and quality medical support into prison structures endangers the health and safety of disabled prisoners. Limited access to medical care in prisons consists of long waiting times to meet with physicians and to consistently receive treatment, as well as the absence of harm reduction measures and updated healthcare protocols. Discriminatory medical treatment also takes place through the withholding of proper diets, medications, and assistance (equipment and interpreters), in addition to failures to adequately train prison staff. Insufficient medical accommodations can worsen prisoners' health conditions through greater risks of depression, HIV/AIDS and Hepatitis C transmission, and unsafe drug injections. In Canada, the usage of prisons as psychiatric facilities may involve issues concerning inadequate access to medical support, particularly mental health counseling, and the inability of prisoners to take part in decision-making regarding their medical treatment. The usage of psychologists employed by the correctional services organization and the lack of confidentiality in therapeutic sessions also present barriers for disabled prisoners. That makes it more difficult for prisoners with disabilities to express discontentment about problems in the available healthcare since it may later complicate their release from the prison. In the United States, the population of older adults in the criminal justice system is growing rapidly, but older prisoners' healthcare needs are not being sufficiently met. One specific issue includes a lack of preparation for correctional officers to be able to identify geriatric disability. Regarding that underrecognition of disability, further improvement is needed in training programs to allow officers to learn when and how to provide proper healthcare intervention and treatment for older adult prisoners. Healthcare policy Ableism has long been a serious concern in healthcare policy, and the COVID-19 pandemic has greatly exaggerated and highlighted the prevalence of this serious concern. Studies frequently show what a "headache" patients with disabilities are for the healthcare system. In a 2020 study, 83.6% of healthcare providers preferred patients without disabilities to those with disabilities. This policy is especially concerning since according to the CDC, people with disabilities are at a heightened risk for contracting COVID-19. Additionally, in the second wave of the COVID-19 pandemic in the UK, people with intellectual disabilities were told that they will not be resuscitated if they become ill with COVID-19. Education Ableism often makes the world inaccessible to disabled people, especially in schools. Within education systems, the use of the medical model of disability and social model of disability contributes to the divide between students within special education and general education classrooms. Oftentimes, the medical model of disability portrays the overarching idea that disability can be corrected and diminished at the result of removing children from general education classrooms. This model of disability suggests that the impairment is more important than the person, who is helpless and should be separated from those who are not disabled. The social model of disability suggests that people with impairments are disabled at the result of the way society acts. When students with disabilities are pulled out of their classrooms into receive the support that they need, that often leads their peers to socially reject them because they don't form relationships with them in the classroom. By using the social model of disability, inclusive schools where the social norm is not to alienate students can promote more teamwork and less division throughout their campuses. Implementing the social model within modern forms of inclusive education provides children of all abilities with the role of changing discriminatory attitudes within the school system. For example, a disabled student may need to read text instead of listening to a tape recording of the text. In the past, schools have focused on fixing the disability, but progressive reforms make schools now focused on minimizing the impact of a student's disability and giving support. Moreover, schools are required to maximize access to their entire community. In 2004, U.S. Congress made into law the Individuals with Disabilities Education Act, which states that free and appropriate education is eligible to children with disabilities with insurance of necessary services. Congress later amended the law, in 2015, to include the Every Student Succeeds Act, which guarantees equal opportunity for people with disabilities full participation in society, and the tools for overall independent success. Media These common ways of framing disability are heavily criticized for being dehumanizing and failing to place importance on the perspectives of disabled people. Disabled villain One common form of media depiction of disability is to portray villains with a mental or physical disability. Lindsey Row-Heyveld notes, for instance, "that villainous pirates are scraggly, wizened and inevitably kitted out with a peg leg, eye patch or hook hand, whereas heroic pirates look like Johnny Depp's Jack Sparrow". The disability of the villain is meant to separate them from the average viewer and dehumanize the antagonist. As a result, stigma forms surrounding the disability and the individuals that live with it. There are many instances in literature where the antagonist is depicted as having a disability or mental illness. Some common examples include Captain Hook, Darth Vader and the Joker. Captain Hook is notorious for having a hook as a hand and seeks revenge on Peter Pan for his lost hand. Darth Vader's situation is unique because Luke Skywalker is also disabled. Luke's prosthetic hand looks lifelike, whereas Darth Vader appears robotic and emotionless because his appearance does not resemble humans and takes away human emotions. The Joker is a villain with a mental illness, and he is an example of the typical depiction of associating mental illness with violence. Inspiration porn Inspiration porn is the use of disabled people performing ordinary tasks as a form of inspiration. Criticisms of inspiration porn say that it distances disabled people from individuals who are not disabled and portrays disability as an obstacle to overcome or rehab. One of the most common examples of inspiration porn includes the Paralympics. Athletes with disabilities often get praised as inspirational because of their athletic accomplishments. Critics of this type of inspiration porn have said, "athletic accomplishments by these athletes are oversimplified as 'inspirational' because they're such a surprise." Pitied character In many forms of media such as films and articles a disabled person is portrayed as a character who is viewed as less than able, different, and an "outcast." Hayes and Black (2003) explore Hollywood films as the discourse of pity towards disability as a problem of social, physical, and emotional confinement. The aspect of pity is heightened through the storylines of media focusing on the individual's weaknesses as opposed to strengths and therefore leaving audiences a negative and ableist portrayal towards disability. Supercrip stereotype The supercrip narrative is generally a story of a person with an apparent disability who is able to "overcome" their physical differences and accomplish an impressive task. Professor Thomas Hehir's "Eliminating Ableism in Education" gives the story of a blind man who climbs Mount Everest, Erik Weihenmayer, as an example of the supercrip narrative. The Paralympics are another example of the supercrip stereotype since they generate a large amount of media attention and demonstrate disabled people doing extremely strenuous physical tasks. Although that may appear inspiring at face value, Hehir explains that many people with disabilities view those news stories as setting unrealistic expectations. Additionally, Hehir mentions that supercrip stories imply that disabled people are required to perform those impressive tasks to be seen as an equal and to avoid pity from those without disabilities. The disability studies scholar Alison Kafer describes how those narratives reinforce the problematic idea that disability can be overcome by an individual's hard work, in contrast to other theories, which understand disability to be a result of a world that is not designed to be accessible. Supercrip stories reinforce ableism by emphasizing independence, reliance on one's body, and the role of individual will in self-cure. Other examples of the supercrip narrative include the stories of Rachael Scdoris, the first blind woman to race in the Iditarod, and Aron Ralston, who has continued to climb after the amputation of his arm. Environmental and outdoor recreation media Disability has often been used as a short-hand in environmental literature for representing distance from nature, in what Sarah Jaquette Ray calls the "disability-equals-alienation-from-nature trope." An example of this trope can be seen in Moby Dick, as Captain Ahab's lost leg symbolizes his exploitative relationship with nature. Additionally, in canonical environmental thought, figures such as Ralph Waldo Emerson and Edward Abbey wrote using metaphors of disability to describe relationships between nature, technology, and the individual. Ableism in outdoor media can also be seen in promotional materials from the outdoor recreation industry: Alison Kafer highlighted a 2000 Nike advertisement, which ran in eleven outdoor magazines promoting a pair of running shoes. Kafer alleged that the advertisement depicted a person with a spinal cord injury and a wheelchair user as a "drooling, misshapen, non-extreme-trail-running husk of [their] former self", and said that the advertisement promised non-disabled runners and hikers the ability to protect their bodies against disability by purchasing the pair of shoes. The advertisement was withdrawn after the company received over six hundred complaints in the first two days after its publication, and Nike apologized. Sports Sports are often an area of society in which ableism is evident. In sports media, disabled athletes are often portrayed to be inferior. When disabled athletes are discussed in the media, there is often an emphasis on rehabilitation and the road to recovery, which is inherently a negative view on the disability. Oscar Pistorius is a South African runner who competed in the 2004, 2008, and 2012 Paralympics and the 2012 Olympic games in London. Pistorius was the first double amputee athlete to compete in the Olympic games. While media coverage focused on inspiration and competition during his time in the Paralympic games, it shifted to questioning whether his prosthetic legs gave him an advantage while competing in the Olympic games. Types of ableism Physical ableism is hate or discrimination based on physical disability. Sanism, or mental ableism, is discrimination based on mental health conditions and cognitive disabilities. Medical ableism exists both interpersonally (as healthcare providers can be ableist) and systemically, as decisions determined by medical institutions and caregivers may prevent the exercise of rights from disabled patients like autonomy and making decisions. The medical model of disability can be used to justify medical ableism. Structural ableism is failing to provide accessibility tools: ramps, wheelchairs, special education equipments, etc. (Which is often also an example of Hostile architecture.) Cultural ableism is behavioural, cultural, attitudinal and social patterns that may discriminate against disabled people, including by denying, dismissing or invisibilising disabled people, and by making accessibility and support unattainable. Internalised ableism is a disabled person discriminating against themself and other disabled people by holding the view that disability is something to be ashamed of or something to hide or by refusing accessibility or support. Internalised ableism may be a result of mistreatment of disabled individuals. Hostile ableism is a cultural or social kind of ableism where people are hostile towards symptoms of a disability or phenotypes of the disabled person. Benevolent ableism is when people treat the disabled person well but like a child (infantilization), instead of considering them full grown adults. Examples include ignoring disabilities, not respecting the life experiences of the disabled person, microaggression, not considering the opinion of the disabled person in important decision making, invasion of privacy or personal boundaries, forced corrective measures, unwanted help, not listening to the disabled person, etc. Ambivalent ableism can be characterized as somewhere in between hostile and benevolent ableism. Causes of ableism Ableism may have evolutionary and existential origins (fear of contagion, fear of death). It may also be rooted in belief systems (social Darwinism, meritocracy), language (such as "suffering from" disability), or unconscious biases. See also Disability abuse Disability and poverty Disability hate crime Disability rights movement Inclusion (disability rights) Mentalism (discrimination) Medical industrial complex Violent behavior in autistic people Violence against people with disabilities References Further reading Fandrey, Walter: Krüppel, Idioten, Irre: zur Sozialgeschichte behinderter Menschen in Deutschland (Cripples, idiots, madmen: the social history of disabled people in Germany) Schweik, Susan. (2009). The Ugly Laws: Disability in Public (History of Disability). NYU Press. Shaver, James P. (1981). Handicapism and Equal Opportunity: Teaching About the Disabled in Social Studies. Library of Congress Card Catalog Number 80-70737 ERIC Number: ED202185 External links Disablism: How to tackle the last prejudice by DEMOS (2004) Social theories Social concepts Prejudice and discrimination by type Disability rights

Gordon's functional health patterns

Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient. The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of the individual's health status and health practices that are used to reach the current level of health or wellness. Health Perception and Management Nutritional metabolic Elimination-excretion patterns and problems need to be evaluated (constipation, incontinence, diarrhea) Activity exercise-whether one is able to do daily activities normally without any problem, self care activities Sleep rest-do they have hypersomnia, insomnia, do they have normal sleeping patterns Cognitive-perceptual-assessment of neurological function is done to assess, check the person's ability to comprehend information Self perception/self concept Role relationship—This pattern should only be used if it is appropriate for the patient's age and specific situation. Sexual reproductivity Coping-stress tolerance Value-Belief Pattern References Further reading Marjory Gordon. Manual of Nursing Diagnosis - Eleventh Edition. . Nursing theory

Organic brain syndrome

Organic brain syndrome, also known as organic brain disease, organic brain damage, organic brain disorder, organic mental syndrome, or organic mental disorder, refers to any syndrome or disorder of mental function whose cause is alleged to be known as organic (physiologic) rather than purely of the mind. These names are older and nearly obsolete general terms from psychiatry, referring to many physical disorders that cause impaired mental function. They are meant to exclude psychiatric disorders (mental disorders). Originally, the term was created to distinguish physical (termed "organic") causes of mental impairment from psychiatric (termed "functional") disorders, but during the era when this distinction was drawn, not enough was known about brain science (including neuroscience, cognitive science, neuropsychology, and mind-brain correlation) for this cause-based classification to be more than educated guesswork labeled with misplaced certainty, which is why it has been deemphasized in current medicine. While mental or behavioural abnormalities related to the dysfunction can be permanent, treating the disease early may prevent permanent damage in addition to fully restoring mental functions. An organic cause to brain dysfunction is suspected when there is no indication of a clearly defined psychiatric or "inorganic" cause, such as a mood disorder. Types Organic brain syndrome can be divided into 2 major subgroups: acute (delirium or acute confusional state) and chronic (dementia). A third entity, encephalopathy (amnestic), denotes a gray zone between delirium and dementia. The Diagnostic and Statistical Manual of Mental Disorders has broken up the diagnoses that once fell under the diagnostic category organic mental disorder into three categories: delirium, dementia, and amnestic. Delirium Delirium or Acute organic brain syndrome is a recently appearing state of mental impairment, as a result of intoxication, drug overdose, infection, pain, and many other physical problems affecting mental status. In medical contexts, "acute" means "of recent onset". As is the case with most acute disease problems, acute organic brain syndrome is often temporary, although this does not guarantee that it will not recur or progress to become chronic, that is, long-term. A more specific medical term for the acute subset of organic brain syndromes is delirium. Dementia Dementia or chronic organic brain syndrome is long-term. For example, some forms of chronic drug or alcohol dependence can cause organic brain syndrome due to their long-lasting or permanent toxic effects on brain function. Other common causes of chronic organic brain syndrome sometimes listed are the various types of dementia, which result from permanent brain damage due to strokes, Alzheimer's disease, or other damaging causes which are irreversible. Amnestic pertains to amnesia and is the impairment in ability to learn or recall new information, or recall previously learned information. Although similar, it is not coupled with dementia or delirium. Amnestic Amnestic conditions denotes a gray zone between delirium and dementia; its early course may fluctuate, but it is often persistent and progressive. Damage to brain functioning could be due not only to organic (physical) injury (a severe blow to the head, stroke, chemical and toxic exposures, organic brain disease, substance use, etc.) and also to non-organic means such as severe deprivation, abuse, neglect, and severe psychological trauma. Symptoms Many of the symptoms of Organic Mental Disorder depend on the cause of the disorder, but are similar and include physical or behavioral elements. Dementia and delirium are the cause of the confusion, orientation, cognition or alertness impairment. Therefore, these symptoms require more attention because hallucinations, delusions, amnesia, and personality changes are the result. These effects of the dementia and delirium are not joined with the changes of sensory or perception abilities. Memory impairment, judgment, logical function and agitation are also some extremely common symptoms. The more common symptoms of OBS are confusion; impairment of memory, judgment, and intellectual function; and agitation. Often these symptoms are attributed to psychiatric illness, which causes a difficulty in diagnosis. Associated conditions Disorders that are related to injury or damage to the brain and contribute to OBS include, but are not limited to: Alcoholism Alzheimer's disease Attention deficit/hyperactivity disorder Autism Concussion Encephalitis Epilepsy Fetal alcohol syndrome Hypoxia Parkinson's disease Intoxication/overdose caused by substance use disorders including alcohol use disorder Non-medical use of sedative hypnotics Intracranial hemorrhage/trauma Korsakoff syndrome Mastocytosis Meningitis Psychoorganic syndrome Stroke/transient ischemic attack (TIA) Withdrawal from drugs, especially sedative hypnotics, e.g. alcohol or benzodiazepines Other conditions that may be related to organic brain syndrome include: clinical depression, neuroses, and psychoses, which may occur simultaneously with the OBS. Treatment While the treatment depends on which particular disorder is involved in Organic Mental Disorder, a few that are possible. Treatments can include, but are not limited to, rehabilitation therapy such as physical or occupational, pharmacological modification of the neurotransmitter function, or medication. The affected parts of the brain can recover some function with the help of different types of therapy, or tractographical psysurgery. Online therapy can be just as intense and helpful as rehabilitation therapy, in person, and can help those affected regain function in daily life. Prognosis Some disorders are short-term and treatable, and their prognosis is not as lengthy. Rest and medication are the most common courses of action for these treatable cases to help the patient return to proper health. Many of the cases are long-term, and there is not as much of a set and defined prognosis. The course of action can include extensive counseling and therapy. There are many reasons that the long-term cases are harder to treat and these include these cases normally get worse over time, and medication or therapy could not work. In this case, many of the prognosis tracks are to help the patient and their family become more comfortable and understand what will happen. Associated conditions Brain injury caused by trauma Bleeding into the brain (intracerebral hemorrhage) Bleeding into the space around the brain (subarachnoid hemorrhage) Blood clot inside the skull causing pressure on brain (subdural hematoma) Concussion Breathing conditions Low oxygen in the body (hypoxia) High carbon dioxide levels in the body (hypercapnia) Cardiovascular disorders Abnormal heart rhythm (arrhythmias) Brain injury due to high blood pressure (hypertensive brain injury) Dementia due to many strokes (multi-infarct dementia) Heart infections (endocarditis, myocarditis) Stroke Transient ischemic attack (TIA) Degenerative disorders Alzheimer's disease (also called senile dementia, Alzheimer's type) Creutzfeldt–Jakob disease Diffuse Lewy Body disease Huntington's disease Multiple sclerosis Normal pressure hydrocephalus Parkinson's disease Pick's disease Dementia due to metabolic causes Drug and alcohol-related conditions Alcohol withdrawal state Intoxication from drug or alcohol use Wernicke–Korsakoff syndrome (a long-term effect of excessive alcohol consumption or malnutrition) Withdrawal from drugs (especially sedative-hypnotics and corticosteroids) Infections Any sudden onset (acute) or long-term (chronic) infection Blood poisoning (sepsis) Brain infection (encephalitis) Meningitis (infection of the lining of the brain and spinal cord) Prion infections such as mad cow disease Late-stage syphilis (general paresis) Other medical disorders Cancer Kidney disease Liver disease Thyroid disease (high or low) Vitamin deficiency (B1, B12, or folate) Lithium toxicity can cause permanent organic brain damage Accumulation of metals in the brains Aluminum Mercury poisoning References External links AllRefer Health.com. 13 December 2006. Mental disorders due to brain damage Syndromes

Psychopathology

Psychopathology is the study of mental illness. It includes the signs and symptoms of all mental disorders. The field includes abnormal cognition, maladaptive behavior, and experiences which differ according to social norms. This discipline is an in-depth look into symptoms, behaviors, causes, course, development, categorization, treatments, strategies, and more. Biological psychopathology is the study of the biological etiology of abnormal cognitions, behaviour and experiences. Child psychopathology is a specialization applied to children and adolescents. History Early explanations for mental illnesses were influenced by religious belief and superstition. Psychological conditions that are now classified as mental disorders were initially attributed to possessions by evil spirits, demons, and the devil. This idea was widely accepted up until the sixteenth and seventeenth centuries. The Greek physician Hippocrates was one of the first to reject the idea that mental disorders were caused by possession of demons or the devil, and instead looked to natural causes. He firmly believed the symptoms of mental disorders were due to diseases originating in the brain. Hippocrates suspected that these states of insanity were due to imbalances of fluids in the body. He identified these fluids to be four in particular: blood, black bile, yellow bile, and phlegm. This later became the basis of the chemical imbalance theory used widely within the present. Furthermore, not far from Hippocrates, the philosopher Plato would come to argue the mind, body, and spirit worked as a unit. Any imbalance brought to these compositions of the individual could bring distress or lack of harmony within the individual. This philosophical idea would remain in perspective until the seventeenth century. It was later challenged by Laing (1960) along with Laing and Esterson (1964) who noted that it was the family environment that led to the formation of adaptive strategies. In the eighteenth century's Romantic Movement, the idea that healthy parent-child relationships provided sanity became a prominent idea. Philosopher Jean-Jacques Rousseau introduced the notion that trauma in childhood could have negative implications later in adulthood. In the 1600s and 1700s insane asylums started to be opened to house those with mental disorders. Asylums were places where restraint techniques and treatments could be tested on patients who were confined. These were early precursors for psychiatric hospitals. The scientific discipline of psychopathology was founded by Karl Jaspers in 1913. It was referred to as "static understanding" and its purpose was to graphically recreate the "mental phenomenon" experienced by the client. A few years earlier, in 1899, the German book Lehrbuch der Psychopathologischen Untersuchungs-Methoden was published by Robert Sommer. Psychoanalysis Sigmund Freud proposed a method for treating psychopathology through dialogue between a patient and a psychoanalyst. Talking therapy would originate from his ideas on the individual's experiences and the natural human efforts to make sense of the world and life. As the study of psychiatric disorders The study of psychopathology is interdisciplinary, with contributions coming from clinical psychology, abnormal psychology, social psychology, and developmental psychology, as well as neuropsychology and other psychology subdisciplines. Other related fields include psychiatry, neuroscience, criminology, social work, sociology, epidemiology, and statistics. Psychopathology can be broadly separated into descriptive and explanatory. Descriptive psychopathology involves categorising, defining and understanding symptoms as reported by people and observed through their behaviour which are then assessed according to a social norm. Explanatory psychopathology looks to find explanations for certain kinds of symptoms according to theoretical models such as psychodynamics, cognitive behavioural therapy or through understanding how they have been constructed by drawing upon Constructivist Grounded Theory (Charmaz, 2016) or Interpretative Phenomenological Analysis (Smith, Flowers & Larkin, 2013). There are several ways to characterise the presence of psychopathology in an individual as a whole. One strategy is to assess a person along four dimensions: deviance, distress, dysfunction, and danger, known collectively as the four Ds. Another conceptualisation, the p factor, sees psychopathology as a general, overarching construct that influences psychiatric symptoms. Mental Disorders Mental disorders are defined by a set of characteristic features, that is more than just one symptom. In order to be classified for diagnosis, the symptoms cannot represent an expected response to a common stress or loss that is related to an event. Syndromes are a set of simultaneous symptoms that represent a disorder. Common mental health disorders include depression, generalized anxiety disorder (GAD), panic disorder, phobias, social anxiety disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Depression is one of the most common and most debilitating mental disorders worldwide. It affects how individuals think, feel, and act. Symptoms vary depending on each individual person and include feeling sad, irritable, hopeless, or losing interest in activities once enjoyed. Generalized anxiety disorder is feeling worried or nervous more frequently than what correlates to real-life stressors. It is more common in women than men and includes symptoms such as having trouble controlling their worries or feelings of nervousness, or feeling restless and have trouble relaxing. The Four Ds A description of the four Ds when defining abnormality: Deviance is variation from statistical norms that result in a conflict with society. This term describes the idea that specific thoughts, behaviors and emotions are considered deviant when they are unacceptable or not common in society. Clinicians must, however, remember that minority groups are not always deemed deviant just because they may not have anything in common with other groups. Therefore, we define an individual's actions as deviant or abnormal when their behaviour is deemed unacceptable by the culture they belong to. However, many disorders have a relation between patterns of deviance and therefore need to be evaluated in a differential diagnostic model. Distress has to do with the discomfort that is experience by the person with the disorder. This term accounts for negative feelings by the individual with the disorder. They may feel deeply troubled and affected by their illness. Behaviors and feelings that cause distress to individuals or to others around them are considered abnormal if the condition is upsetting to the person experiencing it. Distress is related to dysfunction by being a useful asset in accurately perceiving dysfunction in an individual's life. These two are not always related because an individual can be highly dysfunctional and at the same time experience minimal stress. The important characteristic of distress is not dysfunction; rather it is the upsetting events themselves and the way we respond to them. Dysfunction involves an inability to maladaptive behavior that impairs the individual's ability to perform normal daily functions. It includes dysfunction in the psychological, biological, or developmental processes that are associated with mental functioning. This maladaptive behavior has to be significant enough to be considered a diagnosis. It's highly noted to look for dysfunction across an individual's life experience because there is a chance the dysfunction may appear in clear observable view and in places where it is less likely to appear. Such maladaptive behaviours prevent the individual from living a normal, healthy lifestyle. However, dysfunctional behaviour is not always caused by a disorder; it may be voluntary, such as engaging in a hunger strike. Duration is useful for clinicians to use as a criterion for diagnosis. Most symptoms have a specific duration that they last before being diagnosed. Can be harmful as not every person's experience is the same. The p factor Benjamin Lahey and colleagues first proposed a general "psychopathology factor" in 2012, or simply "p factor". This construct shares its conceptual similarity with the g factor of general intelligence. Instead of conceptualising psychopathology as consisting of several discrete categories of mental disorders, the p factor is dimensional and influences whether psychiatric symptoms in general are present or absent. The symptoms that are present then combine to form several distinct diagnoses. The p factor is modelled in the Hierarchical Taxonomy of Psychopathology. Although researchers initially conceived a three-factor explanation for psychopathology generally, subsequent study provided more evidence for a single factor that is sequentially comorbid, recurrent/chronic, and exists on a continuum of severity and chronicity. Higher scores on the p factor dimension have been found to be correlated with higher levels of functional impairment, greater incidence of problems in developmental history, and more diminished early-life brain function. In addition, those with higher levels of the p factor are more likely to have inherited a genetic predisposition to mental illness. The existence of the p factor may explain why it has been "... challenging to find causes, consequences, biomarkers, and treatments with specificity to individual mental disorders." A 2020 review of the p factor found that many studies support its validity and that it is generally stable throughout one's life. A high p factor is associated with many adverse effects, including poor academic performance, impulsivity, criminality, suicidality, reduced foetal growth, lower executive functioning, and a greater number of psychiatric diagnoses. A partial genetic basis for the p factor has also been supported. Alternatively, the p factor has also been interpreted as an index of general impairment rather than being a specific index that causes psychopathology. As mental symptoms The term psychopathology may also be used to denote behaviours or experiences which are indicative of mental illness, even if they do not constitute a formal diagnosis. For example, the presence of hallucinations may be considered as a psychopathological sign, even if there are not enough symptoms present to fulfil the criteria for one of the disorders listed in the DSM or ICD. In a more general sense, any behaviour or experience which causes impairment, distress or disability, particularly if it is thought to arise from a functional breakdown in either the cognitive or neurocognitive systems in the brain, may be classified as psychopathology. It remains unclear how strong the distinction between maladaptive traits and mental disorders actually is, e.g. neuroticism is often described as the personal level of minor psychiatric symptoms. Diagnostic and Statistical Manual of Mental Disorders Main article: Diagnostic and Statistical Manual of Mental Disorders The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a guideline for the diagnosis and understanding of mental disorders. The American Psychiatric Association (APA) sponsors the editing, writing, reviewing and publishing of this book. It is a reference book on mental health and brain-related conditions and disorders. It serves as reference for a range of professionals in medicine and mental health in the United States particularly. These professionals include psychologists, counsellors, physicians, social workers, psychiatric nurses and nurse practitioners, marriage and family therapists, and more. The current DSM is the fifth, most recent edition of this book. It was released in May 2013. Each edition makes significant changes to the classification of disorders. Research Domain Criteria Main article: Research Domain Criteria The RDoC framework is a set of research principles for investigating mental disorders. It is meant to create a new approach to mental illness that leads to better diagnosis, prevention, intervention, and cures. It is not necessarily meant to serve as a diagnostic guide or replace the DSM, however, it is meant to examine various degrees of dysfunction. It was developed by the US National Institute of Mental Health (NIMH). It aims to address heterogeneity by providing a more symptom based framework for understanding mental disorders. It relied on dimensions that span the range from normal to abnormal and allows investigators to work with a larger database. It uses six major functional domains to examine neurobehavioral functioning. Different aspects of each domain are represented by constructs which are studied along the full range of functioning. Together all of the domains form a matrix that could represent research ideas. It is a heuristic, and acknowledges that research topics will change and grow as science emerges. See also Adverse Childhood Experiences movement Biological psychiatry Cerebral atrophy Evidence-based medicine Evolutionary psychiatry Glossary of psychiatry Neurodegeneration Neuroimmunology Neuroinflammation Stress in early childhood Traumatic brain injury References Further reading Atkinson, L et al. (2004). Attachment Issues in Psychopathology and Intervention. Lawrence Erlbaum. Berrios, G.E.(1996) The History of Mental Symptoms: Descriptive Psychopathology since the 19th century. Cambridge, Cambridge University Press, Freud, S (1916) The Psychopathology of Everyday Life. MacMillan. Keating, D P et al. (1991). Constructivist Perspectives on Developmental Psychopathology and Atypical Development. Lawrence Erlbaum. Maddux, J E et al. (2005). Psychopathology: Foundations for a Contemporary Understanding. Lawrence Erlbaum. McMaster University. (2011). Psychological disorders. In Discover psychology (pp. 154–155, 157–158, 162–164) [Introduction]. Toronto, ON: Nelson Education. Sims, A. (2002) Symptoms in the Mind: An Introduction to Descriptive Psychopathology (3rd ed). Elsevier. Widiger, T A et al. (2000). Adult Psychopathology: Issues and Controversies. Annual Review of Psychology. Abnormal psychology Pathology

Acceptance

Acceptance in psychology is a person's recognition and assent to the finality of a situation without attempting to change or protest it. This plays out at both the individual and societal level as people experience change. Types of acceptance The term acceptance is a noun with various meanings. Self-acceptance Self-acceptance is described as the state or ongoing process of striving to be satisfied with one's current self. It is an agreement with oneself to appreciate, validate, and support the self as it is, despite deficiencies and negative past behavior. Some have trouble accepting themselves because of guilt, trauma, or a perceived lack of motivation. Self-acceptance has an effect on a person mentally, emotionally, within relationships and overall life. Psychological acceptance Acceptance is a core element of acceptance and commitment therapy (ACT) and cognitive behavioral therapy (CBT). In this context, acceptance is a process that involves actively contacting psychological internal experiences (emotions, sensations, urges, flashbacks, and other private events) directly, fully, without reacting or becoming defensive. The idea is to accept the things one cannot change, such as psychological experiences, but build the courage to change the things one can. Social acceptance Social acceptance as described in The Psychology Dictionary as the acceptance of a person into a group and/or the absence of social disapproval. Essentially whether or not a person fits in with their immediate peer group, such as class, colleagues, or cohort. Social acceptance can be defined as tolerating and welcoming the differences and diversity in others because most people attempt to look and act like others do in order to fit in. Data shows that those with high self-acceptance scores tend to accept others and feel accepted by others. This concerned is heightened for children and teenagers who tend to desire being accepted by friends. When it comes to mental disorders, social acceptance plays a big role in recovery. Many people do not understand mental illness, so they are unsure of how to embrace people who have a disease, leaving these people with feelings of isolation in friend groups. Being accepted by a friend and having support can help with mental health and give a healthy sense of self. Public acceptance Public acceptance is stated as a general agreement that something is satisfactory or right, or that someone should be included in a group. An example of public acceptance would be the LGBTQ+ community. It is a very important aspect to the movement because it involves understanding, and inclusion of many individuals with different gender identities, and sexual orientation within the public and society in general. Cultural acceptance Cultural acceptance is the ability to accept the individual for their cultural beliefs and their principles. This includes religion, cultural language, identity, and their overall beliefs and/or boundaries. Parental acceptance Parental acceptance is described as the affection, nurturance, support or simply the love a parent has for that child and the experience the children can gain from it. Conditional acceptance A type of acceptance that requires modification of the initial conditions before the final acceptance is made, is called conditional acceptance, or qualified acceptance. For instance, in a contract involving two parties, adjustments or modifications may be made to ensure it aligns with the satisfaction of both parties. When a person receives an offer and is willing to agree to it, provided that certain changes are made to its terms or certain conditions or events occur, it is referred to as conditional acceptance. In a business contract between a company and an employer, both parties have the option to change and modify the terms until mutual agreement or acceptance of the contract's details is reached. Expressed acceptance Expressed acceptance involves making an overt and unambiguous acceptance of the set conditions. For example, a person clearly and explicitly agrees to an offer. They accept the terms without any changes. Implied acceptance Implied acceptance refers to a situation where one's intent to consent to the presented conditions is understood or inferred, even if not explicitly stated. Acceptance is implied by an act that indicates a person's assent to the proposed bargain. References Bibliography "The 5 stages of grief." Assortment Articles: Free Online Articles on Health, Science, Education & More. 12 Apr. 2009. "The Last Phase of Grief: Acceptance, Reorganization and Integration." Getting Past Your Past. 14 Apr. 2009. "The need for social acceptance and approval — its power." The Way. Art of Living. Essays. Topically arranged scripture, proverbs, precepts, quotations. Teachings of Jesus. Conservative Christian outlook emphasizing self-discipline, self-denial, integrity, principle, character, chastity, goodness, morality, virtue. 16 Apr. 2009. "Self Acceptance." Become Who You Want To Be. 16 Apr. 2009. "What A Difference A Friend Makes: Social Acceptance Is Key to Mental Health Recovery." Mental illness, mental health information center. 10 Apr. 2009. External links Art of Accepting Emotions Positive mental attitude

Psychoeducation

Psychoeducation (a portmanteau of psychological education) is an evidence-based therapeutic intervention for patients and their loved ones that provides information and support to better understand and cope with illness. Psychoeducation is most often associated with serious mental illness, including dementia, schizophrenia, clinical depression, anxiety disorders, eating disorders, bipolar and personality disorders. The term has also been used for programs that address physical illnesses, such as cancer. Psychoeducation offered to patients and family members teaches problem-solving and communication skills and provides education and resources in an empathetic and supportive environment. Results from more than 30 studies indicate psychoeducation improves family well-being, lowers rates of relapse and improves recovery. Overview Family members of individuals with serious mental illness (SMI) are often involved in initiating, advocating for, and supporting their relative's mental health care. They may be thrust into the role of case manager, medication monitor, financial planner, or housing coordinator with little education or support to prepare them. Professionally delivered family psychoeducation is a potential resource for both individuals with SMI and their family members, designed to engage, educate, and support family members so that they can better assist the person with SMI in managing their illness. The importance of family involvement and the efficacy of family psychoeducation is recognized by best-practice guidelines for the treatment of individuals with serious mental health conditions. History The concept of psychoeducation was first noted in the medical literature, in an article by John E. Donley "Psychotherapy and re-education" in The Journal of Abnormal Psychology, published in 1911. It wasn't until 30 years later that the first use of the word psychoeducation appeared in the medical literature in title of the book The psychoeducational clinic by Brian E. Tomlinson. New York, NY, US: MacMillan Co. This book was published in 1941. In French, the first instance of the term psychoéducation is in the thesis "La stabilité du comportement" published in 1962. Jeannine Guindon was a pioneer of psychoeducation in her work with disturbed children in Montreal, Canada, in the 1970s. The popularization and development of the term psychoeducation into its current form is widely attributed to the American researcher C.M. Anderson in 1980 in the context of the treatment of schizophrenia. Her research concentrated on educating relatives concerning the symptoms and the process of the schizophrenia. Also, her research focused on the stabilization of social authority and on the improvement in handling of the family members among themselves. Finally, C.M. Anderson's research included more effective stress management techniques. Psychoeducation in behavior therapy has its origin in the patient's relearning of emotional and social skills. In the last few years increasingly systematic group programs have been developed, in order to make the knowledge more understandable to patients and their families. Single and group Psychoeducation can take place in one-on-one discussion or in groups and by any qualified health educator as well as health professionals such as nurses, mental health counselors, social workers, occupational therapists, psychologists, and physicians. In the groups several patients are informed about their illnesses at once. Also, exchanges of experience between the concerned patients and mutual support play a role in the healing process. Brief psychoeducation Brief psychoeducation was developed as a way of reducing the use of the time of health care worker. Brief psychoeducation (less than 10 weeks) increases compliance with the healthcare systems suggested medication. It is unclear whether it decreases relapse though it may in the short term. There is no evidence that it reduces health care efficiency (thought studies may be underpowered). There is low-quality evidence that it may improve certain measures of social functioning such as social disability. There is low quality data that it reduces the change of death. Possible risks and side effects Often acutely sick patients have substantial thinking, concentration, and attention disturbances, at the beginning of their illness and care should be taken not to overwhelm the patient with too much information. Besides positive effects of a therapeutic measure like psychoeducation, in principle, also other possible risks should be considered. The detailed knowledge of the condition, prognosis therapy possibilities and the disease process, can make the patient and/or family member stressed. Therefore, one should draw an exact picture of the risks regarding the psychological condition of the patient. It should be considered how much the patient already understands, and how much knowledge the patient can take up and process in their current condition. The ability to concentrate should be considered as well as the maximum level of emotional stress that the patient can take. In the context of a psychoeducational program a selection of aspects and/or therapy possibilities can be considered and discussed with the patient. Otherwise, the patient may form an incomplete picture of their illness, and they may form ideas about treatment alternatives from a vantage point of incomplete information. However, the professional should also make a complete representation of the possibilities of treatment, and attention should be paid to not make excessive demands of the patient, that is, giving too much information at once. See also Family therapy Group psychotherapy National Alliance on Mental Illness References Bibliography Bäuml, Josef, et al. Psychoeducation: A Basic Psychotherapeutic Intervention for Patients With Schizophrenia and Their Families. Schizophrenia Bulletin. 2006 32 (Supplement 1): S1-S9 Hogarty, GE, Anderson, CM, Reiss, D, et al. Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia: II. Two-year effects of a controlled study on relapse and adjustment. Arch Gen Psychiatry 1991; 48:340–347. Chan, W.-c. S., Kua, E., Tsoi, T., Xiao, C., & Tay, P. K. C. (2012). Dementia: How to care for your loved one and yourself. A caregiver's guide. Singapore: Nu-earth. External links New York State Psychiatric Institute's Patient and Family Library- A Psychoeducation Project New York City Voices: A Consumer-Run Psychoeducative Project The Blog of Will Jiang, MLS the Former NYSPI & Columbia Psychiatry Library Chief Pepperdine | Graduate School of Education and Psychology Social work Psychotherapy by type

Psychomotor retardation

Psychomotor retardation involves a slowing down of thought and a reduction of physical movements in an individual. It can cause a visible slowing of physical and emotional reactions, including speech and affect. Psychomotor retardation is most commonly seen in people with major depression and in the depressed phase of bipolar disorder; it is also associated with the adverse effects of certain drugs, such as benzodiazepines. Particularly in an inpatient setting, psychomotor retardation may require increased nursing care to ensure adequate food and fluid intake and sufficient personal care. Informed consent for treatment is more difficult to achieve in the presence of this condition. Causes Psychiatric disorders: anxiety disorders, bipolar disorder, eating disorders, schizophrenia, severe depression, etc. Psychiatric medicines (if taken as prescribed or improperly, overdosed, or mixed with alcohol) Parkinson's disease Genetic disorders: Qazi–Markouizos syndrome, Say–Meyer syndrome, Tranebjaerg-Svejgaard syndrome, Wiedemann–Steiner syndrome, Wilson's disease, etc. Examples Examples of psychomotor retardation include the following: Unaccountable difficulty in carrying out what are usually considered "automatic" or "mundane" self care tasks for healthy people (i.e., without depressive illness) such as taking a shower, dressing, grooming, cooking, brushing teeth, and exercising. Physical difficulty performing activities that normally require little thought or effort, such as walking up stairs, getting out of bed, preparing meals, and clearing dishes from the table, household chores, and returning phone calls. Tasks requiring mobility suddenly (or gradually) may inexplicably seem "impossible". Activities such as shopping, getting groceries, taking care of daily needs, and meeting the demands of employment or school are commonly affected. Activities usually requiring little mental effort can become challenging. Balancing a checkbook, making a shopping list, and making decisions about mundane tasks (such as deciding what errands need to be done) are often difficult. In schizophrenia, activity level may vary from psychomotor retardation to agitation; the patient experiences periods of listlessness and may be unresponsive, and at the next moment be active and energetic. See also Psychomotor learning Psychomotor agitation Disorders of diminished motivation References External links Symptoms and signs of mental disorders Motor control Mood disorders Disorders of diminished motivation

Delirium

Delirium (formerly acute confusional state, an ambiguous term which is now discouraged) is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes, which usually develops over the course of hours to days. As a syndrome, delirium presents with disturbances in attention, awareness, and higher-order cognition. People with delirium may experience other neuropsychiatric disturbances, including changes in psychomotor activity (e.g. hyperactive, hypoactive, or mixed level of activity), disrupted sleep-wake cycle, emotional disturbances, disturbances of consciousness, or, altered state of consciousness, as well as perceptual disturbances (e.g. hallucinations and delusions), although these features are not required for diagnosis. Diagnostically, delirium encompasses both the syndrome of acute confusion and its underlying organic process known as an acute encephalopathy. The cause of delirium may be either a disease process inside the brain or a process outside the brain that nonetheless affects the brain. Delirium may be the result of an underlying medical condition (e.g., infection or hypoxia), side effect of a medication, substance intoxication (e.g., opioids or hallucinogenic deliriants), substance withdrawal (e.g., alcohol or sedatives), or from multiple factors affecting one's overall health (e.g., malnutrition, pain, etc.). In contrast, the emotional and behavioral features due to primary psychiatric disorders (e.g., as in schizophrenia, bipolar disorder) do not meet the diagnostic criteria for 'delirium'. Delirium may be difficult to diagnose without first establishing a person's usual mental function or 'cognitive baseline'. Delirium can be confused with multiple psychiatric disorders or chronic organic brain syndromes because of many overlapping signs and symptoms in common with dementia, depression, psychosis, etc. Delirium may occur in persons with existing mental illness, baseline intellectual disability, or dementia, entirely unrelated to any of these conditions. Delirium is often confused with schizophrenia, psychosis, organic brain syndromes, and more, because of similar signs and symptoms of these disorders. Treatment of delirium requires identifying and managing the underlying causes, managing delirium symptoms, and reducing the risk of complications. In some cases, temporary or symptomatic treatments are used to comfort the person or to facilitate other care (e.g., preventing people from pulling out a breathing tube). Antipsychotics are not supported for the treatment or prevention of delirium among those who are in hospital; however, they may be used in cases where a person has distressing experiences such as hallucinations or if the person poses a danger to themselves or others. When delirium is caused by alcohol or sedative-hypnotic withdrawal, benzodiazepines are typically used as a treatment. There is evidence that the risk of delirium in hospitalized people can be reduced by non-pharmacological care bundles (see ). According to the text of DSM-5-TR, although delirium affects only 1–2% of the overall population, 18–35% of adults presenting to the hospital will have delirium, and delirium will occur in 29–65% of people who are hospitalized. Delirium occurs in 11–51% of older adults after surgery, in 81% of those in the ICU, and in 20–22% of individuals in nursing homes or post-acute care settings. Among those requiring critical care, delirium is a risk factor for death within the next year. Because of the confusion caused by similar signs and symptoms of delirium with other Neuropsychiatric disorders like Schizophrenia and Psychosis, treating delirium can be difficult, and might even cause death of the patient due to being treated with the wrong medications. Definition In common usage, delirium can refer to drowsiness, agitation, disorientation, or hallucinations. In medical terminology, however, the core features of delirium include an acute disturbance in attention, awareness, and global cognition. Although slight differences exist between the definitions of delirium in the DSM-5-TR and ICD-10, the core features are broadly the same. In 2022, the American Psychiatric Association released the fifth edition text revision of the DSM (DSM-5-TR) with the following criteria for diagnosis: A. Disturbance in attention and awareness. This is a required symptom and involves easy distraction, inability to maintain attentional focus, and varying levels of alertness. B. Onset is acute (from hours to days), representing a change from baseline mentation and often with fluctuations throughout the day C. At least one additional cognitive disturbance (in memory, orientation, language, visuospatial ability, or perception) D. The disturbances (criteria A and C) are not better explained by another neurocognitive disorder E. There is evidence that the disturbances above are a "direct physiological consequence" of another medical condition, substance intoxication or withdrawal, toxin, or various combinations of causes Signs and symptoms Delirium exists across a range of arousal levels, either as a state between normal wakefulness/alertness and coma (hypoactive) or as a state of heightened psychophysiological arousal (hyperactive). It can also alternate between the two (mixed level of activity). While requiring an acute disturbance in attention, awareness, and cognition, the syndrome of delirium encompasses a broad range of additional neuropsychiatric disturbances. Inattention: A disturbance in attention is required for delirium diagnosis. This may present as an impaired ability to direct, focus, sustain, or shift attention. Memory impairment: The memory impairment that occurs in delirium is often due to an inability to encode new information, largely as a result of having impaired attention. Older memories already in storage are retained without need of concentration, so previously formed long-term memories (i.e., those formed before the onset of delirium) are usually preserved in all but the most severe cases of delirium, though recall of such information may be impaired due to global impairment in cognition. Disorientation: A person may be disoriented to self, place, or time. Additionally, a person may be 'disoriented to situation' and not recognize their environment or appreciate what is going on around them. Disorganized thinking: Disorganized thinking is usually noticed with speech that makes limited sense with apparent irrelevancies, and can involve poverty of speech, loose associations, perseveration, tangentiality, and other signs of a formal thought disorder. Language disturbances: Anomic aphasia, paraphasia, impaired comprehension, agraphia, and word-finding difficulties all involve impairment of linguistic information processing. Sleep/wake disturbances: Sleep disturbances in delirium reflect disruption in both sleep/wake and circadian rhythm regulation, typically characterized by fragmented sleep or even sleep-wake cycle reversal (i.e., active at night, sleeping during the day), including as an early sign preceding the onset of delirium. Psychotic and other erroneous beliefs: Symptoms of psychosis include suspiciousness, overvalued ideation and frank delusions. Delusions are typically poorly formed and less stereotyped than in schizophrenia or Alzheimer's disease. They usually relate to persecutory themes of impending danger or threat in the immediate environment (e.g., being poisoned by nurses). Perceptual disturbances: These can include illusions, which involve the misperception of real stimuli in the environment, or hallucinations, which involve the perception of stimuli that do not exist. Mood lability: Distortions to perceived or communicated emotional states as well as fluctuating emotional states can manifest in delirium (e.g., rapid changes between terror, sadness, joking, fear, anger, and frustration). Motor activity changes: Delirium has been commonly classified into psychomotor subtypes of hypoactive, hyperactive, and mixed level of activity, though studies are inconsistent as to their prevalence. Hypoactive cases are prone to non-detection or misdiagnosis as depression. A range of studies suggests that motor subtypes differ regarding underlying pathophysiology, treatment needs, functional prognosis, and risk of mortality, though inconsistent subtype definitions and poorer detection of hypoactive subtypes may influence the interpretation of these findings. The notion of unifying hypoactive and hyperactive states under the construct of delirium is commonly attributed to Lipowski. Hyperactive symptoms include hyper-vigilance, restlessness, fast or loud speech, irritability, combativeness, impatience, swearing, singing, laughing, uncooperativeness, euphoria, anger, wandering, easy startling, fast motor responses, distractibility, tangentiality, nightmares, and persistent thoughts (hyperactive sub-typing is defined with at least three of the above). Hypoactive symptoms include decreased alertness, sparse or slow speech, lethargy, slowed movements, staring, and apathy. Mixed level of activity describes instances of delirium where activity level is either normal or fluctuating between hyperactive and hypoactive. Causes Delirium arises through the interaction of a number of predisposing and precipitating factors. Individuals with multiple and/or significant predisposing factors are at high risk for an episode of delirium with a single and/or mild precipitating factor. Conversely, delirium may only result in low risk individuals if they experience a serious or multiple precipitating factors. These factors can change over time, thus an individual's risk of delirium is modifiable (see ). Predisposing factors Important predisposing factors include the following: 65 or more years of age Cognitive impairment/dementia Physical morbidity (e.g., biventricular failure, cancer, cerebrovascular disease) Psychiatric morbidity (e.g., depression) Sensory impairment (i.e., vision and hearing) Functional dependence (e.g., requiring assistance for self-care or mobility) Dehydration/malnutrition Substance use disorder, including alcohol use disorder Precipitating factors Any serious, acute biological factor that affects neurotransmitter, neuroendocrine, or neuroinflammatory pathways can precipitate an episode of delirium in a vulnerable brain. Certain elements of the clinical environment have also been associated with the risk of developing delirium. Some of the most common precipitating factors are listed below: Prolonged sleep restriction or deprivation Environmental, psychophysiological stress (as found in acute care settings) Inadequately controlled pain Immobilization, use of physical restraints Urinary retention, use of bladder catheter Emotional stress Severe constipation/fecal impaction Medications Sedatives (benzodiazepines, opioids), anticholinergics, dopaminergics, corticosteroids, polypharmacy General anesthetic Substance intoxication or withdrawal Primary neurologic conditions Severe drop in blood pressure, relative to the person's normal blood pressure (orthostatic hypotension) resulting in inadequate blood flow to the brain (cerebral hypoperfusion) Stroke/transient ischemic attack(TIA) Intracranial bleeding Meningitis, encephalitis Concurrent illness Infections – especially respiratory (e.g. pneumonia, COVID-19) and urinary tract infections Iatrogenic complications Hypoxia, hypercapnea, anemia Poor nutritional status, dehydration, electrolyte imbalances, hypoglycemia Shock, heart attacks, heart failure Metabolic derangements (e.g. SIADH, Addison's disease, hyperthyroidism) Chronic/terminal illness (e.g. cancer) Post-traumatic event (e.g. fall, fracture) Mercury poisoning (e.g. erethism) Major surgery (e.g. cardiac, orthopedic, vascular surgery) Pathophysiology The pathophysiology of delirium is still not well understood, despite extensive research. Animal models The lack of animal models that are relevant to delirium has left many key questions in delirium pathophysiology unanswered. Earliest rodent models of delirium used atropine (a muscarinic acetylcholine receptor blocker) to induce cognitive and electroencephalography (EEG) changes similar to delirium, and other anticholinergic drugs, such as biperiden and hyoscine, have produced similar effects. Along with clinical studies using various drugs with anticholinergic activity, these models have contributed to a "cholinergic deficiency hypothesis" of delirium. Profound systemic inflammation occurring during sepsis is also known to cause delirium (often termed sepsis-associated encephalopathy). Animal models used to study the interactions between prior degenerative disease and overlying systemic inflammation have shown that even mild systemic inflammation causes acute and transient deficits in working memory among diseased animals. Prior dementia or age-associated cognitive impairment is the primary predisposing factor for clinical delirium and "prior pathology" as defined by these new animal models may consist of synaptic loss, abnormal network connectivity, and "primed microglia" brain macrophages stimulated by prior neurodegenerative disease and aging to amplify subsequent inflammatory responses in the central nervous system (CNS). Cerebrospinal fluid Studies of cerebrospinal fluid (CSF) in delirium are difficult to perform. Apart from the general difficulty of recruiting participants who are often unable to give consent, the inherently invasive nature of CSF sampling makes such research particularly challenging. However, a few studies have managed to sample CSF from persons undergoing spinal anesthesia for elective or emergency surgery. A 2018 systematic review showed that, broadly, delirium may be associated with neurotransmitter imbalance (namely serotonin and dopamine signaling), reversible fall in somatostatin, and increased cortisol. The leading "neuroinflammatory hypothesis" (where neurodegenerative disease and aging leads the brain to respond to peripheral inflammation with an exaggerated CNS inflammatory response) has been described, but current evidence is still conflicting and fails to concretely support this hypothesis. Neuroimaging Neuroimaging provides an important avenue to explore the mechanisms that are responsible for delirium. Despite progress in the development of magnetic resonance imaging (MRI), the large variety in imaging-based findings has limited our understanding of the changes in the brain that may be linked to delirium. Some challenges associated with imaging people diagnosed with delirium include participant recruitment and inadequate consideration of important confounding factors such as history of dementia and/or depression, which are known to be associated with overlapping changes in the brain also observed on MRI. Evidence for changes in structural and functional markers include: changes in white-matter integrity (white matter lesions), decreases in brain volume (likely as a result of tissue atrophy), abnormal functional connectivity of brain regions responsible for normal processing of executive function, sensory processing, attention, emotional regulation, memory, and orientation, differences in autoregulation of the vascular vessels in the brain, reduction in cerebral blood flow and possible changes in brain metabolism (including cerebral tissue oxygenation and glucose hypometabolism). Altogether, these changes in MRI-based measurements invite further investigation of the mechanisms that may underlie delirium, as a potential avenue to improve clinical management of people with this condition. Neurophysiology Electroencephalography (EEG) allows for continuous capture of global brain function and brain connectivity, and is useful in understanding real-time physiologic changes during delirium. Since the 1950s, delirium has been known to be associated with slowing of resting-state EEG rhythms, with abnormally decreased background alpha power and increased theta and delta frequency activity. From such evidence, a 2018 systematic review proposed a conceptual model that delirium results when insults/stressors trigger a breakdown of brain network dynamics in individuals with low brain resilience (i.e. people who already have underlying problems of low neural connectivity and/or low neuroplasticity like those with Alzheimer's disease). Neuropathology Only a handful of studies exist where there has been an attempt to correlate delirium with pathological findings at autopsy. One research study has been reported on 7 people who died during ICU admission. Each case was admitted with a range of primary pathologies, but all had acute respiratory distress syndrome and/or septic shock contributing to the delirium, 6 showed evidence of low brain perfusion and diffuse vascular injury, and 5 showed hippocampal involvement. A case-control study showed that 9 delirium cases showed higher expression of HLA-DR and CD68 (markers of microglial activation), IL-6 (cytokines pro-inflammatory and anti-inflammatory activities) and GFAP (marker of astrocyte activity) than age-matched controls; this supports a neuroinflammatory cause to delirium, but the conclusions are limited by methodological issues. A 2017 retrospective study correlating autopsy data with mini–mental state examination (MMSE) scores from 987 brain donors found that delirium combined with a pathological process of dementia accelerated MMSE score decline more than either individual process. Diagnosis The DSM-5-TR criteria are often the standard for diagnosing delirium clinically. However, early recognition of delirium's features using screening instruments, along with taking a careful history, can help in making a diagnosis of delirium. A diagnosis of delirium generally requires knowledge of a person's baseline level of cognitive function. This is especially important for treating people who have neurocognitive or neurodevelopmental disorders, whose baseline mental status may be mistaken as delirium. General settings Guidelines recommend that delirium should be diagnosed consistently when present. Much evidence reveals that in most centers delirium is greatly under-diagnosed. A systematic review of large scale routine data studies reporting data on delirium detection tools showed important variations in tool completion rates and tool positive score rates. Some tools, even if completed at high rates, showed delirium positive score rates that there much lower than the expected delirium occurrence level, suggesting low sensitivity in practice. There is evidence that delirium detection and coding rates can show improvements in response to guidelines and education; for example, whole country data in England and Scotland (sample size 7.7M patients per year) show that there were large increases (3-4 fold) in delirium coding between 2012 and 2020. Delirium detection in general acute care settings can be assisted by the use of validated delirium screening tools. Many such tools have been published, and they differ in a variety of characteristics (e.g., duration, complexity, and need for training). It is also important to ensure that a given tool has been validated for the setting where it is being used. Examples of tools in use in clinical practice include: Confusion Assessment Method (CAM), including variants such as the 3-Minute Diagnostic Interview for the CAM (3D-CAM) and brief CAM (bCAM) Delirium Observation Screening Scale (DOS) Nursing Delirium Screening Scale (Nu-DESC) Recognizing Acute Delirium As part of your Routine (RADAR) 4AT (4 A's Test) Delirium Diagnostic Tool-Provisional (DDT-Pro), also for subsyndromal delirium Intensive care unit People who are in the ICU are at greater risk of delirium, and ICU delirium may lead to prolonged ventilation, longer stays in the hospital, increased stress on family and caregivers, and an increased chance of death. In the ICU, international guidelines recommend that every person admitted gets checked for delirium every day (usually twice or more a day) using a validated clinical tool. Key elements of detecting delirium in the ICU are whether a person can pay attention during a listening task and follow simple commands. The two most widely used are the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). Translations of these tools exist in over 20 languages and are used ICUs globally with instructional videos and implementation tips available. For children in need of intensive care there are validated clinical tools adjusted according to age. The recommended tools are preschool and pediatric Confusion Assessment Methods for the ICU (ps/pCAM-ICU) or the Cornell Assessment for Pediatric Delirium (CAPD) as the most valid and reliable delirium monitoring tools in critically ill children or adolescents. More emphasis is placed on regular screening over the choice of tool used. This, coupled with proper documentation and informed awareness by the healthcare team, can affect clinical outcomes. Without using one of these tools, 75% of ICU delirium can be missed by the healthcare team, leaving the person without any likely interventions to help reduce the duration of delirium. Differential diagnosis There are conditions that might have similar clinical presentations to those seen in delirium. These include dementia, depression, psychosis, catatonia, and other conditions that affect cognitive function. Dementia: This group of disorders is acquired (non-congenital) with usually irreversible cognitive and psychosocial functional decline. Dementia usually results from an identifiable degenerative brain disease (e.g., Alzheimer disease or Huntington's disease), requires chronic impairment (versus acute onset in delirium), and is typically not associated with changes in level of consciousness. Dementia is different from delirium in that dementia lasts long-term while delirium lasts short-term. Depression: Similar symptoms exist between depression and delirium (especially the hypoactive subtype). Gathering a history from other caregivers can clarify baseline mentation. Psychosis: In general, people with primary psychosis have intact cognitive function; however, primary psychosis can mimic delirium when it presents with disorganized thoughts and mood dysregulation. This is particularly true in the condition known as delirious mania. Other mental illnesses: Some mental illnesses, such as a manic episode of bipolar disorder, depersonalization disorder, or other dissociative conditions, can present with features similar to that of delirium. Such condition, however, would not qualify for a diagnosis of delirium per DSM-5-TR criterion D (i.e., fluctuating cognitive symptoms occurring as part of a primary mental disorder are results of the said mental disorder itself), while physical disorders (e.g., infections, hypoxia, etc.) can precipitate delirium as a mental side-effect/symptom. Prevention Treating delirium that is already established is challenging and for this reason, preventing delirium before it begins is ideal. Prevention approaches include screening to identify people who are at risk, and medication-based and non-medication based (non-pharmacological) treatments. An estimated 30–40% of all cases of delirium could be prevented in cognitively at-risk populations, and high rates of delirium reflect negatively on the quality of care. Episodes of delirium can be prevented by identifying hospitalized people at risk of the condition. This includes individuals over age 65, with a cognitive impairment, undergoing major surgery, or with severe illness. Routine delirium screening is recommended in such populations. It is thought that a personalized approach to prevention that includes different approaches together can decrease rates of delirium by 27% among the elderly. In 1999, Sharon K. Inouye at Yale University, founded the Hospital Elder Life Program (HELP) which has since become recognized as a proven model for preventing delirium. HELP prevents delirium among the elderly through active participation and engagement with these individuals. There are two working parts to this program, medical professionals such as a trained nurse, and volunteers, who are overseen by the nurse. The volunteer program equips each trainee with the adequate basic geriatric knowledge and interpersonal skills to interact with patients. Volunteers perform the range of motion exercises, cognitive stimulation, and general conversation with elderly patients who are staying in the hospital. Alternative effective delirium prevention programs have been developed, some of which do not require volunteers. Prevention efforts often fall on caregivers. Caregivers often have a lot expected of them and this is where socioeconomic status plays a role in prevention. If prevention requires constant mental stimulation and daily exercise, this takes time out of the caregiver's day. Based on socioeconomic classes, this may be valuable time that would be used working to support the family. This leads to a disproportionate amount of individuals who experience delirium being from marginalized identities. Programs such as the Hospital Elder Life Program can attempt to combat these societal issues by providing additional support and education about delirium that may not otherwise be accessible. Non-pharmacological Delirium may be prevented and treated by using non-pharmacologic approaches focused on risk factors, such as constipation, dehydration, low oxygen levels, immobility, visual or hearing impairment, sleep disturbance, functional decline, and by removing or minimizing problematic medications. Ensuring a therapeutic environment (e.g., individualized care, clear communication, adequate reorientation and lighting during daytime, promoting uninterrupted sleep hygiene with minimal noise and light at night, minimizing room relocation, having familiar objects like family pictures, providing earplugs, and providing adequate nutrition, pain control, and assistance toward early mobilization) may also aid in preventing delirium. Research into pharmacologic prevention and treatment is weak and insufficient to make proper recommendations. Pharmacological Melatonin and other pharmacological agents have been studied for delirium prevention, but evidence is conflicting. Avoidance or cautious use of benzodiazepines has been recommended for reducing the risk of delirium in critically ill individuals. It is unclear if the medication donepezil, a cholinesterase inhibitor, reduces delirium following surgery. There is also no clear evidence to suggest that citicoline, methylprednisolone, or antipsychotic medications prevent delirium. A review of intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery showed little or no difference in postoperative delirium according to the type of anaesthetic maintenance agents in five studies (321 participants). The authors of this review were uncertain whether maintenance of anaesthesia with propofol-based total intravenous anaesthesia (TIVA) or with inhalational agents can affect the incidence rate of postoperative delirium. Interventions for preventing delirium in long-term care or hospital The current evidence suggests that software-based interventions to identify medications that could contribute to delirium risk and recommend a pharmacist's medication review probably reduces incidence of delirium in older adults in long-term care. The benefits of hydration reminders and education on risk factors and care homes' solutions for reducing delirium is still uncertain. For inpatients in a hospital setting, numerous approaches have been suggested to prevent episodes of delirium including targeting risk factors such as sleep deprivation, mobility problems, dehydration, and impairments to a person's sensory system. Often a 'multicomponent' approach by an interdisciplinary team of health care professionals is suggested for people in the hospital at risk of delirium, and there is some evidence that this may decrease to incidence of delirium by up to 43% and may reduce the length of time that the person is hospitalized. Treatment Most often, delirium is reversible; however, people with delirium require treatment for the underlying cause(s) and often to prevent injury and other poor outcomes directly related to delirium. Treatment of delirium requires attention to multiple domains including the following: Identify and treat the underlying medical disorder or cause(s) Addressing any other possible predisposing and precipitating factors that might be disrupting brain function Optimize physiology and conditions for brain recovery (e.g., oxygenation, hydration, nutrition, electrolytes, metabolites, medication review) Detect and manage distress and behavioral disturbances (e.g., pain control) Maintaining mobility Provide rehabilitation through cognitive engagement and mobilization Communicate effectively with the person experiencing delirium and their carers or caregivers Provide adequate follow-up including consideration of possible dementia and post-traumatic stress. Multidomain interventions These interventions are the first steps in managing acute delirium, and there are many overlaps with delirium preventative strategies. In addition to treating immediate life-threatening causes of delirium (e.g., low O, low blood pressure, low glucose, dehydration), interventions include optimizing the hospital environment by reducing ambient noise, providing proper lighting, offering pain relief, promoting healthy sleep-wake cycles, and minimizing room changes. Although multicomponent care and comprehensive geriatric care are more specialized for a person experiencing delirium, several studies have been unable to find evidence showing they reduce the duration of delirium. Family, friends, and other caregivers can offer frequent reassurance, tactile and verbal orientation, cognitive stimulation (e.g. regular visits, familiar objects, clocks, calendars, etc.), and means to stay engaged (e.g. making hearing aids and eyeglasses readily available). Sometimes verbal and non-verbal deescalation techniques may be required to offer reassurances and calm the person experiencing delirium. Restraints should rarely be used as an intervention for delirium. The use of restraints has been recognized as a risk factor for injury and aggravating symptoms, especially in older hospitalized people with delirium. The only cases where restraints should sparingly be used during delirium is in the protection of life-sustaining interventions, such as endotracheal tubes. Another approached called the "T-A-DA (tolerate, anticipate, don't agitate) method" can be an effective management technique for older people with delirium, where abnormal behaviors (including hallucinations and delusions) are tolerated and unchallenged, as long as caregiver safety and the safety of the person experiencing delirium is not threatened. Implementation of this model may require a designated area in the hospital. All unnecessary attachments are removed to anticipate for greater mobility, and agitation is prevented by avoiding excessive reorientation/questioning. Medications The use of medications for delirium is generally restricted to managing its distressing or dangerous neuropsychiatric disturbances. Short-term use (one week or less) of low-dose haloperidol is among the more common pharmacological approaches to delirium. Evidence for effectiveness of atypical antipsychotics (e.g. risperidone, olanzapine, ziprasidone, and quetiapine) is emerging, with the benefit for fewer side effects Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson's disease or dementia with Lewy bodies. Evidence for the effectiveness of medications (including antipsychotics and benzodiazepines) in treating delirium is weak. Benzodiazepines can cause or worsen delirium, and there is no reliable evidence of efficacy for treating non-anxiety-related delirium. Similarly, people with dementia with Lewy bodies may have significant side effects with antipsychotics, and should either be treated with a none or small doses of benzodiazepines. The antidepressant trazodone is occasionally used in the treatment of delirium, but it carries a risk of over-sedation, and its use has not been well studied. For adults with delirium that are in the ICU, medications are used commonly to improve the symptoms. Dexmedetomidine may shorten the length of the delirium in adults who are critically ill, and rivastigmine is not suggested. For adults with delirium who are near the end of their life (on palliative care) high quality evidence to support or refute the use of most medications to treat delirium is not available. Low quality evidence indicates that the antipsychotic medications risperidone or haloperidol may make the delirium slightly worse in people who are terminally ill, when compared to a placebo treatment. There is also moderate to low quality evidence to suggest that haloperidol and risperidone may be associated with a slight increase in side effects, specifically extrapyramidal symptoms, if the person near the end of their life has delirium that is mild to moderate in severity. Prognosis There is substantial evidence that delirium results in long-term poor outcomes in older persons admitted to hospital. This systematic review only included studies that looked for an independent effect of delirium (i.e., after accounting for other associations with poor outcomes, for example co-morbidity or illness severity). In older persons admitted to hospital, individuals experiencing delirium are twice as likely to die than those who do not (meta-analysis of 12 studies). In the only prospective study conducted in the general population, older persons reporting delirium also showed higher mortality (60% increase). A large (N=82,770) two-centre study in unselected older emergency population found that delirium detected as part of normal care using the 4AT tool was strongly linked to 30-day mortality, hospital length of stay, and days at home in the year following the 4AT test date. Institutionalization was also twice as likely after an admission with delirium (meta-analysis of seven studies). In a community-based population examining individuals after an episode of severe infection (though not specifically delirium), these persons acquired more functional limitations (i.e., required more assistance with their care needs) than those not experiencing infection. After an episode of delirium in the general population, functional dependence increased threefold. The association between delirium and dementia is complex. The systematic review estimated a 13-fold increase in dementia after delirium (meta-analysis of two studies). However, it is difficult to be certain that this is accurate because the population admitted to hospital includes persons with undiagnosed dementia (i.e., the dementia was present before the delirium, rather than caused by it). In prospective studies, people hospitalised from any cause appear to be at greater risk of dementia and faster trajectories of cognitive decline, but these studies did not specifically look at delirium. In the only population-based prospective study of delirium, older persons had an eight-fold increase in dementia and faster cognitive decline. The same association is also evident in persons already diagnosed with Alzheimer's dementia. Recent long-term studies showed that many people still meet criteria for delirium for a prolonged period after hospital discharge, with up to 21% of people showing persistent delirium at 6 months post-discharge. Dementia in ICU survivors Between 50% and 70% of people admitted to the ICU have permanent problems with brain dysfunction similar to those experienced by people with Alzheimer's or those with a traumatic brain injury, leaving many ICU survivors permanently disabled. This is a distressing personal and public health problem and continues to receive increasing attention in ongoing investigations. The implications of such an "acquired dementia-like illness" can profoundly debilitate a person's livelihood level, often dismantling his/her life in practical ways like impairing one's ability to find a car in a parking lot, complete shopping lists, or perform job-related tasks done previously for years. The societal implications can be enormous when considering work-force issues related to the inability of wage-earners to work due to their own ICU stay or that of someone else they must care for. Epidemiology The highest rates of delirium (often 50–75% of people) occur among those who are critically ill in the intensive care unit (ICU). This was historically referred to as "ICU psychosis" or "ICU syndrome"; however, these terms are now widely disfavored in relation to the operationalized term ICU delirium. Since the advent of validated and easy-to-implement delirium instruments for people admitted to the ICU such as the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC), it has been recognized that most ICU delirium is hypoactive, and can easily be missed unless evaluated regularly. The causes of delirium depend on the underlying illnesses, new problems like sepsis and low oxygen levels, and the sedative and pain medicines that are nearly universally given to all ICU patients. Outside the ICU, on hospital wards and in nursing homes, the problem of delirium is also a very important medical problem, especially for older patients. The most recent area of the hospital in which delirium is just beginning to be monitored routinely in many centers is the Emergency Department, where the prevalence of delirium among older adults is about 10%. A systematic review of delirium in general medical inpatients showed that estimates of delirium prevalence on admission ranged 10–31%. About 5–10% of older adults who are admitted to hospital develop a new episode of delirium while in hospital. Rates of delirium vary widely across general hospital wards. Estimates of the prevalence of delirium in nursing homes are between 10% and 45%. Society and culture Delirium is one of the oldest forms of mental disorder known in medical history. The Roman author Aulus Cornelius Celsus used the term to describe mental disturbance from head trauma or fever in his work De Medicina. Sims (1995, p. 31) points out a "superb detailed and lengthy description" of delirium in "The Stroller's Tale" from Charles Dickens' The Pickwick Papers. Historically, delirium has also been noted for its cognitive sequelae. For instance, the English medical writer Philip Barrow noted in 1583 that if delirium (or "frensy") resolves, it may be followed by a loss of memory and reasoning power. Costs In the US, the cost of a hospital admission for people with delirium is estimated at between $16k and $64k, suggesting the national burden of delirium may range from $38 bn to $150 bn per year (2008 estimate). In the UK, the cost is estimated as £13k per admission. References Further reading External links Cognitive disorders Intensive care medicine Psychopathological syndromes

Causes of mental disorders

A mental disorder is an impairment of the mind disrupting normal thinking, feeling, mood, behavior, or social interactions, and accompanied by significant distress or dysfunction. The causes of mental disorders are very complex and vary depending on the particular disorder and the individual. Although the causes of most mental disorders are not fully understood, researchers have identified a variety of biological, psychological, and environmental factors that can contribute to the development or progression of mental disorders. Most mental disorders result in a combination of several different factors rather than just a single factor. Research results Risk factors for mental illness include psychological trauma, adverse childhood experiences, genetic predisposition, and personality traits. Correlations of mental disorders with drug use include almost all psychoactive substances, e.g., cannabis, alcohol, and caffeine. Mental illnesses have risk factors, for instance including unequal parental treatment, adverse life events and drug use in depression, migration and discrimination, childhood trauma, loss or separation in families, and cannabis use in schizophrenia and psychosis, and parenting factors, child abuse, family history (e.g. of anxiety), and temperament and attitudes (e.g. pessimism) in anxiety. Many psychiatric disorders include problems with impulse and other emotional control. In February 2013, a study found genetic links between five major psychiatric disorders: autism, ADHD, bipolar disorder, major depressive disorder, and schizophrenia. Abnormal functioning of neurotransmitter systems is also responsible for some mental disorders, including serotonin, norepinephrine, dopamine, and glutamate system's abnormal functioning. Differences have also been found in the size or activity of specific brain regions in some cases. Psychological mechanisms have also been implicated, such as cognitive (e.g. reasoning) biases, emotional influences, personality dynamics, temperament, and coping style. Studies have indicated that variation in genes can play an important role in the evolution of mental disorders, although the reliable identification of connections between specific genes and specific disorders has proven more difficult. Environmental events surrounding pregnancy (such as maternal hypertension, preeclampsia, or infection) and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. Throughout the years, there have been inconsistent links found to certain viral infections, substance misuse, and general physical health that have been false. Adverse experiences affect a person's mental health, including abuse, neglect, bullying, social stress, traumatic events, and other overwhelming life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated, including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures. Mental stress is a common cause of mental illnesses, so finding a coping solution to cope with mental stress would be beneficial. Many solutions that have helped reduce stress are yoga, exercise, and some medications that may help. Theories General theories Several theories or models seek to explain the causes (etiology) of mental disorders. These theories may differ in regards to how they explain the cause of the disorder, how to treat the disorder, and how they classify mental disorders. Theories also differ about the philosophy of mind they accept; that is, whether the mind and brain are identical or not. During most of the 20th century, mental illness was ascribable to problematic relationships between children and their parents. This view was held well into the late 1990s, in which people still believed this child-parent relationship was a large determinant of severe mental illness, such as depression and schizophrenia. In the 21st century, additional factors have been identified such as genetic contributions, though experience also plays a role. So, the perceived causes of mental illness have changed over time and will most likely continue to alter while more research develops throughout the years. Outside the West, community approaches remain a focus. A practical mixture of models will explain particular issues and disorders, although there may be difficulty defining boundaries for indistinct psychiatric syndromes. Medical or biomedical model An overall distinction is also commonly made between a "medical model" (also known as a biomedical or disease model) and a "social model" (also known as an empowerment or recovery model) of mental disorder and disability, with the former focusing on hypothesized disease processes and symptoms, along with latter focusing on hypothesized social constructionism and social contexts. Biological psychiatry has tended to follow a biomedical model focused on organic or "hardware" pathology of the brain, where many mental disorders are conceptualized as disorders of brain circuits shaped by a complex interplay of genetics and experience. The social and medical models of mental disorders each work to identify and study distinct aspects, solutions, and potential therapies of disorders. The intersection and cross reference between the two models can further be used to develop more holistic models of mental disorders. Many criticisms historically of each model is the exclusivity of the other perspective. Therefore, intersectional research improved the impact and importance of future findings. Biopsychosocial model The primary model of contemporary mainstream Western psychiatry is the biopsychosocial model (BPS), which integrates biological, psychological, and social factors. The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person's medical condition it is not simply the biological factors to consider, but also the psychological and social factors . The biopsychosocial approach systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. Biological, psychological, and social factors exist along a continuum of natural systems. The factors within the model contain the following: Biological (physiological pathology) Psychological (thoughts emotions and behaviours such as psychological distress, fear/avoidance beliefs, current coping methods and attribution) Social (socio-economical, socio-environmental, and cultural factors such as work issues, family circumstances and benefits/economics) This model is commonly used for case conceptualization of psychological disorders as well as chronic pain, with the view that the pain is a psychophysiological behavior pattern that cannot be categorised into biological, psychological, or social factors alone. A related view, the diathesis-stress model, posits that mental disorders result from genetic dispositions and environmental stressors, combining to cause patterns of distress or dysfunction. The model is one way to explain why some individuals are more vulnerable to mental disorders than others. Additionally, it explains why some people may develop a mental disorder after exposure to stressful life events while others do not. Psychoanalytic theories Psychoanalytic theories focus on unresolved internal and relational conflicts. These theories have been predicated as explanations of mental disorders. Many psychoanalytic groups are said to adhere to the biopsychosocial model and to accept an eclectic mix of subtypes of psychoanalysis. Sigmund Freud developed the psychoanalytic theory. This theory focuses on the impact of unconscious forces on human behavior. According to Freud, a personality has three parts: the id, ego, and superego. The id operates under the pleasure principle, the ego operates under the reality principle, and the superego is the "conscience" and incorporates what is and is not socially acceptable into a person's value system. According to the psychoanalytic theory, there are five stages of psychosexual development that everyone goes through the oral stage, anal stage, phallic stage, latency stage, and genital stage. Mental disorders can be caused by an individual receiving too little or too much gratification in one of the psychosexual developmental stages. When this happens, the individual is said to be in that developmental stage. Attachment theory Attachment theory is a kind of evolutionary-psychological approach sometimes applied in the context of mental disorders, which focuses on the role of early caregiver-child relationships, responses to danger, and the search for a satisfying reproductive relationship in adulthood. According to this theory, a child's attachment is to a nurturing adult, the more likely that child will maintain healthy relationships with others in their life. As found by the Strange Situation experiment run by Mary Ainsworth based on the formulations of John Bowlby, there are four patterns of attachment: secure attachment, avoidant attachment, disorganized attachment, and ambivalent attachment. Later research found the fourth pattern of attachment is known as disorganized disoriented attachment. Secure attachments reflect trust in the child-caretaker relationship while insecure attachment reflects mistrust. The security of attachment in a child affects the child's emotional, cognitive, and social competence later in life. Evolutionary psychology Evolutionary psychology and evolutionary psychiatry posit that mental disorders involve the dysfunctional operation of mental modules adapted to ancestral physical or social environments but not necessarily to modern ones. Behavioral abnormalities that resemble human mental illness have been found in related species (great apes). Other theories suggest that mental illness could have evolutionary advantages for the species, including enhancing creativity and stress to enhance survival by activating the flight-or-fight response in anticipation of danger. Mania and depression could have benefited from seasonal changes by helping to increase energy levels during times of plenty and rejuvenating energy during times of scarcity. In this way, mania was set in motion during the spring and summer to facilitate energy for hunting; depression worked best during the winter, similar to how bears hibernate to recover their energy levels. This may explain the connection between circadian genes and Bipolar Disorder and explain the relationship between light and seasonal affective disorder. Biological factors Biological factors consist of anything physical that can cause adverse effects on a person's mental health. Biological factors include genetics, prenatal damage, infections, exposure to toxins, brain defects or injuries, and substance abuse. Many professionals believe that the cause of mental disorders is the biology of the brain and the nervous system. Mind mentions genetic factors, long-term physical health conditions, and head injuries or epilepsy (affecting behavior and mood) as factors that may trigger an episode of mental illness. Genetics Some rare mental disorders are caused only by genetics such as Huntington's disease. Family linkage and some twin studies have indicated that genetic factors often play a role in the heritability of mental disorders. The reliable identification of specific genetic variation can cause indication of higher risk to particular disorders, through linkage, Genome Wide Association Scores or association studies, has proven difficult. This is due to the complexity of interactions between genes, environmental events, and early development or the need for new research strategies. No specific gene results in a complex trait disorder, but specific variations of alleles result in higher risk for a trait. The heritability of behavioral traits associated with a mental disorder may be in permissive than in restrictive environments, and susceptibility genes probably work through both "within-the-skin" (physiological) pathways and "outside-the-skin" (behavioral and social) pathways. Investigations increasingly focus on links between genes and endophenotypes because they are more specific traits. Some include neurophysiological, biochemical, endocrinological, neuroanatomical, cognitive, or neuropsychological, rather than disease categories. Concerning a well-known mental disorder, schizophrenia, it is said with certainty that alleles (forms of genes) were responsible for this disorder. Some research has indicated only multiple, rare mutations are thought to alter neurodevelopmental pathways that can ultimately contribute to schizophrenia; virtually every rare structural mutation was different in each individual. Research has shown that many conditions are polygenic meaning there are multiple defective genes rather than only one that is responsible for a disorder, and these genes may also be pleiotropic meaning that they cause multiple disorders, not just one. Schizophrenia and Alzheimer's are both examples of hereditary mental disorders. When exonic genes encode for proteins, these proteins do not just affect one trait. The pathways that contribute to complex traits and phenotypes interact with multiple systems, even though proteins have specific functions. brain plasticity (neuroplasticity) raises questions of whether some brain differences may be caused by mental illnesses or by pre-existing and then causing them. Attention deficit hyperactivity disorder Bipolar disorder Prenatal damage Any damage that occurs to a fetus while still in its mother's womb is considered prenatal damage. Mental disorders can develop if the pregnant mother uses drugs or alcohol or is exposed to illnesses or infections during pregnancy. Environmental events surrounding pregnancy and birth have increased the development of mental illness in the offspring. Some events may include maternal exposure to stress or trauma, conditions of famine, obstetric birth complications, infections, and gestational exposure to alcohol or cocaine. These factors have been hypothesized to affect areas of neurodevelopment, general development, and restrict neuroplasticity. Infection, disease and toxins Infection There have been some findings of links between infection by the parasite Toxoplasma gondii and schizophrenia. AIDS has been linked to some mental disorders. Research shows that infections and exposure to toxins such as HIV and streptococcus cause dementia. This HIV infection that makes its way to the brain is called encephalopathy which spreads itself through the brain leading to dementia. The infections or toxins that trigger a change in the brain chemistry can develop into a mental disorder. Depression and emotional liability may be also be caused by babesiosis. There is some evidence that there may be a relationship between BoDV-1 infection and psychiatric disease. The research on Lyme disease caused by a deer tick and toxins is expanding the link between bacterial infections and mental illness. Disease Depression, anxiety, mania, psychosis, vegetative symptoms, cognitive deficit and consciousness impairment may be caused by internal disease as well as endocrine and metabolic disorders, deficiency states and neurologic disorders. Injury and brain defects Any damage to the brain can cause a mental disorder. The brain is the control system for the nervous system and the rest of the body. Without it, the body cannot function properly. Increased mood swings, insane behavior, and substance abuse disorders are traumatic brain injury (TBI) examples. Findings on the relationship between TBI severity and prevalence of subsequent psychiatric disorders have been inconsistent, and occurrence relates to prior mental health problems. Direct neurophysiological effects in a complex interaction with personality, attitude, and social influences. Head trauma classifies as either open or closed head injury. In open head injury, the skull is punctured and the brain tissue is demolished. Closed head injury is more common, the skull is not punctured because there is an impact of the brain against the skull that creates permanent structural damage (subdural hematoma). With both types, symptoms may disappear or persist over time. Typically the longer the length of time spent unconscious and the length of post-traumatic amnesia the worse the prognosis for the individual. The cognitive residual symptoms of head trauma are associated with the type of injury (either an open head injury or closed head injury) and the amount of tissue destroyed. Closed injury head trauma symptoms include; Deficits in abstract reasoning ability, judgment, memory, and marked personality changes. Open injury head trauma symptoms tend to be the experience of classic neuropsychological syndromes like aphasia, visual-spatial disorders, and types of memory or perceptual disorders. Brain tumors are classified as either malignant and benign, and as intrinsic (directly infiltrate the parenchyma of the brain) or extrinsic (grows on the external surface of the brain and produces symptoms as a result of pressure on the brain tissue). Progressive cognitive changes associated with brain tumors may include confusion, poor comprehension, and even dementia. Symptoms tend to depend on the location of the tumor in the brain. For example, tumors on the frontal lobe tend to be associated with the sign of impairment of judgment, apathy, and loss of the ability to regulate/modulate behavior. Findings have indicated abnormal functioning of brainstem structures in individuals with mental disorders such as schizophrenia, and other disorders that have to do with impairments in maintaining sustained attention. Some abnormalities in the average size or shape of some regions of the brain have been found in some disorders, reflecting genes and experiences. Studies of schizophrenia have tended to find enlarged ventricles and sometimes reduced volume of the cerebrum and hippocampus, while studies of (psychotic) bipolar disorder have sometimes found increased amygdala volume. Findings differ over whether volumetric abnormalities are risk factors or are only found alongside the course of mental health problems, possibly reflecting neurocognitive or emotional stress processes and medication use or substance use. Some studies have also found reduced hippocampal volumes in major depression, possibly worsening with time depression. Neurotransmitter systems Abnormal levels of dopamine activity correspond with several disorders (reduced in ADHD and OCD, and increased in schizophrenia). The dysfunction in serotonin and other monoamine neurotransmitters (norepinephrine and dopamine) correspond with certain mental disorders and their associated neural networks. Some include major depression, obsessive-compulsive disorder, phobias, post-traumatic stress disorder, and generalized anxiety disorder. Studies of depleted levels of monoamine neurotransmitters show an association with depression and other psychiatric disorders, but "... it should be questioned whether 5-HT [serotonin] represents just one of the final and not the main, factors in the neurological chain of events underlying psychopathological symptoms...." Simplistic "chemical imbalance" explanations for mental disorders have never received empirical support; and most prominent psychiatrists, neuroscientists, and psychologists have not espoused such ill-defined, facile etiological theories. Instead, neurotransmitter systems have been understood in the context of the diathesis-stress or biopsychosocial models. The following 1967 quote from renowned psychiatric and neuroscience researchers exemplifies this more sophisticated understanding (in contrast to the woolly "chemical imbalance" notion). Whereas specific genetic factors may be of importance in the etiology of some, and possibly all, depressions, it is equally conceivable that early experiences of the infant or child may cause enduring biochemical changes, that may predispose some individuals to depressions in adulthood. It is not likely that changes in the metabolism of the biogenic amines alone will account for the complex phenomena of normal or pathological affect. Substance abuse Substance abuse, especially long-term abuse, can cause or exacerbate many mental disorders. Alcoholism is linked to depression while abuse of amphetamines and LSD can leave a person feeling paranoid and anxious. Correlations of mental disorders with drug use include cannabis, alcohol, and caffeine. At more than 300 mg, caffeine may cause anxiety or worsen anxiety disorders. Illicit drugs can stimulate particular parts of the brain that can affect development in adolescence. Cannabis has also been found to worsen depression and lessen an individual's motivation. Alcohol has the potential to damage "white matter" in the brain that affects thinking and memory. Alcohol is a problem in many countries due to many people participating in excessive drinking or binge drinking. Environmental factors The term "environment" is very loosely defined in the context of mental illnesses. Unlike biological and psychological causes, environmental causes denote a wide range of stressors that individuals experience in everyday life. They are more psychologically than biologically based. Events that evoke feelings of loss are the most likely to cause a mental disorder to develop in an individual. Environmental factors include but are not limited to dysfunctional home life, poor interpersonal relationships, substance abuse, not meeting social expectations, low self-esteem, and poverty. The British charity organisation Mind lists childhood abuse, trauma, violence, neglect, social isolation, discrimination, grief, stress, homelessness, social disadvantage, debt, unemployment, caring for a family member or friend, and significant trauma as an adult (such as war, an accident, or being the victim of a violent crime) as possible triggers of an episode of mental illness. Repeating generational patterns, behaviors that are passed down through different familial generations, are also a risk factor for mental illness, especially in children. Life events and emotional stress Mistreatment in childhood or adulthood (including sexual-, physical-, and emotional abuse, domestic violence, and bullying) has been linked to the onset of mental disorders through an interaction of societal, familial, psychological, and biological factors. More generally, negative or stressful life events have been implicated in the development of a range of disorders, including mood and anxiety disorders. The main risks appear to be from the accumulation of such experiences over time, although a single major trauma can sometimes lead to disorders, especially post-traumatic stress disorder. Resilience to such experiences varies; a person may be resistant to some stressors but not to others. The psychological resilience of an individual can be affected by genetics, temperamental characteristics, cognitive flexibility, coping strategies, and previous experiences. For example, in the case of bipolar disorder, stress is not a specific cause but does place genetically and biologically vulnerable people at risk for more severe forms of the illness. Adverse childhood experiences The Adverse Childhood Experiences Study has shown a strong dose–response relationship between adverse childhood experiences or ACEs (such as physical and/or emotional neglect, abuse, poverty, malnutrition, and traumatic experiences) and numerous health, social, and behavioral problems including suicide attempts and the frequency of depressive episodes. Several such experiences can cause toxic stress. ACEs may affect the structural and functional development of the brain and lead to abnormalities, and chronic trauma can disrupt immune responses and cause lasting dysregulated inflammatory response. A child's neurological development can be disrupted when chronically exposed to stressful events, and his/her cognitive functioning and/or ability to cope with negative emotions can diminish. Over time, the child may adopt various harmful coping strategies that contribute to later mental and physical problems. Findings have been mixed, but some studies suggest that cognitive deficit is more related to neglect than other forms of adversity. Poor parenting is a risk factor for depression and anxiety. Separation, grief in families, and other forms childhood trauma are risk factors for schizophrenia. Children are more susceptible to psychological harm from traumatic events than adults, but their reaction does vary by individual child, age, the type of event, and the length of exposure. Neglect is a form of mistreatment in which the responsible caretakers fail to provide the necessary age-appropriate care, supervision, and protection. It is different from abuse in that it is, in this context, not intentional in causing harms. The long-term effects of neglect can be reduced physical, emotional, and mental health throughout the victim's life. Familial and close relationships Parental divorce, death, absence, or the lack of stability appears to increase the risk of mental disorders in a child. Early social privation, and the lack of "ongoing, harmonious, secure, committed" relationships have been implicated in the development of mental illnesses. Continuous conflict with friends, one's support system, and family can all increase the risk of developing a mental illness or can worsen one's mental health. Divorce is a factor that affects adults as well as children. Divorcees may have emotional adjustment problems due to a loss of intimacy and social connections; however, new statistics show that the negative effects of divorce have been overstated. Social expectations and self-esteem Having both too low or too high self-esteem can be detrimental to an individual's mental health. Low self-esteem in particular can result in aggression, self-deprecating behavior, anxiety, and other mental disorders. Being perceived as someone who does not "fit in" can result in bullying and other types of emotional abuse, which can lead to the victim experiencing depression, anger, and loneliness. Poverty Studies show that there is a direct correlation between poverty and mental illness: the lower the socioeconomic status of an individual, the higher the risk of mental illness. Impoverished people in England, defined as those who live in the lowest 20% income bracket, are two to three times more likely to develop mental illness than those of a higher economic class. This increased risk remains consistent for all poor individuals regardless of any in-group demographic differences, as all disadvantaged families experience economic stressors such as unemployment or lack of housing. A lower or more insecure educational, occupational, economic, or social position is generally linked to more mental disorders. Children from these backgrounds may have low levels of self-efficiency and self-worth. Studies have also shown a strong relationship between poverty and substance abuse, another risk factor in the onset of mental disorders. Problems in one's community or culture including poverty, unemployment or underemployment, a lack of social cohesion, and migration have been associated with the development of mental disorders. Personal resources, community factors, and interactions between individual and regional-level income levels have been implicated. Socioeconomic deprivation in neighborhoods can cause worsen mental health, even after accounting for genetic factors. According to a 2009 meta-analysis by Paul and Moser, countries with high income inequality and poor unemployment protections have worse mental health outcomes among the unemployed. The effects of different socioeconomic factors varies by country. Minority ethnic groups, including first or second-generation immigrants, are at a greater risk of developing mental disorders. This has been attributed to the insecurities in their lives and their disadvantages, including racism. There have been alternate models, such as the drift hypothesis to account for the complex relationship between an individual's social status and mental health. Psychological and individual factors, including resilience Some clinicians believe that psychological characteristics alone determine mental disorders. Others speculate that abnormal behavior can be explained by a mix of social and psychological factors. In many examples, environmental and psychological triggers complement one another resulting in emotional stress, which in turn activates a mental illness. Each person is unique in how they will react to psychological stressors. What may break one person may have little to no effect on another. Psychological stressors, which can trigger mental illness, are as follows: emotional, physical, or sexual abuse, loss of a significant loved one, neglect, and being unable to relate to others. The inability to relate to others is also known as emotional detachment. Emotional detachment makes it difficult for an individual to empathize with others or to share their feelings. These individuals tend to stress the importance of their independence and tend to struggle relating to others. An emotionally detached person may try to rationalize or apply logic to a situation to which there is no logical explanation. Often, the inability to relate to others stems from a traumatic event. Mental characteristics of individuals, as assessed by both neurological and psychological studies, have been linked to the development and maintenance of mental disorders. This includes cognitive or neurocognitive factors, such as the way a person perceives, thinks, or feels about certain things; or an individual's overall personality, temperament, or coping style or the extent of protective factors or "positive illusions" such as optimism, personal control and a sense of meaning. See also Air pollution Social medicine Winner and loser culture References Biology of bipolar disorder Mental disorders Biology of attention deficit hyperactivity disorder Biology of obsessive–compulsive disorder

Classification of mental disorders

The classification of mental disorders, also known as psychiatric nosology or psychiatric taxonomy, is central to the practice of psychiatry and other mental health professions. The two most widely used psychiatric classification systems are chapter V of the International Classification of Diseases, 10th edition (ICD-10), produced by the World Health Organization (WHO); and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), produced by the American Psychiatric Association (APA). Both systems list disorders thought to be distinct types, and in recent revisions the two systems have deliberately converged their codes so that their manuals are often broadly comparable, though differences remain. Both classifications employ operational definitions. Other classification schemes, used more locally, include the Chinese Classification of Mental Disorders. Manuals of limited use, by practitioners with alternative theoretical persuasions, include the Psychodynamic Diagnostic Manual. Definitions In the scientific and academic literature on the definition or categorization of mental disorders, one extreme argues that it is entirely a matter of value judgments (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms); other views argue that the concept refers to a "fuzzy prototype" that can never be precisely defined, or that the definition will always involve a mixture of scientific facts (e.g. that a natural or evolved function is not working properly) and value judgments (e.g. that it is harmful or undesired). Lay concepts of mental disorder vary considerably across different cultures and countries, and may refer to different sorts of individual and social problems. The WHO and national surveys report that there is no single consensus on the definition of mental disorder, and that the phrasing used depends on the social, cultural, economic and legal context in different contexts and in different societies. The WHO reports that there is intense debate about which conditions should be included under the concept of mental disorder; a broad definition can cover mental illness, intellectual disability, personality disorder and substance dependence, but inclusion varies by country and is reported to be a complex and debated issue. There may be a criterion that a condition should not be expected to occur as part of a person's usual culture or religion. However, despite the term "mental", there is not necessarily a clear distinction drawn between mental (dys)functioning and brain (dys)functioning, or indeed between the brain and the rest of the body. Most international clinical documents avoid the term "mental illness", preferring the term "mental disorder". However, some use "mental illness" as the main overarching term to encompass mental disorders. Some consumer/survivor movement organizations oppose use of the term "mental illness" on the grounds that it supports the dominance of a medical model. The term "serious mental impairment" (SMI) is sometimes used to refer to more severe and long-lasting disorders while "mental health problems" may be used as a broader term, or to refer only to milder or more transient issues. Confusion often surrounds the ways and contexts in which these terms are used. Mental disorders are generally classified separately to neurological disorders, learning disabilities or intellectual disabilities. ICD-10 The International Classification of Diseases (ICD) is an international standard diagnostic classification for a wide variety of health conditions. The ICD-10 states that mental disorder is "not an exact term", although is generally used "...to imply the existence of a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions." Chapter V focuses on "mental and behavioural disorders" and consists of 10 main groups: F0 – F9: Organic, including symptomatic, mental disorders F10 – F-19: Mental and behavioural disorders due to use of psychoactive substances F20 – F25: Schizophrenia, schizotypal and delusional disorders F30 – F39: Mood [affective] disorders F40 – F49: Neurotic, stress-related and somatoform disorders F50 – F59: Behavioural syndromes associated with physiological disturbances and physical factors F60 – F69: Disorders of personality and behaviour in adult persons F70 – F79: Mental retardation F80 – F89: Disorders of psychological development F90 – 98: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence In addition, a group of F99 "unspecified mental disorders". Within each group there are more specific subcategories. The WHO has revised ICD-10 to produce the latest version of the ICD, ICD-11 adopted by the 72nd World Health Assembly in 2019 and came into effect on 1 January 2022. DSM-IV The DSM-IV was originally published in 1994 and listed more than 250 mental disorders. It was produced by the American Psychiatric Association and it characterizes mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual,...is associated with present distress...or disability...or with a significantly increased risk of suffering" but that "...no definition adequately specifies precise boundaries for the concept of 'mental disorder'...different situations call for different definitions" (APA, 1994 and 2000). The DSM also states that "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorders." The DSM-IV-TR (Text Revision, 2000) consisted of five axes (domains) on which disorder could be assessed. The five axes were: Axis I: Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation) Axis II: Personality Disorders and Mental Retardation Axis III: General Medical Conditions (must be connected to a Mental Disorder) Axis IV: Psychosocial and Environmental Problems (for example limited social support network) Axis V: Global Assessment of Functioning (Psychological, social and job-related functions are evaluated on a continuum between mental health and extreme mental disorder) The axis classification system was removed in the DSM-5 and is now mostly of historical significance. The main categories of disorder in the DSM are: Other schemes The Chinese Society of Psychiatry's Chinese Classification of Mental Disorders (currently CCMD-3) The Latin American Guide for Psychiatric Diagnosis (GLDP). The Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health The Hierarchical Taxonomy of Psychopathology (HiTOP), developed by the HiTOP consortium, a group of psychologists and psychiatrists who had a record of scientific contributions to classification of psychopathology. Childhood diagnosis Child and adolescent psychiatry sometimes uses specific manuals in addition to the DSM and ICD. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) was first published in 1994 by Zero to Three to classify mental health and developmental disorders in the first four years of life. It has been published in 9 languages. The Research Diagnostic criteria-Preschool Age (RDC-PA) was developed between 2000 and 2002 by a task force of independent investigators with the goal of developing clearly specified diagnostic criteria to facilitate research on psychopathology in this age group. The French Classification of Child and Adolescent Mental Disorders (CFTMEA), operational since 1983, is the classification of reference for French child psychiatrists. Usage The ICD and DSM classification schemes have achieved widespread acceptance in psychiatry. A survey of 205 psychiatrists, from 66 countries across all continents, found that ICD-10 was more frequently used and more valued in clinical practice and training, while the DSM-IV was more frequently used in clinical practice in the United States and Canada, and was more valued for research, with accessibility to either being limited, and usage by other mental health professionals, policy makers, patients and families less clear. . A primary care (e.g. general or family physician) version of the mental disorder section of ICD-10 has been developed (ICD-10-PHC) which has also been used quite extensively internationally. A survey of journal articles indexed in various biomedical databases between 1980 and 2005 indicated that 15,743 referred to the DSM and 3,106 to the ICD. In Japan, most university hospitals use either the ICD or DSM. ICD appears to be the somewhat more used for research or academic purposes, while both were used equally for clinical purposes. Other traditional psychiatric schemes may also be used. Types of classification schemes Categorical schemes The classification schemes in common usage are based on separate (but may be overlapping) categories of disorder schemes sometimes termed "neo-Kraepelinian" (after the psychiatrist Kraepelin) which is intended to be atheoretical with regard to etiology (causation). These classification schemes have achieved some widespread acceptance in psychiatry and other fields, and have generally been found to have improved inter-rater reliability, although routine clinical usage is less clear. Questions of validity and utility have been raised, both scientifically and in terms of social, economic and political factors—notably over the inclusion of certain controversial categories, the influence of the pharmaceutical industry, or the stigmatizing effect of being categorized or labelled. Non-categorical schemes Some approaches to classification do not use categories with single cut-offs separating the ill from the healthy or the abnormal from the normal (a practice sometimes termed "threshold psychiatry" or "dichotomous classification"). Classification may instead be based on broader underlying "spectra", where each spectrum links together a range of related categorical diagnoses and nonthreshold symptom patterns. Some approaches go further and propose continuously varying dimensions that are not grouped into spectra or categories; each individual simply has a profile of scores across different dimensions. DSM-5 planning committees are currently seeking to establish a research basis for a hybrid dimensional classification of personality disorders. However, the problem with entirely dimensional classifications is they are said to be of limited practical value in clinical practice where yes/no decisions often need to be made, for example whether a person requires treatment, and moreover the rest of medicine is firmly committed to categories, which are assumed to reflect discrete disease entities. While the Psychodynamic Diagnostic Manual has an emphasis on dimensionality and the context of mental problems, it has been structured largely as an adjunct to the categories of the DSM. Moreover, dimensionality approach was criticized for its reliance on independent dimensions whereas all systems of behavioral regulations show strong inter-dependence, feedback and contingent relationships Descriptive vs Somatic Descriptive classifications are based almost exclusively on either descriptions of behavior as reported by various observers, such as parents, teachers, and medical personnel; or symptoms as reported by individuals themselves. As such, they are quite subjective, not amenable to verification by third parties, and not readily transferable across chronologic and/or cultural barriers. Somatic nosology, on the other hand, is based almost exclusively on the objective histologic and chemical abnormalities which are characteristic of various diseases and can be identified by appropriately trained pathologists. While not all pathologists will agree in all cases, the degree of uniformity allowed is orders of magnitude greater than that enabled by the constantly changing classification embraced by the DSM system. Some models, like Functional Ensemble of Temperament suggest to unify nosology of somatic, biologically based individual differences in healthy people (temperament) and their deviations in a form of mental disorders in one taxonomy. Cultural differences Classification schemes may not apply to all cultures. The DSM is based on predominantly American research studies and has been said to have a decidedly American outlook, meaning that differing disorders or concepts of illness from other cultures (including personalistic rather than naturalistic explanations) may be neglected or misrepresented, while Western cultural phenomena may be taken as universal. Culture-bound syndromes are those hypothesized to be specific to certain cultures (typically taken to mean non-Western or non-mainstream cultures); while some are listed in an appendix of the DSM-IV they are not detailed and there remain open questions about the relationship between Western and non-Western diagnostic categories and sociocultural factors, which are addressed from different directions by, for example, cross-cultural psychiatry or anthropology. Historical development Antiquity In Ancient Greece, Hippocrates and his followers are generally credited with the first classification system for mental illnesses, including mania, melancholia, paranoia, phobias and Scythian disease (transvestism). They held that they were due to different kinds of imbalance in four humors. Middle ages to Renaissance The Persian physicians 'Ali ibn al-'Abbas al-Majusi and Najib ad-Din Samarqandi elaborated upon Hippocrates' system of classification. Avicenna (980−1037 CE) in the Canon of Medicine listed a number of mental disorders, including "passive male homosexuality". Laws generally distinguished between "idiots" and "lunatics". Thomas Sydenham (1624–1689), the "English Hippocrates", emphasized careful clinical observation and diagnosis and developed the concept of a syndrome, a group of associated symptoms having a common course, which would later influence psychiatric classification. 18th century Evolution in the scientific concepts of psychopathology (literally referring to diseases of the mind) took hold in the late 18th and 19th centuries following the Renaissance and Enlightenment. Individual behaviors that had long been recognized came to be grouped into syndromes. Boissier de Sauvages developed an extremely extensive psychiatric classification in the mid-18th century, influenced by the medical nosology of Thomas Sydenham and the biological taxonomy of Carl Linnaeus. It was only part of his classification of 2400 medical diseases. These were divided into 10 "classes", one of which comprised the bulk of the mental diseases, divided into four "orders" and 23 "genera". One genus, melancholia, was subdivided into 14 "species". William Cullen advanced an influential medical nosology which included four classes of neuroses: coma, adynamias, spasms, and vesanias. The vesanias included amentia, melancholia, mania, and oneirodynia. Towards the end of the 18th century and into the 19th, Pinel, influenced by Cullen's scheme, developed his own, again employing the terminology of genera and species. His simplified revision of this reduced all mental illnesses to four basic types. He argued that mental disorders are not separate entities but stem from a single disease that he called "mental alienation". Attempts were made to merge the ancient concept of delirium with that of insanity, the latter sometimes described as delirium without fever. On the other hand, Pinel had started a trend for diagnosing forms of insanity 'without delirium' (meaning hallucinations or delusions) – a concept of partial insanity. Attempts were made to distinguish this from total insanity by criteria such as intensity, content or generalization of delusions. 19th century Pinel's successor, Esquirol, extended Pinel's categories to five. Both made a clear distinction between insanity (including mania and dementia) as opposed to mental retardation (including idiocy and imbecility). Esquirol developed a concept of monomania—a periodic delusional fixation or undesirable disposition on one theme—that became a broad and common diagnosis and a part of popular culture for much of the 19th century. The diagnosis of "moral insanity" coined by James Prichard also became popular; those with the condition did not seem delusional or intellectually impaired but seemed to have disordered emotions or behavior. The botanical taxonomic approach was abandoned in the 19th century, in favor of an anatomical-clinical approach that became increasingly descriptive. There was a focus on identifying the particular psychological faculty involved in particular forms of insanity, including through phrenology, although some argued for a more central "unitary" cause. French and German psychiatric nosology was in the ascendency. The term "psychiatry" ("Psychiatrie") was coined by German physician Johann Christian Reil in 1808, from the Greek "ψυχή" (psychē: "soul or mind") and "ιατρός" (iatros: "healer or doctor"). The term "alienation" took on a psychiatric meaning in France, later adopted into medical English. The terms psychosis and neurosis came into use, the former viewed psychologically and the latter neurologically. In the second half of the century, Karl Kahlbaum and Ewald Hecker developed a descriptive categorizion of syndromes, employing terms such as dysthymia, cyclothymia, catatonia, paranoia and hebephrenia. Wilhelm Griesinger (1817–1869) advanced a unitary scheme based on a concept of brain pathology. French psychiatrists Jules Baillarger described "folie à double forme" and Jean-Pierre Falret described "la folie circulaire"—alternating mania and depression. The concept of adolescent insanity or developmental insanity was advanced by Scottish Asylum Superintendent and Lecturer in Mental Diseases Thomas Clouston in 1873, describing a psychotic condition which generally impacts those aged 18–24 years, particularly males, and in 30% of cases proceeded to "a secondary dementia". The concept of hysteria (wandering womb) had long been used, perhaps since ancient Egyptian times, and was later adopted by Freud. Descriptions of a specific syndrome now known as somatization disorder were first developed by the French physician, Paul Briquet in 1859. An American physician, Beard, described "neurasthenia" in 1869. German neurologist Westphal, coined the term "obsessional neurosis" now termed obsessive-compulsive disorder, and agoraphobia. Alienists created a whole new series of diagnoses that highlighted single, impulsive behavior, such as kleptomania, dipsomania, pyromania, and nymphomania. The diagnosis of drapetomania was also developed in the Southern United States to explain the perceived irrationality of black slaves trying to escape what was thought to be a suitable role. The scientific study of homosexuality began in the 19th century, informally viewed either as natural or as a disorder. Kraepelin included it as a disorder in his Compendium der Psychiatrie that he published in successive editions from 1883. In the late 19th century, Koch referred to "psychopathic inferiority" as a new term for moral insanity. In the 20th century the term became known as "psychopathy" or "sociopathy", related specifically to antisocial behavior. Related studies led to the DSM-III category of antisocial personality disorder. 20th century Influenced by the approach of Kahlbaum and others, and developing his concepts in publications spanning the turn of the century, German psychiatrist Emil Kraepelin advanced a new system. He grouped together a number of existing diagnoses that appeared to all have a deteriorating course over time—such as catatonia, hebephrenia and dementia paranoides—under another existing term "dementia praecox" (meaning "early senility", later renamed schizophrenia). Another set of diagnoses that appeared to have a periodic course and better outcome were grouped together under the category of manic-depressive insanity (mood disorder). He also proposed a third category of psychosis, called paranoia, involving delusions but not the more general deficits and poor course attributed to dementia praecox. In all he proposed 15 categories, also including psychogenic neurosis, psychopathic personality, and syndromes of defective mental development (mental retardation). He eventually included homosexuality in the category of "mental conditions of constitutional origin". The neuroses were later split into anxiety disorders and other disorders. Freud wrote extensively on hysteria and also coined the term, "anxiety neurosis", which appeared in DSM-I and DSM-II. Checklist criteria for this led to studies that were to define panic disorder for DSM-III. Early 20th century schemes in Europe and the United States reflected a brain disease (or degeneration) model that had emerged during the 19th century, as well as some ideas from Darwin's theory of evolution and/or Freud's psychoanalytic theories. Psychoanalytic theory did not rest on classification of distinct disorders, but pursued analyses of unconscious conflicts and their manifestations within an individual's life. It dealt with neurosis, psychosis, and perversion. The concept of borderline personality disorder and other personality disorder diagnoses were later formalized from such psychoanalytic theories, though such ego psychology-based lines of development diverged substantially from the paths taken elsewhere within psychoanalysis. The philosopher and psychiatrist Karl Jaspers made influential use of a "biographical method" and suggested ways to diagnose based on the form rather than content of beliefs or perceptions. In regard to classification in general he prophetically remarked that: "When we design a diagnostic schema, we can only do so if we forego something at the outset … and in the face of facts we have to draw the line where none exists... A classification therefore has only provisional value. It is a fiction which will discharge its function if it proves to be the most apt for the time". Adolph Meyer advanced a mixed biosocial scheme that emphasized the reactions and adaptations of the whole organism to life experiences. In 1945, William C. Menninger advanced a classification scheme for the US army, called Medical 203, synthesizing ideas of the time into five major groups. This system was adopted by the Veterans Administration in the United States and strongly influenced the DSM. The term stress, having emerged from endocrinology work in the 1930s, was popularized with an increasingly broad biopsychosocial meaning, and was increasingly linked to mental disorders. The diagnosis of post-traumatic stress disorder was later created. Mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949. Three years later, in 1952, the American Psychiatric Association created its own classification system, DSM-I. The Feighner Criteria group described fourteen major psychiatric disorders for which careful research studies were available, including homosexuality. These developed as the Research Diagnostic Criteria, adopted and further developed by the DSM-III. The DSM and ICD developed, partly in sync, in the context of mainstream psychiatric research and theory. Debates continued and developed about the definition of mental illness, the medical model, categorical vs dimensional approaches, and whether and how to include suffering and impairment criteria. There is some attempt to construct novel schemes, for example from an attachment perspective where patterns of symptoms are construed as evidence of specific patterns of disrupted attachment, coupled with specific types of subsequent trauma. 21st century The ICD-11 and DSM-5 are being developed at the start of the 21st century. Any radical new developments in classification are said to be more likely to be introduced by the APA than by the WHO, mainly because the former only has to persuade its own board of trustees whereas the latter has to persuade the representatives of over 200 countries at a formal revision conference. In addition, while the DSM is a bestselling publication that makes huge profits for APA, the WHO incurs major expense in determining international consensus for revisions to the ICD. Although there is an ongoing attempt to reduce trivial or accidental differences between the DSM and ICD, it is thought that the APA and the WHO are likely to continue to produce new versions of their manuals and, in some respects, to compete with one another. Criticism There is some ongoing scientific doubt concerning the construct validity and reliability of psychiatric diagnostic categories and criteria even though they have been increasingly standardized to improve inter-rater agreement in controlled research. In the United States, there have been calls and endorsements for a congressional hearing to explore the nature and extent of harm potentially caused by this "minimally investigated enterprise". Other specific criticisms of the current schemes include: attempts to demonstrate natural boundaries between related syndromes, or between a common syndrome and normality, have failed; inappropriateness of statistical (factor-analytic) arguments and lack of functionality considerations in the analysis of a structure of behavioral pathology; the disorders of current classification are probably surface phenomena that can have many different interacting causes, yet "the mere fact that a diagnostic concept is listed in an official nomenclature and provided with a precise operational definition tends to encourage us to assume that it is a "quasi-disease entity" that can be invoked to explain the patient's symptoms"; and that the diagnostic manuals have led to an unintended decline in careful evaluation of each individual person's experiences and social context. Psychodynamic schemes have traditionally given the latter phenomenological aspect more consideration, but in psychoanalytic terms that have been long criticized on numerous grounds. Some have argued that reliance on operational definition demands that intuitive concepts, such as depression, need to be operationally defined before they become amenable to scientific investigation. However, John Stuart Mill pointed out the dangers of believing that anything that could be given a name must refer to a thing and Stephen Jay Gould and others have criticized psychologists for doing just that. One critic states that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions. Thus in psychology, as in economics, the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992, 275) for mainstream methodological practice." According to Tadafumi Kato, since the era of Kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews. Kato argues there has been little progress over the last century and that only modest improvements are possible in this way; he suggests that only neurobiological studies using modern technology could form the basis for a new classification. According to Heinz Katsching, expert committees have combined phenomenological criteria in variable ways into categories of mental disorders, repeatedly defined and redefined over the last half century. The diagnostic categories are termed "disorders" and yet, despite not being validated by biological criteria as most medical diseases are, are framed as medical diseases identified by medical diagnoses. He describes them as top-down classification systems similar to the botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori which visible aspects of plants were relevant. Katsching notes that while psychopathological phenomena are certainly observed and experienced, the conceptual basis of psychiatric diagnostic categories is questioned from various ideological perspectives. Psychiatrist Joel Paris argues that psychiatry is sometimes susceptible to diagnostic fads. Some have been based on theory (overdiagnosis of schizophrenia), some based on etiological (causation) concepts (overdiagnosis of post-traumatic stress disorder), and some based on the development of treatments. Paris points out that psychiatrists like to diagnose conditions they can treat, and gives examples of what he sees as prescribing patterns paralleling diagnostic trends, for example an increase in bipolar diagnosis once lithium came into use, and similar scenarios with the use of electroconvulsive therapy, neuroleptics, tricyclic antidepressants, and SSRIs. He notes that there was a time when every patient seemed to have "latent schizophrenia" and another time when everything in psychiatry seemed to be "masked depression", and he fears that the boundaries of the bipolar spectrum concept, including in application to children, are similarly expanding. Allen Frances has suggested fad diagnostic trends regarding autism and Attention deficit hyperactivity disorder. Since the 1980s, psychologist Paula Caplan has had concerns about psychiatric diagnosis, and people being arbitrarily "slapped with a psychiatric label". Caplan says psychiatric diagnosis is unregulated, so doctors are not required to spend much time understanding patients situations or to seek another doctor's opinion. The criteria for allocating psychiatric labels are contained in the Diagnostic and Statistical Manual of Mental Disorders, which can "lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient's suffering". So, according to Caplan, getting a psychiatric diagnosis and label often hinders recovery. The DSM and ICD approach remains under attack both because of the implied causality model and because some researchers believe it better to aim at underlying brain differences which can precede symptoms by many years. See also Abnormal psychology Diagnosis Diagnostic classification and rating scales used in psychiatry Medical classification DSM-IV codes Structured Clinical Interview for DSM-IV (SCID) Nosology Operationalism Psychopathology Relational disorder (proposed DSM-5 new diagnosis) References External links Dalal PK, Sivakumar T. (2009) Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification. Indian Journal of Psychiatry, Volume 51, Issue 4, Page 310–319. Classification of mental disorders Mental disorders

Therapeutic community

Therapeutic community is a participative, group-based approach to long-term mental illness, personality disorders and drug addiction. The approach was usually residential, with the clients and therapists living together, but increasingly residential units have been superseded by day units. It is based on milieu therapy principles, and includes group psychotherapy as well as practical activities. Therapeutic communities have gained some reputation for success in rehabilitation and patient satisfaction in Britain and abroad. In Britain, 'democratic analytic' therapeutic communities have tended to specialise in the treatment of moderate to severe personality disorders and complex emotional and interpersonal problems. The evolution of therapeutic communities in the United States has followed a different path with hierarchically arranged communities (or concept houses) specialising in the treatment of drug and alcohol dependence. History Antecedents There are several antecedents to the therapeutic community movement. One of the earliest is the change in treatment of institutionalised patients in the late 18th century, continuing throughout the 19th century. A major contributor to this change is Philippe Pinel, a French physician who advocated for a more humane treatment of psychiatric patients. In Britain William Tuke founded the Retreat where patients were treated according to humanitarian principles, called moral treatment. Tuke based the treatment of mentally ill people partly on the Quaker ideology. The influence of Quaker principles continues throughout the development of the therapeutic community. Moral treatment focused on a more humane treatment of patients and a stimulating environment that engages them in healthy behaviour. An important distinction between the later therapeutic community is the strong hierarchy in moral treatment facilities. The superintendent had authority over and responsibility of the patients. The patients followed a strict schedule to promote obedience and self-control. After the First World War, multiple varieties of living-and-learning communities for young adults were established. Examples are the Little Commonwealth school run by Homer Lane, the Q camps initiated by Marjorie Franklin, and Finchden Manor, founded by George Lyward. The Q camps were based on Planned Environmental Therapy, which focused on normally functioning parts of a patient's personality and use them to deal with difficult social situations. Lyward’s work at Finchden Manor and its predecessor, provided from 1930 to 1973 what he called a ‘type of hospitality’ for emotionally troubled boys and young men of high intelligence.  Finchden Manor operated without rules and sanctions, but there were traditions and expectations, backed up by what Lyward called ‘stern love’. These projects all emphasized shared responsibility and decision-making and participation in the community. What influenced the establishment of these projects were, among others, the developments in psychoanalytic theory in Great-Britain. United Kingdom The work conducted by pioneering NZ plastic surgeon Arcihibald McIndoe at Queen Victoria Hospital and others at Northfield Military Hospital during World War II is considered by many psychiatrists to have been the first example of an intentional therapeutic community. But this story is prone to adopt a origin myth approach. The principles developed at Northfield were also developed and adapted at Civil Resettlement Units established at the end of the war to help returning prisoners of war to adapt back to civilian society and for civilians to adapt to having these men back amongst them. The term was coined by Thomas Main in his 1946 paper, "The hospital as a therapeutic institution", and subsequently developed by others including Maxwell Jones, R. D. Laing at the Philadelphia Association, David Cooper at Villa 21, and Joshua Bierer. Under the influence of Maxwell Jones, Main, Wilmer and others (Caudill 1958; Rapoport 1960), combined with the publications of critiques of the existing mental health system (Greenblatt et al. 1957, Stanton and Schwartz 1954) and the sociopolitical influences that permeated the psychiatric world towards the end of and following the Second World War, the concept of the therapeutic community and its attenuated form – the therapeutic milieu – caught on and dominated the field of inpatient psychiatry throughout the 1960s. The first development of therapeutic community in a large institution took place at Claybury Hospital under the guidance of Denis Martin and John Pippard. Beginning in 1955 it involved over 2,000 patients and hundreds of staff. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other's mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. One phrase commonly used to summarise this treatment philosophy is 'the Community as Doctor'. 'TC's have sometimes eschewed or limited medication in favor of group-based therapies. The Henderson Hospital first established in 1947 by Maxwell Jones and named after David Henderson evolved the specific concept of Democratic Therapeutic Community (DTC). Admission to and early discharge from the one year of residential treatment was by majority vote and residents of the DTC always held the majority in these votes. No psychotropic medication or one to one therapy sessions were available and so all the work of the DTC was pursued, on the one hand, in small or larger therapy groups or work groups and community meetings, which could be called (by the residents) day or night; and on the other hand, in the unstructured time in between these more formal spaces, in which belonging in and membership of a living community could become in itself a healing experience. The Henderson Hospital DTC became an international centre of excellence for the care of survivors of severe trauma who did not fall under conventional psychiatric classifications and towards the end of the twentieth century it was funded to replicate the treatment model in two other DTCs: Main House in Birmingham and Webb House in Crewe. The availability of the treatment on the National Health Service in the United Kingdom came under threat because of changes in funding systems. Researchers at the University of Oxford and King's College London studied one of these national Democratic Therapeutic Community services over four years and found external policy 'steering' by officials eroded the community's democratic model of care, which in turn destabilised its well established approach to clinical risk management (this had been jointly developed by clients and staff). Fischer (2012), who studied this community's development at first hand, described how an 'intractable conflict' between embedded and externally imposed management models led to escalating organizational 'turbulence', producing an interorganizational crisis which led to the unit's forced closure. The three 'Henderson' DTCs had all closed their doors by 2008. However, development of 'mini' therapeutic communities, meeting for three or fewer days each week and supported out of hours by various forms of 'service user led informal networks of care' (for example telephone, texting and physical support), now offers a more resource and cost effective alternative to traditional inpatient therapeutic communities. The most recent exponent, the North Cumbria model, uses a dedicated out of hours website moderated by service users according to therapeutic community principles. This extends the community beyond the face to face 'therapeutic days'. The website guarantees a safe group-based response not always possible with other systems. The use of 'starter' groups as a preparation for entry into therapeutic communities has lowered attrition rates and they now represent a cost-effective model still aimed at producing durable personal and intergenerational effects; this is at odds with the current trend towards the defensive needs of service providers, rather than service users, for less intensive treatments and management of pathways to control risk. United States In the late 1960s within the US correctional system, the Asklepion Foundation initiated therapeutic communities in the Marion Federal Penitentiary and other institutions that included clinical intervention based upon Transactional Analysis, the Synanon Game, internal twelve-step programs and other therapeutic modalities. Some of these programs lasted into the mid-1980s, such as the House of Thought in the Virginia Correctional system, and were able to demonstrate a reduction of 17% in recidivism in a matched-pair study of drug-abusing felons and sex offenders who participated in the program for one year or more. Modified therapeutic communities are currently used for substance abuse treatment in correctional facilities of several U.S. states including Pennsylvania, Washington, Colorado, Texas, Delaware, and New York. In New York City, a program for men is located in the Arthur Kill Correctional Facility on Staten Island and the women's program is part of the Bayview Correctional Facility in Manhattan. Main ideas The therapeutic community approach aims to help patients deal with social situations and to change perceptions they have about themselves. Difficult situations are re-enacted and experienced and patients are encouraged to examine and try to learn from them with the help of group and individual therapy. The communities function as a living-and-learning situations, where every interaction can serve as a learning moment. There is no encompassing definition of what a therapeutic community should be. Some have therefore also argued that it follows a family resemblance. A common conception of therapeutic community is a group of people living together in a non-hierarchical, democratic way that brings psychological awareness of individual as well as group processes. Furthermore, the community has clear boundaries of place, time and roles of the participants. They are democratic because the patients are involved in decision-making to encourage a sense of responsibility. This is fostered by the non-hierarchical structure that tries to minimise dependency on the staff. A key principle is the creation of a culture of enquiry. Everyone within the community is encouraged to reflect and ask question about themselves and others. In this way the participants are supported by continuous feedback to create better self-awareness. The therapeutic community approach is informed by systems theory, organisation theory and psychoanalytic practice. Effectiveness As an intervention model for drug-using offenders with co-occurring mental health disorders, therapeutic communities may help people reduce drug use and subsequent criminal activity. Research evidence for the effectiveness of therapeutic community treatment is substantial and a demonstration of the cost efficacy of a year of residential therapeutic community treatment was instrumental in funding being granted in the late 1990s for the replication of the Henderson Hospital DTC. In popular culture The Alfred Hitchcock film Spellbound takes place within a therapeutic community called Green Manors. Leonard Cohen and his touring band The Army gave an impromptu concert at the Henderson Hospital DTC in August 1970, just before the Isle of Wight Festival, after being invited by one of the residents. References Further reading Hickey, Brendan (2008) Lothlorien Community: A Holistic Approach to Recovery from Mental Health Problems External links European Federation of Therapeutic Communities (EFTC) World Federation of Therapeutic Communities (WFTC) The association of therapeutic communities Therapeutic Community Open Forum Gould Farm Healing Community CooperRiis Healing Community American Residential Treatment Association Fountain House Clubhouse International Comunidade Terapêutica Buddhist Therapeutic Community in South West Scotland Types of communities

Psychiatric hospital

A psychiatric hospital, also known as a mental health hospital, or a behavioral health hospital, is a specialized medical facility that focuses on the treatment of severe mental disorders. These institutions cater to patients with conditions such as schizophrenia, bipolar disorder, major depressive disorder, and eating disorders, among others. Overview Psychiatric hospitals vary considerably in size and classification. Some specialize in short-term or outpatient therapy for low-risk patients, while others provide long-term care for individuals requiring routine assistance or a controlled environment due to their psychiatric condition. Patients may choose voluntary commitment, but those deemed to pose a significant danger to themselves or others may be subject to involuntary commitment and treatment. In general hospitals, psychiatric wards or units serve a similar purpose. Modern psychiatric hospitals have evolved from the older concept of lunatic asylums, shifting focus from mere containment and restraint to evidence-based treatments that aim to help patients function in society. With successive waves of reform, and the introduction of effective evidence-based treatments, most modern psychiatric hospitals emphasize treatment, usually including a combination of psychiatric medications and psychotherapy, that assist patients in functioning in the outside world. Many countries have prohibited the use of physical restraints on patients, which includes tying psychiatric patients to their beds for days or even months at a time, though this practice still is periodically employed in the United States, India, Japan, and other countries. History Modern psychiatric hospitals evolved from, and eventually replaced, the older lunatic asylum. Their development also entails the rise of organized institutional psychiatry. Hospitals known as bimaristans were built in the Middle East in the early ninth century; the first was built in Baghdad under the leadership of Harun al-Rashid. While not devoted solely to patients with psychiatric disorders, early psychiatric hospitals often contained wards for patients exhibiting mania or other psychological distress. Because of cultural taboos against refusing to care for one's family members, mentally ill patients would be surrendered to a bimaristan only if the patient demonstrated violence, incurable chronic illness, or some other extremely debilitating ailment. Psychological wards were typically enclosed by iron bars owing to the aggression of some of the patients. In Western Europe, the first idea and set up for a proper mental hospital entered through Spain. A member of the Mercedarian Order named Juan Gilaberto Jofré traveled frequently to Islamic countries and observed several institutions that confined the insane. He proposed the founding of an institution exclusive for "sick people who had to be treated by doctors", something very modern for the time. The foundation was carried out in 1409 thanks to several wealthy men from Valencia who contributed funds for its completion. It was considered the first institution in the world at that time specialized in the treatment of mental illnesses. Later on, physicians, including Philippe Pinel at Bicêtre Hospital in France and William Tuke at York Retreat in England, began to advocate for the viewing of mental illness as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. In the Western world, the arrival of institutionalisation as a solution to the problem of madness was very much an advent of the nineteenth century. The first public mental asylums were established in Britain; the passing of the County Asylums Act 1808 empowered magistrates to build rate-supported asylums in every county to house the many 'pauper lunatics'. Nine counties first applied, the first public asylum opening in 1812 in Nottinghamshire. In 1828, the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 made the construction of asylums in every county compulsory with regular inspections on behalf of the Home Secretary, and required asylums to have written regulations and a resident physician. At the beginning of the 19th century there were a few thousand people housed in a variety of disparate institutions throughout England, but by 1900 that figure had grown to about 100,000. This growth coincided with the growth of alienism, later known as psychiatry, as a medical specialism. The treatment of inmates in early lunatic asylums was sometimes very brutal and focused on containment and restraint. In the late 19th and early 20th centuries, psychiatric institutions ceased using terms such as "madness", "lunacy" or "insanity", which assumed a unitary psychosis, and began instead splitting into numerous mental diseases, including catatonia, melancholia, and dementia praecox, which is now known as schizophrenia. In 1961, sociologist Erving Goffman described a theory of the "total institution" and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor", suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Asylums as a key text in the development of deinstitutionalization. With successive waves of reform and the introduction of effective evidence-based treatments, modern psychiatric hospitals provide a primary emphasis on treatment; and further, they attempt—where possible—to help patients control their own lives in the outside world with the use of a combination of psychiatric drugs and psychotherapy. These treatments can be involuntary. Involuntary treatments are among the many psychiatric practices which are questioned by the mental patient liberation movement. Types There are several different types of modern psychiatric hospitals, but all of them house people with mental illnesses of varying severity. In the United Kingdom, both crisis admissions and medium-term care are usually provided on acute admissions wards. Juvenile or youth wards in psychiatric hospitals or psychiatric wards are set aside for children or youth with mental illness. Long-term care facilities have the goal of treatment and rehabilitation within a short time-frame (two or three years). Another institution for the mentally ill is a community-based halfway house. Crisis stabilization Crisis Stabilization Units (CSU) are small facilities with minimal beds used for people in crisis whose needs cannot be met safely in residential service settings. Open units Open psychiatric units are not as secure as crisis stabilization units. They are not used for acutely suicidal people; instead, the focus in these units is to make life as normal as possible for patients while continuing treatment to the point where they can be discharged. However, patients are usually still not allowed to hold their own medications in their rooms because of the risk of an impulsive overdose. While some open units are physically unlocked, other open units still use locked entrances and exits, depending on the type of patients admitted. Medium term Another type of psychiatric hospital is medium term, which provides care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect, and the main purpose of these hospitals is to monitor the patient for the first few weeks of therapy to ensure the treatment is effective. Juvenile wards Juvenile wards are sections of psychiatric hospitals or psychiatric wards set aside for children with mental illness. However, there are a number of institutions specializing only in the treatment of juveniles, particularly when dealing with drug abuse, self-harm, eating disorders, anxiety, depression or other mental illnesses. Long-term care facilities In the United Kingdom, long-term care facilities are now being replaced with smaller secure units, some within hospitals. Modern buildings, modern security, and being locally situated to help with reintegration into society once medication has stabilized the condition are often features of such units. Examples of this include the Three Bridges Unit at St Bernard's Hospital in West London and the John Munroe Hospital in Staffordshire. These units have the goal of treatment and rehabilitation to allow for transition back into society within a short time-frame, usually lasting two or three years. Not all patients' treatment meets this criterion, however, leading larger hospitals to retain this role. These hospitals provide stabilization and rehabilitation for those who are actively experiencing uncontrolled symptoms of mental disorders such as depression, bipolar disorders, eating disorders, and so on. Halfway houses One type of institution for the mentally ill is a community-based halfway house. These facilities provide assisted living for an extended period of time for patients with mental illnesses, and they often aid in the transition to self-sufficiency. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although some localities lack sufficient funding. Political imprisonment In some countries, the mental institution may be used for the incarceration of political prisoners as a form of punishment. One notable historical example was the use of punitive psychiatry in the Soviet Union and China. Like the former Soviet Union and China, Belarus also has used punitive psychiatry toward political opponents and critics of current government in modern times. Secure units In the United Kingdom, criminal courts or the Home Secretary can, under various sections of the Mental Health Act, order the detention of offenders in a psychiatric hospital, but the term "criminally insane" is no longer legally or medically recognized. Secure psychiatric units exist in all regions of the UK for this purpose; in addition, there are a few specialist hospitals which offer treatment with high levels of security. These facilities are divided into three main categories: High, Medium and Low Secure. Although the phrase "Maximum Secure" is often used in the media, there is no such classification. "Local Secure" is a common misnomer for Low Secure units, as patients are often detained there by local criminal courts for psychiatric assessment before sentencing. Run by the National Health Service, these facilities which provide psychiatric assessments can also provide treatment and accommodation in a safe hospital environment which prevents absconding. Thus there is far less risk of patients harming themselves or others. In Dublin, the Central Mental Hospital performs a similar function. Community hospital utilization Community hospitals across the United States regularly discharge mental health patients, who are then typically referred to out-patient treatment and therapy. A study of community hospital discharge data from 2003 to 2011, however, found that mental health hospitalizations had increased for both children and adults. Compared to other hospital utilization, mental health discharges for children were the lowest while the most rapidly increasing hospitalizations were for adults under 64. Some units have been opened to provide therapeutically enhanced Treatment, a subcategory to the three main hospital unit types. In the UK, high secure hospitals exist, including Ashworth Hospital in Merseyside, Broadmoor Hospital in Crowthorne, Rampton Secure Hospital in Retford, and the State Hospital in Carstairs, Scotland. In Northern Ireland, the Isle of Man, and the Channel Islands, medium and low secure units exist but high secure units on the UK mainland are used for patients who qualify for the treatment under the Out of Area (Off-Island Placements) Referrals provision of the Mental Health Act 1983. Among the three unit types, medium secure facilities are the most prevalent in the UK. As of 2009, there were 27 women-only units in England. Irish units include those at prisons in Portlaise, Castelrea, and Cork. Criticism Psychiatrist Thomas Szasz in Hungary has argued that psychiatric hospitals are like prisons unlike other kinds of hospitals, and that psychiatrists who coerce people (into treatment or involuntary commitment) function as judges and jailers, not physicians. Historian Michel Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Madness and Civilization. He argued that Tuke and Pinel's asylum was a symbolic recreation of the condition of a child under a bourgeois family. It was a microcosm symbolizing the massive structures of bourgeois society and its values: relations of Family–Children (paternal authority), Fault–Punishment (immediate justice), Madness–Disorder (social and moral order). Erving Goffman coined the term "total institution" for mental hospitals and similar places which took over and confined a person's whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organizations, orphanages, and monasteries. In his book Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone "dull, harmless and inconspicuous"; in turn, it reinforces notions of chronicity in severe mental illness. The Rosenhan experiment of 1973 demonstrated the difficulty of distinguishing sane patients from insane patients. Franco Basaglia, a leading psychiatrist who inspired and planned the psychiatric reform in Italy, also defined the mental hospital as an oppressive, locked, and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents. Patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. American psychiatrist Loren Mosher noticed that the psychiatric institution itself gave him master classes in the art of the "total institution": labeling, unnecessary dependency, the induction and perpetuation of powerlessness, the degradation ceremony, authoritarianism, and the primacy of institutional needs over the patients, whom it was ostensibly there to serve. The anti-psychiatry movement coming to the fore in the 1960s has opposed many of the practices, conditions, or existence of mental hospitals; due to the extreme conditions in them. The psychiatric consumer/survivor movement has often objected to or campaigned against conditions in mental hospitals or their use, voluntarily or involuntarily. The mental patient liberation movement emphatically opposes involuntary treatment but it generally does not object to any psychiatric treatments that are consensual, provided that both parties can withdraw consent at any time. Undercover journalism Alongside the 1973 academic investigation by Rosenhan and other similar experiments, several journalists have been willingly admitted to hospitals in order to conduct undercover journalism. These include: Julius Chambers, who visited Bloomingdale Insane Asylum in 1872, leading to the 1876 book A Mad World and Its People. Nellie Bly, who admitted herself to a mental institution in 1887, leading to the work Ten Days in a Mad-House. Frank Smith in 1935 admitted himself into a Kankakee hospital, leading to the articles "Seven days in the Madhouse" in the Chicago Daily Times. Michael Mok, who investigated similarly in New York 1961, winning the Lasker prize. Frank Sutherland, who received coaching from a psychiatrist in order to accurately feign symptoms, and spent 31 days in late 1973 to early 1974, leading to a series of articles in the Nashville Tennessean. Betty Wells, who investigated in 1974, with the articles titled "A Trip into Darkness" for the Wichita Eagle. See also Deinstitutionalisation History of mental disorders History of psychiatric institutions Institutional syndrome Kirkbride Plan Mental health law MindFreedom International New Freedom Commission on Mental Health Psychiatric survivors movement Political abuse of psychiatry in the Soviet Union Salutogenesis, a best-practice methodology for the design of psychiatric facilities Treatment Advocacy Center, involuntary treatment proponent group References External links Camarillo State Mental Hospital History Historical Asylums website Asylum Projects – Asylum wiki database National Resource Center on Psychiatric Advance Directives Kirkbride Buildings History and photographs of early psychiatric hospitals TheTimeChamber Asylum List Comprehensive List of Victorian Insane Asylums in the UK Bipolar Disorder at WebMD Psychiatric hospitals rankings Hospital departments Psychiatric specialities Penology Total institutions

Dialectical behavior therapy

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis. This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington. She defines it as "a synthesis or integration of opposites". DBT was designed to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and by helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions. Linehan later disclosed to the public her own struggles and belief that she suffers from borderline personality disorder. DBT grew out of a series of failed attempts to apply the standard cognitive behavioral therapy (CBT) protocols of the late 1970s to chronically suicidal clients. Research on its effectiveness in treating other conditions has been fruitful. DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates that DBT might help patients with symptoms and behaviors associated with spectrum mood disorders, including self-injury. Work also suggests its effectiveness with sexual-abuse survivors and chemical dependency. DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from contemplative meditative practice. DBT is based upon the biosocial theory of mental illness and is the first therapy that has been experimentally demonstrated to be generally effective in treating borderline personality disorder (BPD). The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment dropouts when compared to usual treatment. A meta-analysis found that DBT reached moderate effects in individuals with BPD. DBT may not be appropriate as a universal intervention, as it was shown to be harmful or have null effects in a study of an adapted DBT skills-training intervention in adolescents in schools, though conclusions of iatrogenic harm are unwarranted as the majority of participants did not significantly engage with the assigned activities with higher engagement predicting more positive outcomes. Overview DBT is sometimes considered a part of the "third wave" of cognitive-behavioral therapy, as DBT adapts CBT to assist patients in dealing with stress. DBT focuses on treating disorders that are characterised by impulsivity and emotional dysregulation. DBT strives to have the patient view the therapist as an accepting ally rather than an adversary in the treatment of psychological issues: many treatments at this time left patients feeling "criticized, misunderstood, and invalidated" due to the way these methods "focused on changing cognitions and behaviors." Accordingly, the therapist aims to accept and validate the client's feelings at any given time, while, nonetheless, informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives. In particular, DBT targets self-harm and suicide attempts by identifying the function of that behavior and obtaining that function safely through DBT coping skills. DBT focuses on the client acquiring new skills and changing their behaviors, with the ultimate goal of achieving a "life worth living". In DBT's biosocial theory of BPD, clients have a biological predisposition for emotional dysregulation, and their social environment validates maladaptive behavior. DBT skills training alone is being used to address treatment goals in some clinical settings, and the broader goal of emotion regulation that is seen in DBT has allowed it to be used in new settings, for example, supporting parenting. There has been little study into adapting DBT into an online environment, but a review indicates that attendance is improved online, with comparable improvements for clients to the traditional mode. Four modules Mindfulness Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional contemplative religious practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one's emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their five senses: touch, smell, sight, taste, and sound. Mindfulness relies heavily on the principle of acceptance, sometimes referred to as "radical acceptance". Acceptance skills rely on the patient's ability to view situations with no judgment, and to accept situations and their accompanying emotions. This causes less distress overall, which can result in reduced discomfort and symptomology. Acceptance and change The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must first become comfortable with the idea of therapy; once the patient and therapist have established a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to first grasp the idea of radical acceptance: radical acceptance embraces the idea of facing situations, both positive and negative, without judgment. Acceptance also incorporates mindfulness and emotional regulation skills, which depend on the idea of radical acceptance. These skills, specifically, are what set DBT apart from other therapies. Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with change. DBT has five specific states of change which the therapist will review with the patient: pre-contemplation, contemplation, preparation, action, and maintenance. Precontemplation is the first stage, in which the patient is completely unaware of their problem. In the second stage, contemplation, the patient realizes the reality of their illness: this is not an action, but a realization. It is not until the third stage, preparation, that the patient is likely to take action, and prepares to move forward. This could be as simple as researching or contacting therapists. Finally, in stage 4, the patient takes action and receives treatment. In the final stage, maintenance, the patient must strengthen their change in order to prevent relapse. After grasping acceptance and change, a patient can fully advance to mindfulness techniques. There are six mindfulness skills used in DBT to bring the client closer to achieving a "wise mind", the synthesis of the rational mind and emotion mind: three "what" skills (observe, describe, participate) and three "how" skills (nonjudgementally, one-mindfully, effectively). Distress tolerance The concept of distress tolerance arose from methods used in person-centered, psychodynamic, psychoanalytic, gestalt, and/or narrative therapies, along with religious and spiritual practices. Distress tolerance means learning to bear emotional discomfort skillfully, without resorting to maladaptive reactions. Healthier coping behaviors are learned, including intentional self-distraction, self-soothing, and 'radical acceptance.' Distress tolerance skills are meant to arise naturally as a consequence of mindfulness. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. It is meant to be a non-judgmental stance, one of neither approval nor resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into intense, desperate, and often destructive emotional reactions. Emotion regulation Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include: Identify and label emotions Identify obstacles to changing emotions Reduce vulnerability to emotion mind Increase positive emotional events Increase mindfulness to current emotions Take opposite action Apply distress tolerance techniques Emotional regulation skills are based on the theory that intense emotions are a conditioned response to troublesome experiences, the conditioned stimulus, and therefore, are required to alter the patient's conditioned response. These skills can be categorized into four modules: understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and managing extreme conditions: Learning how to understand and name emotions: the patient focuses on recognizing their feelings. This segment relates directly to mindfulness, which also exposes a patient to their emotions. Changing unwanted emotions: the therapist emphasizes the use of opposite-reactions, fact-checking, and problem solving to regulate emotions. While using opposite-reactions, the patient targets distressing feelings by responding with the opposite emotion. Reducing vulnerability: the patient learns to accumulate positive emotions and to plan coping mechanisms in advance, in order to better handle difficult experiences in the future. Managing extreme conditions: the patient focuses on incorporating their use of mindfulness skills to their current emotions, to remain stable and alert in a crisis. Interpersonal effectiveness The three interpersonal skills focused on in DBT include self-respect, treating others "with care, interest, validation, and respect", and assertiveness. The dialectic involved in healthy relationships involves balancing the needs of others with the needs of the self, while maintaining one's self-respect. Tools Diary cards Specially formatted diary cards can be used to track relevant emotions and behaviors. Diary cards are most useful when they are filled out daily. The diary card is used to find the treatment priorities that guide the agenda of each therapy session. Both the client and therapist can use the diary card to see what has improved, gotten worse, or stayed the same. Chain analysis Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining. A growing body of research supports the use of behavior chain analysis with multiple populations. Efficacy Borderline personality disorder DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder. Several studies have found there are neurobiological changes in individuals with BPD after DBT treatment. Depression A Duke University pilot study compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behavior therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behavior therapy in remission. Complex post-traumatic stress disorder (CPTSD) Exposure to complex trauma, or the experience of prolonged trauma with little chance of escape, can lead to the development of complex post-traumatic stress disorder (CPTSD) in an individual. The American Psychiatric Association (APA) does not recognize CPTSD as a diagnosis in the DSM-5 (Diagnostical and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though many practitioners argue that CPTSD is separate from post-traumatic stress disorder (PTSD). As of 2020, over 40 studies from 15 different countries had "consistently demonstrated the distinction between PTSD and CPTSD" and "replicated the distinct symptoms associated with each disorder" according to a 2021 literature review. CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others. CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress, and that the most common precedents are sexual traumas. Currently, the prevalence rate for CPTSD is an estimated 0.5%, while PTSD's is 1.5%. Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organization (WHO), The International Society for Traumatic Stress Studies (ISTSS), and individual clinicians and researchers. Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognize CPTSD, the WHO has recognized this syndrome in its 11th edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterized by low self-esteem, interpersonal deficits, and deficits in affect regulation. These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with borderline personality disorder (BPD). Similarities Between CPTSD and borderline personality disorder In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit splitting, mood swings, and fears of abandonment. Like patients with borderline personality disorder, patients with CPTSD were traumatized frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviors to cope. Thus, treatment for CPTSD involves stabilizing and teaching successful coping behaviors, affect regulation, and creating and maintaining interpersonal connections. In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities, for example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality). Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom. Because of the two disorders' shared symptomatology and physiological correlates, psychologists began hypothesizing that a treatment which was effective for one disorder may be effective for the other as well. DBT as a treatment for CPTSD DBT's use of acceptance and goal orientation as an approach to behavior change can help to instill empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming overwhelmed by their history of trauma. This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client's suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation, DBT can be an option to stabilize suicidality and aid in other treatment modalities. Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviors (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and emotions such as guilt and shame. The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories. The recommended multiphase model consists of establishing safety, distress tolerance, and social relations. Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective. Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session. A study co-authored by Linehan found that among women receiving outpatient care for BPD and who had attempted suicide in the previous year, 56% additionally met criteria for PTSD. Because of the correlation between borderline personality disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms. Some providers opt to combine DBT with other PTSD interventions, such as prolonged exposure therapy (PE) (repeated, detailed description of the trauma in a psychotherapy session) or cognitive processing therapy (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories). For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma's occurrence and how it may continue to affect them throughout their lives. Participants in clinical trials of this DBT PE regimen exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviors were reported. Later trials similarly show increased effectiveness versus DBT. Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low. Biosocial theory posits that emotion dysregulation is caused by an individual's heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and how the outcome could have been changed). An individual who has these features is likely to use maladaptive coping behaviors. DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency. The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations. Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of traumatic brain injury (TBI), and insurance coverage (i.e. shortening treatment). Populations with comorbid BPD may need to spend longer in the "Establishing Safety" phase. In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately. In populations with comorbid substance use, adaptations may be made on a case-by-case basis. For example, a provider may wish to incorporate elements of motivational interviewing (psychotherapy which uses empowerment to inspire behavior change). The degree of substance use should also be considered. For some individuals, substance use is the only coping behavior they know, and as such the provider may seek to implement skills training before targeting substance reduction. Inversely, a client's substance use may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma. See also References Citations General and cited sources Further reading For clinicians Cognitive Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan. 1993. . Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan. 1993. . Dialectical Behavior Therapy with Suicidal Adolescents by Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan. Foreword by Charles R. Swenson. . Self-help DBT For Dummies (2021) by Gillian Galen PsyD, Blaise Aguirre MD. . Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety by Thomas Marra. . Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (New Harbinger Self-Help Workbook) by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley. . Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control (New Harbinger Self-Help Workbook) by Scott E. Spradlin. . The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation by Alan E. Fruzzetti. . The Miracle of Mindfulness by Thích Nhất Hạnh. . Other Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality and Character by Stuart C. Yudovsky. . – described as "for patients and clinicians alike" External links DBT and Borderline Personality Disorder Marsha Linehan's description of DBT Borderline personality disorder Cognitive therapy Mindfulness (psychology) Psychotherapy by type

Differential diagnosis

In healthcare, a differential diagnosis (DDx) is a method of analysis that distinguishes a particular disease or condition from others that present with similar clinical features. Differential diagnostic procedures are used by clinicians to diagnose the specific disease in a patient, or, at least, to consider any imminently life-threatening conditions. Often, each individual option of a possible disease is called a differential diagnosis (e.g., acute bronchitis could be a differential diagnosis in the evaluation of a cough, even if the final diagnosis is common cold). More generally, a differential diagnostic procedure is a systematic diagnostic method used to identify the presence of a disease entity where multiple alternatives are possible. This method may employ algorithms, akin to the process of elimination, or at least a process of obtaining information that decreases the "probabilities" of candidate conditions to negligible levels, by using evidence such as symptoms, patient history, and medical knowledge to adjust epistemic confidences in the mind of the diagnostician (or, for computerized or computer-assisted diagnosis, the software of the system). Differential diagnosis can be regarded as implementing aspects of the hypothetico-deductive method, in the sense that the potential presence of candidate diseases or conditions can be viewed as hypotheses that clinicians further determine as being true or false. A differential diagnosis is also commonly used within the field of psychiatry/psychology, where two different diagnoses can be attached to a patient who is exhibiting symptoms that could fit into either diagnosis. For example, a patient who has been diagnosed with bipolar disorder may also be given a differential diagnosis of borderline personality disorder, given the similarity in the symptoms of both conditions. Strategies used in preparing a differential diagnosis list vary with the experience of the healthcare provider. While novice providers may work systemically to assess all possible explanations for a patient's concerns, those with more experience often draw on clinical experience and pattern recognition to protect the patient from delays, risks, and cost of inefficient strategies or tests. Effective providers utilize an evidence-based approach, complementing their clinical experience with knowledge from clinical research. General components A differential diagnosis has four general steps. The clinician will: Gather relevant information about the patient and create a symptoms list. List possible causes (candidate conditions) for the symptoms. The list need not be in writing. Prioritize the list by balancing the risks of a diagnosis with the probability. These are subjective, not objective parameters. Perform tests to determine the actual diagnosis. This is known by the colloquial phrase "to Rule Out". Even after the process, the diagnosis is not clear. The clinician again considers the risks and may treat them empirically, often called "Educated Best Guess." A mnemonic to help in considering multiple possible pathological processes is VINDICATEM: ascular nflammatory / nfectious eoplastic egenerative / / rugs diopathic / ntoxication / atrogenic ongenital utoimmune / llergic / natomic raumatic ndocrine / nvironmental etabolic Specific methods There are several methods for differential diagnostic procedures and several variants among those. Furthermore, a differential diagnostic procedure can be used concomitantly or alternately with protocols, guidelines, or other diagnostic procedures (such as pattern recognition or using medical algorithms). For example, in case of medical emergency, there may not be enough time to do any detailed calculations or estimations of different probabilities, in which case the ABC protocol (airway, breathing and circulation) may be more appropriate. Later, when the situation is less acute, a more comprehensive differential diagnostic procedure may be adopted. The differential diagnostic procedure may be simplified if a "pathognomonic" sign or symptom is found (in which case it is almost certain that the target condition is present) or in the absence of a sine qua non sign or symptom (in which case it is almost certain that the target condition is absent). A diagnostician can be selective, considering first those disorders that are more likely (a probabilistic approach), more serious if left undiagnosed and untreated (a prognostic approach), or more responsive to treatment if offered (a pragmatic approach). Since the subjective probability of the presence of a condition is never exactly 100% or 0%, the differential diagnostic procedure may aim at specifying these various probabilities to form indications for further action. The following are two methods of differential diagnosis, being based on epidemiology and likelihood ratios, respectively. Epidemiology-based method One method of performing a differential diagnosis by epidemiology aims to estimate the probability of each candidate condition by comparing their probabilities to have occurred in the first place in the individual. It is based on probabilities related both to the presentation (such as pain) and probabilities of the various candidate conditions (such as diseases). Theory The statistical basis for differential diagnosis is Bayes' theorem. As an analogy, when a die has landed the outcome is certain by 100%, but the probability that it Would Have Occurred in the First Place (hereafter abbreviated WHOIFP) is still 1/6. In the same way, the probability that a presentation or condition would have occurred in the first place in an individual (WHOIFPI) is not same as the probability that the presentation or condition has occurred in the individual, because the presentation has occurred by 100% certainty in the individual. Yet, the contributive probability fractions of each condition are assumed the same, relatively: where: Pr(Presentation is caused by condition in individual) is the probability that the presentation is caused by condition in the individual; condition without further specification refers to any candidate condition Pr(Presentation has occurred in individual) is the probability that the presentation has occurred in the individual, which can be perceived and thereby set at 100% Pr(Presentation WHOIFPI by condition) is the probability that the presentation Would Have Occurred in the First Place in the Individual by condition Pr(Presentation WHOIFPI) is the probability that the presentation Would Have Occurred in the First Place in the Individual When an individual presents with a symptom or sign, Pr(Presentation has occurred in individual) is 100% and can therefore be replaced by 1, and can be ignored since division by 1 does not make any difference: The total probability of the presentation to have occurred in the individual can be approximated as the sum of the individual candidate conditions: Also, the probability of the presentation to have been caused by any candidate condition is proportional to the probability of the condition, depending on what rate it causes the presentation: where: Pr(Presentation WHOIFPI by condition) is the probability that the presentation Would Have Occurred in the First Place in the Individual by condition Pr(Condition WHOIFPI) is the probability that the condition Would Have Occurred in the First Place in the Individual rCondition → presentation is the rate at which a condition causes the presentation, that is, the fraction of people with conditions that manifests with the presentation. The probability that a condition would have occurred in the first place in an individual is approximately equal to that of a population that is as similar to the individual as possible except for the current presentation, compensated where possible by relative risks given by known risk factor that distinguish the individual from the population: where: Pr(Condition WHOIFPI) is the probability that the condition Would Have Occurred in the First Place in the Individual RRcondition is the relative risk for condition conferred by known risk factors in the individual that are not present in the population Pr(Condition in population) is the probability that the condition occurs in a population that is as similar to the individual as possible except for the presentation The following table demonstrates how these relations can be made for a series of candidate conditions: One additional "candidate condition" is the instance of there being no abnormality, and the presentation is only a (usually relatively unlikely) appearance of a basically normal state. Its probability in the population (P(No abnormality in population)) is complementary to the sum of probabilities of "abnormal" candidate conditions. Example This example case demonstrates how this method is applied but does not represent a guideline for handling similar real-world cases. Also, the example uses relatively specified numbers with sometimes several decimals, while in reality, there are often simply rough estimations, such as of likelihoods being very high, high, low or very low, but still using the general principles of the method. For an individual (who becomes the "patient" in this example), a blood test of, for example, serum calcium shows a result above the standard reference range, which, by most definitions, classifies as hypercalcemia, which becomes the "presentation" in this case. A clinician (who becomes the "diagnostician" in this example), who does not currently see the patient, gets to know about his finding. By practical reasons, the clinician considers that there is enough test indication to have a look at the patient's medical records. For simplicity, let's say that the only information given in the medical records is a family history of primary hyperparathyroidism (here abbreviated as PH), which may explain the finding of hypercalcemia. For this patient, let's say that the resultant hereditary risk factor is estimated to confer a relative risk of 10 (RRPH = 10). The clinician considers that there is enough motivation to perform a differential diagnostic procedure for the finding of hypercalcemia. The main causes of hypercalcemia are primary hyperparathyroidism (PH) and cancer, so for simplicity, the list of candidate conditions that the clinician could think of can be given as: Primary hyperparathyroidism (PH) Cancer Other diseases that the clinician could think of (which is simply termed "other conditions" for the rest of this example) No disease (or no abnormality), and the finding is caused entirely by statistical variability The probability that 'primary hyperparathyroidism' (PH) would have occurred in the first place in the individual (P(PH WHOIFPI)) can be calculated as follows: Let's say that the last blood test taken by the patient was half a year ago and was normal and that the incidence of primary hyperparathyroidism in a general population appropriately matches the individual (except for the presentation and mentioned heredity) is 1 in 4000 per year. Ignoring more detailed retrospective analyses (such as including speed of disease progress and lag time of medical diagnosis), the time-at-risk for having developed primary hyperparathyroidism can roughly be regarded as being the last half-year because a previously developed hypercalcemia would probably have been caught up by the previous blood test. This corresponds to a probability of primary hyperparathyroidism (PH) in the population of: With the relative risk conferred from the family history, the probability that primary hyperparathyroidism (PH) would have occurred in the first place in the individual given from the currently available information becomes: Primary hyperparathyroidism can be assumed to cause hypercalcemia essentially 100% of the time (rPH → hypercalcemia = 1), so this independently calculated probability of primary hyperparathyroidism (PH) can be assumed to be the same as the probability of being a cause of the presentation: For cancer, the same time-at-risk is assumed for simplicity, and let's say that the incidence of cancer in the area is estimated at 1 in 250 per year, giving a population probability of cancer of: For simplicity, let's say that any association between a family history of primary hyperparathyroidism and risk of cancer is ignored, so the relative risk for the individual to have contracted cancer in the first place is similar to that of the population (RRcancer = 1): However, hypercalcemia only occurs in, very approximately, 10% of cancers, (rcancer → hypercalcemia = 0.1), so: The probabilities that hypercalcemia would have occurred in the first place by other candidate conditions can be calculated in a similar manner. However, for simplicity, let's say that the probability that any of these would have occurred in the first place is calculated at 0.0005 in this example. For the instance of there being no disease, the corresponding probability in the population is complementary to the sum of probabilities for other conditions: The probability that the individual would be healthy in the first place can be assumed to be the same: The rate at which the case of no abnormal condition still ends up in measurement of serum calcium of being above the standard reference range (thereby classifying as hypercalcemia) is, by the definition of standard reference range, less than 2.5%. However, this probability can be further specified by considering how much the measurement deviates from the mean in the standard reference range. Let's say that the serum calcium measurement was 1.30 mmol/L, which, with a standard reference range established at 1.05 to 1.25 mmol/L, corresponds to a standard score of 3 and a corresponding probability of 0.14% that such degree of hypercalcemia would have occurred in the first place in the case of no abnormality: Subsequently, the probability that hypercalcemia would have resulted from no disease can be calculated as: The probability that hypercalcemia would have occurred in the first place in the individual can thus be calculated as: Subsequently, the probability that hypercalcemia is caused by primary hyperparathyroidism (PH) in the individual can be calculated as: Similarly, the probability that hypercalcemia is caused by cancer in the individual can be calculated as: and for other candidate conditions: and the probability that there actually is no disease: For clarification, these calculations are given as the table in the method description: Thus, this method estimates that the probability that the hypercalcemia is caused by primary hyperparathyroidism, cancer, other conditions or no disease at all are 37.3%, 6.0%, 14.9%, and 41.8%, respectively, which may be used in estimating further test indications. This case is continued in the example of the method described in the next section. Likelihood ratio-based method The procedure of differential diagnosis can become extremely complex when fully taking additional tests and treatments into consideration. One method that is somewhat a tradeoff between being clinically perfect and being relatively simple to calculate is one that uses likelihood ratios to derive subsequent post-test likelihoods. Theory The initial likelihoods for each candidate condition can be estimated by various methods, such as: By epidemiology as described in the previous section. By clinic-specific pattern recognition, such as statistically knowing that patients coming into a particular clinic with a particular complaint statistically has a particular likelihood of each candidate condition. One method of estimating likelihoods even after further tests uses likelihood ratios (which is derived from sensitivities and specificities) as a multiplication factor after each test or procedure. In an ideal world, sensitivities and specificities would be established for all tests for all possible pathological conditions. In reality, however, these parameters may only be established for one of the candidate conditions. Multiplying with likelihood ratios necessitates conversion of likelihoods from probabilities to odds in favor (hereafter simply termed "odds") by: However, only the candidate conditions with known likelihood ratio need this conversion. After multiplication, conversion back to probability is calculated by: The rest of the candidate conditions (for which there is no established likelihood ratio for the test at hand) can, for simplicity, be adjusted by subsequently multiplying all candidate conditions with a common factor to again yield a sum of 100%. The resulting probabilities are used for estimating the indications for further medical tests, treatments or other actions. If there is an indication for an additional test, and it returns with a result, then the procedure is repeated using the likelihood ratio of the additional test. With updated probabilities for each of the candidate conditions, the indications for further tests, treatments, or other actions change as well, and so the procedure can be repeated until an endpoint where there no longer is any indication for currently performing further actions. Such an endpoint mainly occurs when one candidate condition becomes so certain that no test can be found that is powerful enough to change the relative probability profile enough to motivate any change in further actions. Tactics for reaching such an endpoint with as few tests as possible includes making tests with high specificity for conditions of already outstandingly high-profile-relative probability, because the high likelihood ratio positive for such tests is very high, bringing all less likely conditions to relatively lower probabilities. Alternatively, tests with high sensitivity for competing candidate conditions have a high likelihood ratio negative, potentially bringing the probabilities for competing candidate conditions to negligible levels. If such negligible probabilities are achieved, the clinician can rule out these conditions, and continue the differential diagnostic procedure with only the remaining candidate conditions. Example This example continues for the same patient as in the example for the epidemiology-based method. As with the previous example of epidemiology-based method, this example case is made to demonstrate how this method is applied but does not represent a guideline for handling similar real-world cases. Also, the example uses relatively specified numbers, while in reality, there are often just rough estimations. In this example, the probabilities for each candidate condition were established by an epidemiology-based method to be as follows: These percentages could also have been established by experience at the particular clinic by knowing that these are the percentages for final diagnosis for people presenting to the clinic with hypercalcemia and having a family history of primary hyperparathyroidism. The condition of highest profile-relative probability (except "no disease") is primary hyperparathyroidism (PH), but cancer is still of major concern, because if it is the actual causative condition for the hypercalcemia, then the choice of whether to treat or not likely means life or death for the patient, in effect potentially putting the indication at a similar level for further tests for both of these conditions. Here, let's say that the clinician considers the profile-relative probabilities of being of enough concern to indicate sending the patient a call for a clinician visit, with an additional visit to the medical laboratory for an additional blood test complemented with further analyses, including parathyroid hormone for the suspicion of primary hyperparathyroidism. For simplicity, let's say that the clinician first receives the blood test (in formulas abbreviated as "BT") result for the parathyroid hormone analysis and that it showed a parathyroid hormone level that is elevated relative to what would be expected by the calcium level. Such a constellation can be estimated to have a sensitivity of approximately 70% and a specificity of approximately 90% for primary hyperparathyroidism. This confers a likelihood ratio positive of 7 for primary hyperparathyroidism. The probability of primary hyperparathyroidism is now termed Pre-BTPH because it corresponds to before the blood test (Latin preposition prae means before). It was estimated at 37.3%, corresponding to an odds of 0.595. With the likelihood ratio positive of 7 for the blood test, the post-test odds is calculated as: where: Odds(PostBTPH) is the odds for primary hyperparathyroidism after the blood test for parathyroid hormone Odds(PreBTPH is the odds in favor of primary hyperparathyroidism before the blood test for parathyroid hormone LH(BT) is the likelihood ratio positive for the blood test for parathyroid hormone An Odds(PostBTPH) of 4.16 is again converted to the corresponding probability by: The sum of the probabilities for the rest of the candidate conditions should therefore be: Before the blood test for parathyroid hormone, the sum of their probabilities were: Therefore, to conform to a sum of 100% for all candidate conditions, each of the other candidates must be multiplied by a correcting factor: For example, the probability of cancer after the test is calculated as: The probabilities for each candidate conditions before and after the blood test are given in following table: These "new" percentages, including a profile-relative probability of 80% for primary hyperparathyroidism, underlie any indications for further tests, treatments, or other actions. In this case, let's say that the clinician continues the plan for the patient to attend a clinician visit for a further checkup, especially focused on primary hyperparathyroidism. A clinician visit can, theoretically, be regarded as a series of tests, including both questions in a medical history, as well as components of a physical examination, where the post-test probability of a previous test, can be used as the pre-test probability of the next. The indications for choosing the next test are dynamically influenced by the results of previous tests. Let's say that the patient in this example is revealed to have at least some of the symptoms and signs of depression, bone pain, joint pain or constipation of more severity than what would be expected by the hypercalcemia itself, supporting the suspicion of primary hyperparathyroidism, and let's say that the likelihood ratios for the tests, when multiplied together, roughly results in a product of 6 for primary hyperparathyroidism. The presence of unspecific pathologic symptoms and signs in the history and examination are often concurrently indicative of cancer as well, and let's say that the tests gave an overall likelihood ratio estimated at 1.5 for cancer. For other conditions, as well as the instance of not having any disease at all, let's say that it is unknown how they are affected by the tests at hand, as often happens in reality. This gives the following results for the history and physical examination (abbreviated as P&E): These probabilities after the history and examination may make the physician confident enough to plan the patient for surgery for a parathyroidectomy to resect the affected tissue. At this point, the probability of "other conditions" is so low that the physician cannot think of any test for them that could make a difference that would be substantial enough to form an indication for such a test, and the physician thereby practically regards "other conditions" as ruled out, in this case not primarily by any specific test for such other conditions that were negative, but rather by the absence of positive tests so far. For "cancer", the cutoff at which to confidently regard it as ruled out maybe more stringent because of severe consequences of missing it, so the physician may consider that at least a histopathologic examination of the resected tissue is indicated. This case is continued in the example of Combinations in the corresponding section below. Coverage of candidate conditions The validity of both the initial estimation of probabilities by epidemiology and further workup by likelihood ratios are dependent on the inclusion of candidate conditions that are responsible for a large part as possible of the probability of having developed the condition, and it is clinically important to include those where relatively fast initiation of therapy is most likely to result in the greatest benefit. If an important candidate condition is missed, no method of differential diagnosis will supply the correct conclusion. The need to find more candidate conditions for inclusion increases with the increasing severity of the presentation itself. For example, if the only presentation is a deviating laboratory parameter and all common harmful underlying conditions have been ruled out, then it may be acceptable to stop finding more candidate conditions, but this would much more likely be unacceptable if the presentation would have been severe pain. Combinations If two conditions get high post-test probabilities, especially if the sum of the probabilities for conditions with known likelihood ratios becomes higher than 100%, then the actual condition is a combination of the two. In such cases, that combined condition can be added to the list of candidate conditions, and the calculations should start over from the beginning. To continue the example used above, let's say that the history and physical examination were indicative of cancer as well, with a likelihood ratio of 3, giving an Odds(PostH&E) of 0.057, corresponding to a P(PostH&E) of 5.4%. This would correspond to a "Sum of known P(PostH&E)" of 101.5%. This is an indication for considering a combination of primary hyperparathyroidism and cancer, such as, in this case, a parathyroid hormone-producing parathyroid carcinoma. A recalculation may therefore be needed, with the first two conditions being separated into "primary hyperparathyroidism without cancer", "cancer without primary hyperparathyroidism" as well as "combined primary hyperparathyroidism and cancer", and likelihood ratios being applied to each condition separately. In this case, however, tissue has already been resected, wherein a histopathologic examination can be performed that includes the possibility of parathyroid carcinoma in the examination (which may entail appropriate sample staining). Let's say that the histopathologic examination confirms primary hyperparathyroidism, but also showed a malignant pattern. By an initial method by epidemiology, the incidence of parathyroid carcinoma is estimated at 1 in 6 million people per year, giving a very low probability before taking any tests into consideration. In comparison, the probability that non-malignant primary hyperparathyroidism would have occurred at the same time as an unrelated non-carcinoma cancer that presents with malignant cells in the parathyroid gland is calculated by multiplying the probabilities of the two. The resultant probability is, however, much smaller than the 1 in 6 million. Therefore, the probability of parathyroid carcinoma may still be close to 100% after histopathologic examination despite the low probability of occurring in the first place. Machine differential diagnosis Machine differential diagnosis is the use of computer software to partly or fully make a differential diagnosis. It may be regarded as an application of artificial intelligence. Alternatively, it may be seen as "augmented intelligence" if it meets the FDA criteria, namely that (1) it reveals the underlying data, (2) reveals the underlying logic, and (3) leaves the clinician in charge to shape and make the decision. Machine learning AI is generally seen as a device by the FDA, whereas augmented intelligence applications are not. Many studies demonstrate improvement of quality of care and reduction of medical errors by using such decision support systems. Some of these systems are designed for a specific medical problem such as schizophrenia, Lyme disease or ventilator-associated pneumonia. Others are designed to cover all major clinical and diagnostic findings to assist physicians with faster and more accurate diagnosis. However, these tools all still require advanced medical skills to rate symptoms and choose additional tests to deduce the probabilities of different diagnoses. Machine differential diagnosis is also currently unable to diagnose multiple concurrent disorders. Their usage by non-experts is therefore not a substitute for professional diagnosis. History The method of differential diagnosis was first suggested for use in the diagnosis of mental disorders by Emil Kraepelin. It is more systematic than the old-fashioned method of diagnosis by gestalt (impression). Alternative medical meanings "Differential diagnosis" is also used more loosely to refer simply to a list of the most common causes of a given symptom, to a list of disorders similar to a given disorder, or to such lists when they are annotated with advice on how to narrow the list down (French's Index of Differential Diagnosis is an example). Thus, a differential diagnosis in this sense is medical information specially organized to aid in diagnosis. Usage apart from in medicine Methods similar to those of differential diagnostic processes in medicine are also used by biological taxonomists to identify and classify organisms, living and extinct. For example, after finding an unknown species, there can first be a listing of all potential species, followed by ruling out of one by one until, optimally, only one potential choice remains. Similar procedures may be used by plant and maintenance engineers and automotive mechanics and used to be used in diagnosing faulty electronic circuitry. In popular culture In the American television medical drama House, the main protagonist Dr. Gregory House leads a team of diagnosticians who regularly use differential diagnostics procedures. See also Comorbidity Diagnosis of exclusion Dual diagnosis Gender-bias in medical diagnosis List of medical symptoms References Medical terminology Medical diagnosis Medical mnemonics de:Diagnose#Differenzialdiagnose

Self-help

Self-help or self-improvement is "a focus on self-guided, in contrast to professionally guided, efforts to cope with life problems" —economically, physically, intellectually, or emotionally—often with a substantial psychological basis. When engaged in self-help, people often use publicly available information, or support groups—on the Internet as well as in person—in which people in similar situations work together. From early examples in pro se legal practice and home-spun advice, the connotations of the word have spread and often apply particularly to education, business, exercise, psychology, and psychotherapy, as commonly distributed through the popular genre of self-help books. According to the APA Dictionary of Psychology, potential benefits of self-help groups that professionals may not be able to provide include friendship, emotional support, experiential knowledge, identity, meaningful roles, and a sense of belonging. Many different self-help group programs exist, each with its own focus, techniques, associated beliefs, proponents, and in some cases leaders. Concepts and terms originating in self-help culture and Twelve-Step culture, such as recovery, dysfunctional families, and codependency have become integrated into mainstream language. Self-help groups associated with health conditions may consist of patients and caregivers. As well as featuring long-time members sharing experiences, these health groups can become support groups and clearinghouses for educational material. Those who help themselves by learning and identifying health problems can be said to exemplify self-help, while self-help groups can be seen more as peer-to-peer or mutual-support groups. History In classical antiquity, Hesiod's Works and Days "opens with moral remonstrances, hammered home in every way that Hesiod can think of." The Stoics offered ethical advice "on the notion of —of well-being, welfare, flourishing." The Discourses of Epictetus can be read as a sort of early self-help advice column, and the Meditations of Marcus Aurelius as the journal of someone engaged on a deliberate self-help program. The genre of mirror-of-princes writing, which has a long history in Greco-Roman and Western Renaissance literature, represents a secular cognate of Biblical wisdom literature. Proverbs from many periods, collected and uncollected, embody traditional moral and practical advice of diverse cultures. The hyphenated compound word "self-help" often appeared in the 1800s in a legal context, referring to the doctrine that a party in a dispute has the right to use lawful means on their initiative to remedy a wrong. Some consider the self-help movement to have been inaugurated by George Combe's Constitution (1828), from the way that it advocated personal responsibility and the possibility of naturally sanctioned self-improvement through education or proper self-control. In 1841, an essay by Ralph Waldo Emerson, entitled Compensation, was published suggesting "every man in his lifetime needs to thank his faults" and "acquire habits of self-help" as "our strength grows out of our weakness." Samuel Smiles (1812–1904) published the first explicitly "self-help" book, titled Self-Help, in 1859. Its opening sentence: "Heaven helps those who help themselves", provides a variation of "God helps them that help themselves", the oft-quoted maxim that had also appeared previously in Benjamin Franklin's Poor Richard's Almanack (1733–1758). Early 20th century In 1902, James Allen published As a Man Thinketh, which proceeds from the conviction that "a man is literally what he thinks, his character being the complete sum of all his thoughts." Noble thoughts, the book maintains, make for a noble person, while lowly thoughts make for a miserable person. Napoleon Hill's Think and Grow Rich (1937) described the use of repeated positive thoughts to attract happiness and wealth by tapping into an "Infinite Intelligence". In 1936, Dale Carnegie further developed the genre with How to Win Friends and Influence People. Having failed in several careers, Carnegie became fascinated with success and its link to self-confidence, and his books have since sold over 50 million copies. The market Group and corporate attempts to help people help themselves have created a self-help marketplace, with Large Group Awareness Trainings (LGATs) and psychotherapy systems represented. These offer more-or-less prepackaged solutions to instruct people seeking their betterment, just as "the literature of self-improvement directs the reader to familiar frameworks... what the French social theorist Gabriel Tarde called 'the grooves of borrowed thought'." A subgenre of self-help book series exists, such as the for Dummies guides and The Complete Idiot's Guide to..., that are varieties of how-to books. Statistics At the start of the 21st century, "the self-improvement industry, inclusive of books, seminars, audio and video products, and personal coaching, [was] said to constitute a 2.48-billion dollars-a-year industry" in the United States alone. By 2006, research firm Marketdata estimated the "self-improvement" market in the U.S. as worth more than —including infomercials, mail-order catalogs, holistic institutes, books, audio cassettes, motivation-speaker seminars, the personal coaching market, and weight-loss and stress-management programs. Market data projected that the total market size would grow to over by 2008. In 2013 Kathryn Schulz examined "an $11 billion industry". Self-help and professional service delivery Self-help and mutual-help are very different from—though they may complement—aid by professionals. Conflicts can and do arise on that interface, however, with some professionals considering that, for example, "the twelve-step approach encourages a kind of contemporary version of 19th-century amateurism or enthusiasm in which self-examination and very general social observations are enough to draw rather large conclusions." Research The rise of self-help culture led to boundary disputes with other approaches and disciplines. Some would object to their classification as "self-help" literature, as with "Deborah Tannen's denial of the self-help role of her books" to maintain her academic credibility, aware of the danger that "writing a book that becomes a popular success...all but ensures that one's work will lose its long-term legitimacy." Placebo effects can never be wholly discounted. Careful studies of "the power of subliminal self-help tapes... showed that their content had no real effect... But that's not what the participants thought." "If they thought they'd listened to a self-esteem tape (even though half the labels were wrong), they felt that their self-esteem had gone up. No wonder people keep buying subliminal tapes: even though the tapes don't work, people think they do." Much of the self-help industry may be thought of as part of the "skin trades. People need haircuts, massage, dentistry, wigs and glasses, sociology and surgery, love and advice."—a skin trade, "not a profession and a science". Its practitioners thus function as "part of the personal service industry rather than as mental health professionals." While "there is no proof that twelve-step programs 'are superior to any other intervention in reducing alcohol dependence or alcohol-related problems'," at the same time it is clear that "there is something about 'groupishness' itself which is curative." Thus for example "smoking increases mortality risk by a factor of just 1.6, while social isolation does so by a factor of 2.0... suggest[ing] an added value to self-help groups such as Alcoholics Anonymous as surrogate communities." Some psychologists advocate for positive psychology, and explicitly embrace an empirical self-help philosophy. "[T]he role of positive psychology is to become a bridge between the ivory tower and the main street—between the rigor of academe and the fun of the self-help movement." They aim to refine the self-improvement field by intentionally increasing scientifically sound research and well-engineered models. The division of focus and methodologies has produced several sub-fields, in particular: general positive psychology, focusing primarily on studying psychological phenomenon and effects; and personal effectiveness, focusing primarily on analysis, design, and implementation of qualitative personal growth. The latter of these includes intentionally training new patterns of thought and feeling. As business strategy communicator Don Tapscott puts it, "Why not courses that emphasize designing a great brain?... The design industry is something done to us. I'm proposing we each become designers. But I suppose 'I love the way she thinks' could take on new meaning." Both self-talk—the propensity to engage in verbal or mental self-directed conversation and thought—and social support can be used as instruments of self-improvement, often via empowering action-promoting messages. Psychologists designed experiments to shed light on how self-talk can result in self-improvement. Research has shown that people prefer second-person pronouns over first-person pronouns when engaging in self-talk to achieve goals, regulate their behavior, thoughts, or emotions, and facilitate performance. Self-talk also plays an important role in regulating emotions under social stress. People who use non-first-person language tend to exhibit a higher level of visual distance during the process of introspection, indicating that using non-first-person pronouns and one's own name may result in enhanced self-distancing. This form of self-help can enhance people's ability to regulate their thoughts, feelings, and behavior under social stress, which would lead them to appraise social-anxiety-provoking events in more challenging and less threatening terms. Criticism Scholars have targeted many self-help claims as misleading and incorrect. In 2005, Steve Salerno portrayed the American self-help movement—he uses the acronym SHAM: the Self-Help and Actualization Movement—not only as ineffective in achieving its goals but also as socially harmful. "Salerno says that 80 percent of self-help and motivational customers are repeat customers and they keep coming back whether the program worked for them or not." Another critic pointed out that with self-help books "supply increases the demand… The more people read them, the more they think they need them… more like an addiction than an alliance." Self-help writers have been described as working "in the area of the ideological, the imagined, the narrativized… although a veneer of scientism permeates the[ir] work, there is also an underlying armature of moralizing." Christopher Buckley in his book God Is My Broker asserts: "The only way to get rich from a self-help book is to write one". Gerald Rosen raised concerns that psychologists were promoting untested self-help books with exaggerated claims rather than conducting studies that could advance the effectiveness of these programs to help the public. Rosen noted the potential benefits of self-help but cautioned that good intentions were not sufficient to assure the efficacy and safety of self-administered instructional programs. Rosen and colleagues observed that many psychologists promote untested self-help programs rather than contributing to the meaningful advancement of self-help. In the media Kathryn Schulz suggests that "the underlying theory of the self-help industry is contradicted by the self-help industry’s existence". Parodies and fictional analogies The self-help world has become the target of parodies. Walker Percy's odd genre-busting Lost in the Cosmos has been described as "a parody of self-help books, a philosophy textbook, and a collection of short stories, quizzes, diagrams, thought experiments, mathematical formulas, made-up dialogue". Al Franken's self-help guru persona Stuart Smalley was a ridiculous recurring feature on Saturday Night Live in the early 1990s. In their 2006 book Secrets of The SuperOptimist, authors W.R. Morton and Nathaniel Whitten revealed the concept of "super optimism" as a humorous antidote to the overblown self-help book category. In his comedy special Complaints and Grievances (2001), George Carlin observes that there is "no such thing" as self-help: anyone looking for help from someone else does not technically get "self" help; and one who accomplishes something without help did not need help to begin with. In Margaret Atwood's semi-satiric dystopia Oryx and Crake, university literary studies have declined to the point that the protagonist, Snowman, is instructed to write his thesis on self-help books as literature; more revealing of the authors and of the society that produced them than genuinely helpful. See also Arete Conduct book Dale Carnegie Individualism Internal locus of control Law of attraction (New Thought) Life hack List of twelve-step groups Live in the Moment Lucinda Redick Bassett Manifestation Mirror-of-princes writing Mutual aid society Mutual self-help housing Napoleon Hill Neurohacking New Thought Movement Outline of self Personal development Popular psychology Positive psychology Preschool education Self Awareness Self-experimentation Self-healing Self-help groups for mental health Self (psychology) Self-sustainability Self-taught Sophism The Secret (2006 film) Think and Grow Rich True Will Twelve-step program References External links Personal development Self-care

Mental health in education

Mental health in education is the impact that mental health (including emotional, psychological, and social well-being) has on educational performance. Mental health often viewed as an adult issue, but in fact, almost half of adolescents in the United States are affected by mental disorders, and about 20% of these are categorized as “severe.” Mental health issues can pose a huge problem for students in terms of academic and social success in school. Education systems around the world treat this topic differently, both directly through official policies and indirectly through cultural views on mental health and well-being. These curriculums are in place to effectively identify mental health disorders and treat it using therapy, medication, or other tools of alleviation. Students' mental health and well-being is very much supported by schools. Schools try to promote mental health awareness and resources. Schools can help these students with interventions, support groups, and therapies. These resources can help reduce the negative impact on mental health. Schools can create mandatory classes based on mental health that can help them see signs of mental health disorders. Prevalence of mental health issues in adolescents According to the National Institute of Mental Health, approximately 46% of American adolescents aged 13–18 will suffer from some form of mental disorder. About 21% will suffer from a disorder that is categorized as “severe,” meaning that the disorder impairs their daily functioning, but almost two-thirds of these adolescents will not receive formal mental health support. The most common types of disorders among adolescents as reported by the NIMH is anxiety disorders (including generalized anxiety disorder, phobias, post-traumatic stress disorder, obsessive-compulsive disorder, and others), with a lifetime prevalence of about 25% in youth aged 13–18 and 6% of those cases being categorized as severe. Next is mood disorders (major depressive disorder, dysthymic disorder, and/or bipolar disorder), with a lifetime prevalence of 14% and 4.7% for severe cases in adolescents. A similarly common disorder is Attention deficit hyperactivity disorder (ADHD), which is categorized as a childhood disorder but oftentimes carries through into adolescence and adulthood. The prevalence for ADHD in American adolescents is 9%, and 1.8% for severe cases. It is important to understand that ADHD is a serious issue in not only children but adults. When children have ADHD a number of mental illnesses can come from that which can affect their education and hold them back from succeeding. According to Mental Health America, more than 10% of young people exhibit symptoms of depression strong enough to severely undermine their ability to function at school, at home, or whilst managing relationships. A 2021 study conducted by NIMH managed to link 31.4% of suicide deaths to a mental health disorder, the most common ones being attention-deficit/hyperactivity disorder (ADHD) or depression. Suicide was the second leading cause of death among persons aged 10–29 years in the United States during 2011–2019. More teenagers and young adults die from suicide than cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined. There are an average of over 3,470 attempts by students in grades 9–12. According to APA, the percentage of students going for college mental health counselling has been rising in recent years, which by report for anxiety as the most common factor, depression as the second, stress as the third, family issues as the fourth, and academic performance and relationship problems as the fifth and sixth most. “Consequences of Student Mental Health Issues.” Consequences of Student Mental Health Issues – Suicide Prevention Resource Center, sprc.org/settings/colleges-and-universities/consequences-of-student-mental-health-issues/#:~:text=One%20study%20found%20that%20five,not%20been%20experiencing%20such%20disorders. Accessed 15 Sept. 2024. Common disorders effects on academics and school life Mental disorders can affect classroom learning, such as poor attendance, difficulties with academic performance, poor social integration, trouble adjusting to school, problems with behavior regulation, and attention and concentration issues, all of which is critical to the success of the student. Not only do mental health disorders effect the individuals life but also the competitive job market. Students who are unable to perform in school, will be less likely to be able to perform in the workforce. High school students who screen positive for psychosocial dysfunction report three times as many absent and tardy days as students who do not identify dysfunction. This leads to much higher dropout rates and lower overall academic achievement. In the United States, only 40 percent of students with emotional, behavioral and mental health disorders graduate from high school, compared to the national average of 76 percent. An analysis of 40,350 undergraduates from 70 institutions by Posselt and Lipson found that they had a 37% higher chance of developing depression and a 69% higher chance of developing anxiety if they perceived their classroom environments as highly competitive. Anxiety Students with anxiety disorders are statistically less likely to attend college than those without it, and those with social phobias are twice as likely to fail a grade or not finish high school as compared to students without the condition. Anxiety disorders are typically more difficult to recognize than disruptive behavior disorders, such as ADHD, because the symptoms are internalized. Anxiety may manifest as recurring fears and worries about routine parts of everyday life, avoiding activities, school or social interactions and it can interfere with the ability to focus and learn. There is a specific character that people with anxiety often experience. People with anxiety experience frequent worries and fears about everyday situations. Anxiety can also be identified as a sudden feeling of intense fear or terror that can reach a peak within minutes. These anxiety symptoms usually develops during childhood or teen years and may continue into adulthood. Some examples of symptoms include: feeling nervous, restless or tense, having a sense of impeding danger, panic, or doom, having an increased heart rate, breathing rapidly, sweating, trembling, feeling weak or tired, trouble concentrating or thinking about anything other than the present worry, having trouble sleeping, experiencing gastrointestinal problems, having difficulty controlling worry, or having the urge to avoid things that trigger anxiety. There are multiple types of anxieties that each present with unique symptoms. The most common type of anxiety is Generalized Anxiety Disorder, which presents with persistent and excessive worry that interferes with daily activities, feeling on edge/fatigued, worries about everyday things, and can cause physical symptoms, such as restlessness. Panic disorders are characterized by recurrent panic attacks, cause physical and psychological distress, and panic attacks, which consist of palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, and a fear of dying. People with phobias experience excessive and persistent fear of objects or situations that are generally not harmful. Fear is excessive, which patients are aware of. Examples of phobias can include public speaking, spiders, or flying. Social anxiety disorder is a condition where people have significant anxiety about being embarrassed, so they will avoid situations that could cause embarrassment. An example of a situation that would be avoided would be eating or drinking in public. Finally, separation anxiety disorder is characterized by excessive fear or anxiety about separation which can cause functioning problems. People may be worried about leaving others and may have attachment issues. Treatments for anxiety can include medications, such as antidepressants, anti-anxiety medications, sedatives (such as benzodiazepines), and beta blockers. These medications function to relieve short-term anxiety, but are not meant to be used as long-term solutions. Cognitive behavioral therapy is the most efficient form of treatment and is used as a short-term treatment. This therapy focuses on teaching specific skills for coping in order to improve symptoms. This can include exposure therapy, which increases exposure to potential triggers and is used to treat phobias. Depression Depression can cause students to have problems in class, from completing their work, to even attending class at all. In 2020, approximately 13% of youth aged 12 to 17 years old have had one major depressive episode (MDE) in the past year, with an overwhelming 70% left untreated. According to the National Center for Mental Health Checkups at Columbia University, "High depression scores have been associated with low academic achievement, high scholastic anxiety, increased school suspensions, and decreased ability or desire to complete homework, concentrate, and attend classes." Depression symptoms can make it challenging for students to keep up with course loads, or even find the energy to make it through the full school day. Depression can be defined as a multi-problematic medical illness that negatively affects how one feels, thinks, and acts. The symptoms of depression can cause disturbances with interpersonal, social, and occupational functioning. This can later lead onto having varieties of emotional and physical problems. This can also decrease the ability to function mentally and physically. Some examples of depression symptoms are feeling sad, loss of interest, changes in appetite, trouble sleeping, loss of energy, increase in purposeless physical activity, feeling worthless, difficulty in thinking, concentrating, or making decisions, and thoughts of death or suicide. These symptoms must last two weeks and also represent a change in functioning in order for a diagnosis of depression. Treatments for depression can include normothymic drugs, antidepressant drugs (which have significant side effects), solving unresolved conflicts, relaxation, light therapy, sleep deprivation therapy, electroconvulsive therapy, as well as cognitive behavioral therapy. Depression treatments need to be aimed at long-term treatment because depression can reoccur if not completely treated. Medications are better short-term treatments, while cognitive behavioral therapy is typically used as a more long-term treatment. Attention deficit hyperactivity disorder Attention disorders are the principal predictors of diminished academic achievement. Students with ADHD tend to have trouble mastering behaviors and practices demanded of them by the public education system in the United States, such as the ability to quietly sit still or to apply themselves to one focused task for extended durations. ADHD can mean that students have problems concentration, filtering out distracting external stimuli, and seeing large tasks through to completion. These students can also struggle with time management and organization. Symptoms of ADHD can include inattention, hyperactivity, impulsivity, and other internalizing symptoms, such as depression. ADHD stands for attention-deficit/hyperactivity disorder. This is considered as one of the most common mental disorders for children, however it affects many adults as well. Some examples of symptoms are not paying attention to details and making careless mistakes, having problems of staying focused on activities, not being able to be seen as listening, having problems in organizing, avoiding tasks, and forgetting daily tasks. These symptoms can cause a disturbance in the education of the affected student as well as other students in the class. Treatments for ADHD can include behavioral therapy, medications (both stimulants and nonstimulants), education about ADHD, and training for parents on how to care for their affected children. Other common struggles for adolescents Alcoholism More than 90 percent of all alcoholic drinks consumed by young people are consumed through binge drinking, which can lead to Alcoholism. Alcoholism can affect ones’ mental health by being dependent on it, putting drinking before their own classwork. People who consume alcohol before the age of fourteen are more likely to drink more often without thinking about the consequences later on. Students who drink alcohol can also experience consequences such as higher risk of suicide, memory problems, and misuse of other drugs. A 2017 survey found that 30% of high school students have drunk alcohol and 14% of high schoolers have binge drank. Bullying Bullying in schools can cause adverse effects on students. Academic outcomes for bullied youth are typically below normal. Bullying is associated with a lower grade point average (GPA), lower achievement test scores, and lower teacher-rated academic engagement. Students who become victims of bullying can experience difficulties with social-emotional functioning and they have more difficulty making friends. This also causes poor relationships with peers and classmates which can cause them to feel lonely. Feeling like an outcast, feeling lonely, and being shut out of friend groups can cause students to feel isolated, which can cause anxiety and depression. These conditions come with their own unique implications as far as school goes. Suicide According to the California Dept. of Public Health there were 2,210 suicides in 2019 in the US age range of 15-19 and a total of 6,500 suicides from ages 5–25. Some research estimates that among 15-24 year-olds, there are approximately 100-200 suicide attempts for every suicide. Adolescent suicidality may be a product of network positions characterized by either relative isolation or structural imbalance and a growing body of research links social isolation to suicide. Most suicides reported in Ohio from 1963 to 1965 revealed that they tended to be social outcasts (played no sports, had no hobbies, and were not part of any clubs). They also suggested that half of these students were failing or near-failing at the time of their deaths. These periods of failure and frustration lower the individual's self-concept to a point where they have little sense of self-worth. In fact, students who perceive their academic performance as "failing" are three times more likely to attempt suicide than those who perceive their performance to be acceptable. However, academic failure in school is not the only cause of suicide in schools. Bullying, social isolation, and issues at home are all reasons why students commit suicide. Reaching Out For Help The American Psychological Association reports that from 2008 to 2018, a survey showed that 5.8% of American people were not receiving the care they needed for their mental health. According to the survey's results, 12.7% of young people between the ages of 18 and 25 said that their mental health issues weren't addressed. The majority of respondents to the survey stated that cost considerations were one of the primary reasons why their needs weren't met. Students in education often find themselves in difficult situations that require assistance. Data suggests a concerning trend of rising rates of suicidal ideation and self-harm behaviors among college students, pointing to the urgent need for effective prevention and intervention strategies. Solving the mental health crisis in America should not solely fall back onto the schools, but they are definitely a huge part of the solution; according to experts, by bringing treatment to these children, school officials are key in addressing existing problems and preventing further diagnoses in these children. Some ways that we are able to bring mental health solutions to the children include an on-duty counselor or a psychiatrist, both of which would be able to evaluate students and help them with receiving the proper medications. For those who require assistance, it is essential to acknowledge mental health services. According to the poll, 26% of respondents believed they could manage their mental needs without receiving treatment. Many students shy away from the main problem because they think their problems aren't serious enough to warrant assistance. By consuming their thoughts and emotions, students discover that they are increasing their stress and anxiety. In order to encourage students to seek treatment when necessary, educational materials should mention the mental health services that are accessible. Covid-19 and mental health Early Covid-19 Predictions Outbreaks of disease forecast a rise in mental health policies. Increased levels of unemployment and emotional distress during the global COVID-19 pandemic led to and evidenced such as rise in 2020. There were cases of increased isolation and depression rates of the elderly, xenophobia against people of Asian descent, and resulting mental health effects of large-scale quarantine and business closures. Not only is an achievement gap projected for students that undergo the COVID-19 pandemic, but significant repercussions are expected for the mental health and well-being of students in low-income families, since more than half of students utilize reduced-priced or free mental health resources provided by schools. JAMA Pediatrics expects that the global health crisis will worsen pre-existing mental health disorders in students and the number of childhood mental health disorders will increase with the higher prevalence of social isolation and familial income decline due to economic recession. The Kaiser Family Foundation reported that 56% of Americans have endured at least one negative mental health effect due to stress related to the outbreak. This can surface as increased alcohol and drug use, frequent headaches, trouble sleeping and eating, or short tempers. Additionally, in May 2020, Well Being Trust reported that the pandemic could lead to 75,000 additional "deaths of despair" from overusing drugs and alcohol or suicide from unemployment, social isolation, and general anxiety regarding the virus. Thus, although as of 2020 there are no federal requirements in place, a rise in mental health awareness and approval of policies is expected post-COVID-19. Current Covid-19 Effects "The COVID-19 pandemic led to a worldwide lockdown and school closures, which have placed a substantial mental health burden on children and college students. Through a systematic search of the literature on PubMed and Collabovid of studies published January 2020–July 2021, findings of five studies on children and 16 studies on college students found that both groups reported feeling more anxious, depressed, fatigued, and distressed than prior to the pandemic. As a result of COVID-19, children, adolescent, and college students are experiencing long duration of quarantine, physical isolation from their friends, teachers, and extended family members, and are forced to adapt to a virtual way of learning. A two-year study during the pandemic on Greek University students revealed severe prevalence of stress, anxiety, and depression especially during the second year of the pandemic. Due to this unexpected and forced transition, children and college students may not have adequate academic resources, social contact and support, or a learning-home environment, which may lead to a heightened sense of loneliness, distress, anger, and boredom—causing an increase in negative psychological outcomes. Mental health issues may also arise from the disease itself, such as grief from loss of lives, opportunities, and employment." Policies in public schools United States Concerning U.S. state policies as of 2020, three states have approved mandatory mental health curriculums. In July 2018, New York and Virginia passed legislation that made mental health instruction mandatory in public education. New York has made it mandatory for students from Kindergarten to 12th grade to undergo mental health instruction. After experiencing traumatizing suicidal behavior with his own son, Virginia Senator Creigh Deeds thought it necessary to teach warning signs to 9th and 10th graders so they can look out for the safety of their peers and themselves. The board of education is in charge of deliberating details of the curriculum but the senator is hopeful that teachers will also receive training on warning signs. Even though investment in mental health has never been higher, the state legislature has yet to approve extra funding to implement the curriculum. In July 2019, Florida's board of education made 5 hours of mental health education mandatory for grades 6 through 12, making it the third state to approve such instruction. Nationally, there has been some effort to increase education on mental health in the public school system. In 2020, the U.S. Department of Education awarded School-Based Mental Health Services grants to 6 state education agencies (SEAs) to increase the number of qualified (i.e., licensed, certified, well-trained, or credentialed) mental health service providers that provide school-based mental health services to students in local educational agencies (LEAs) with demonstrated need. There has been a growing popularity with school-based mental health services in United States public school systems, in which schools have their students covered for mental health care. People, on both the local and federal level, across the states are taking steps to redesign a system that is more favorable for students. This includes focusing on providing mental health services to them. This concept has the potential to allow students to have access to services that can help them understand and work through any stressors they may face within their schooling, as well as a better chance of intervention for those students who need it. In a study conducted in 2018 it was found that around 20% of college students in the United States had made attempts at suicide. A report by Healthy Minds in 2021 revealed that 5% of students had reported having planned to commit suicide in the preceding year. There are different kinds of students everywhere. Some might need more support than others, and some might learn at a faster pace than others. It is important to create an inclusive environment for all. Canada In Canada, the Mental Health Strategy highlights the importance of mental health promotion, stigma reduction, and early recognition of mental health problems in schools to be a priority (Mental Health Commission, 2012). Ontario conducts a survey every year to keep track of how effective policies are for public schools. Administered by People for Education, the 2022-23 annual report provided insight into the lack of mental health support for students and how inaccessible specialists are for not only students, but educators as well. These surveys are useful data in making decisions on how money can be spent on public schools and what policies should or should not be enforced. Implementing comprehensive school health and post-secondary mental health initiatives that promote mental health and prevention for those at risk was recommended by the Mental Health Commission of Canada. Bhutan In Bhutan, efforts toward developing education began in 1961 thanks to Ugyen Wangchuck and the introduction of the First Development Plan, which provided free primary education. By 1998, 400 schools were established. Students' tuition, books, supplies, equipment, and food were all free for boarding schools in the 1980s, and some schools also provided their students with clothing. The assistance of the United Nations Food and Agriculture Organizations' World Food Programme allowed free midday meals in some primary schools. This governmental assistance is important to note in the country's Gross National Happiness (GNH), which is at the forefront of developmental policies and is the responsibility of the government. Article 9 of the Constitution of Bhutan states that "the state shall strive to promote those conditions that will enable the pursuit of Gross National Happiness." Gross national happiness GNH in Bhutan is based on four principles: sustainable and equitable economic development, conservation of the environment, preservation and promotion of culture, and good governance. Their constitution prescribes that the state will provide free access to public health services through a three-tiered health system which provides preventative, promotive, and curative services. Because of this policy, Bhutan was able to eliminate iodine deficiency disorder in 2003, leprosy in 1997, and achieved childhood immunization for all children in 1991. It became the first country to ban tobacco in 2004, and cases of malaria decreased from 12,591 cases in 1999 to 972 cases in 2009. The elimination of these diseases and the strong push for GNH allows for all people (including adolescents who are provided with many necessary items and free education) to live happier lives than they otherwise may have had. United Kingdom The Department for Education in United Kingdom is working on developing an organizational approach to support mental health and character education. An October 2017 joint report from the Departments for Education and Health outlines this approach with regard to staff training, raising awareness of mental health challenges that children face, and involvement of parents and families in students' mental health. The first wave of the government-led Children and Young People’s Mental Health Implementation programme was launched in 2018. 58 mental health support teams were set up in schools and further education colleges to improve mental health in those aged 5 – 18 years. An evaluation on this initial roll-out found general satisfaction with the programme among schools, colleges and the young people who accessed support. Singapore REACH is a program in Singapore that looks to provide interventions for students struggling with mental illness. A quote from the REACH website reads, "The majority of children and adolescents do not suffer from mental illness. However, when a student has been identified, the school counselor, with consultation from the school’s case management team, will look into managing the care of the student. When necessary, guidance specialists and educational psychologists from the Ministry of Education will render additional support. In 2010, the Voluntary Welfare Organizations (VWOs), in collaboration with the National Council of Social Service (NCSS), have also been invited to join this network to provide community and clinical support to at-risk children. Students and children with severe emotional and behavioral problems may need more help. The REACH team collaborates with school counselors/VWOs to provide suitable school-based interventions to help these students. Such school/VWO based interventions often provide the requisite, timely help that these students and children need. Further specialized assessment or treatment may be necessary for more severe cases. The student or child may be referred to the Child Guidance Clinic after assessment by the REACH team for further psychiatric evaluation and intervention. These interventions may include medications, psychotherapy, group or family work and further assessments." Mexico Traditionally, mental health was not considered a part of public health in Mexico because of other health priorities, lack of knowledge about the true magnitude of mental health problems, and a complex approach involving the intervention of other sectors in addition to the public health sector. Among the key documents anticipating the policy change was a report presented by the Mexican Health Foundation in 1995, which opened a very constructive debate. It introduced basic tenets for health improvement, elements for an analysis of the health situation related to the burden of disease approach, and a strategic proposal with concurrent recommendations for reforming the system. Mexico has an extensive legal frame of reference dealing with health and mental health. The objectives are to promote a healthy psychosocial development of different population groups, and reduce the effects of behavioral and psychiatric disorders. This should be achieved through graded and complementary interventions, according to the level of care, and with the coordinated participation of the public, social, and private sectors in municipal, state, and national settings. The strategic lines consider training and qualification of human resources, growth, rehabilitation, and regionalization of mental health service networks, formulation of guidelines and evaluation. All age groups as well as specific sub-populations (indigenous groups, women, street children, populations in disaster areas), and other state and regional priorities are considered. Japan In Japan and China, the approach to mental health is focused on the collective of students, much like the national aims of these Asian countries. Much like in the US, there is much research done in the realm of student mental health, but not many national policies in place to prevent and aid mental health problems students face. Japanese students face considerable academic pressure as imposed by society and school systems. In 2006, Japanese police gathered notes left from students who had committed suicide that year and noted overarching school pressures as the primary source of their problems. Additionally, the dynamic of collective thinking—the centripetal force of Japan's society, wherein individual identity is sacrificed for the functioning benefit of a greater collective—results in the stigmatization of uniqueness. As child psychiatrist Dr. Ken Takaoka explained to CNN, schools prioritize this collectivism, and “children who do not get along in a group will suffer.” China Chinese society widely agrees that attending prestigious schools can lead to high-paying careers and long-term happiness for children. Yet, in the pursuit of these objectives, a significant number of Chinese families are currently grappling with the challenge of educational anxiety. The data from the Program of International Student Assessment (PISA, 2018) reveal that Chinese students achieve high global rankings in academics, leading in reading, mathematics, and science. However, their life satisfaction scores, an important measure of mental health, are notably low. This situation indicates a trend where the increasing academic competition not only elevates the financial and time investments in education but also contributes to a rise in extracurricular tutoring and a significant academic workload for students. Several systematic reviews examining the occurrence of depressive symptoms among students in China found that, on average, 17.2% of primary school students and 28.4% of Chinese university students exhibited signs of depression. In China, the focus on mental well-being of children and adolescents is highlighted in three interconnected policy frameworks: firstly, their mental health is recognized in broader national policies; secondly, it is a key focus within maternal and child health initiatives; and thirdly, specific policies are devoted exclusively to the mental health of this young population. Studies indicate that mental health promotion programs rank among the most effective efforts within health-promoting school initiatives. Efforts have been made to address academic stress, with recent initiatives aiming to reduce the burden on students and promote a healthier educational environment. In July 2021, the "Double Reduction Policy" was introduced, mandating schools to decrease excessive homework and off-campus training, potentially alleviating academic pressure and enhancing students' psychological well-being. With China's nine-year compulsory education program, primary schools play a key role in promoting and improving child mental health, serving as ideal venues for delivering related services. According to the 'Work Plan for Mental Health in China (2011–2020)', 85% coverage of mental health education was chosen as a target in urban primary schools and 70% in rural areas by 2015. Additionally, it argued for assessing the prevalence of mental disorders and for increasing awareness of child and adolescent mental health from 30%–40% in 2005 to 80% by 2015. The plan also emphasized the importance of providing accessible information on mental disorder prevention and screening through primary care physicians. As per the revised 'Mental Health Law of the People’s Republic of China' that was enacted in May 2013, numerous provisions have been introduced concerning the mental well-being of children and adolescents. Psychologists and counsellors are mandated to be available in schools at all levels to address mental disorders and psychological issues. Furthermore, preschool educational institutions must conduct relevant forms of mental health education. In cases of traumatic events or other stressors, schools are obligated to gather specialists and provide psychological counseling and mental health support to children in need. On December 30, 2016, 22 ministries and commissions, including the National Health and Family Planning Commission and various others, collectively released the 'Guiding Opinions on Strengthening Mental Health Services' (‘Opinions’). It stressed the importance of improving the mental health service system in education, advocating for the establishment of counseling centers and the presence of mental health workers across all types of educational institutions, from colleges and universities to preschools. South Korea South Korea has traditionally placed much value on education. As a nation that has a degree of enthusiasm like no other for education has created an environment where children are pressured to study more than ever. When mental health issues affect students there are very few resources available to help students cope. The nation's general view of mental health problems, such as anxiety, depression or thoughts of suicide, is that they are believed to be a sign of personal weakness that could bring shame upon a family if a member would be discovered to have such an illness. This is true if the problem arises in a social, educational or family setting. Rather than perceiving mental health issues as a medical condition and concern requiring treatment especially in students, a majority of Korea's population has perceived them as a cultural stigma. A study found when surveying over 600 Korean citizens from the age of 20-60+ years in 2008, most of the older people, many of whom are parents, shared similar and negative views on mental health issues such as depression. The older adults generally were also found to have a negative view of mental health services, including those offered through the educational system, as they are deeply influenced by the cultural stigma around the topic. This negative view of mental health services in education has provided implications for students who are struggling emotionally, as many do not know what, if any, help might be available in the facilities of education. However, this does not mean no mental health services exist in the world or in the educational setting. The World Health Organization (WHO) in 2006 collected data regarding Korea's mental health system. The goal of collecting this information was to attempt to improve the mental health system and to provide a baseline for monitoring the change. Despite Korea having a low budget for mental health services compared to other developed countries, it has taken steps to create long term mental health plans to advance its national health system such as raising more awareness for mental health, creating communities for students, and removing the cultural stigma around mental health. Alleviation and fostering adjustment Prevention The pressures of school, extracurricular activities, work and relationships with friends and family can be a lot for an individual to manage and at times can be overwhelming. In order to prevent these overwhelming feelings from turning into a mental health problem, taking measures to prevent these emotions from escalating is essential. School-based programs that help students with emotional-regulation, stress management, conflict resolution, and active coping and cognitive restructuring are a few suggested ways that give students resources that can promote their mental health (Mental Health Commission, 2012). Research shows that students who receive social-emotional and mental health will have a higher chance of more academic achievements. Since most children spend a large portion of the day at school, about 6 hours, schools are the ideal place for students to receive the services they need. When mental health is not addressed, this can cause issues with causing distractions to fellow students and teachers. A 2020 survey found that 43% of academic researchers were harassed or bullied at work. Many respondents claimed that their work environment hindered research. According to a 2019 article regarding school social workers, the field of social workers in schools is continuing to grow. In 1996, there were only about 9,000 social workers in schools. This had increased to be between 20,000 and 22,000 social workers. According to the United States Department of Labor, Bureau of Labor Statistics, it is estimated the field will continue to grow from 2016 to 2026 due to the increase of mental health services that are being demanded in schools. Belonging Belonging in the school environment may be the most important and relevant factors affecting students' performance in an academic setting. School-related stress and an increase in academic expectations may increase school-related stress and in turn negatively affect their academic performance. The absence of social acceptance has been shown to lead lowered interest and engagement because students have difficulty sustaining engagement in environments where they do not feel valued and welcome. The feeling of belonging creates a buffer between students and depressive symptoms and lessens the feelings of anxiety in school. Other components of not belonging can also affect students' feeling of belonging, which include not being represented racially, ethnically minority, or lack of first-generation representation in schools. An issue that is faced in our society today is bullying which can happen at school or even in class. Bullying can cause issues for students such as chemical dependency, physical harm, and a decrease in performance academically. According to the NASP, a large percentage, about 70%-80%, of people have experienced bullying in their school years in which the student could have been the bully, victim, or even the bystander. In order for staff at schools to understand how to notice this as an issue and what to do to resolve it, NASP advocates for guiding principals in how to resolve these issues as well as providing information on available programs. A 2020 survey by the UK non-profit Ditch The Label found that of those people who had been bullied that year 36% reported depression, 33% had suicidal thoughts, and 27% self-harmed. See also College health Effects of stress on memory Learning disability Teacher burnout Mental Health School climate School bullying Mental health day Mental health during the COVID-19 pandemic Mental health first aid Self-help groups for mental health Social determinants of mental health World Mental Health Day Mental health of Asian Americans Mental health in the workplace References School counseling Disability Social constructionism Positive psychology

Mental health professional

A mental health professional is a health care practitioner or social and human services provider who offers services for the purpose of improving an individual's mental health or to treat mental disorders. This broad category was developed as a name for community personnel who worked in the new community mental health agencies begun in the 1970s to assist individuals moving from state hospitals, to prevent admissions, and to provide support in homes, jobs, education, and community. These individuals (i.e., state office personnel, private sector personnel, and non-profit, now voluntary sector personnel) were the forefront brigade to develop the community programs, which today may be referred to by names such as supported housing, psychiatric rehabilitation, supported or transitional employment, sheltered workshops, supported education, daily living skills, affirmative industries, dual diagnosis treatment, individual and family psychoeducation, adult day care, foster care, family services and mental health counseling. Psychiatrists - physicians who use the biomedical model to treat mental health problems - may prescribe medication. The term counselors often refers to office-based professionals who offer therapy sessions to their clients, operated by organizations such as pastoral counseling (which may or may not work with long-term services clients) and family counselors. Mental health counselors may refer to counselors working in residential services in the field of mental health in community programs. As community professionals As Dr. William Anthony, father of psychiatric rehabilitation, described, psychiatric nurses (RNMH, RMN, CPN), clinical psychologists (PsyD or PhD), clinical social workers (MSW or MSSW), mental health counselors (MA or MS), professional counselors, pharmacists, as well as many other professionals are often educated in "psychiatric fields" or conversely, educated in a generic community approach (e.g. human services programs or health and human services in 2013). However, his primary concern is education that leads to a willingness to work with "long-term services and supports" community support in the community to lead to better life quality for the individual, the families and the community. The community support framework in the US of the 1970s is taken-for-granted as the base for new treatment developments (e.g., eating disorders, drug addiction programs) which tend to be free-standing clinics for specific "disorders". Typically, the term "mental health professional" does not refer to other categorical disability areas, such as intellectual and developmental disability (which trains its own professionals and maintains its own journals, and US state systems and institutions). Psychiatric rehabilitation has also been reintroduced into the transfer to behavioral health care systems. As certified and licensed (across institutions and communities) These professionals often deal with the same illnesses, disorders, conditions, and issues (though may separate on-site locations, such as hospital or community for the same clientele); however, their scope of practice differs and more particularly, their positions and roles in the fields of mental health services and systems. The most significant difference between mental health professionals are the laws regarding required education and training across the various professions. However, the most significant change has been the Supreme Court Olmstead decision on the most integrated setting which should further reduce state hospital utilization; yet with new professionals seeking right for community treatment orders and rights to administer medications (original community programs, residents taught to self-administer medications, 1970s). In 2013, new mental health practitioners are licensed or certified in the community (e.g., PhD, education in private clinical practice) by states, degrees and certifications are offered in fields such as psychiatric rehabilitation (MS, PhD), BA psychology (liberal arts, experimental/clinical/existential/community) to MA licensing is now more popular, BA (to PhD) mid-level program management, qualified civil service professionals, and social workers remain the mainstay of community admissions procedures (licensed by state, often generic training) in the US. Surprisingly, state direction has moved from psychiatry or clinical psychology to community leadership and professionalization of community services management. Entry level recruitment and training remain a primary concern (since the 1970s, then often competing with fast food positions), and the US Direct Support Workforce includes an emphasis on also training of psychiatric aides, behavioral aides, and addictions aides to work in homes and communities. The Centers for Medicaid and Medicare have new provisions for "self-direction" in services and new options are in place for individual plans for better life outcomes. Community programs are increasingly using health care financing, such as Medicaid, and Mental Health Parity is now law in the US. Professional distinctions Comparison of American mental health professionals Additional Sources/Clarifications: now operating programs with health care financing in the community. Higher paid medical and health services manager which only operates facilities, considered to be easier than dispersed services management in the community for long-term services and supports (LTSS) often by disability NGOs or state governments (civil service). The Mental Health Professional Class has often not been included in these occupational schemas in which Occupational Handbooks often separate Human Service Management Classes and Professional Classes from the term Health Care. Common salary ranges are in the $30,000-40,000 for the higher professional at the small community agency. The professionals are considered to be part of the federal Health and Human Services Professions. Their responsibilities at the high gates are greater than a psychiatrist assistant who is responsible, to date, only to the psychiatrist. The occupational therapist is considered as an aide to that professional level, as is a behavioral specialist as hired by the agency and the nurse practitioner. Mental health workers in the community (e.g., workers with the homeless, in homes, families and jails, community programs such as group homes) may still be termed Community Support Workers with diverse degrees and qualifications [US Direct Support Professional Workforce]. Children's professionals in the field of mental health include inclusion educators (over $80,000 at the PhD levels) who have been cross-educated in the fields, and "residential treatment" personnel which need dual reviews of credentials (child care, family support, child welfare, independent living, special education and home life, residential skills training programs). Treatment diversity and community mental health Mental health professionals exist to improve the mental health of individuals, couples, families and the community-at-large. [In this generic use, mental health is available to the entire population, similar to the use by mental health associations.] Because mental health covers a wide range of elements, the scope of practice greatly varies between professionals. Some professionals may enhance relationships while others treat specific mental disorders and illness; still, others work on population-based health promotion or prevention activities. Often, as with the case of psychiatrists and psychologists, the scope of practice may overlap often due to common hiring and promotion practices by employers. As indicated earlier, community mental health professionals have been involved in the beginning and operating community programs which include ongoing efforts to improve life outcomes, originally through long term services and supports (LTSS). Termed functional or competency-based programs, this service also stressed decision making and self-determination or empowerment as critical aspects. Community mental health professionals may also serve children who have different needs, as do families, including family therapy, financial assistance and support services. Community mental health professionals serve people of all ages from young children with autism, to children with emotional (or behavioral) needs, to grandma who has Alzheimer's or dementia and is living at home after dad dies. Most qualified mental health professionals will refer a patient or client to another professional if the specific type of treatment needed is outside of their scope of practice. The main community concern is "zero rejection" from community services for individuals who have been termed "hard to serve" in the population ["schizophrenia"] ["dual diagnosis"] or who have additional needs such as mobility and sensory impairments. Additionally, many mental health professionals may sometimes work together using a variety of treatment options such as concurrent psychiatric medication and psychotherapy and supported housing. Additionally, specific mental health professionals may be utilized based upon their cultural and religious background or experience, as part of a theory of both alternative medicines and of the nature of helping and ethnicity. Primary care providers, such as internists, pediatricians, and family physicians, may provide initial components of mental health diagnosis and treatment for children and adults; however, family physicians in some states refuse to even prescribe a psychotropic medication deferring to separately funded "medication management" services. Community programs in the categorical field of mental health were designed (1970s) to have a personal family physician for every client in their programs, except for institutional settings and nursing facilities which have only one or two for a large facility (1980, 2013). In particular, family physicians are trained during residency in interviewing and diagnostic skills, and may be quite skilled in managing conditions such as ADHD in children and depression in adults. Likewise, many (but not all) pediatricians may be taught the basic components of ADHD diagnosis and treatment during residency. In many other circumstances, primary care physicians may receive additional training and experience in mental health diagnosis and treatment during their practice years. Relative effectiveness Both primary care physicians (PCP) (also known as General Practitioners (GP)) and psychiatrist are just as effective (in terms of remission rates) for the treatment of depression. However, treatment resistant depression, suicidal, homicidal ideation, psychosis and catatonia should be handled by mental health specialists. Treatment-resistant depression (or treatment refractory depression) refers to depression which remains at large after at least two antidepressant medications have been trailed on their own. Peer workers Some think that mental health professionals are less credible when they have personal experience of mental health. In fact, the mental health sector goes out of its way to hire people with mental illness experience. Those in the mental health workforce with personal experience of mental health are referred to as 'peer support workers' or 'peer support specialists'. The balance of evidence appears to favor their employment: Randomized controlled trials consistently demonstrate peer staff produce outcomes on par with non-peer staff in ancillary roles, but they actually perform better in reducing hospitalization rates, engaging clients who are difficult to reach, and cutting substance use. There is research that indicates peer workers cultivate a perception among service users that the service is more responsive to non-treatment things, increases their hope, family satisfaction, self-esteem and community belonging. Psychiatrists Psychiatrists are physicians and one of the few professionals in the mental health industry who specialize and are certified in treating mental illness using the biomedical approach to mental disorders including the use of medications. However, biological, genetic and social processes as part of premedicine have been the basis of education in fields such as other mental health training since the 1970s, and in 2013, such academic degrees also may include extensive work on the status of brain, DNA research and its applications. Psychiatrists may also go through significant training to conduct psychotherapy and cognitive behavioral therapy. The amount of training a psychiatrist holds in providing these types of therapies varies from program to program and also differs greatly based upon region. [Cognitive therapy also stems from cognitive rehabilitation techniques, and may involve long-term community clients with brain injuries seeking jobs, education and community housing.] In the 1970s, psychiatrists were considered to be hospital-based, assessment, and clinical education personnel which was not involved in establishing community programs. Specialties of psychiatrists As part of their evaluation of the patient, psychiatrists are one of only a few mental health professionals who may conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. A medical professional must evaluate the patient for any medical problems or diseases that may be the cause of the mental illness. Historically psychiatrists have been the only mental health professional with the power to prescribe medication to treat specific types of mental illness. Currently, Physician Assistants response to the psychiatrist (in lieu of and supervised) and advanced practice psychiatric nurses may prescribe medications, including psychiatric medications. Clinical psychologists have gained the ability to prescribe psychiatric medications on a limited basis in a few U.S. states after completing additional training and passing an examination. Educational requirements for psychiatrists Typically the requirements to become a psychiatrist are substantial but differ from country to country. In general there is an initial period of several years of academic and clinical training and supervised work in different areas of medicine, in order to become a licensed medical doctor, followed by several years of supervised work and study in psychiatry, in order to become a licensed psychiatrist. In the United States and Canada one must first complete a Bachelor's degree. Students may typically decide any major subject of their choice, however they must enroll in specific courses, usually outlined in a pre-medical program. One must then apply to and attend 4 years of medical school in order to earn his MD or DO and to complete his medical education. Psychiatrists must then pass three successive rigorous national board exams (United States Medical Licensing Exams "USMLE", Steps 1, 2, and 3), which draws questions from all fields of medicine and surgery, before gaining an unrestricted license to practice medicine. Following this, the individual must complete a four-year residency in Psychiatry as a psychiatric resident and sit for annual national in-service exams. Psychiatry residents are required to complete at least four post-graduate months of internal medicine (pediatrics may be substituted for some or all of the internal medicine months for those planning to specialize in child and adolescent psychiatry) and two months of neurology, usually during the first year, but some programs require more. Occasionally, some prospective psychiatry residents will choose to do a transitional year internship in medicine or general surgery, in which case they may complete the two months of neurology later in their residency. After completing their training, psychiatrists take written and then oral specialty board examinations. The total amount of time required to qualify in the field of psychiatry in the United States is typically 4 to 5 years after obtaining the MD or DO (or in total 8 to 9 years minimum). Many psychiatrists pursue an additional 1–2 years in subspecialty fellowships on top of this such as child psychiatry, geriatric psychiatry, and psychosomatic medicine. In the United Kingdom, the Republic of Ireland, and most Commonwealth countries, the initial degree is the combined Bachelor of Medicine and Bachelor of Surgery, usually a single period of academic and clinical study lasting around five years. This degree is most often abbreviated 'MBChB', 'MB BS' or other variations, and is the equivalent of the American 'MD'. Following this the individual must complete a two-year foundation programmer that mainly consists of supervised paid work as a Foundation House Officer within different specialties of medicine. Upon completion the individual can apply for "core specialist training" in psychiatry, which mainly involves supervised paid work as a Specialty Registrar in different subspecialties of psychiatry. After three years there is an examination for Membership of the Royal College of Psychiatrists (abbreviated MRCPsych), with which an individual may then work as a "Staff grade" or "Associate Specialist" psychiatrist, or pursue an academic psychiatry route via a PhD. If, after the MRCPsych, an additional 3 years of specialization known as "advanced specialist training" are taken (again mainly paid work), and a Certificate of Completion of Training is awarded, the individual can apply for a post taking independent clinical responsibility as a "consultant" psychiatrist. Clinical psychologists A clinical psychologist studies and applies psychology for the purpose of understanding, preventing and relieving psychologically based distress or dysfunction and to promote subjective well-being and personal development. In many countries it is a regulated profession that addresses moderate to more severe or chronic psychological problems, including diagnosable mental disorders. Clinical psychology includes a wide range of practices, such as research, psychological assessment, teaching, consultation, forensic testimony, and program development and administration. Central to clinical psychology is the practice of psychotherapy, which uses a wide range of techniques to change thoughts, feelings, or behaviors in service to enhancing subjective well-being, mental health, and life functioning. Unlike other mental health professionals, psychologists are trained to conduct psychological assessment. Clinical psychologists can work with individuals, couples, children, older adults, families, small groups, and communities. Specialties of clinical psychologists Clinical psychologists who focus on treating mental health specializes in evaluating patients and providing psychotherapy. They do not prescribe medication as this is a role of a psychiatrist (physician who specializes in psychiatry). There are a wide variety of therapeutic techniques and perspectives that guide practitioners, although most fall into the major categories of Psychodynamic, Cognitive Behavioral, Existential-Humanistic, and Systems Therapy (e.g. family or couples therapy). In addition to therapy, clinical psychologists are also trained to administer and interpret psychological personality tests such as the MCMI, MMPI and the Rorschach inkblot test, and various standardized tests of intelligence, memory, and neuropsychological functioning. Common areas of specialization include: specific disorders (e.g. trauma), neuropsychological disorders, child and adolescent, family and relationship counseling. Internationally, psychologists are generally not granted prescription privileges. In the US, prescriptive rights have been granted to appropriately trained psychologists only in the states of New Mexico and Louisiana, with some limited prescriptive rights in Indiana and the US territory of Guam. Educational requirements for clinical psychologists Clinical psychologists, having completed an undergraduate degree usually in psychology or other social science, generally undergo specialist postgraduate training lasting at least two years (e.g. Australia), three years (e.g. UK), or four to six years depending how much research activity is included in the course (e.g. US). In countries where the course is of shorter duration, there may be an informal requirement for applicants to have undertaken prior work experience supervised by a clinical psychologist, and a proportion of applicants may also undertake a separate PhD research degree. Today, in the U.S., about half of licensed psychologists are trained in the Scientist-Practitioner Model of Clinical Psychology (PhD)—a model that emphasizes both research and clinical practice and is usually housed in universities. The other half are being trained within a Practitioner-Scholar Model of Clinical Psychology (PsyD), which focuses on practice. A third training model called the Clinical Scientist Model emphasizes training in clinical psychology research. Outside of coursework, graduates of both programs generally are required to have had 2 to 3 years of supervised clinical experience, a certain amount of personal psychotherapy, and the completion of a dissertation (PhD programs usually require original quantitative empirical research, whereas the PsyD equivalent of dissertation research often consists of literature review and qualitative research, theoretical scholarship, program evaluation or development, critical literature analysis, or clinical application and analysis). Continuing education requirements for clinical psychologists Most states in the US require clinical psychologists to obtain a certain number of continuing education credits in order to renew their license. This was established to ensure that psychologists stay current with information and practices in their fields. The license renewal cycle varies, but renewal is generally required every two years. The number of continuing education credits required for clinical psychologists varies between states. In Nebraska, psychologists are required to obtain 24 hours of approved continuing education credits in the 24 months before their license renewal. In California, the requirement is for 36 hours of credits. New York State does not have any continuing education requirements for license renewal at this time (2014). Activities that count towards continuing education credits generally include completing courses, publishing research papers, teaching classes, home study, and attending workshops. Some states require that a certain number of the education credits be in ethics. Most states allow psychologists to self-report their credits but randomly audit individual psychologists to ensure compliance. Counseling psychologist or psychotherapist Counseling generally involves helping people with what might be considered "normal" or "moderate" psychological problems, such as the feelings of anxiety or sadness resulting from major life changes or events. As such, counseling psychologists often help people adjust to or cope with their environment or major events, although many also work with more serious problems as well. One may practice as a counseling psychologist with a PhD or EdD, and as a counseling psychotherapist with a master's degree. Compared with clinical psychology, there are fewer counseling psychology graduate programs (which are commonly housed in departments of education), counselors tend to conduct more vocational assessment and less projective or objective assessment, and they are more likely to work in public service or university clinics (rather than hospitals or private practice). Despite these differences, there is considerable overlap between the two fields and distinctions between them continue to fade. Mental health counselors and residential counselors are also the name for another class of counselors or mental health professionals who may work with long-term services and supports (LTSS) clients in the community. Such counselors may be advanced or senior staff members in a community program, and may be involved in developing skill teaching, active listening (and similar psychological and educational methods), and community participation programs. They also are often skilled in on-site intervention, redirection and emergency techniques. Supervisory personnel often advance from this class of workers in community programs. Behavior analysts and community/institutional roles Behavior analysts are licensed in five states to provide services for clients with substance abuse, developmental disabilities, and mental illness. This profession draws on the evidence base of applied behavior analysis, behavior therapy, and the philosophy of radical behaviorism. Behavior analysts have at least a master's degree in behavior analysis or in a mental health related discipline as well as at least five core courses in applied behavior analysis (narrow focus in psychological education). Many behavior analysts have a doctorate. Most programs have a formalized internship program and several programs are offered online. Most practitioners have passed the examination offered by the behavior analysis certification board or the examination in clinical behavior therapy by the World Association for Behavior Analysis. The model licensing act for behavior analysts can be found at the Association for Behavior Analysis International's website. Behavior analysts (who grew from the definition of mental health as a behavioral problem) often use community situational activities, life events, functional teaching, community "reinforcers", family and community staff as intervenors, and structured interventions as the base in which they may be called upon to provide skilled professional assistance. Approaches that are based upon person-centered approaches have been used to update the stricter, hospital based interventions used by behavior analysts for applicability to community environments Behavioral approaches have often been infused with efforts at client self-determination, have been aligned with community lifestyle planning, and have been criticized as "aversive technology" which was "outlawed" in the field of severe disabilities in the 1990s. School psychologist and inclusion educators School psychologists' primary concern is with the academic, social, and emotional well-being of children within a scholastic environment. Unlike clinical psychologists, they receive much more training in education, child development and behavior, and the psychology of learning, often graduating with a post-master's educational specialist degree (EdS), EdD or Doctor of Philosophy (PhD) degree. Besides offering individual and group therapy with children and their families, school psychologists also evaluate school programs, provide cognitive assessment, help design prevention programs (e.g. reducing drops outs), and work with teachers and administrators to help maximize teaching efficacy, both in the classroom and systemically. In today's world, the school psychologist remains the responsible party in "mental health" regarding children with emotional and behavioral needs, and have not always met these needs in the regular school environment. Inclusion (special) educators support participation in local school programs and after school programs, including new initiatives such as Achieve my Plan by the Research and Training Center on Family Support and Children's Mental Health at Portland State University. Referrals to residential schools and certification of the personnel involved in the residential schools and campuses have been a multi-decade concern with counties often involved in national efforts to better support these children and youth in local schools, families, homes and communities. Psychiatric rehabilitation Psychiatric rehabilitation, similar to cognitive rehabilitation, is a designated field in the rehabilitation often academically prepared in either Schools of Allied Health and Sciences (near the field of Physical Medicine and Rehabilitation) and as rehabilitation counseling in the School of Education. Both have been developed specifically as preparing community personnel (at the MA and PHD levels) and to aid in the transition to professionally competent and integrated community services. Psychiatric rehabilitation personnel have a community integration-related base, support recovery and skills-based model of mental health, and may be involved with community programs based upon normalization and social role valorization throughout the US. Psychiatric rehabilitation personnel have been involved in upgrading the skills of staff in institutions in order to move clients into community settings. Most common in international fields are community rehabilitation personnel which traditionally come from the rehabilitation counseling or community fields. In the new "rehabilitation centers" (new campus buildings), designed similar to hospital "rehab" (physical and occupational therapy, sports medicine), often no designated personnel in the fields of mental health (now "senior behavioral services" or "residential treatment units"). Psychiatric rehabilitation textbooks are currently on the market describing the community services their personnel were involved within community development (commonly known as deinstitutionalization). Psychiatric rehabilitation professionals (and psychosocial services) are the mainstay of community programs in the US, and the national service providers association itself may certify mental health staff in these areas. Psychiatric interventions which vary from behavioral ones are described in a review on their use in "residential, vocational, social or educational role functioning" as a "preferred methods for helping individuals with serious psychiatric disabilities". Other competencies in education may involve working with families, user-directed planning methods and financing, housing and support, personal assistance services, transitional or supported employment, Americans with Disabilities Act (ADA), supported housing, integrated approaches (e.g., substance use, or intellectual disabilities), and psychosocial interventions, among others. In addition, rehabilitation counselors (PhD, MS) may also be educated "generically" (breadth and depth) or for all diagnostic groups, and can work in these fields; other personnel may have certifications in areas such as supported employment which has been verified for use in psychiatric, neurological, traumatic brain injury, and intellectual disabilities, among others. Social worker Social workers in the area of mental health may assess, treat, develop treatment plans, provide case management and/or rights advocacy to individuals with mental health problems. They can work independently or within clinics/service agencies, usually in collaboration with other health care professionals. In the US, they are often referred to as clinical social workers; each state specifies the responsibilities and limitations of this profession. State licensing boards and national certification boards require clinical social workers to have a master's or doctoral degree (MSW or DSW/PhD) from a university. The doctorate in social work requires submission of a major original contribution to the field in order to be awarded the degree. In the UK, there is a now a standardized three-year undergraduate social work degree, or two-year postgraduate masters for those who already have an undergraduate social sciences degree or others and relevant work experience. These courses include mandatory supervised work experience in social work, which may include mental health services. Successful completion allows an individual to register and work as a qualified social worker. There are various additional optional courses for gaining qualifications specific to mental health, for example training in psychotherapy or, in England and Wales, for the role of Approved Mental Health Professional (two years' training for a legal role in the assessment and detention of eligible mentally disordered people under the Mental Health Act (1983) as amended in 2007). Social workers in England and Wales are now able to become Approved Clinicians (AC) under the Mental Health Act 2007 following a period of further training (likely at postgraduate degree/diploma or doctoral level). Historically, this role was reserved for psychiatrist medical doctors, but has now extended to registered mental health professionals, such as social workers, psychologists and mental health nurses. In general, it is the psycho-social model rather than, or in addition to, the dominant medical model, that is the underlying rationale for mental health social work. This may include a focus on social causation, labeling, critical theory and social constructiveness. Many argue social workers need to work with medical and health colleagues to provide an effective service but they also need to be at the forefront of processes that include and empower service users. Social workers also prepare social work administration and may hold positions in human services systems as administration or Executives to Administration in the US. Social workers, similar to psychiatric rehabilitation, updates its professional education programs based upon current developments in the fields (e.g., support services) and serve a multicultural client base. Educational requirements for social workers In the United States, the minimum requirement for social workers is generally a bachelor's degree in social work, though a bachelor's degree in a related field such as sociology or psychology may qualify an applicant for certain jobs. Higher-level jobs typically require a master's degree in social work. Master's programs in social work usually last two years and consist of at least 900 hours of supervised instruction in the field. Regulatory boards generally require that degrees be obtained from programs that are accredited by the Council of Social Work Education (CSWE) or another nationally recognized accrediting agency for promotion and future collaboration. Before social workers can practice, they are required to meet the licensing, certification, or registration requirements of the state. The requirements vary depending on the state but usually involve a minimum number of supervised hours in the field and passing of an exam. All states except California also require pre-licensure from the Association of Social Work Boards (ASWB). The ASWB offers four categories of social work license. The lowest level is a Bachelors, for which a bachelor's degree in social work is required. The next level up is a Masters and a master's degree in social work is required. The Advanced Generalist category of social worker requires a master's degree in social work and two years of supervised post-degree experience. The highest ASWB category is a Clinical Social Worker which requires a master's degree in social work along with two years of post-master's direct experience in social work. Continuing education requirements for social workers Most states require social workers to acquire a minimum number of continuing education credits per license, certification, or registration renewal period. The purpose of these requirements is to ensure that social workers stay up-to-date with information and practices in their professions. In most states, the renewal process occurs every two or three years. The number of continuing education credits that is required varies between states but is generally 20 to 45 hours during the two- or three-year period prior to renewal. Courses and programs that are approved as continuing education for social workers generally must be relevant to the profession and contribute to the advancement of professional competence. They often include continuing education courses, seminars, training programs, community service, research, publishing articles, or serving on a panel. Many states enforce that a minimum amount of the credits be on topics such as ethics, HIV/AIDs, or domestic violence. Psychiatric and mental health nurse Psychiatric Nurses or Mental Health Nurse Practitioners work with people with a large variety of mental health problems, often at the time of highest distress, and usually within hospital settings. These professionals work in primary care facilities, outpatient mental health clinics, as well as in hospitals and community health centers. MHNPs evaluate and provide care for patients who have anything from psychiatric disorders, medical mental conditions, to substance abuse problems. They are licensed to provide emergency psychiatric services, assess the psycho-social and physical state of their patients, create treatment plans, and continually manage their care. They may also serve as consultants or as educators for families and staff; however, the MHNP has a greater focus on psychiatric diagnosis (typically the province of the MD or PhD), including the differential diagnosis of medical disorders with psychiatric symptoms and on medication treatment for psychiatric disorders. Educational requirements for psychiatric and mental health nurses Psychiatric and mental health nurses receive specialist education to work in this area. In some countries, it is required that a full course of general nurse training be completed prior to specializing as a psychiatric nurse. In other countries, such as the U.K., an individual completes a specific nurse training course that determines their area of work. As with other areas of nursing, it is becoming usual for psychiatric nurses to be educated to degree level and beyond. Psychiatric aides, now being trained by educational psychology in 2014, are part of the entry-level workforce which is projected to be needed in communities in the US in the next decades. In order to become a nurse practitioner in the U.S., at least six years of college education must be obtained. After earning the bachelor's degree (usually in nursing, although there are master's entry level nursing graduate programs intended for individuals with a bachelor's degree outside of nursing) the test for a license as a registered nurse (the NCLEX-RN) must be passed. Next, the candidate must complete a state-approved master's degree advanced nursing education program which includes at least 600 clinical hours. Several schools are now also offering further education and awarding a DNP (Doctor of Nursing Practice). Individuals who choose a master's entry level pathway will spend an extra year at the start of the program taking classes necessary to pass the NCLEX-RN. Some schools will issue a BSN, others will issue a certificate. The student then continues with the normal MSN program. Mental health care navigator A mental health care navigator is an individual who assists patients and families to find appropriate mental health caregivers, facilities and services. Individuals who are care navigators are often also trained therapists and doctors. The need for mental health care navigators arises from the fragmentation of the mental health industry, which can often leave those in need with more questions than answers. Care navigators work closely with patients through discussion and collaboration to provide information on options and referrals to healthcare professionals, facilities, and organizations specializing in the patients' needs. The difference between other mental health professionals and a care navigator is that a care navigator provides information and directs a patient to the best help rather than offering diagnosis, prescription of medications or treatment. Many mental health organizations use "navigator" and "navigation" to describe the service of providing guidance through the health care industry. Care navigators are also sometimes referred to as "system navigators". One type of care navigator is an "educational consultant". Workforce shortage Behavioral health disorders are prevalent in the United States, but accessing treatment can be challenging. Nearly 1 in 5 adults experience a mental health condition for which approximately only 43% received treatment. When asked about access to mental health treatment, two-thirds of primary care physicians reported that they were unable to secure outpatient mental health treatment for their patients. This is due, in part, to the workforce shortage in behavioral health. In rural areas, 55% of US counties have no practicing psychiatrist, psychologist, or social worker. Overall, 77% of counties have a severe shortage of mental health workers and 96% of counties had some unmet need. Some of the reasons for the workforce shortage include high turnover rates, high levels of work-related stress, and inadequate compensation. Annual turnover rate is 33% for clinicians and 23% for clinical supervisors. This is compared to an annual PCP turnover rate of 7.1%. Compensation in behavioral health field is notably low. The average licensed clinical social worker, a position that requires a master's degree and 2000 hours of post-graduate experience, earns $45,000/year. As a point of reference, the average physical therapist earns $75,000/year. Substance abuse counselor earnings are even lower, with an average salary of $34,000/year. Job stress is another factor that may lead to the high turnover rates and workforce shortage. It is estimated that 21-67% of mental health workers experience high levels of burnout including symptoms of emotional exhaustion, high levels of depersonalization and a reduced sense of personal accomplishment. Researchers have offered various recommendations to reduce the critical workforce gaps in behavioral health. Some of these recommendations include the following: expanding loan repayment programs to incentivize mental health providers to work in underserved (often rural) areas, integrating mental health into primary care, and increasing reimbursement to health care professionals. Social workers also tend to experience competing for work and family demands, which negatively affects their job well-being and subsequently their job satisfaction, resulting in high turnover in the profession. See also Community integration Community Psychology Clinical Psychology List of credentials in psychology Psychologist Psychotherapy Clinical Associate (Psychology) Global mental health Health care providers Inclusion (education) Mental health Mental illness Psychiatric rehabilitation Psychiatry Anti-psychiatry List of counseling topics Supported housing References Further reading Psychiatry Mental health occupations

The Myth of Mental Illness

The Myth of Mental Illness: Foundations of a Theory of Personal Conduct is a 1961 book by the psychiatrist Thomas Szasz, in which the author criticizes psychiatry and argues against the concept of mental illness. It received much publicity, and has become a classic, well known as an argument that "mentally ill" is a label which psychiatrists have used against people "disabled by living" rather than truly having a disease. Background Szasz writes that he became interested in writing The Myth of Mental Illness in approximately 1950, when, having become established as a psychiatrist, he became convinced that the concept of mental illness was vague and unsatisfactory. He began work on the book in 1954, when he was relieved of the burdens of a full-time psychiatric practice by being called to active duty in the navy. Later in the 1950s, it was rejected by the first publisher to whom Szasz submitted the manuscript. Szasz next sent the manuscript to Paul Hoeber, director of the medical division of Harper & Brothers, who arranged for it to be published. Summary Szasz argues that it does not make sense to classify psychological problems as diseases or illnesses, and that speaking of "mental illness" involves a logical or conceptual error. In his view, the term "mental illness" is an inappropriate metaphor and there are no true illnesses of the mind. His position has been characterized as involving a rigid distinction between the physical and the mental. The legitimacy of psychiatry is questioned by Szasz, who compares it to alchemy and astrology, and argues that it offends the values of autonomy and liberty. Szasz believes that the concept of mental illness is not only logically absurd but has harmful consequences: instead of treating cases of ethical or legal deviation as occasions when a person should be taught personal responsibility, attempts are made to "cure" the deviants, for example by giving them tranquilizers. Psychotherapy is regarded by Szasz as useful not to help people recover from illnesses, but to help them "learn about themselves, others, and life." Discussing Jean-Martin Charcot and hysteria, Szasz argues that hysteria is an emotional problem and that Charcot's patients were not really ill. Reception The Myth of Mental Illness received much publicity, quickly became a classic, and made Szasz a prominent figure. The book was reviewed in the American Journal of Psychiatry, Journal of Nervous and Mental Disease, Psychosomatic Medicine, Archives of General Psychiatry, Clinical Psychology Review, and Psychologies. Published at a vulnerable moment for psychiatry, when Freudian theorizing was just beginning to fall out of favor and the field was trying to become more medically oriented and empirically based, the book provided an intellectual foundation for mental patient advocates and anti-psychiatry activists. It became well known in the mental health professions and was favorably received by those skeptical of modern psychiatry, but placed Szasz in conflict with many doctors. Soon after The Myth of Mental Illness was published, the Commissioner of the New York State Department of Mental Hygiene demanded, in a letter citing the book, that Szasz be dismissed from his university position because he did not accept the concept of mental illness. The philosopher Karl Popper, in a 1961 letter to Szasz, called the book admirable and fascinating, adding that, "It is a most important book, and it marks a real revolution." The psychiatrist David Cooper wrote that The Myth of Mental Illness, like the psychiatrist R. D. Laing's The Divided Self (1960), "proved stimulating in the development of [anti-psychiatry]", though he noted that neither book is itself an anti-psychiatric work. He described Szasz's work as "a decisive, carefully documented demystification of psychiatric diagnostic labelling in general." Socialist author Peter Sedgwick, writing in 1982, commented that in The Myth of Mental Illness, Szasz expounded a "game-playing model of social interaction" which is "zestful and insightful" but "neither particularly uncommon nor particularly iconoclastic by the standards of recent social-psychological theorising." Sedgwick argued that many of Szasz's observations are valuable regardless of the validity of Szasz's rejection of the concept of mental illness, and could easily be accepted by psychotherapists. Although agreeing with Szasz that the assignation of mental illness could undermine individual responsibility, he noted that this did not constitute an objection to the concept itself. The philosopher Michael Ruse called Szasz the most forceful proponent of the thesis that mental illness is a myth. However, while sympathetic to Szasz, he considered his case over-stated. Ruse criticized Szasz's arguments on several grounds, maintaining that while the concepts of disease and illness were originally applied only to the physiological realm, they can properly be extended to the mind, and there is no logical absurdity involved in doing so. Kenneth Lewes wrote that The Myth of Mental Illness is the most notable example of the "critique of the institutions of psychiatry and psychoanalysis" that occurred as part of the "general upheaval of values in the 1960s", though he saw the work as less profound than Michel Foucault's Madness and Civilization (1961). The psychiatrist Peter Breggin called The Myth of Mental Illness a seminal work. The author Richard Webster described the book as a well known argument against the tendency of psychiatrists to label people who are "disabled by living" as mentally ill. He observed that while some of Szasz's arguments are similar to his, he disagreed with Szasz's view that hysteria was an emotional problem and that Charcot's patients were not genuinely mentally ill. The lawyer Linda Hirshman wrote that while few psychiatrists adopted the views Szasz expounded in The Myth of Mental Illness, the book helped to encourage a revision of their diagnostic and therapeutic claims. The historian Lillian Faderman called the book the most notable attack on psychiatry published in the 1960s, adding that "Szasz's insights and critiques would prove invaluable to the homophile movement." See also Game theory — for Szasz, mental illness is best understood through the lens of game theory Neurodiversity — A belief of promoting the acceptance of numerous different brain types typically considered to be mental disorders or illnesses by the scientific community References External links Text of the original paper The Myth of Mental Illness 1961 non-fiction books American non-fiction books Anti-psychiatry books Books by Thomas Szasz English-language books Harper & Row books

Involuntary commitment

Involuntary commitment, civil commitment, or involuntary hospitalization/hospitalisation is a legal process through which an individual who is deemed by a qualified person to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily. This treatment may involve the administration of psychoactive drugs, including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community; this is sometimes referred to as outpatient commitment and shares legal processes with commitment. Criteria for civil commitment are established by laws which vary between nations. Commitment proceedings often follow a period of emergency hospitalization, during which an individual with acute psychiatric symptoms is confined for a relatively short duration (e.g. 72 hours) in a treatment facility for evaluation and stabilization by mental health professionals who may then determine whether further civil commitment is appropriate or necessary. Civil commitment procedures may take place in a court or only involve physicians. If commitment does not involve a court there is normally an appeal process that does involve the judiciary in some capacity, though potentially through a specialist court. Purpose For most jurisdictions, involuntary commitment is applied to individuals believed to be experiencing a mental illness that impairs their ability to reason to such an extent that the agents of the law, state, or courts determine that decisions will be made for the individual under a legal framework. In some jurisdictions, this is a proceeding distinct from being found incompetent. Involuntary commitment is used in some degree for each of the following although different jurisdictions have different criteria. Some jurisdictions limit involuntary treatment to individuals who meet statutory criteria for presenting a danger to self or others. Other jurisdictions have broader criteria. The legal process by which commitment takes place varies between jurisdictions. Some jurisdictions have a formal court hearing where testimony and other evidence may also be submitted and the subject of the hearing is typically entitled to legal counsel and may challenge a commitment order through habeas corpus. Other jurisdictions have delegated these power to physicians, though may provide an appeal process that involves the judiciary but may also involve physicians. For example, in the UK a mental health tribunal consists of a judge, a medical member, and a lay representative. First aid Training is gradually becoming available in mental health first aid to equip community members such as teachers, school administrators, police officers, and medical workers with training in recognizing, and authority in managing, situations where involuntary evaluations of behavior are applicable under law. The extension of first aid training to cover mental health problems and crises is a quite recent development. A mental health first aid training course was developed in Australia in 2001 and has been found to improve assistance provided to persons with an alleged mental illness or mental health crisis. This form of training has now spread to a number of other countries (Canada, Finland, Hong Kong, Ireland, Singapore, Scotland, England, Wales, and the United States). Mental health triage may be used in an emergency room to make a determination about potential risk and apply treatment protocols. Observation Observation is sometimes used to determine whether a person warrants involuntary commitment. It is not always clear on a relatively brief examination whether a person should be committed. Containment of danger Austria, Belgium, Germany, Israel, the Netherlands, Northern Ireland, the Republic of Ireland, Russia, Taiwan, Ontario (Canada), and the United States have adopted commitment criteria based on the presumed danger of the defendant to self or to others. People with suicidal thoughts may act on these impulses and harm or kill themselves. People with psychosis are occasionally driven by their delusions or hallucinations to harm themselves or others. Research has found that those with schizophrenia are between 3.4 and 7.4 times more likely to engage in violent behaviour than members of the general public. However, because other confounding factors such as childhood adversity and poverty are correlated with both schizophrenia and violence it can be difficult to determine whether this effect is due to schizophrenia or other factors. In an attempt to avoid these confounding factors, researchers have tried comparing the rates of violence amongst people diagnosed with schizophrenia to their siblings in a similar manner to twin studies. In these studies people with schizophrenia are found to be between 1.3 and 1.8 times more likely to engage in violent behaviour. People with certain types of personality disorders can occasionally present a danger to themselves or others. This concern has found expression in the standards for involuntary commitment in every US state and in other countries as the danger to self or others standard, sometimes supplemented by the requirement that the danger be imminent. In some jurisdictions, the danger to self or others standard has been broadened in recent years to include need-for-treatment criteria such as "gravely disabled". Deinstitutionalization Starting in the 1960s, there has been a worldwide trend toward moving psychiatric patients from hospital settings to less restricting settings in the community, a shift known as "deinstitutionalization". Because the shift was typically not accompanied by a commensurate development of community-based services, critics say that deinstitutionalization has led to large numbers of people who would once have been inpatients as instead being incarcerated or becoming homeless. In some jurisdictions, laws authorizing court-ordered outpatient treatment have been passed in an effort to compel individuals with chronic, untreated severe mental illness to take psychiatric medication while living outside the hospital (e.g. Laura's Law, Kendra's Law). In a study of 269 patients from Vermont State Hospital done by Courtenay M. Harding and associates, about two-thirds of the ex-patients did well after deinstitutionalization. Around the world France In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies, and, in 1839, he opened the first school for intellectually disabled people. His method of treatment was based on the idea that intellectually disabled people did not suffer from disease. United Kingdom In the United Kingdom, provision for the care of the mentally ill began in the early 19th century with a state-led effort. Public mental asylums were established in Britain after the passing of the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many "pauper lunatics". Nine counties first applied, and the first public asylum opened in 1812 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem Hospital - its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions in which the inmates lived. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 was a landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, focusing on reform of the legislation concerning lunacy. The commission consisted of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act; the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. A national body for asylum superintendents - the Medico-Psychological Association - was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841. At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, those so detained had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization was soon disappointed. Psychiatrists were pressured by an ever-increasing patient population. The average number of patients in asylums kept increasing. Asylums were quickly becoming almost indistinguishable from custodial institutions, and the reputation of psychiatry in the medical world had was at an extreme low. Sectioning is now regulated by the Mental Health Act 2007 in England and Wales, the Mental Health (Care and Treatment) (Scotland) Act 2003 in Scotland and other legislation in Northern Ireland. United States In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. In the United States and most other developed societies, severe restrictions have been placed on the circumstances under which a person may be committed or treated against their will as such actions have been ruled by the United States Supreme Court and other national legislative bodies as a violation of civil rights and/or human rights. The Supreme Court case O'Connor v. Donaldson established that the mere presence of mental illness and the necessity for treatment are not sufficient by themselves to justify involuntary commitment, if the patient is capable of surviving in freedom and does not present a danger of harm to themselves or others. Criteria for involuntary commitment are generally set by the individual states, and often have both short- and long-term types of commitment. Short-term commitment tends to be a few days or less, requiring an examination by a medical professional, while longer-term commitment typically requires a court hearing, or sentencing as part of a criminal trial. Indefinite commitment is rare and is usually reserved for individuals who are violent or present an ongoing danger to themselves and others. New York City officials under several administrations have implemented programs involving the involuntary hospitalization of people with mental illnesses in the city. Some of these policies have involved reinterpreting the standard of "harm to themselves or others" to include neglecting their own well-being or posing a harm to themselves or others in the future. In 1987–88, a homeless woman named Joyce Brown worked with the New York Civil Liberties Union to challenge her forced hospitalization under a new Mayor Ed Koch administration program. The trial, which attracted significant media attention, ended in her favor, and while the city won on appeal she was ultimately released after a subsequent case determined she could not be forcibly medicated. In 2022, Mayor Eric Adams announced a similar compulsory hospitalization program, relying on similar legal interpretations. Historically, until the mid-1960s in most jurisdictions in the United States, all committals to public psychiatric facilities and most committals to private ones were involuntary. Since then, there have been alternating trends towards the abolition or substantial reduction of involuntary commitment, a trend known as deinstitutionalisation. In many currents, individuals can voluntarily admit themselves to a mental health hospital and may have more rights than those who are involuntarily committed. This practice is referred to as voluntary commitment. In the United States, Kansas v. Hendricks established the procedures for a long-term or indefinite form of commitment applicable to people convicted of some sexual offences. United Nations United Nations General Assembly Resolution 46/119, "Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care", is a non-binding resolution advocating certain broadly drawn procedures for the carrying out of involuntary commitment. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programs in some countries to assist in this process. Criticism The potential dangers of institutions have been noted and criticized by reformers/activists almost since their foundation. Charles Dickens was an outspoken and high-profile early critic, and several of his novels, in particular Oliver Twist and Hard Times demonstrate his insight into the damage that institutions can do to human beings. Enoch Powell, when Minister for Health in the early 1960s, was a later opponent who was appalled by what he witnessed on his visits to the asylums, and his famous "water tower" speech in 1961 called for the closure of all NHS asylums and their replacement by wards in general hospitals: Scandal after scandal followed, with many high-profile public inquiries. These involved the exposure of abuses such as unscientific surgical techniques such as lobotomy and the widespread neglect and abuse of vulnerable patients in the US and Europe. The growing anti-psychiatry movement in the 1960s and 1970s led in Italy to the first successful legislative challenge to the authority of the mental institutions, culminating in their closure. During the 1970s and 1990s the hospital population started to fall rapidly, mainly because of the deaths of long-term inmates. Significant efforts were made to re-house large numbers of former residents in a variety of suitable or otherwise alternative accommodation. The first 1,000+ bed hospital to close was Darenth Park Hospital in Kent, swiftly followed by many more across the UK. The haste of these closures, driven by the Conservative governments led by Margaret Thatcher and John Major, led to considerable criticism in the press, as some individuals slipped through the net into homelessness or were discharged to poor quality private sector mini-institutions. Wrongful involuntary commitment There are instances in which mental health professionals have wrongfully deemed individuals to have been displaying the symptoms of a mental disorder, and committed the individual for treatment in a psychiatric hospital upon such grounds. Claims of wrongful commitment are a common theme in the anti-psychiatry movement. In 1860, the case of Elizabeth Packard, who was wrongfully committed that year and filed a lawsuit and won thereafter, highlighted the issue of wrongful involuntary commitment. In 1887, investigative journalist Nellie Bly went undercover at an asylum in New York City to expose the terrible conditions that mental patients at the time had to deal with. She published her findings and experiences as articles in New York World, and later made the articles into one book called Ten Days in a Mad-House. In the first half of the twentieth century there were a few high-profile cases of wrongful commitment based on racism or punishment for political dissenters. In the former Soviet Union, psychiatric hospitals were used as prisons to isolate political prisoners from the rest of society. British playwright Tom Stoppard wrote Every Good Boy Deserves Favour about the relationship between a patient and his doctor in one of these hospitals. Stoppard was inspired by a meeting with a Russian exile. In 1927, after the execution of Sacco and Vanzetti in the United States, demonstrator Aurora D'Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of the anarchists. Throughout the 1940s and 1950s in Canada, 20,000 Canadian children, called the Duplessis orphans, were wrongfully certified as being mentally ill and as a result were committed to psychiatric institutions where they were allegedly forced to take psychiatric medication that they did not need and were abused. They were named after Maurice Duplessis, the premier of Quebec at the time, who deliberately committed these children to misappropriate additional subsidies from the federal government. Decades later in the 1990s, several of the orphans sued Quebec and the Catholic Church for the abuse and wrongdoing. In 1958, black pastor and activist Clennon Washington King Jr. tried enrolling at the University of Mississippi, which at the time was white, for summer classes; the local police secretly arrested and involuntarily committed him to a mental hospital for 12 days. Patients are able to sue if they believe that they have been wrongfully committed. In one instance, Junius Wilson, an African American man, was committed to Cherry Hospital in Goldsboro, North Carolina in 1925 for an alleged crime without a trial or conviction. He was castrated. He continued to be held at Cherry Hospital for the next 67 years of his life. It turned out he was deaf rather than mentally ill. In many U.S. states, sex offenders who have completed a period of incarceration can be civilly committed to a mental institution based on a finding of dangerousness due to a mental disorder. Although the United States Supreme Court determined that this practice does not constitute double jeopardy, organizations such as the American Psychiatric Association (APA) strongly oppose the practice. The Task Force on Sexually Dangerous Offenders, a component of APA's Council on Psychiatry and Law, reported that "in the opinion of the task force, sexual predator commitment laws represent a serious assault on the integrity of psychiatry, particularly with regard to defining mental illness and the clinical conditions for compulsory treatment. Moreover, by bending civil commitment to serve essentially non-medical purposes, statutes threaten to undermine the legitimacy of the medical model of commitment." See also In the creative arts One Flew Over the Cuckoo's Nest (novel), (One Flew Over the Cuckoo's Nest (film)), (One Flew Over the Cuckoo's Nest (play)) if.... Forrest Gump novel and film based on the novel Cool Hand Luke Rebel without a Cause References Notes Citations Further reading HTML. Report of the Committee of Inquiry into allegations of ill-treatment of patients and other irregularities at the Ely Hospital, Cardiff, HMSO 1969 Extracts of the Report of the Committee of Inquiry into Normansfield Hospital - British Medical Journal, 1978, 2, 1560-1563 Erving Goffman Asylums Whyte, William H., The Organization Man, Doubleday Publishing, 1956. (excerpts from Whyte's book) The Production and Reproduction of Scandals in Chronic Sector Hospitals Amy Munson- Barkshire 1981 External links National Resource Center on Psychiatric Advance Directives (United States) Provides information related to Florida's Civil Commitment Statute. National Alliance on Mental Illness (United States) Mental health law

Alogia

In psychology, alogia (; from Greek ἀ-, "without", and λόγος, "speech" + New Latin -ia) is poor thinking inferred from speech and language usage. There may be a general lack of additional, unprompted content seen in normal speech, so replies to questions may be brief and concrete, with less spontaneous speech. This is termed poverty of speech or laconic speech. The amount of speech may be normal but conveys little information because it is vague, empty, stereotyped, overconcrete, overabstract, or repetitive. This is termed poverty of content or poverty of content of speech. Under Scale for the Assessment of Negative Symptoms used in clinical research, thought blocking is considered a part of alogia, and so is increased latency in response. This condition is associated with schizophrenia, dementia, severe depression, and autism. As a symptom, it is commonly seen in patients with schizophrenia and schizotypal personality disorder, and is traditionally considered a negative symptom. It can complicate psychotherapy severely because of the considerable difficulty in holding a fluent conversation. The alternative meaning of alogia is inability to speak because of dysfunction in the central nervous system, found in mental deficiency and dementia. In this sense, the word is synonymous with aphasia, and in less severe form, it is sometimes called dyslogia. Characteristics Alogia may be on a continuum with normal behaviors. People without mental illness may have it occasionally including when fatigued or disinhibited, when writers use language creatively, when people in certain disciplinessuch as politicians, administrators, philosophers, ministers, and scientistsuse language pedantically. Hence, deciding if an individual has alogia depends on contextual clues. Is the person in control? Can the person moderate the effect if asked to be specific or concise? Is it better with another topic? Are there other significant symptoms? Alogia is characterized by a lack of speech, often caused by a disruption in the thought process. Usually, an injury to the left side of the brain may cause alogia to appear in an individual. While in conversation, alogic patients will reply very sparsely and their answers to questions will lack spontaneous content; sometimes, they will even fail to answer at all. Their responses will be brief, generally only appearing as a response to a question or prompt. Apart from the lack of content in a reply, the manner in which the person delivers the reply is affected as well. Patients affected by alogia will often slur their responses, and not pronounce the consonants as clearly as usual. The few words spoken usually trail off into a whisper, or are just ended by the second syllable. Studies have shown a correlation between alogic ratings in individuals and the amount and duration of pauses in their speech when responding to a series of questions posed by the researcher. The inability to speak stems from a deeper mental inability that causes alogic patients to have difficulty grasping the right words mentally, as well as formulating their thoughts. A study investigating alogiacs and their results on the category fluency task showed that people with schizophrenia who exhibit alogia display a more disorganized semantic memory than controls. While both groups produced the same number of words, the words produced by people with schizophrenia were much more disorderly and the results of cluster analysis revealed bizarre coherence in the alogiac group. If the condition is assessed using a language other than the individual's primary language, the medical professional needs to make sure that the problem is not from language barriers. This condition is associated with schizophrenia, dementia, and severe depression. Example The following table shows an example of "poverty of speech" which shows replies to questions that are brief and concrete, with a reduction in spontaneous speech: The following example of "poverty of content of speech" is a response from a patient when asked why he was in a hospital. Speech is vague, conveys little information, but is not grossly incoherent and the amount of speech is not reduced. "I often contemplate—it is a general stance of the world—it is a tendency which varies from time to time—it defines things more than others—it is in the nature of habit—this is what I would like to say to explain everything." Causes Alogia can be brought on by frontostriatal dysfunction which causes degradation of the semantic store, the center located in the temporal lobe that processes meaning in language. A subgroup of chronic schizophrenia patients in a word generation experiment generated fewer words than the unaffected subjects and had limited lexicons, evidence of the weakening of the semantic store. Another study found that when given the task of naming items in a category, schizophrenia patients displayed a great struggle but improved significantly when experimenters employed a second stimulus to guide behavior unconsciously. This conclusion was similar to results produced from patients with Huntington's and Parkinson's disease, ailments which also involve frontostriatal dysfunction. Treatment Medical studies conclude that certain adjunctive drugs effectively palliate the negative symptoms of schizophrenia, mainly alogia. In one study, Maprotiline produced the greatest reduction in alogia symptoms with severity reduction in 50% of patients (out of 10). Of the negative symptoms of schizophrenia, alogia had the second best responsiveness to the drugs, surpassed only by attention deficiency. D-amphetamine is another drug that has been tested on people with schizophrenia and found success in alleviating negative symptoms. This treatment, however, has not been developed greatly as it seems to have adverse effects on other aspects of schizophrenia such as increasing the severity of positive symptoms. Relation to schizophrenia Although alogia is found as a symptom in a variety of health disorders, it is most commonly found as a negative symptom of schizophrenia. Previous studies and analyses conclude that at least three factors are needed to cover both the positive and negative symptoms of schizophrenia; the three are: psychotic, disorganization, and negative symptom factors. Studies suggest that an inappropriate affect is strongly associated with bizarre behavior and positive formal thought disorder on a disorganization factor; attention impairment correlates significantly with psychotic, disorganization, and negative symptom factors. Alogia contains both positive and negative symptoms, with the poverty of content of speech as the disorganization factor, and poverty of speech, response latency, and thought blocking as the negative symptom factors. Alogia is a major diagnostic sign of schizophrenia, when organic mental disorders have been excluded. In schizophrenia, negative symptoms including flattening of affect, avolition, and alogia are responsible for the considerable morbidity of the disease compared with other psychotic disorders. Negative symptoms are common in the prodromal and residual phases of the disease and can be severe. During the first year, negative symptoms can progress, especially alogia, which may start off from a relatively low rate. Within 2 years, up to 25% of patients will have significant negative symptoms. Psychotic symptoms tend to diminish as the individuals age, but negative symptoms tend to persist. Prominent negative symptoms at disease onset, including alogia, are good predictors of worse outcomes. Negative symptoms can arise in the presence of other psychiatric symptoms. Positive symptoms are a common cause of apathy, social withdrawal, and alogia. Secondary causes of negative symptoms, such as depression and demoralization, often remit within a year, which helps distinguishing them from primary negative symptoms. Symptoms that don't diminish over a year with medications should be reconsidered as possible primary negative symptoms. See also Aphasia Communication deviance List of language disorders Mutism References Other references Medical signs Schizophrenia

Functional disorder

Functional disorders are a group of recognisable medical conditions which are due to changes to the functioning of the systems of the body rather than due to a disease affecting the structure of the body. Functional disorders are common and complex phenomena that pose challenges to medical systems. Traditionally in western medicine, the body is thought of as consisting of different organ systems, but it is less well understood how the systems interconnect or communicate. Functional disorders can affect the interplay of several organ systems (for example gastrointestinal, respiratory, musculoskeletal or neurological) leading to multiple and variable symptoms. Less commonly there is a single prominent symptom or organ system affected. Most symptoms that are caused by structural disease can also be caused by a functional disorder. Because of this, individuals often undergo many medical investigations before the diagnosis is clear. Though research is growing to support explanatory models of functional disorders, structural scans such as MRIs, or laboratory investigation such as blood tests do not usually explain the symptoms or the symptom burden. This difficulty in 'seeing' the processes underlying the symptoms of functional disorders has often resulted in these conditions being misunderstood and sometimes stigmatised within medicine and society. Despite being associated with high disability, functional symptoms are not a threat to life, and are considered modifiable with appropriate treatment. Definition Functional disorders are mostly understood as conditions characterised by: persistent and troublesome symptoms associated with impairment or disability where the pathophysiological basis is related to problems with the functioning and communication of the body systems (as opposed to disease affecting the structure of organs or tissues) Examples There are many different functional disorder diagnoses that might be given depending on the symptom or syndrome that is most troublesome. There are many examples of symptoms that individuals may experience; some of these include persistent or recurrent pain, fatigue, weakness, shortness of breath or bowel problems. Single symptoms may be assigned a diagnostic label, such as "functional chest pain", "functional constipation" or "functional seizures". Characteristic collections of symptoms might be described as one of the functional somatic syndromes. A syndrome is a collection of symptoms. Somatic means 'of the body'. Examples of functional somatic syndromes include: irritable bowel syndrome; cyclic vomiting syndrome; some persistent fatigue and chronic pain syndromes, such as fibromyalgia (chronic widespread pain), or chronic pelvic pain; interstitial cystitis; functional neurologic disorder; and multiple chemical sensitivity. Overlap Most medical specialties define their own functional somatic syndrome, and a patient may end up with several of these diagnoses without understanding how they are connected. There is overlap in symptoms between all the functional disorder diagnoses. For example, it is not uncommon to have a diagnosis of irritable bowel syndrome (IBS) and chronic widespread pain/fibromyalgia. All functional disorders share risk factors and factors that contribute to their persistence. Increasingly researchers and clinicians are recognising the relationships between these syndromes. Classification The terminology for functional disorders has been fraught with confusion and controversy, with many different terms used to describe them. Sometimes functional disorders are equated or mistakenly confused with diagnoses like category of "somatoform disorders", "medically unexplained symptoms", "psychogenic symptoms" or "conversion disorders". Many historical terms are now no longer thought of as accurate, and are considered by many to be stigmatising. Psychiatric illnesses have historically also been considered as functional disorders in some classification systems, as they often fulfil the criteria above. Whether a given medical condition is termed a functional disorder depends in part on the state of knowledge. Some diseases, such as epilepsy, were historically categorized as functional disorders but are no longer classified that way. Prevalence Functional disorders can affect individuals of all ages, ethnic groups and socioeconomic backgrounds. In clinical populations, functional disorders are common and have been found to present in around one-third of consultations in both specialist practice and primary care. Chronic courses of disorders are common and are associated with high disability, health-care usage and social costs. Rates differ in the clinical population compared with the general population, and will vary depending on the criteria used to make the diagnosis. For example, irritable bowel syndrome is thought to affect 4.1%, and fibromyalgia 0.2–11.4% of the global population. A recent large study carried out on population samples in Denmark showed the following: In total, 16.3% of adults reported symptoms fulfilling the criteria for at least one Functional Somatic Syndrome, and 16.1% fulfilled criteria for Bodily Distress Syndrome. Diagnosis The diagnosis of functional disorders is usually made in the healthcare setting most often by a doctor — this could be a primary care physician or family doctor, hospital physician or specialist in the area of psychosomatic medicine or a consultant-liaison psychiatrist. The primary care physician or family doctor will generally play an important role in coordinating treatment with a secondary care clinician if necessary. The diagnosis is essentially clinical, whereby the clinician undertakes a thorough medical and mental health history and physical examination. Diagnosis should be based on the nature of the presenting symptoms, and is a "rule in" as opposed to "rule out" diagnosis — this means it is based on the presence of positive symptoms and signs that follow a characteristic pattern. There is usually a process of clinical reasoning to reach this point and assessment might require several visits, ideally with the same doctor. In the clinical setting, there are no laboratory or imaging tests that can consistently be used to diagnose the conditions; however, as is the case with all diagnoses, often additional diagnostic tests (such as blood tests, or diagnostic imaging) will be undertaken to consider the presence of underlying disease. There are however diagnostic criteria that can be used to help a doctor assess whether an individual is likely to suffer from a particular functional syndrome. These are usually based on the presence or absence of characteristic clinical signs and symptoms. Self-report questionnaires may also be useful. There has been a tradition of a separate diagnostic classification systems for "somatic" and "mental" disorder classifications. Currently, the 11th version of the International Classification System of Diseases (ICD-11) has specific diagnostic criteria for certain disorders which would be considered by many clinicians to be functional somatic disorders, such as IBS or chronic widespread pain/fibromyalgia, and dissociative neurological symptom disorder. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the older term somatoform (DSM-IV) has been replaced by somatic symptom disorder, which is a disorder characterised by persistent somatic (physical) symptoms, and associated psychological problems to the degree that it interferes with daily functioning and causes distress. (APA, 2022). Bodily distress disorder is a related term in the ICD-11. Somatic symptom disorder and bodily distress disorder have significant overlap with functional disorders and are often assigned if someone would benefit from psychological therapies addressing psychological or behavioural factors which contribute to the persistence of symptoms. However, people with symptoms partly explained by structural disease (for example, cancer) may also meet the criteria for diagnosis of functional disorders, somatic symptom disorder and bodily distress disorder. It is not unusual for a functional disorder to coexist with another diagnosis (for example, functional seizures can coexist with epilepsy, or irritable bowel syndrome with inflammatory bowel disease. This is important to recognise as additional treatment approaches might be indicated in order that the patient achieves adequate relief from their symptoms. The diagnostic process is considered an important step in order for treatment to move forward successfully. When healthcare professionals are giving a diagnosis and carrying out treatment, it is important to communicate openly and honestly and not to fall into the trap of dualistic concepts – that is "either mental or physical" thinking; or attempt to "reattribute" symptoms to a predominantly psychosocial cause. It often important to recognise the need to cease unnecessary additional diagnostic testing if a clear diagnosis has been established . Causes Explanatory models that support our understanding of functional disorders take into account the multiple factors involved in symptom development. A personalised, tailored approach is usually needed in order to consider the factors which relate to that individual's biomedical, psychological, social, and material environment. More recent functional neuroimaging studies have suggested malfunctioning of neural circuits involved in stress processing, emotional regulation, self-agency, interoception, and sensorimotor integration. A recent article in Scientific American proposed that important brain structures suspected in the pathophysiology of functional neurological disorder include increased activity of the amygdala and decreased activity within the right temporoparietal junction. Healthcare professionals might find it useful to consider three main categories of factors: predisposing, precipitating, and perpetuating (maintaining) factors. Predisposing factors These are factors that make the person more vulnerable to the onset of a functional disorder; and include biological, psychological and social factors. Like all health conditions, some people are probably predisposed to develop functional disorders due to their genetic make-up. However, no single genes have been identified that are associated with functional disorders. Epigenetic mechanisms (mechanisms that affect interaction of genes with their environment) are likely to be important, and have been studied in relation to the hypothalamic–pituitary–adrenal axis. Other predisposing factors include current or prior somatic/physical illness or injury, and endocrine, immunological or microbial factors. Functional disorders are diagnosed more frequently in female patients. The reasons for this are complex and multifactorial, likely to include both biological and social factors. Female sex hormones might affect the functioning of the immune system, for example. Medical bias possibly contributes to the sex differences in diagnosis: women are more likely to be diagnosed than men with a functional disorder by doctors. People with functional disorders also have higher rates of pre-existing mental and physical health conditions, including depression and anxiety disorders, Post-traumatic stress disorder, multiple sclerosis and epilepsy. Personality style has been suggested as a risk factor in the development of functional disorders but the effect of any individual personality trait is variable and weak. Alexithymia (difficulties recognising and naming emotions) has been widely studied in patients with functional disorders and is sometimes addressed as part of treatment. Migration, cultural and family understanding of illness, are also factors that influence the chance of an individual developing a functional disorder. Being exposed to illness in the family while growing up or having parents who are healthcare professionals are sometimes considered risk factors. Adverse childhood experiences and traumatic experiences of all kinds are known important risk factors. Newer hypotheses have suggested minority stressors may play a role in the development of functional disorders in marginalized communities. Precipitating factors These are the factors that for some patients appear to trigger the onset of a functional disorder. Typically, these involve either an acute cause of physical or emotional stress, for example an operation, a viral illness, a car accident, a sudden bereavement, or a period of intense and prolonged overload of chronic stressors (for example relationship difficulties, job or financial stress, or caring responsibilities). Not all affected individuals will be able to identify obvious precipitating factors and some functional disorders develop gradually over time. Perpetuating factors These are the factors that contribute to the development of functional disorder as a persistent condition and maintaining symptoms. These can include the condition of the physiological systems including the immune and neuroimmune systems, the endocrine system, the musculoskeletal system, the sleep-wake cycle, the brain and nervous system, the person's thoughts and experience, their experience of the body, social situation and environment. All these layers interact with each other. Illness mechanisms are important therapeutically as they are seen as potential targets of treatment. The exact illness mechanisms that are responsible for maintaining an individual's functional disorder should be considered on an individual basis. However, various models have been suggested to account for how symptoms develop and continue. For some people there seems to be a process of central-sensitisation, chronic low grade inflammation or altered stress reactivity mediated through the hypothalamic-pituitary-adrenal (HPA) axis (Fischer et al., 2022). For some people attentional mechanisms are likely to be important. Commonly, illness-perceptions or behaviours and expectations (Henningsen, Van den Bergh et al. 2018 ) contribute to maintaining an impaired physiological condition. Perpetuating illness mechanisms are often conceptualized as "vicious cycles", which highlights the non-linear patterns of causality characteristic of these disorders. Other people adopt a pattern of trying to achieve a lot on "good days" which results in exhaustion for days following and a flare up of symptoms, which has led to various energy management tools being used in the patient community, such as "Spoon Theory." Depression, PTSD, sleep disorders, and anxiety disorders can also perpetuate functional disorders and should be identified and treated where they are present. Side effects or withdrawal effects of medication often need to be considered. Iatrogenic factors such as lack of a clear diagnosis, not feeling believed or not taken seriously by a healthcare professional, multiple (invasive) diagnostic procedures, ineffective treatments and not getting an explanation for symptoms can increase worry and unhelpful illness behaviours. Stigmatising medical attitudes and unnecessary medical interventions (tests, surgeries or drugs) can also cause harm and worsen symptoms. Treatment Functional disorders can be treated successfully and are considered reversible conditions. Treatment strategies should integrate biological, psychological and social perspectives. The body of research around evidence-based treatment in functional disorders is growing. With regard to self-management, there are many basic things that can be done to optimise recovery. Learning about and understanding the condition is helpful in itself. Many people are able to use bodily complaints as a signal to slow down and reassess their balance between exertion and recovery. Bodily complaints can be used as a signal to begin incorporating stress reduction and balanced lifestyle measures (routine, regular activity and relaxation, diet, social engagement) that can help reduce symptoms and are central to improving quality of life. Mindfulness practice can be helpful for some people. Family members or friends can also be helpful in supporting recovery. Most affected people benefit from support and encouragement in this process, ideally through a multi-disciplinary team with expertise in treating functional disorders. Family members or friends may also be helpful in supporting recovery. The aim of treatment overall is to first create the conditions necessary for recovery, and then plan a programme of rehabilitation to re-train mind-body connections making use of the body's ability to change. Particular strategies can be taught to manage bowel symptoms, pain or seizures. Though medication alone should not be considered curative in functional disorders, medication to reduce symptoms might be indicated in some instances, for example where mood or pain is a significant issue, preventing adequate engagement in rehabilitation. It is important to address accompanying factors such as sleep disorders, pain, depression and anxiety, and concentration difficulties. Physiotherapy may be relevant for exercise and activation programs, or when weakness or pain is a problem. Psychotherapy might be helpful to explore a pattern of thoughts, actions and behaviours that could be driving a negative cycle – for example tackling illness expectations or preoccupations about symptoms. Some existing evidence-based treatments include cognitive behavioural therapy (CBT) for functional neurological disorder; physiotherapy for functional motor symptoms, and dietary modification or gut targeting agents for irritable bowel syndrome. Controversies and stigma Despite some progress in the last decade, people with functional disorders continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. Stigma is a common experience for individuals who present with functional symptoms and is often driven by historical narratives and factual inaccuracies. Given that functional disorders do not usually have specific biomarkers or findings on structural imaging that are typically undertaken in routine clinical practice, this leads to potential for symptoms to be misunderstood, invalidated, or dismissed, leading to adverse experiences when individuals are seeking help. Part of this stigma is also driven by theories around "mind body dualism", which frequently surfaces as an area of importance for patients, researchers and clinicians in the realm of functional disorders. Artificial separation of the mind/brain/body (for example the use of phrases such as; "physical versus psychological" or "organic versus non-organic") furthers misunderstanding and misconceptions around these disorders, and only serves to hinder progress in scientific domain and for patients seeking treatment. Some patient groups have fought to have their illnesses not classified as functional disorders, because in some insurance based health-care systems these have attracted lower insurance payments. Current research is moving away from dualistic theories, and recognising the importance of the whole person, both mind and body, in diagnosis and treatment of these conditions. People with functional disorders frequently describe experiences of doubt, blame, and of being seen as less 'genuine' than those with other disorders. Some clinicians perceive those individuals with functional disorders are imagining their symptoms, are malingering, or doubt the level of voluntary control they have over their symptoms. As a result, individuals with these disorders often wait long periods of time to be seen by specialists and receive appropriate treatment. Currently, there is a lack of specialised treatment services for functional disorders in many countries. However, research is growing in this area, and it is hoped that the implementation of the increased scientific understanding of functional disorders and their treatment will allow effective clinical services supporting individuals with functional disorders to develop. Patient membership organisations/advocate groups have been instrumental in gaining recognition for individuals with these disorders. Research Directions for research involve understanding more about the processes underlying functional disorders, identifying what leads to symptom persistence and improving integrated care/treatment pathways for patients. Research into the biological mechanisms which underpin functional disorders is ongoing. Understanding how stress effects the body over a lifetime, for example via the immune endocrine and autonomic nervous systems, is important Ying-Chih et.al 2020, Tak et. al. 2011, Nater et al. 2011). Subtle dysfunctions of these systems, for example through low grade chronic inflammation, or dysfunctional breathing patterns, are increasingly thought to underlie functional disorders and their treatment. However, more research is needed before these theoretical mechanisms can be used clinically to guide treatment for an individual patient. See also Idiopathic disease Functional gastrointestinal disorder Functional neurologic disorder Functional symptom Psychosomatic medicine References Diseases and disorders Medical terminology

Adverse childhood experiences

Adverse childhood experiences (ACEs) include childhood emotional, physical, or sexual abuse and household dysfunction during childhood. The categories are verbal abuse, physical abuse, contact sexual abuse, a battered mother/father, household substance abuse, household mental illness, incarcerated household members, and parental separation or divorce. The experiences chosen were based upon prior research that has shown to them to have significant negative health or social implications, and for which substantial efforts are being made in the public and private sector to reduce their frequency of occurrence. Scientific evidence is mounting that such adverse childhood experiences (ACEs) have a profound long-term effect on health. Research shows that exposure to abuse and to serious forms of family dysfunction in the childhood family environment are likely to activate the stress response, thus potentially disrupting the developing nervous, immune, and metabolic systems of children. ACEs are associated with lifelong physical and mental health problems that emerge in adolescence and persist into adulthood, including cardiovascular disease, chronic obstructive pulmonary disease, autoimmune diseases, substance abuse, and depression. Definition and types The concept of adverse childhood experiences refers to various traumatic events or circumstances affecting children before the age of 18 and causing mental or physical harm. There are 10 types of ACEs: Physical abuse: Any intentional act that causes physical harm through bodily contact. Sexual abuse: Any forceful, unwanted, or otherwise abusive sexual behavior. Psychological abuse: Any intentional act that causes psychological harm, such as gaslighting, bullying, or guilt-tripping. Physical neglect: Failure to help meet the basic biological needs of a child, such as food, water, and shelter. Psychological neglect: Failure to help meet the basic emotional needs of a child, such as attention and affection. Witnessing domestic abuse: Observing violence occurring between individuals in a domestic setting, such as between parents or other family members. Witnessing drug or alcohol abuse: Having a close family member who misused drugs or alcohol. Mental health problems: Having a close family member or otherwise important individual experience mental health problems. Imprisonment: Having a close family member or otherwise important individual serve time in prison. Parental separation or divorce: Parents or guardians separating or divorcing on account of a relationship breakdown. The different adverse childhood experiences are not isolated and in many cases multiple ACEs impact someone at the same time. Prevalence Adverse childhood experiences are common across all parts of societies, in 2009 the CDC started collecting data on the prevalence of ACEs as part of the Behavioral Risk Factor Surveillance System (BRFSS). In the first year data was collected across five US states and included over 24,000 people. The prevalence of each ACE ranged from a high of 29.1% for household substance abuse to a low of having an incarcerated family member (7.2%). Approximately one quarter (25.9%) of respondents reported verbal abuse, 14.8% reported physical abuse, and 12.2% reported sexual abuse. For ACEs measuring family dysfunction, 26.6% reported separated or divorced parents; 19.4% reported that they had lived with someone who was depressed, mentally ill, or suicidal; and 16.3% reported witnessing domestic violence. Men and women reported similar prevalences for each ACE, with the exception of sexual abuse (17.2% for women and 6.7% for men), living with a mentally ill household member (22.0% for women and 16.7% for men), and living with a substance-abusing family member (30.6% for women and 27.5% for men). Younger respondents more often reported living with an incarcerated and/or mentally ill household member. For each ACE, a sharp decrease was observed in prevalence reported by adults aged ≥55 years. For example, the prevalence of reported physical abuse was 16.9% among adults aged 18--24 years compared with 9.6% among those aged ≥55 years. Non-Hispanic black respondents reported the lowest prevalence of each ACE category among all racial/ethnic groups, with the exception of having had an incarcerated family member, parental separation or divorce, and witnessing domestic violence. Hispanics reported a higher prevalence than non-Hispanic whites of physical abuse, witnessing domestic violence, and having an incarcerated family member (p<0.05). Those respondents with less than a high school education compared with those with more than a high school education had a greater prevalence of physical abuse, an incarcerated family member, substance abuse, and separation/divorce. Among the five states, little variation was observed. Approximately 41% of respondents reported having no ACEs, 22% reported one ACE, and 8.7% reported five or more ACEs. Men (6.9%) were less likely to report five or more ACEs compared with women (10.3%). Respondents aged ≥55 years reported the fewest ACEs, but the younger age groups did not differ from one another. Non-Hispanic blacks were less likely to report five or more ACEs (4.9%) compared with non-Hispanic whites (8.9%), Hispanics (9.1%), and other non-Hispanics (11.7%). However, non-Hispanic black respondents were not significantly more likely to report zero ACEs compared with other racial/ethnic groups. Respondents with the lowest educational attainment were significantly more likely to report five or more ACEs compared with those with higher education levels (14.9% versus 8.7% among high school graduates and 7.7% in those with more than a high school education). Overall, little state-by-state variation was observed in the number of ACEs reported by each respondent. There are no reliable global estimates for the prevalence of child maltreatment. Data for many countries, especially low- and middle-income countries, are lacking. Current estimates vary widely depending on the country and the method of research used. Approximately 20% of women and 5–10% of men report being sexually abused as children, while 25–50% of all children report being physically abused. Health outcomes due to ACEs Childhood With one in four children experiencing or witnessing a potentially traumatic event, the relationship between ACEs and poor health outcomes has been established for years. With multiple adverse childhood experiences being equal to various stresses, and adversity. Children who grow up in an unsafe environment are at risk for developing adverse health outcomes, affecting brain development, immune systems, and regulatory systems. Adverse childhood experiences can alter the structural development of neural networks and the biochemistry of neuroendocrine systems and may have long-term effects on the body, including speeding up the processes of disease and aging and compromising immune systems. Further research on ACEs determined that children who experience ACEs are more likely than their similar-aged peers to experience challenges in their biological, emotional, social, and cognitive functioning. Also, children who have experienced an ACE are at higher risk of being re-traumatized or suffering multiple ACEs. The amount and types of ACEs can cause significant negative impacts and increase the risk of internalizing and externalizing in children. Additionally behavioral challenges can arise in children who have been exposed to ACEs including juvenile recidivism, reduced resiliency, and lower academic performance. Adulthood Adults with ACE exposure report having worse mental and physical health, more serious symptoms related to illnesses, and poorer life outcomes. Across numerous studies these effects go beyond behavioral and medical issues, and include damage to DNA, higher levels of stress hormones, and reduced immune function. The effects of ACEs goes beyond just physical and behavioral health with studies reporting that people with high ACEs scores showed less trust in government COVID-19 information and policies. Biological changes Due to many of the early life stressors caused by exposure to ACEs there are noted changes the body in people with ACE exposures compared to people with little to no ACE exposure. This is most evident in structural changes in the brain with the hippocampus, the amygdala, and the corpus callosum being important targets of study. These areas of the brain are more vulnerable than others due to the higher density of glucocorticoid receptors in these regions of the brain. Multiple effects have been noted including diminished thickness, reduced size, and reduced size of connective networks in the brain. Physical health ACEs have been linked to numerous negative health and lifestyle issues into adulthood across multiple countries and regions including the United States, the European Union, South Africa, and Asia. Across all these groups researchers have reported seeing the adoption of higher rates of unhealthy lifestyle behavior including sexual risk taking, smoking, heavy drinking, and obesity. The associations between these lifestyle issues and ACEs shows a dose response relationship with people having four or more ACEs have significantly more of these lifestyle problems. Physical health problems arise in people with ACEs with a similar dose response relationship. Chronic illnesses such as asthma, arthritis, cardiovascular disease, cancer, diabetes, stroke, and migraines show increased symptom severity in step with exposure to ACEs. Mental health Mental health issues have been well known in the face of childhood trauma and exposure to ACEs is no different. According to a large study conducted in 21 countries nearly one in three mental health conditions in adulthood are directly related to an adverse childhood experience. A study of high school students in Chicago showed significantly elevated levels of school problems, hyperactivity, and lower levels of personal adjustment as number of ACEs increased. Multiple mental health conditions found to have a dose response relationship with symptom severity and prevalence including depression, attention-deficit/hyperactivity disorder, anxiety suicidality, bipolar disorder and schizophrenia. Depressive symptoms in adulthood showed one of the strongest dose response relationships with ACEs, with an ACE score of one increasing the risk of depressive symptoms by 50% and an ACE score of four or more showing a fourfold increase. Later research also demonstrated that ACE scores are related to increased rates and severity of psychiatric and mental disorders, as well as higher rates of prescription psychotropic medication use. Special populations Additionally, epigenetic transmission may occur due to stress during pregnancy or during interactions between mother and newborns. Maternal stress, depression, and exposure to partner violence have all been shown to have epigenetic effects on infants. Implementing practices Globally knowledge about the prevalence and consequences of adverse childhood experiences has shifted policy makers and mental health practitioners towards increasing, trauma-informed and resilience-building practices. This work has been over 20 years in the making bringing together research are implemented in communities, education settings, public health departments, social services, faith-based organizations and criminal justice. Communities As knowledge about the prevalence and consequences of ACEs increases, more communities seek to integrate trauma-informed and resilience-building practices into their agencies and systems. Indigenous populations show similar patterns of mental and physical health challenges as other minority groups. Interventions have been developed in American Indian tribal communities and have demonstrated that social support and cultural involvement can ameliorate the negative physical health effects of ACEs. There is a paucity of empirical research documenting the experiences of communities who have attempted to implement information about ACEs and trauma-informed practice into widespread public action. A study on Pottstown, Pennsylvania's process demonstrated the challenges associated with community implementation. The Pottstown Trauma-Informed Community Connection (PTICC) initiative evolved from a series of prior collectives that all had similar goals of creating community resilience in order to prevent and treat ACEs. Over the course of the two-year study, over 230 individuals from nearly 100 organizations attended one training offered by the PTICC, raising the number of engaged public sectors from 2 to 14. Participation in training and events was fairly steady and this was largely due to community networking. However, the PTICC faced several challenges similar to those predicted by the Building Community Resilience model. These barriers included availability of resources over time, competition for power within the group, and the lack of systemic change needed to support long-term goals. Still, Pottstown has built a trauma-informed community foundation and offers lessons to other communities who have similar goals: start with a dedicated small team, identify community connectors, secure long-term financial backing, and conduct data-informed evaluations throughout. Other community examples exist, such as Tarpon Springs, Florida which became the first trauma-informed community in 2011. Trauma-informed initiatives in Tarpon Springs include trauma-awareness training for the local housing authority, changes in programs for ex-offenders, and new approaches to educating students with learning difficulties. Education ACEs exposure is widespread globally, one study from the National Survey of Children's Health in the United States reported that approximately 68% of children 0–17 years old had experienced one or more ACEs. The impact of ACEs on children can manifest in difficulties focusing, self regulating, trusting others, and can lead to negative cognitive effects. One study found that a child with 4 or more ACEs was 32 times more likely to be labeled with a behavioral or cognitive problem than a child with no ACEs. Another study found that students with at least three ACEs are three times as likely to experience academic failure, six times as likely to have behavioral problems, and five times as likely to have attendance problems. The trauma-informed school movement aims to train teachers and staff to help children self-regulate, and to help families that are having problems that result in children's normal response to trauma. It also seeks to provide behavioral consequences that will not re-traumatize a child. Trauma-informed education refers to the specific use of knowledge about trauma and its expression to modify support for children to improve their developmental success. The National Child Traumatic Stress Network (NCTSN) describes a trauma-informed school system as a place where school community members work to provide trauma awareness, knowledge and skills to respond to potentially negative outcomes following traumatic stress. The NCTSN published a study that discussed the Attachment, Self-Regulation, and Competency (ARC) model, which other researchers have based their subsequent studies of trauma-informed education practices off of. Trauma-sensitive or trauma-informed schooling has become increasingly popular in Washington, Massachusetts, and California in the last 10 years. In their 2002 survey, the AAUW reported that, of students who had been harassed, 38% were harassed by teachers or other school employees. One survey that was conducted with psychology students reports that 10% had sexual interactions with their educators; in turn, 13% of educators reported sexual interaction with their students. In a national survey conducted for the American Association of University Women Educational Foundation in 2000, it was found that roughly 290,000 students experienced some sort of physical sexual abuse by a public school employee between 1991 and 2000. A major 2004 study commissioned by the U.S. Department of Education found that nearly 10 percent of U.S. public school students reported having been targeted with sexual attention by school employees. Charol Shakeshaft, a researcher in the field, claimed that sexual abuse in public schools "is likely more than 100 times the abuse by priests." Literacy ACEs in childhood and adolescence can affect literacy development in many ways. Children who have faced trauma encounter more learning challenges in school and higher levels of stress internally. Building literacy skills can be negatively impacted both by the lack of literacy experiences in the home, missing parts of early-childhood education, and by actually altering brain development. There are techniques that can be employed by educators and clinicians to try and remediate the effects of the adverse experiences and move children forward in their literacy and educational development. ACEs affect parts of the brain that involve memory, executive functioning, and attention. The parts of the brain and hormones that register fear and stress are in overdrive, whereas the prefrontal cortex, which regulates executive functions, is compromised. This impacts impulse control, focus, and critical thinking. Memory is also a struggle as there is less capacity to process new input. The stress of ACEs creates a state of "fight, flight, or freeze" which leaves children unavailable for learning. The ability to process new information or collaborate with peers in school is eclipsed by the brain's necessity to survive the stress experienced in their environment outside of school. The inconsistency and instability of the home environment alters the many cognitive processes necessary for effective literacy acquisition.    Young people who are refugees experience trauma whether they were part of the immigration process or were born in the country (where they currently attend school) where the family settled. During this resettlement phase many of the second-generation refugee child's problems come to light. The disruption in education and instability in the home, as a result of the family's journey, can lead to gaps in exposures to literacy in the home . Literacy experiences outside of school include parents reading with kids and borrowing or buying books for the home. Early-childhood literacy education includes explicit teaching of reading and writing skills, building phonological awareness, and academic vocabulary. Resettlement affects children's phonemic awareness and exposure to academic vocabulary since many families are unable to fully provide these out of school experiences. If the child was non-English speaking, then they are acquiring English as a new language. There already exists an achievement gap between native-English speakers in the United States and students who are learning English as their second (or third or fourth) language. The resulting literacy issues from trauma, reflected in low reading scores, puts children with ACEs at-risk for grade retention. As students, they are almost twice as likely to leave high school without graduating. While there are many years from when a young child starts kindergarten and an adolescent enters high school, there is a link between weak emergent literacy leading to eventually dropping out of high school. It is crucial to intervene as early as possible.    Trauma-informed educators and clinicians can help remediate both young children and adolescents in school. With a knowledge and sensitivity of ACEs and their effects, proper and effective interventions can be implemented. This can also begin to create a stable environment in which children can learn and create stable attachments. Physical movement in the form of "brain energizers" can help regulate children's brains and alleviate stress when done 1–2 times during the school day. In one study, both behavior and literacy skills were assessed to see how effective the physical movement, or "brain energizers" were. Literacy scores for a classroom that used the brain energizers (which ranged from movement activities found online to other movement activities selected by the teacher and students), improved by 117% from beginning to end of year. In a school setting, the person who has experienced trauma and the person who is in the moment with the person trying to talk or write about it can connect, even when language fails to adequately describe the depth and complexity of the emotions felt. While there is an inherent discomfort in this, educators can embrace this discomfort and give children a space to express this, as best they can, in the classroom. Those who are able to develop more "resilience" might be able to function better in school, but this is dependent on the ratio of protective factors compared to ACEs. Social services Social service providers—including welfare systems, housing authorities, homeless shelters, and domestic violence centers – are adopting trauma-informed approaches that help to prevent ACEs or minimize their impact. Utilizing tools that screen for trauma can help a social service worker direct their clients to interventions that meet their specific needs. Trauma-informed practices can also help social service providers look at how trauma impacts the whole family. Trauma-informed approaches can improve child welfare services by openly discussing trauma and addressing parental trauma. The New Hampshire Division for Children Youth and Families (DCYF) is taking a trauma-informed approach to their foster care services by educating staff about childhood trauma, screening children entering foster care for trauma, using trauma-informed language to mitigate further traumatization, mentoring birth parents and involving them in collaborative parenting, and training foster parents to be trauma-informed. Housing authorities are also becoming trauma-informed. Supportive housing can sometimes recreate control and power dynamics associated with clients' early trauma. This can be reduced through trauma-informed practices, such as training staff to be respectful of clients' space by scheduling appointments and not letting themselves into clients' private spaces, and also understanding that an aggressive response may be trauma-related coping strategies. Up to 50% of people with housing insecurity experienced at least four ACEs. A study in the UK looked at the views of young people exposed to ACEs on what support they needed from social services. The study grouped the findings into three categories: emotional support, practical support and service delivery. Emotional support included interacting with other young people for support and a sense solidarity, and supportive relationships with adults that are based on empathy, active listening and non-judgement. Practical support meant information about the available services, practical advice about everyday challenges and respite from these challenges through recreation. Young people expected service delivery to be continuous and dependable, and they needed flexibility and control over the support processes. The needs of young people with ACEs were found not to match the types of support they are offered. Health care services Screening for or talking about ACEs with parents and children can help to foster healthy physical and psychological development and can help doctors understand the circumstances that children and their parents are facing. By screening for ACEs in children, pediatric doctors and nurses can better understand behavioral problems. Some doctors have questioned whether some behaviors resulting in attention deficit hyperactivity disorder (ADHD) diagnoses are in fact reactions to trauma. Children who have experienced four or more ACEs are three times as likely to take ADHD medication when compared with children with less than four ACEs. Screening parents for their ACEs allows doctors to provide the appropriate support to parents who have experienced trauma, helping them to build resilience, foster attachment with their children, and prevent a family cycle of ACEs. For people whose adverse childhood experiences were of abuse or neglect cognitive behavioural therapy has been studied and shown to be effective. Public health Objections to screening for ACEs include the lack of randomized controlled trials that show that such measures can be used to actually improve health outcomes, the scale collapses items and has limited item coverage, there are no standard protocols for how to use the information gathered, and that revisiting negative childhood experiences could be emotionally traumatic. Other obstacles to adoption include that the technique is not taught in medical schools, is not billable, and the nature of the conversation makes some doctors personally uncomfortable. Some public health centers see ACEs as an important way (especially for mothers and children) to target health interventions for individuals during sensitive periods of development. Resilience and resources Resilience is the ability to adapt or cope in the face of significant adversity and threats such as health problems, stress experienced in the workplace or home. Resiliency can mediate the relationship of the effects of ACEs and health problem in adulthood. Being able use emotion regulation resources such as cognitive reappraisal and mindfulness people are able to protect themselves from the potential negative effects of stressors. These skills can be taught to people but people living with ACEs score lower on measures of resilience and emotion regulation. Resilience and access to other resources are protective factors against the effects of exposure to ACEs. Increasing resilience in children can help provide a buffer for those who have been exposed to trauma and have a higher ACE score. People and children who have fostered resiliency have the skills and abilities to embrace behaviors that can foster growth. In childhood, resiliency and attachment security can be fostered from having a caring adult in a child's life. Adverse childhood experiences study The Adverse Childhood Experiences (ACE) Study was a collaborative effort between Kaiser Permanente (San Diego, CA) and the Centers for Disease Control and Prevention (Atlanta, GA) designed to examine the long-term relationship between adverse childhood experiences (ACEs) and a variety of health behaviours and health outcomes in adulthood. An underlying thesis of the ACE Study is that stressful or traumatic childhood experiences have negative neurodevelopmental impacts that persist over the lifespan and that increase the risk of a variety of health and social problems. The ACE Study was based at Kaiser Permanente's San Diego Health Appraisal Clinic, a primary care clinic where each year more than 50,000 adult members of the Kaiser Permanente Health Maintenance Organization receive an annual, standardized, biopsychosocial medical examination. Each member who visits the Health Appraisal Clinic completes a standardized medical questionnaire. The medical history is completed by a health care provider who also performs a general physical examination and reviews laboratory test results with the patient. Appointments for most members are obtained by self-referral with 20% referred by their health care provider. A review of Kaiser Permanente members aged 25 years or older in San Diego and continuously enrolled between 1992 and 1995 revealed that 81% of those members had been evaluated at the Health Appraisal Clinic. All Kaiser members who completed medical examinations at the Health Appraisal Clinic between August and November of 1995, between January and March of 1996 (Wave I: 13,494 persons), and between April and October of 1997 (Wave II: 13,330 persons) were eligible to participate in the ACE Study. Within two weeks after a member's visit to the Health Appraisal Clinic, a Study questionnaire was mailed asking questions about health behaviours and adverse childhood experiences. A total of 17,421 (68%) persons responded; 84 persons had incomplete information on race and educational attainment leaving 17,337 persons available in the baseline cohort. In the 1980s, the dropout rate of participants at Kaiser Permanente's obesity clinic in San Diego, California, was about 50%; despite all of the dropouts successfully losing weight under the program. Vincent Felitti, head of Kaiser Permanente's Department of Preventive Medicine in San Diego, conducted interviews with people who had left the program, and discovered that a majority of 286 people he interviewed had experienced childhood sexual abuse. The interview findings suggested to Felitti that weight gain might be a coping mechanism for depression, anxiety, and fear. Felitti and Robert Anda from the Centers for Disease Control and Prevention (CDC) went on to survey childhood trauma experiences of over 17,000 Kaiser Permanente patient volunteers. The 17,337 participants were volunteers from approximately 26,000 consecutive Kaiser Permanente members. About half were female; 74.8% were white; the average age was 57; 75.2% had attended college; all had jobs and good health care, because they were members of the Kaiser health maintenance organization. Participants were asked about different types of adverse childhood experiences that had been identified in earlier research literature: Physical abuse, Sexual abuse, Emotional abuse, Physical neglect, Emotional neglect, Exposure to domestic violence, Household substance abuse, Household mental illness, Parental separation or divorce, Incarcerated household member. Findings According to the United States' Substance Abuse and Mental Health Services Administration, the ACE study found that: Adverse childhood experiences are common. For example, 28% of study participants reported physical abuse and 21% reported sexual abuse. Many also reported experiencing a divorce or parental separation, or having a parent with a mental and/or substance use disorder. Adverse childhood experiences often occur together. Almost 40% of the original sample reported two or more ACEs and 12.5% experienced four or more. Because ACEs occur in clusters, many subsequent studies have examined the cumulative effects of ACEs rather than the individual effects of each. Adverse childhood experiences have a dose–response relationship with many health problems. As researchers followed participants over time, they discovered that a person's cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioral problems throughout their lifespan, including substance use disorders. Furthermore, many problems related to ACEs tend to be comorbid, or co-occurring. About two-thirds of individuals reported at least one adverse childhood experience; 87% of individuals who reported one ACE reported at least one additional ACE. The number of ACEs was strongly associated with adulthood high-risk health behaviors such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan. Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven-fold (700%) increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphysema; an ACE score above six was associated with a 30-fold (3000%) increase in attempted suicide. The ACE study's results suggest that maltreatment and household dysfunction in childhood contribute to health problems decades later. These include chronic diseases—such as heart disease, cancer, stroke, and diabetes—that are the most common causes of death and disability in the United States. These findings are important because they provided a link between the effects of child maltreatment and negative effects later in life which had not been established as clearly before this study. Subsequent surveys The ACE Study has produced more than 50 articles that look at the prevalence and consequences of ACEs. It has been influential in several areas. Subsequent studies have confirmed the high frequency of adverse childhood experiences. The original study questions have been used to develop a 10-item screening questionnaire. Numerous subsequent surveys have confirmed that adverse childhood experiences are frequent. The Behavioral Risk Factor Surveillance System (BRFSS) which is run by the CDC, is an annual survey conducted in waves by groups of individual state and territory health departments. An expanded ACE survey instrument was included in several states found each state. Adverse childhood experiences were even more frequent in studies in urban Philadelphia and in a survey of young mothers (mostly younger than 19). Surveys of adverse childhood experiences have been conducted in multiple EU member countries. See also Adverse childhood experiences among Hispanic and Latino Americans Adverse Childhood Experiences International Questionnaire Stress in early childhood Developmental impact of child neglect in early childhood Early childhood trauma Social determinants of health Verbal abuse References Further reading Center for Disease Control, Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence External links Adverse Childhood Experiences Resources Centers for Disease Control and Prevention ACEs and Toxic Stress FAQ, Harvard Center on the Developing Child Veto Violence Child abuse Human development Child development Determinants of health Initiatives Public health Articles with short description

Mental distress

Mental distress or psychological distress encompasses the symptoms and experiences of a person's internal life that are commonly held to be troubling, confusing or out of the ordinary. Mental distress can potentially lead to a change of behavior, affect a person's emotions in a negative way, and affect their relationships with the people around them. Certain traumatic life experiences (such as bereavement, stress, lack of sleep, use of drugs, assault, abuse, or accidents such as the death of a loved one) can induce mental distress. Those who are members of vulnerable populations might experience discrimination that places them at increased risk for experiencing mental distress as well. This may be something which resolves without further medical intervention, though people who endure such symptoms longer term are more likely to be diagnosed with mental illness. This definition is not without controversy as some mental health practitioners would use the terms "mental distress" and "mental disorder" interchangeably. Some users of mental health services prefer the term "mental distress" in describing their experience as they feel it better captures that sense of the unique and personal nature of their experience, while also making it easier to relate to, since everyone experiences distress at different times. The term also fits better with the social model of disability. Differences from mental disorder Some psychiatrists may use these two terms "mental distress" and "mental disorder" interchangeably. However, it can be argued that there are fundamental variations between mental distress and mental disorder. "Mental distress" has a wider scope than the related term "mental illness", which refers to a specific set of medically defined conditions. A person in mental distress may exhibit some of the broader symptoms described in psychiatry, without actually being 'ill' in a medical sense. People with mental distress may also exhibit temporary symptoms on a daily basis, while patients diagnosed with mental disorder may potentially have to be treated by a psychiatrist. Types The following are types of major mental distress: Anxiety disorder Post-traumatic stress disorder (PTSD) Depression Bipolar disorder Schizophrenia Symptoms and causes The symptoms for mental distress include a wide range of physical to mental conditions. Physical symptoms may include sleep disturbance, anorexia (lack of appetite), loss of menstruation for women, headaches, chronic pain, and fatigue. Mental conditions may include difficulty in anger management, compulsive/obsessive behavior, a significant change in social behavior, a diminished sexual desire, and mood swings. Minor mental distress cases are caused by stress in daily problems, such as forgetting your car keys or being late for an event. However, the major types of mental distress described can be caused by other important factors. One such cause is chemical imbalances in the brain, which can lead to irrational decisions and emotional pain. For example, when the brain lacks serotonin, a chemical that regulates the brain's functioning, it can lead to depression, appetite changes, aggression, and anxiety. Another cause of mental distress can be exposure to severely distressing life-threatening situations and experiences. A third cause, in very rare cases, can be inheritance. Some research has shown that very few people have the genetics for the potential to develop mental distress. However, there are many factors that must be accounted for. Mental distress is not a contagious disease that can be caught like the common cold. Mental distress is a psychological condition. In the United States African-Americans The social disparities associated with mental health in the Black community have remained constant over time. According to the Office of Minority Health, African Americans are 30% more likely than European Americans to report serious psychological distress. Moreover, Black people are more likely to have Major Depressive Disorder, and communicate higher instances of intense symptoms/disability. For this reason, researchers have attempted to examine the sociological causes and systemic inequalities which contribute to these disparities in order to highlight issues for further investigation. Nonetheless, much of the research on the mental well-being of Black people are unable to separate race, culture, socioeconomic status, ethnicity, or behavioural and biological factors. According to Hunter and Schmidt (2010), there are three distinct beliefs embraced by Black people which speak to their socio-cultural experience in the United States: racism, stigma associated with mental illness, and the importance of physical health. African Americans are less likely to report depression due to heavy social stigma within their community and culture. These social aspects of mental health can generate distress. Therefore, discrimination within the healthcare community and larger society, attitudes related to mental health, and general physical health contribute to the mental well-being of Black people. There are also disparities with mental health among Black women. One of the reasons why Black women tend to neglect mental health support and treatment is the aura of the Strong Black Woman schema or S.B.W. According to Watson and Hunter, scholars have traced the origins of the S.B.W. race-gender schema to slavery and have suggested that the schema persist because of the struggles that African-American women continue to experience, such as financial hardship, racism, and sexism. Watson and Hunter state that due to the Strong Black Woman schema, Black women have a tendency to handle tough and difficult situations alone. African-American youth Comparable to their adult counterparts, Black adolescents experience mental health disparities. The primary reasons for this have been stipulated to be discrimination, inadequate treatment, and underutilization of mental health services, though Black youth have been shown to have higher self-esteem than their white counterparts. Similarly, children of immigrants, or second-generation Americans, often encounter barriers to optimal mental well-being. Discrimination and its effects on mental health are evident in adolescents' ability to achieve in school and overall self-esteem. Researchers have been unable to pinpoint exact causes for Black teenagers' underutilization of mental health services. One study attributed it to using alternative methods of support instead of formal treatments. Moreover, Black youth used other means of support such as peers and spiritual leaders. This demonstrates that Black teens are uncomfortable disclosing personal matters to professionals. It is difficult to decipher if this is cultural or a youth-related issue, as most teens do not choose to access formal providers for their mental health needs. Common stigma among immigrants "Mental health stigma, particularly personal stigma, is important because those who hold stigma beliefs are less willing to obtain the needed treatment (1-9). Often due to stigma, individuals will avoid treatment until the disorder is nearly incapacitating. This avoidance is particularly pronounced in members of ethnic minority groups because they are less likely to seek mental health treatment than those of European Americans [e.g., Ref. (4, 10–12)]. Expressly, Immigrants who hold personal stigma against mental illness are less likely to seek treatment. Its often that immigrants feel stigmatized because they're already undocumented which makes them feel embarrassed, causing them to refrain from treatment. Demographic and societal factors There has been a history of disparity and exclusion in regards to the treatment of Black Americans which consists of slavery, imprisonment in the criminal justice system, the inability to vote, marry, attend school, or own property amongst other factors. These factors have attributed to the increase of mental distress in the Black community and due to the lack of resources afforded/known in the community also leads to a lack of resources and treatments available for members of the community to seek and receive some for of help. LGBTQ+ Community Those who identify as part of the LGBTQ+ community have a higher risk of experiencing mental distress, most likely as a result of continued discrimination and victimization. Members of this population are often confronted with derogatory and hateful comments (physically and/or through social media). This discrimination has the potential of affecting their feelings of self-worth and confidence, leading to anxiety, depression, and even suicidality. It is for this reason that members of the LGBTQ+ community may experience higher rates of mental distress than their cisgender and heterosexual counterparts. Along with the increased risk of experiencing mental distress, members of this community may refrain from seeking mental health care due to past discrimination by medical professionals. In addition to the lack of knowledge and research with this population, this group is marginalized due to the lack of funding as most of the funds go to campaigns for the younger LGBTQ+ population. A study published in 2021 found that "LGBTQ+ students experienced more bullying and psychological distress". References Further reading External links Mental Distress Changes Psychological stress

Forensic psychiatry

Forensic psychiatry is a subspeciality of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry. According to the American Academy of Psychiatry and the Law, it is defined as "a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment." A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment, such as medications and psychotherapy, to criminals. Court work Forensic psychiatrists work with courts in evaluating an individual's competency to stand trial, defenses based on mental disorders (e.g., the insanity defense), and sentencing recommendations. The two major areas of criminal evaluations in forensic psychiatry are competency to stand trial (CST) and mental state at the time of the offense (MSO). Competency to stand trial Competency to stand trial (CST) is the competency evaluation to determine that defendants have the mental capacity to understand the charges and assist their attorneys. In the United States, this is seated in the Fifth Amendment to the United States Constitution, which ensures the right to be present at one's trial, to face one's accusers, and to have help from an attorney. CST, sometimes referred to as adjudicative competency, serves three purposes: "preserving the dignity of the criminal process, reducing the risk of erroneous convictions, and protecting defendants' decision-making autonomy". In 1960, the Supreme Court of the United States in Dusky v. United States established the standard for federal courts, ruling that "the test must be whether the defendant has sufficient present ability to consult with his attorney with a reasonable degree of rational understanding and a rational as well as factual understanding of proceedings against him." The evaluations must assess a defendant's ability to assist their legal counsel, meaning that they understand the legal charges against them, the implications of being a defendant, and the adversarial nature of the proceedings, including the roles played by defense counsel, prosecutors, judges, and the jury. They must be able to communicate relevant information to their attorney, and understand information provided by their attorney. Finally, they must be competent to make important decisions, such as whether or not to accept a plea agreement. In England, Wales, Scotland, and Ireland, a similar legal concept is that of "fitness to plead". As an expert witness Forensic psychiatrists are often called to be expert witnesses in both criminal and civil proceedings. Expert witnesses give their opinions about a specific issue. Often, the psychiatrist will have prepared a detailed report before testifying. The primary duty of the expert witness is to provide an independent opinion to the court. An expert is allowed to testify in court with respect to matters of opinion only when the matters in question are not ordinarily understandable to the finders of fact, be they judge or jury. As such, prominent leaders in the field of forensic psychiatry, from Thomas Gutheil to Robert Simon and Liza Gold and others have identified teaching as a critical dimension in the role of expert witness. The expert will be asked to form an opinion and to testify about that opinion, but in so doing will explain the basis for that opinion, which will include important concepts, approaches, and methods used in psychiatry. Mental state opinion Mental state opinion (MSO) gives the court an opinion, and only an opinion, as to whether a defendant was able to understand what he/she was doing at the time of the crime. This is worded differently in many states, and has been rejected altogether in some, but in every setting, the intent to do a criminal act and the understanding of the criminal nature of the act bear on the final disposition of the case. Much of forensic psychiatry is guided by significant court rulings or laws that bear on this area which include these three standards: M'Naghten rules: Excuses a defendant who, by virtue of a defect of reason or disease of the mind, does not know the nature and quality of the act, or, if he or she does, does not know that the act is indeed wrong. Durham rule: Excuses a defendant whose conduct is the product of mental disorder. ALI test: Excuses a defendant who, because of a mental disease or defect, lacks substantial capacity to appreciate the criminality (wrongfulness) of his or her conduct or to conform his conduct to the requirements of law. "Not guilty by reason of insanity" (NGRI) is one potential outcome in this type of trial. Importantly, insanity is a legal and not a medical term. Often, psychiatrists may be testifying for both the defense and the prosecution. Forensic psychiatrists are also involved in the care of prisoners, both in jails and prisons, and in the care of the mentally ill who have committed criminal acts (such as those who have been found not guilty by reason of insanity). Forensic psychiatry vs psychology Forensic psychiatry Forensic psychiatrists focus on how biology applies to the legal system. They focus more on the scientific facts as well as diagnosing and treating mental disorders. They legally assess clients, provide a diagnosis, and can prescribe medication if necessary. They are licensed medical doctors (MD) that make roughly $190,000 annually. Forensic psychology Forensic psychologists examine how different disorders and conditions can apply in court. Their jobs typically entail working as research assistants and probation officers. They often determine trial competency, assess the risk of inmates, and aid in jury selection. Forensic psychologists can use information learned about mental health and criminal justice to advocate for those who are mentally ill. After earning a master's and a PhD in psychology or a Doctor of Psychology, PsyD, they can become forensic psychologists. While they are required to be licensed by the state, they are not required to be medical doctors. This means that they cannot prescribe medication. Forensic psychologists make roughly $67,000 annually. Risk management Many past offenders against other people, and suspected or potential future offenders with mental health problems or an intellectual or developmental disability, are supervised in the community by forensic psychiatric teams made up of a variety of professionals, including psychiatrists, psychologists, nurses, and care workers. These teams have dual responsibilities: to promote both the welfare of their clients and the safety of the public. The aim is not so much to predict as to prevent violence, by means of risk management. Risk assessment and management is a growth area in the forensic field, with much Canadian academic work being done in Ontario and British Columbia. This began with the attempt to predict the likelihood of a particular kind of offense being repeated, by combining "static" indicators from personal history and offense details in actuarial instruments such as the RRASOR and Static-99, which were shown to be more accurate than unaided professional judgment. More recently, use is being made also of "dynamic" risk factors, such as attitudes, impulsivity, mental state, family and social circumstances, substance use, and the availability and acceptance of support, to make a "structured professional judgment." The aim of this is to move away from prediction to prevention, by identifying and then managing risk factors. This may entail monitoring, treatment, rehabilitation, supervision, and victim safety planning and depends on the availability of funding and legal powers. Risk management in forensic psychiatry is often done using standardised tests called structured professional judgement tools. Two such tools include the HCR-20 and the newer SAPROF developed in the late 2010s. These tools are used to measure the likelihood of recidivism and identify protective factors for offenders. United Kingdom In the UK, most forensic psychiatrists work for the National Health Service, in specialist secure units caring for mentally ill offenders (as well as people whose behaviour has made them impossible to manage in other hospitals). These can be either medium secure units (of which there are many throughout the country) or high secure hospitals (also known as special hospitals), of which three are in England and one in Scotland (the State Hospital, Carstairs), the best known of which is Broadmoor Hospital. The other 'specials' are Ashworth hospital in Maghull, Liverpool, and Rampton hospital in Nottinghamshire. Also, a number of private-sector medium secure units sell their beds exclusively to the NHS, as not enough secure beds are available in the NHS system. Forensic psychiatrists often also do prison inreach work, in which they go into prisons and assess and treat people suspected of having mental disorders; much of the day-to-day work of these psychiatrists comprises care of very seriously mentally ill patients, especially those with schizophrenia. Some units also treat people with severe personality disorder or learning disabilities. The areas of assessment for courts are also somewhat different in Britain, because of differing mental health law. Fitness to plead and mental state at the time of the offence are indeed issues given consideration, but the mental state at the time of trial is also a major issue, and this assessment most commonly leads to the use of mental health legislation to detain people in hospitals, as opposed to their getting a prison sentence. Learning-disabled offenders who are a continuing risk to others may be detained in learning-disability hospitals (or specialised community-based units with a similar regimen, as the hospitals have mostly been closed). This includes those who commit serious crimes of violence, including sexual violence, and fire-setting. They would be cared for by learning disability psychiatrists and registered learning disability nurses. Some psychiatrists doing this work have dual training in learning disability and forensic psychiatry or learning disability and adolescent psychiatry. Some nurses would have training in mental health, also. Court work (medicolegal work) is generally undertaken as private work by psychiatrists (most often forensic psychiatrists), as well as forensic and clinical psychologists, who usually also work within the NHS. This work is generally funded by the Legal Services Commission (used to be called Legal Aid). United States Forensic psychiatrists typically work with attorneys and judges. Their purpose is to mediate psychiatric-legal issues that require a more professional perspective. Their scope of practice also includes helping their clients improve their mental status. A few duties that are typically expected of a forensic psychiatrist include determining readiness for parole, conducting assessments to determine any mental issues, evaluating injuries and their effects on the client, and determining competency. All of these tasks have one thing in common: their main focus is on evaluating capacity and competence. These workers play an important role in combating the phenomenon of "double revolving doors" between hospitals and prisons. Many mentally ill patients will rotate between hospitals and prisons because they are not getting the help they need. Legal decisions affecting psychiatric patients are not made lightly and require an in-depth analysis of anyone involved. Forensic psychiatrists have a background in both the medical aspect of psychiatry as well as the legal aspects of a courtroom. Canada Criminal law framework In Canada, certain credentialed medical practitioners may, at their discretion, make state-sanctioned investigations into and diagnosis of mental illness. Appropriate use of the DSM-IV-TR is discussed in its section entitled "Use of the DSM-IV-TR in Forensic Settings". Concerns have been expressed that the Canadian criminal justice system discriminates based on DSM IV diagnosis within the context of Part XX of the Criminal Code. This part sets out provisions for, among other things, court ordered attempts at "treatment" before individuals receive a trial as described in section 672.58 of the Criminal Code. Also provided for are court ordered "psychiatric assessments". Critics have also expressed concerns that use of the DSM-IV-TR may conflict with section 2(b) of the Canadian Charter of Rights and Freedoms, which guarantees the fundamental freedom of "thought, belief, opinion, and expression". Confidentiality The position of the Canadian Psychiatric Association holds, "in recent years, serious incursions have been made by governments, powerful commercial interests, law enforcement agencies, and the courts on the rights of persons to their privacy." It goes on to state, "breaches or potential breaches of confidentiality in the context of therapy seriously jeopardize the quality of the information communicated between patient and psychiatrist and also compromise the mutual trust and confidence necessary for effective therapy to occur." An outline of the forensic psychiatric process as it occurs in the province of Ontario is presented in the publication The Forensic Mental Health System In Ontario: An Information Guide published by the Centre for Addiction and Mental Health in Toronto. The Guide states: "Whatever you tell a forensic psychiatrist and the other professionals assessing you is not confidential." The Guide further states: "The forensic psychiatrist will report to the court using any available information, such as: police and hospital records, information given by your friends, family or co-workers, observations of you in the hospital." Also according to the Guide: "You have the right to refuse to take part in some or all of the assessment. Sometimes your friends or family members will be asked for information about you. They have the right to refuse to answer questions, too." Of note, the emphasis in the guide is on the right to refuse participation. This may seem unusual given that a result of a verdict of "Not Criminally Responsible by reason of Mental Disorder" is often portrayed as desirable to the defence, similar to the insanity defense in the United States. A verdict of "Not Criminally Responsible" is referred to as a "defence" by the Criminal Code. However, the issue of the accused's mental state can also be raised by the Crown or by the court itself, rather than solely by the defence counsel, differentiating it from many other legal defences. Treatment/assessment conflict In Ontario, a court-ordered inpatient forensic assessment for criminal responsibility typically involves both treatment and assessment being performed with the accused in the custody of a single multidisciplinary team over a 30- or 60-day period. Concerns have been expressed that an accused may feel compelled on ethical, medical, or legal grounds to divulge information, medical, or otherwise, to assessors in an attempt to allow for and ensure safe and appropriate treatment during that period of custody. Some Internet references address treatment/assessment conflict as it relates to various justice systems, particularly civil litigation in other jurisdictions. The American Academy Of Psychiatry and the Law states in its ethics guidelines, "when a treatment relationship exists, such as in correctional settings, the usual physician-patient duties apply", which may be seen as contradiction. South Africa In South Africa, patients are referred for observation for a period of 30 days by the courts if questions exist as to CST and MSO. Serious crimes require a panel, which may include two or more psychiatrists. Should the courts find the defendant not criminally responsible, the defendant may become a state patient and be admitted in a forensic psychiatric hospital. They are referred to receive treatment for an indefinite period, but most were back in the community after three years. Educational requirements A psychiatrist is a medical doctor who has completed undergraduate school, medical school, and residency training. Forensic psychiatrists typically have additional training that is relevant to the job they hold (such as a focus in child/adolescent, geriatric, or addiction). Many forensic psychiatrists will complete a more specific training after their residency in a related area. This training typically lasts another one or two years. Because they have earned a doctorate in medicine (MD), they are able to both diagnose and treat disorders related to their mental state. They are also able to prescribe medication. Training standards Some practitioners of forensic psychiatry have taken extra training in that specific area. In the United States, one-year fellowships are offered in this field to psychiatrists who have completed their general psychiatry training. Such psychiatrists may then be eligible to sit for a board certification examination in forensic psychiatry. In Britain, one is required to complete a three-year subspeciality training in forensic psychiatry, after completing one's general psychiatry training, before receiving a Certificate of Completion of Training as a forensic psychiatrist. In some countries, general psychiatrists can practice forensic psychiatry, as well. However, other countries, such as Japan, require a specific certification from the government to do this type of work. See also Forensic psychology Daubert v. Merrell Dow Pharmaceuticals, Inc. which established the Daubert standard delimiting the admissibility of scientific expert witness testimony Rennie v. Klein - right to refuse treatment Kansas v. Hendricks - involuntary civil commitment for sexual predators Ultimate issue Twinkie defense Bruneri-Canella case, an early landmark case which introduced new forensic techniques in juridic debate References External links Studies in Forensic Psychiatry, by Bernard Glueck, Sr., 1916, reprinted 1969, from Project Gutenberg The Role of a Forensic Psychiatrist in Legal Proceedings, by Harold J. Bursztajn, MD, 1993, from Journal of the Massachusetts Academy of Trial Attorneys with permission of Harold J. Bursztajn, MD. Forensic psychiatry, by Samuel Lézé, Ph.D, 2014, from Andrew Scull (ed.), Cultural Sociology of Mental Illness : an A-to-Z Guide, Sage, pp. 313–14 MedicoLegal Psychiatry

Biopsychosocial model

Biopsychosocial models are a class of trans-disciplinary models which look at the interconnection between biology, psychology, and socio-environmental factors. These models specifically examine how these aspects play a role in a range of topics but mainly psychiatry, health and human development.   The term is generally used to describe a model advocated by George L. Engel in 1977. The model builds upon the idea that "illness and health are the result of an interaction between biological, psychological, and social factors." which according to Derick T. Wade and Peter W. Halligan, as of 2017, is generally accepted.  The idea behind the model was to express mental distress as a triggered response of a disease that a person is genetically vulnerable when stressful life events occur. In that sense, it is also known as vulnerability-stress model. It is now referred to as a generalized model that interprets similar aspects, and has become an alternative to the biomedical and/or psychological dominance of many health care systems. The biopsychosocial model has been growing in interest for researchers in healthcare and active medical professionals in the past decade. History George L. Engel and Jon Romano of the University of Rochester in 1977, are widely credited with being the first to propose a biopsychosocial model. However, it had been proposed 100 years earlier and by others. Engel struggled with the then-prevailing biomedical approach to medicine as he strove for a more holistic approach by recognizing that each patient has their own thoughts, feelings, and history. In developing his model, Engel framed it for both illnesses and psychological problems. The biopsychosocial model is not just one of many competing possibilities - another intelligently constructed explanation of health. Its emergence is best understood within a historical context. The biopsychosocial model's emergence in psychiatry was influenced by the credibility problem in psychiatry as a medical specialism that arose during wartime conditions.   By the 20th century, psychiatry was still a relatively new field. In the Victorian era, psychiatry was faced with two key challenges: firstly, taking control of the asylum system from lay administrators and secondly, constructing a credible knowledge base for medical authority over mental illness. At the time, the solution to this was developing a rhetoric of justification for psychiatry which was that the brain is the root of insanity, and physicians are the guardians of mental health. This position both reflected and contributed to the rise of eugenics thought in western intellectual culture. However, this was challenged by the shellshock problem after World War I – there was a fundamental incompatibility between a eugenic view of lunacy and the sad reality of respectable men breaking down with predictable regularity in the war trenches. This led to the recognition of neurosis and acceptance of psychoanalysis in psychiatric discourse. A year after the end of the war, the British Psychoanalytical Society and the Medical Section of the British Psychological Society were both established, marking the start of a nuanced interplay between biological psychiatry and medical psychotherapy. The Tavistock Clinic played a significant role in bridging the gap between these approaches and favoured a unified psychosomatic approach. Under these conditions, the biopsychosocial model was set up to revolutionise our understanding of psychiatry and health. There are a number of key theorists that predate the biopsychosocial model. For example, Engel broadened medical thinking by re-proposing a separation of body and mind. The idea of mind–body dualism goes back at least to René Descartes, but was forgotten during the biomedical approach. Engel emphasized that the biomedical approach is flawed because the body alone does not contribute to illness. Instead, the individual mind (psychological and social factors) play a significant role in how an illness is caused and how it is treated. Engel proposed a dialogue between the patient and the doctor in order to find the most effective treatment solution. The idea that there are several factors that may contribute to one's mental suffering is nothing new. Past psychologists such as Urie Bronfenbrenner, popularized the belief that social factors play a role in developing illnesses and behaviors. Simply, Engel used Bronfenbrenner's research as a column of his biopsychosocial model and framed this model to display health at the center of social, psychological, and biological aspects. Adolf Meyer's psychobiology model is considered the forerunner to the biopsychosocial model by many. Meyer emphasised understanding mental illness in the context of a patient's personal history over diagnostic categories. Meyer laid down the groundwork for understanding the interplay of psychology and biology but tended to view these as separate entities that interacted. Engel's model represents a broader and more integrated approach that considers biological, psychological, and social factors as interconnected elements. However, Roy Grinker actually coined the term 'biopsychosocial' long before Engel (1954 vs 1977). The difference between the two researchers is that Grinker sought to highlight biological aspects of mental health. Engel instead emphasised psychosocial aspects of general health. After publication, the biopsychosocial model was adopted by the World Health Organization (WHO) in 2002 as a basis for the International Classification of Function (ICF). However, The WHO definition of health adopted in 1948 clearly implied a broad socio-medical perspective. Patient Populations The patients that fall under the biopsychosocial model may not fall under the biomedical model, as the biopsychosocial model considers factors that may not physiologically manifest in a person. By broadening the scope of patients that are encompassed in healthcare, the biopsychosocial model incorporates the idea of non-biological factors such as socioeconomic status, race, and sex to be important components to one's health along with the common biological indicators. Until recent years, the conventional method for handling health and illness centered around the medical or biological model, concentrating solely on medical interventions to address an individual's health issues. While this approach was once deemed sufficient, contemporary research within psychology and the social sciences has cast doubt on its effectiveness. Scholars are now working on developing a broader health model, incorporating insights from psychology and social sciences, with the intention of improving its practical application in clinical settings. Patient populations that the biopsychosocial model accounts for that may not be considered under the biomedical model include those affected by health inequities and those at risk of infirmity.   Health inequities, often rooted in social determinants of health, highlight the disparities in health outcomes experienced by different populations. The biopsychosocial model, which considers biological, psychological, and social factors in understanding health, provides a framework for comprehending how these disparities arise and persist, which makes it a model of interest in targeting health inequities. A holistic biopsychosocial model approach considers additional elements influencing the perceived necessity for healthcare and the focus on health-related matters: Information, Beliefs, and Conduct. Based on the model's dependence on perception, it has been considered imperative to actively engage the individuals or communities whose requirements are being addressed, regardless of whether the focus is on their health, education, employment, housing, or any other needs. A key term in the biopsychosocial model is "syndemic" which refers to a set of health problem factors that interact synergistically with each other ranging from socioeconomic status to genetics. Preventative medicine is a large component of biopsychosocial model which considers preventative measures to stop patients from obtaining infirmity in the first place. By combatting preventable chronic diseases which make up a majority of deaths in patients of the US, the BPS model has been considered a potential tool to improve patient outcomes. Biopsychosocial model vs. Biomedical model The biomedical and biopsychosocial models offer distinct perspectives on understanding and addressing health and illness. The biomedical model, historically prevalent, takes a reductionist approach by focusing on biological factors and treating diseases through medical interventions. In contrast, the biopsychosocial model adopts a holistic viewpoint, acknowledging the complex interplay of biological, psychological, and social factors in shaping health and illness. Unlike the biomedical model, which sees diseases as isolated physical abnormalities, the biopsychosocial model views them as outcomes of dynamic interactions among various dimensions. Treatment under the biopsychosocial model is comprehensive, involving medical, psychological, and social interventions to address overall well-being. This model emphasizes the interconnectedness of these dimensions, recognizing their mutual influence on an individual's health. Institutional Recognition of the Biopsychosocial model In the last decade, there has been a rising interest among healthcare researchers and practicing medical professionals in the biopsychosocial model. However, despite the rising interest, medical schools have had limited use of the model in their curriculums relative to the increasing literature about the model. Current status of the model The biopsychosocial model is still widely used as both a philosophy of clinical care and a practical clinical guide useful for broadening the scope of a clinician's gaze. Borrell-Carrió and colleagues reviewed Engel's model 25 years on. They proposed the model had evolved into a biopsychosocial and relationship-centered framework for physicians. They proposed three clarifications to the model, and identified seven established principles. Self-awareness. Active cultivation of trust. An emotional style characterized by empathic curiosity. Self-calibration as a way to reduce bias. Educating the emotions to assist with diagnosis and forming therapeutic relationships. Using informed intuition. Communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. Gatchel and colleagues argued in 2007 the biopsychosocial model is the most widely accepted as the most heuristic approach to understanding and treating chronic pain. Relevant theories and theorists Other theorists and researchers are using the term biopsychosocial, or sometimes bio-psycho-social to distinguish Engel's model. Lumley and colleagues used a non-Engel model to conduct a biopsychosocial assessment of the relationship between and pain and emotion. Zucker and Gomberg used a non-Engel biopsychosocial perspective to assess the etiology of alcoholism in 1986. Crittenden considers the Dynamic-Maturational Model of Attachment and Adaptation (DMM), to be a biopsychosocial model. It incorporates many disciplines to understand human development and information processing. Kozlowska's Functional Somatic Symptoms model uses a biopsychosocial approach to understand somatic symptoms. Siegel's Interpersonal Neurobiology (IPNB) model is similar, although, perhaps to distinguish IPNB from Engel's model, he describes how the brain, mind, and relationships are part of one reality rather three separate elements. Most trauma informed care models are biopsychosocial models. Biopsychosocial research Wickrama and colleagues have conducted several biopsychosocial-based studies examining marital dynamics. In a longitudinal study of women divorced midlife they found that divorce contributed to an adverse biopsychosocial process for the women. In another study of enduring marriages, they looked to see if hostile marital interactions in the early middle years could wear down couples regulator systems through greater psychological distress, more health-risk behaviors, and a higher body mass index (BMI). Their findings confirmed negative outcomes and increased vulnerability to later physical health problems for both husbands and wives. Kovacs and colleagues meta-study examined the biopsychosocial experiences of adults with congenital heart disease. Zhang and colleagues used a biopsychosocial approach to examine parents own physiological response when facing children's negative emotions, and how it related to parents’ ability to engage in sensitive and supportive behaviors. They found parents’ physiological regulatory functioning was an important factor in shaping parenting behaviors directed toward children's emotions. A biopsychosocial approach was used to assess race and ethnic differences in aging and to develop the Michigan Cognitive Aging Project. Banerjee and colleagues used a biopsychosocial narrative to describe the dual pandemic of suicide and COVID-19. Potential applications When Engel first proposed the biopsychosocial model it was for the purpose of better understanding health and illness. While this application still holds true the model is relevant to topics such as health, medicine, and development. Firstly, as proposed by Engel, it helps physicians better understand their whole patient. Considering not only physiological and medical aspects but also psychological and sociological well-being. Furthermore, this model is closely tied to health psychology. Health psychology examines the reciprocal influences of biology, psychology, behavioral, and social factors on health and illness. One application of the biopsychosocial model within health and medicine relates to pain, such that several factors outside an individual's health may affect their perception of pain. For example, a 2019 study linked genetic and biopsychosocial factors to increased post-operative shoulder pain. Future studies are needed to model and further explore the relationship between biopsychosocial factors and pain. The developmental applications of this model are equally relevant. One particular advantage of applying the biopsychosocial model to developmental psychology is that it allows for an intersection within the nature versus nurture debate. This model provides developmental psychologists a theoretical basis for the interplay of both hereditary and psychosocial factors on an individual's development. In gender Within the framework of the biopsychosocial model, gender is regarded by some as a complex and nuanced construct, shaped by the intricate interplay of social, psychological, and biological factors. This perspective, as echoed by the Gender Spectrum Organization, defines gender as the multifaceted interrelationship between three key dimensions: body, identity, and social gender. In essence, this characterization aligns with the fundamental principles of the biopsychosocial model, emphasizing the need to consider not only biological determinants but also the profound influences of psychological and social contexts on the formation of gender. According to the insights of Alex Iantaffi and Meg-John Barker, the biopsychosocial model provides a comprehensive framework to understand the complexities of gender. They illustrate that biological, psychological, and social factors are not isolated entities but rather intricately intertwined elements that continually interact and shape one another. In this dynamic process, a person's gender identity emerges as the result of a complex interplay between their biological characteristics, psychological experiences, and social interactions. This holistic perspective is in harmony with the biopsychosocial model's approach, which acknowledges the inseparable connection between these various dimensions in influencing an individual's overall well-being. In essence, within the biopsychosocial paradigm, gender is not merely a product of biological determinants; rather, it is a dynamic and interconnected aspect of human identity. This perspective urges a more nuanced understanding, encouraging researchers and medical professionals to consider the intricate interplay of social, psychological, and biological factors when exploring and addressing the complexities of gender. Criticisms There have been a number of criticisms of Engel's biopsychosocial model. Benning summarized the arguments against the model including that it lacked philosophical coherence, was insensitive to patients' subjective experience, was unfaithful to the general systems theory that Engel claimed it be rooted in, and that it engendered an undisciplined eclecticism that provides no safeguards against either the dominance or the under-representation of any one of the three domains of bio, psycho, or social. Psychiatrist Hamid Tavakoli argues that Engel's biopsychosocial model should be avoided because it unintentionally promotes an artificial distinction between biology and psychology, and merely causes confusion in psychiatric assessments and training programs, and that ultimately it has not helped the cause of trying to de-stigmatize mental health. The perspectives model does not make that arbitrary distinction. A number of these criticisms have been addressed over recent years. For example, the biopsychosocial pathways model describes how it is possible to conceptually separate, define, and measure biological, psychological, and social factors, and thereby seek detailed interrelationships among these factors. While Engel's call to arms for a biopsychosocial model has been taken up in several healthcare fields and developed in related models, it has not been adopted in acute medical and surgical domains, as of 2017. References Interdisciplinary branches of psychology

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD and anxiety disorders. Cognitive behavioral therapy focuses on challenging and changing cognitive distortions (such as thoughts, beliefs, and attitudes) and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health and other conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies. CBT is a common form of talk therapy based on the combination of the basic principles from behavioral and cognitive psychology. It is different from other approaches to psychotherapy, such as the psychoanalytic approach, where the therapist looks for the unconscious meaning behind the behaviors and then formulates a diagnosis. Instead, CBT is a "problem-focused" and "action-oriented" form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist's role is to assist the client in finding and practicing effective strategies to address the identified goals and to alleviate symptoms of the disorder. CBT is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of many psychological disorders and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms. When compared to psychoactive medications, review studies have found CBT alone to be as effective for treating less severe forms of depression, and borderline personality disorder. Some research suggests that CBT is most effective when combined with medication for treating mental disorders, such as major depressive disorder. CBT is recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and conduct disorder. Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults. Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice. History Early roots The prevailing body of research consistently indicates that maintaining a faith or belief system generally contributes positively to mental well-being. Religious institutions have proactively established charities, such as the Samaritans, to address mental health issues. Cognitive behavioral therapy has undergone scrutiny as studies investigating the impact of religious belief and practices have gained prominence. Numerous randomized controlled trials have explored the correlation of CBT within diverse religious frameworks, including Judaism, Taoism, and predominantly, Christianity. Buddhism Principles originating from Buddhism have significantly impacted the evolution of various new forms of CBT, including dialectical behavior therapy, mindfulness-based cognitive therapy, spirituality-based CBT, and compassion-focused therapy. Philosophy Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism. Stoic philosophers, particularly Epictetus, believed logic could be used to identify and discard false beliefs that lead to destructive emotions, which has influenced the way modern cognitive-behavioral therapists identify cognitive distortions that contribute to depression and anxiety. Aaron T. Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers". Another example of Stoic influence on cognitive theorists is Epictetus on Albert Ellis. A key philosophical figure who influenced the development of CBT was John Stuart Mill through his creation of Associationism, a predecessor of classical conditioning and behavioral theory. The modern roots of CBT can be traced to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Behavioral therapy Groundbreaking work of behaviorism began with John B. Watson and Rosalie Rayner's studies of conditioning in 1920. Behaviorally-centered therapeutic approaches appeared as early as 1924 with Mary Cover Jones' work dedicated to the unlearning of fears in children. These were the antecedents of the development of Joseph Wolpe's behavioral therapy in the 1950s. It was the work of Wolpe and Watson, which was based on Ivan Pavlov's work on learning and conditioning, that influenced Hans Eysenck and Arnold Lazarus to develop new behavioral therapy techniques based on classical conditioning. During the 1950s and 1960s, behavioral therapy became widely used by researchers in the United States, the United Kingdom, and South Africa. Their inspiration was by the behaviorist learning theory of Ivan Pavlov, John B. Watson, and Clark L. Hull. In Britain, Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization, applied behavioral research to the treatment of neurotic disorders. Wolpe's therapeutic efforts were precursors to today's fear reduction techniques. British psychologist Hans Eysenck presented behavior therapy as a constructive alternative. At the same time as Eysenck's work, B. F. Skinner and his associates were beginning to have an impact with their work on operant conditioning. Skinner's work was referred to as radical behaviorism and avoided anything related to cognition. However, Julian Rotter in 1954 and Albert Bandura in 1969 contributed to behavior therapy with their works on social learning theory by demonstrating the effects of cognition on learning and behavior modification. The work of Claire Weekes in dealing with anxiety disorders in the 1960s is also seen as a prototype of behavior therapy. The emphasis on behavioral factors has been described as the "first wave" of CBT. Cognitive therapy One of the first therapists to address cognition in psychotherapy was Alfred Adler, notably with his idea of basic mistakes and how they contributed to creation of unhealthy behavioral and life goals.Abraham Low believed that someone's thoughts were best changed by changing their actions. Adler and Low influenced the work of Albert Ellis, who developed the earliest cognitive-based psychotherapy called rational emotive behavioral therapy, or REBT. The first version of REBT was announced to the public in 1956. In the late 1950s, Aaron T. Beck was conducting free association sessions in his psychoanalytic practice. During these sessions, Beck noticed that thoughts were not as unconscious as Freud had previously theorized, and that certain types of thinking may be the culprits of emotional distress. It was from this hypothesis that Beck developed cognitive therapy, and called these thoughts "automatic thoughts". He first published his new methodology in 1967, and his first treatment manual in 1979. Beck has been referred to as "the father of cognitive behavioral therapy". It was these two therapies, rational emotive therapy, and cognitive therapy, that started the "second wave" of CBT, which emphasized cognitive factors. Merger of behavioral and cognitive therapies Although the early behavioral approaches were successful in many so-called neurotic disorders, they had little success in treating depression. Behaviorism was also losing popularity due to the cognitive revolution. The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behavior therapists, despite the earlier behaviorist rejection of mentalistic concepts like thoughts and cognitions. Both of these systems included behavioral elements and interventions, with the primary focus being on problems in the present. In initial studies, cognitive therapy was often contrasted with behavioral treatments to see which was most effective. During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US. Over time, cognitive behavior therapy came to be known not only as a therapy, but as an umbrella term for all cognitive-based psychotherapies. These therapies include, but are not limited to, REBT, cognitive therapy, acceptance and commitment therapy, dialectical behavior therapy, metacognitive therapy, metacognitive training, reality therapy/choice theory, cognitive processing therapy, EMDR, and multimodal therapy. This blending of theoretical and technical foundations from both behavior and cognitive therapies constituted the "third wave" of CBT. The most prominent therapies of this third wave are dialectical behavior therapy and acceptance and commitment therapy. Despite the increasing popularity of third-wave treatment approaches, reviews of studies reveal there may be no difference in the effectiveness compared with non-third wave CBT for the treatment of depression. Medical uses In adults, CBT has been shown to be an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression, eating disorders, chronic low back pain, personality disorders, psychosis, schizophrenia, substance use disorders, and bipolar disorder. It is also effective as part of treatment plans in the adjustment, depression, and anxiety associated with fibromyalgia, and with post-spinal cord injuries. In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression and suicidality, eating disorders and obesity, obsessive–compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), as well as tic disorders, trichotillomania, and other repetitive behavior disorders. CBT has also been applied to a variety of childhood disorders, including depressive disorders and various anxiety disorders. CBT has shown to be the most effective intervention for people exposed to adverse childhood experiences in the form of abuse or neglect. Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners. However, evidence supports the effectiveness of CBT for anxiety and depression. Evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues. The United Kingdom's National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including PTSD, OCD, bulimia nervosa, and clinical depression. Depression and anxiety disorders Cognitive behavioral therapy has been shown as an effective treatment for clinical depression. The American Psychiatric Association Practice Guidelines (April 2000) indicated that, among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder. A 2001 meta-analysis comparing CBT and psychodynamic psychotherapy suggested the approaches were equally effective in the short term for depression. In contrast, a 2013 meta-analysis suggested that CBT, interpersonal therapy, and problem-solving therapy outperformed psychodynamic psychotherapy and behavioral activation in the treatment of depression. According to a 2004 review by INSERM of three methods, cognitive behavioral therapy was either proven or presumed to be an effective therapy on several mental disorders. This included depression, panic disorder, post-traumatic stress, and other anxiety disorders. CBT has been shown to be effective in the treatment of adults with anxiety disorders. In a 2020 Cochrane review it was determined that CBT for children and adolescents was probably more effective (short term) than wait list or no treatment and more effective than attention control. Results from a 2018 systematic review found a high strength of evidence that CBT-exposure therapy can reduce PTSD symptoms and lead to the loss of a PTSD diagnosis. CBT has also been shown to be effective for post-traumatic stress disorder in very young children (3 to 6 years of age). A Cochrane review found low quality evidence that CBT may be more effective than other psychotherapies in reducing symptoms of posttraumatic stress disorder in children and adolescents. A systematic review of CBT in depression and anxiety disorders concluded that "CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists." Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression. Theoretical approaches One etiological theory of depression is Aaron T. Beck's cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. Beck's theory rests on the aspect of cognitive behavioral therapy known as schemata. Schemata are the mental maps used to integrate new information into memories and to organize existing information in the mind. An example of a schema would be a person hearing the word "dog" and picturing different versions of the animal that they have grouped together in their mind. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events, and the negative schema is activated later in life when the person encounters similar situations. Beck also described a negative cognitive triad. The cognitive triad is made up of the depressed individual's negative evaluations of themselves, the world, and the future. Beck suggested that these negative evaluations derive from the negative schemata and cognitive biases of the person. According to this theory, depressed people have views such as "I never do a good job", "It is impossible to have a good day", and "things will never get better". A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. Beck further proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, overgeneralization, magnification, and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema. On the other hand, a positive cognitive triad relates to a person's positive evaluations of themself, the world, and the future. More specifically, a positive cognitive triad requires self-esteem when viewing oneself and hope for the future. A person with a positive cognitive triad has a positive schema used for viewing themself in addition to a positive schema for the world and for the future. Cognitive behavioral research suggests a positive cognitive triad bolsters resilience, or the ability to cope with stressful events. Increased levels of resilience is associated with greater resistance to depression. Another major theoretical approach to cognitive behavioral therapy treatment is the concept of Locus of Control outlined in Julian Rotter's Social Learning Theory. Locus of control refers to the degree to which an individual's sense of control is either internal or external. An internal locus of control exists when an individual views an outcome of a particular action as being reliant on themselves and their personal attributes whereas an external locus of control exists when an individual views other's or some outside, intangible force such as luck or fate as being responsible for the outcome of a particular action. A basic concept in some CBT treatments used in anxiety disorders is in vivo exposure. CBT-exposure therapy refers to the direct confrontation of feared objects, activities, or situations by a patient. For example, a woman with PTSD who fears the location where she was assaulted may be assisted by her therapist in going to that location and directly confronting those fears. Likewise, a person with a social anxiety disorder who fears public speaking may be instructed to directly confront those fears by giving a speech. This "two-factor" model is often credited to O. Hobart Mowrer. Through exposure to the stimulus, this harmful conditioning can be "unlearned" (referred to as extinction and habituation). CBT for children with phobias is normally delivered over multiple sessions, but one-session treatment has been shown to be equally effective and is cheaper. Specialized forms of CBT CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youths who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable. Acceptance and commitment therapy (ACT) is a specialist branch of CBT (sometimes referred to as contextual CBT). ACT uses mindfulness and acceptance interventions and has been found to have a greater longevity in therapeutic outcomes. In a study with anxiety, CBT and ACT improved similarly across all outcomes from pre- to post-treatment. However, during a 12-month follow-up, ACT proved to be more effective, showing that it is a highly viable lasting treatment model for anxiety disorders. Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders, including children. Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls. CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety. Combined with other treatments Studies have provided evidence that when examining animals and humans, that glucocorticoids may lead to a more successful extinction learning during exposure therapy for anxiety disorders. For instance, glucocorticoids can prevent aversive learning episodes from being retrieved and heighten reinforcement of memory traces creating a non-fearful reaction in feared situations. A combination of glucocorticoids and exposure therapy may be a better-improved treatment for treating people with anxiety disorders. Prevention For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalized anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes. In another study, 3% of the group receiving the CBT intervention developed generalized anxiety disorder by 12 months postintervention compared with 14% in the control group. Individuals with subthreshold levels of panic disorder significantly benefitted from use of CBT. Use of CBT was found to significantly reduce social anxiety prevalence. For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older. Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles. A further study also saw a neutral result. A meta-study of the Coping with Depression course, a cognitive behavioral intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression. Bipolar disorder Many studies show CBT, combined with pharmacotherapy, is effective in improving depressive symptoms, mania severity and psychosocial functioning with mild to moderate effects, and that it is better than medication alone. INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including bipolar disorder. This included schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency. Psychosis In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse, and managing relapses. Meta-analyses confirm the effectiveness of metacognitive training (MCT) for the improvement of positive symptoms (e.g., delusions). For people at risk of psychosis, in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT. Schizophrenia INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including schizophrenia. A Cochrane review reported CBT had "no effect on long‐term risk of relapse" and no additional effect above standard care. A 2015 systematic review investigated the effects of CBT compared with other psychosocial therapies for people with schizophrenia and determined that there is no clear advantage over other, often less expensive, interventions but acknowledged that better quality evidence is needed before firm conclusions can be drawn. Addiction and substance use disorders Pathological and problem gambling CBT is also used for pathological and problem gambling. The percentage of people who problem gamble is 1–3% around the world. Cognitive behavioral therapy develops skills for relapse prevention and someone can learn to control their mind and manage high-risk cases. There is evidence of efficacy of CBT for treating pathological and problem gambling at immediate follow up, however the longer term efficacy of CBT for it is currently unknown. Smoking cessation CBT looks at the habit of smoking cigarettes as a learned behavior, which later evolves into a coping strategy to handle daily stressors. Since smoking is often easily accessible and quickly allows the user to feel good, it can take precedence over other coping strategies, and eventually work its way into everyday life during non-stressful events as well. CBT aims to target the function of the behavior, as it can vary between individuals, and works to inject other coping mechanisms in place of smoking. CBT also aims to support individuals with strong cravings, which are a major reported reason for relapse during treatment. A 2008 controlled study out of Stanford University School of Medicine suggested CBT may be an effective tool to help maintain abstinence. The results of 304 random adult participants were tracked over the course of one year. During this program, some participants were provided medication, CBT, 24-hour phone support, or some combination of the three methods. At 20 weeks, the participants who received CBT had a 45% abstinence rate, versus non-CBT participants, who had a 29% abstinence rate. Overall, the study concluded that emphasizing cognitive and behavioral strategies to support smoking cessation can help individuals build tools for long term smoking abstinence. Mental health history can affect the outcomes of treatment. Individuals with a history of depressive disorders had a lower rate of success when using CBT alone to combat smoking addiction. A Cochrane review was unable to find evidence of any difference between CBT and hypnosis for smoking cessation. While this may be evidence of no effect, further research may uncover an effect of CBT for smoking cessation. Substance use disorders Studies have shown CBT to be an effective treatment for substance use disorders. For individuals with substance use disorders, CBT aims to reframe maladaptive thoughts, such as denial, minimizing and catastrophizing thought patterns, with healthier narratives. Specific techniques include identifying potential triggers and developing coping mechanisms to manage high-risk situations. Research has shown CBT to be particularly effective when combined with other therapy-based treatments or medication. INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including alcohol dependency. Internet addiction Research has identified Internet addiction as a new clinical disorder that causes relational, occupational, and social problems. Cognitive behavioral therapy (CBT) has been suggested as the treatment of choice for Internet addiction, and addiction recovery in general has used CBT as part of treatment planning. There is also evidence for the efficacy of CBT in multicenter randomized controlled trials such as STICA (Short-Term Treatment of Internet and Computer Game Addiction). Eating disorders Though many forms of treatment can support individuals with eating disorders, CBT is proven to be a more effective treatment than medications and interpersonal psychotherapy alone. CBT aims to combat major causes of distress such as negative cognitions surrounding body weight, shape and size. CBT therapists also work with individuals to regulate strong emotions and thoughts that lead to dangerous compensatory behaviors. CBT is the first line of treatment for bulimia nervosa, and non-specific eating disorders. While there is evidence to support the efficacy of CBT for bulimia nervosa and binging, the evidence is somewhat variable and limited by small study sizes. INSERM's 2004 review found that CBT is an effective therapy for several mental disorders, including bulimia and anorexia nervosa. With autistic adults Emerging evidence for cognitive behavioral interventions aimed at reducing symptoms of depression, anxiety, and obsessive-compulsive disorder in autistic adults without intellectual disability has been identified through a systematic review. While the research was focused on adults, cognitive behavioral interventions have also been beneficial to autistic children. A 2021 Cochrane review found limited evidence regarding the efficacy of CBT for obsessive-compulsive disorder in adults with Autism Spectrum Disorder stating a need for further study. Dementia and mild cognitive impairment A Cochrane review in 2022 found that adults with dementia and mild cognitive impairment (MCI) who experience symptoms of depression may benefit from CBT, whereas other counselling or supportive interventions might not improve symptoms significantly. Across 5 different psychometric scales, where higher scores indicate severity of depression, adults receiving CBT reported somewhat lower mood scores than those receiving usual care for dementia and MCI overall. In this review, a sub-group analysis found clinically significant benefits only among those diagnosed with dementia, rather than MCI. The likelihood of remission from depression also appeared to be 84% higher following CBT, though the evidence for this was less certain. Anxiety, cognition and other neuropsychiatric symptoms were not significantly improved following CBT, however this review did find moderate evidence of improved quality of life and daily living activity scores in those with dementia and MCI. Post-traumatic stress Cognitive behavioral therapy interventions may have some benefits for people who have post-traumatic stress related to surviving rape, sexual abuse, or sexual assault. Other uses Evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD), hypochondriasis, and bipolar disorder, but more study is needed and results should be interpreted with caution. Moderate evidence from a 2024 systematic review supports the effectiveness of CBT and neurofeedback as part of psychosocial interventions for improving ADHD symptoms in children and adolescents. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter, but not in reducing stuttering frequency. There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia. Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating insomnia. Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls. CCBT was found to be equally effective as face-to-face CBT in insomnia. A Cochrane review of interventions aimed at preventing psychological stress in healthcare workers found that CBT was more effective than no intervention but no more effective than alternative stress-reduction interventions. Cochrane Reviews have found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youths under their care, nor was it helpful in treating people who abuse their intimate partners. CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality disorders and behavioral problems. INSERM's 2004 review found that CBT is an effective therapy for personality disorders. CBT has been used with other researchers as well to minimize chronic pain and help relieve symptoms from those suffering from irritable bowel syndrome (IBS). Individuals with medical conditions In the case of people with metastatic breast cancer, data is limited but CBT and other psychosocial interventions might help with psychological outcomes and pain management. A 2015 Cochrane review also found that CBT for symptomatic management of non-specific chest pain is probably effective in the short term. However, the findings were limited by small trials and the evidence was considered of questionable quality. Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. CBT combined with hypnosis and distraction reduces self-reported pain in children. There is limited evidence to support CBT's use in managing the impact of multiple sclerosis, sleep disturbances related to aging, and dysmenorrhea, but more study is needed and results should be interpreted with caution. Previously CBT has been considered as moderately effective for treating myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), however a National Institutes of Health Pathways to Prevention Workshop stated that in respect of improving treatment options for ME/CFS that the modest benefit from cognitive behavioral therapy should be studied as an adjunct to other methods. The Centres for Disease Control advice on the treatment of ME/CFS makes no reference to CBT while the National Institute for Health and Care Excellence states that cognitive behavioral therapy (CBT) has sometimes been assumed to be a cure for ME/CFS, however, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness." Age CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age. Of the small number of studies examining CBT for the management of depression in older people, there is currently no strong support. Description Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in behavior and affect, but recent variants emphasize changes in one's relationship to maladaptive thinking rather than changes in thinking itself. Cognitive distortions Therapists use CBT techniques to help people challenge their patterns and beliefs and replace errors in thinking, known as cognitive distortions with "more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior". Cognitive distortions can be either a pseudo-discrimination belief or an overgeneralization of something. CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward cognitive distortions so as to diminish their impact. Mainstream CBT helps individuals replace "maladaptive... coping skills, cognitions, emotions and behaviors with more adaptive ones", by challenging an individual's way of thinking and the way that they react to certain habits or behaviors, but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioral elements such as exposure and skills training. Assumptions Chaloult, Ngo, Cousineau and Goulet have attempted to identify the main assumptions of cognitive therapy used in CBT based on the research literature (Beck; Walen and Wessler; Beck, Emery and Greenberg, and Auger). They describe fourteen assumptions: Human emotions are primarily caused by people's thoughts and perceptions rather than events. Events, thoughts, emotions, behaviors, and physiological reactions influence each other. Dysfunctional emotions are typically caused by unrealistic thoughts. Reducing dysfunctional emotions requires becoming aware of irrational thoughts and changing them. Human beings have an innate tendency to develop irrational thoughts. This tendency is reinforced by their environment. People are largely responsible for their own dysfunctional emotions, as they maintain and reinforce their own beliefs. Sustained effort is necessary to modify dysfunctional thoughts, emotions, and behaviors. Rational thinking usually causes a decrease in the frequency, intensity, and duration of dysfunctional emotions, rather than an absence of affect or feelings. A positive therapeutic relationship is essential to successful cognitive therapy. Cognitive therapy is based on a teacher-student relationship, where the therapist educates the client. Cognitive therapy uses Socratic questioning to challenge cognitive distortions. Homework is an essential aspect of cognitive therapy. It consolidates the skills learned in therapy. The cognitive approach is active, directed, and structured. Cognitive therapy is generally short. Cognitive therapy is based on predictable steps. These steps largely involve learning about the CBT model; making links between thoughts, emotions, behaviors, and physiological reactions; noticing when dysfunctional emotions occur; learning to question the thoughts associated with these emotions; replacing irrational thoughts with others more grounded in reality; modifying behaviors based on new interpretations of events; and, in some cases, learning to recognize and change the major beliefs and attitudes underlying cognitive distortions. Chaloult, Ngo, Cousineau and Goulet have also described the assumptions of behavioral therapy as used in CBT. They refer to the work of Agras, Prochaska and Norcross, and Kirk. The assumptions are: Behaviors play an essential role in the onset, perpetuation and exacerbation of psychopathology. Learning theory is key in understanding the treatment of mental illness, as behaviors can be learned and unlearned. A rigorous evaluation (applied behavior analysis) is essential at the start of treatment. It includes identifying behaviors; precipitating, moderating, and perpetuating factors; the consequences of the behaviors; avoidance, and personal resources. The effectiveness of the treatment is monitored throughout its duration. Behavior therapy is scientific and the different forms of treatment are evaluated with rigorous evidence. Behavior therapy is active, directed, and structured. Together, these sets of assumptions cover the cognitive and behavioral aspects of CBT. Phases in therapy CBT can be seen as having six phases: Assessment or psychological assessment; Reconceptualization; Skills acquisition; Skills consolidation and application training; Generalization and maintenance; Post-treatment assessment follow-up. These steps are based on a system created by Kanfer and Saslow. After identifying the behaviors that need changing, whether they be in excess or deficit, and treatment has occurred, the psychologist must identify whether or not the intervention succeeded. For example, "If the goal was to decrease the behavior, then there should be a decrease relative to the baseline. If the critical behavior remains at or above the baseline, then the intervention has failed." The steps in the assessment phase include: Identify critical behaviors; Determine whether critical behaviors are excesses or deficits; Evaluate critical behaviors for frequency, duration, or intensity (obtain a baseline); If excess, attempt to decrease frequency, duration, or intensity of behaviors; if deficits, attempt to increase behaviors. The re-conceptualization phase makes up much of the "cognitive" portion of CBT. Delivery protocols There are different protocols for delivering cognitive behavioral therapy, with important similarities among them. Use of the term CBT may refer to different interventions, including "self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting". Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches. Related techniques CBT may be delivered in conjunction with a variety of diverse but related techniques such as exposure therapy, stress inoculation, cognitive processing therapy, cognitive therapy, metacognitive therapy, metacognitive training, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy. Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process. Methods of access Therapist A typical CBT program would consist of face-to-face sessions between patient and therapist, made up of 6–18 sessions of around an hour each with a gap of 1–3 weeks between sessions. This initial program might be followed by some booster sessions, for instance after one month and three months. CBT has also been found to be effective if patient and therapist type in real time to each other over computer links. Cognitive-behavioral therapy is most closely allied with the scientist–practitioner model in which clinical practice and research are informed by a scientific perspective, clear operationalization of the problem, and an emphasis on measurement, including measuring changes in cognition and behavior and the attainment of goals. These are often met through "homework" assignments in which the patient and the therapist work together to craft an assignment to complete before the next session. The completion of these assignments – which can be as simple as a person with depression attending some kind of social event – indicates a dedication to treatment compliance and a desire to change. The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment. Effective cognitive behavioral therapy is dependent on a therapeutic alliance between the healthcare practitioner and the person seeking assistance. Unlike many other forms of psychotherapy, the patient is very involved in CBT. For example, an anxious patient may be asked to talk to a stranger as a homework assignment, but if that is too difficult, he or she can work out an easier assignment first. The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure. Computerized or Internet-delivered (CCBT) Computerized cognitive behavioral therapy (CCBT) has been described by NICE as a "generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet, or interactive voice response system", instead of face-to-face with a human therapist. It is also known as internet-delivered cognitive behavioral therapy or ICBT. CCBT has potential to improve access to evidence-based therapies, and to overcome the prohibitive costs and lack of availability sometimes associated with retaining a human therapist. In this context, it is important not to confuse CBT with 'computer-based training', which nowadays is more commonly referred to as e-Learning. Although improvements in both research quality and treatment adherence is required before advocating for the global dissemination of CCBT, it has been found in meta-studies to be cost-effective and often cheaper than usual care, including for anxiety and PTSD. Studies have shown that individuals with social anxiety and depression experienced improvement with online CBT-based methods. A study assessing an online version of CBT for people with mild-to-moderate PTSD found that the online approach was as effective as, and cheaper than, the same therapy given face-to-face. A review of current CCBT research in the treatment of OCD in children found this interface to hold great potential for future treatment of OCD in youths and adolescent populations. Additionally, most internet interventions for post-traumatic stress disorder use CCBT. CCBT is also predisposed to treating mood disorders amongst non-heterosexual populations, who may avoid face-to-face therapy from fear of stigma. However presently CCBT programs seldom cater to these populations. In February 2006 NICE recommended that CCBT be made available for use within the NHS across England and Wales for patients presenting with mild-to-moderate depression, rather than immediately opting for antidepressant medication, and CCBT is made available by some health systems. The 2009 NICE guideline recognized that there are likely to be a number of computerized CBT products that are useful to patients, but removed endorsement of any specific product. Smartphone app-delivered Another new method of access is the use of mobile app or smartphone applications to deliver self-help or guided CBT. Technology companies are developing mobile-based artificial intelligence chatbot applications in delivering CBT as an early intervention to support mental health, to build psychological resilience, and to promote emotional well-being. Artificial intelligence (AI) text-based conversational application delivered securely and privately over smartphone devices have the ability to scale globally and offer contextual and always-available support. Active research is underway including real-world data studies that measure effectiveness and engagement of text-based smartphone chatbot apps for delivery of CBT using a text-based conversational interface. Recent market research and analysis of over 500 online mental healthcare solutions identified 3 key challenges in this market: quality of the content, guidance of the user and personalisation. A study compared CBT alone with a mindfulness-based therapy combined with CBT, both delivered via an app. It found that mindfulness-based self-help reduced the severity of depression more than CBT self-help in the short-term. Overall, NHS costs for the mindfulness approach were £500 less per person than for CBT. Reading self-help materials Enabling patients to read self-help CBT guides has been shown to be effective by some studies. However one study found a negative effect in patients who tended to ruminate, and another meta-analysis found that the benefit was only significant when the self-help was guided (e.g. by a medical professional). Group educational course Patient participation in group courses has been shown to be effective. In a meta-analysis reviewing evidence-based treatment of OCD in children, individual CBT was found to be more efficacious than group CBT. Types Brief cognitive behavioral therapy Brief cognitive behavioral therapy (BCBT) is a form of CBT which has been developed for situations in which there are time constraints on the therapy sessions and specifically for those struggling with suicidal ideation and/or making suicide attempts. BCBT was based on Rudd's proposed "suicidal mode", an elaboration of Beck's modal theory. BCBT takes place over a couple of sessions that can last up to 12 accumulated hours by design. This technique was first implemented and developed with soldiers on active duty by Dr. M. David Rudd to prevent suicide. Breakdown of treatment Orientation Commitment to treatment Crisis response and safety planning Means restriction Survival kit Reasons for living card Model of suicidality Treatment journal Lessons learned Skill focus Skill development worksheets Coping cards Demonstration Practice Skill refinement Relapse prevention Skill generalization Skill refinement Cognitive emotional behavioral therapy Cognitive emotional behavioral therapy (CEBT) is a form of CBT developed initially for individuals with eating disorders but now used with a range of problems including anxiety, depression, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anger problems. It combines aspects of CBT and dialectical behavioral therapy and aims to improve understanding and tolerance of emotions in order to facilitate the therapeutic process. It is frequently used as a "pretreatment" to prepare and better equip individuals for longer-term therapy. Structured cognitive behavioral training Structured cognitive-behavioral training (SCBT) is a cognitive-based process with core philosophies that draw heavily from CBT. Like CBT, SCBT asserts that behavior is inextricably related to beliefs, thoughts, and emotions. SCBT also builds on core CBT philosophy by incorporating other well-known modalities in the fields of behavioral health and psychology: most notably, Albert Ellis's rational emotive behavior therapy. SCBT differs from CBT in two distinct ways. First, SCBT is delivered in a highly regimented format. Second, SCBT is a predetermined and finite training process that becomes personalized by the input of the participant. SCBT is designed to bring a participant to a specific result in a specific period of time. SCBT has been used to challenge addictive behavior, particularly with substances such as tobacco, alcohol and food, and to manage diabetes and subdue stress and anxiety. SCBT has also been used in the field of criminal psychology in the effort to reduce recidivism. Moral reconation therapy Moral reconation therapy, a type of CBT used to help felons overcome antisocial personality disorder (ASPD), slightly decreases the risk of further offending. It is generally implemented in a group format because of the risk of offenders with ASPD being given one-on-one therapy reinforces narcissistic behavioral characteristics, and can be used in correctional or outpatient settings. Groups usually meet weekly for two to six months. Stress inoculation training This type of therapy uses a blend of cognitive, behavioral, and certain humanistic training techniques to target the stressors of the client. This is usually used to help clients better cope with their stress or anxiety after stressful events. This is a three-phase process that trains the client to use skills that they already have to better adapt to their current stressors. The first phase is an interview phase that includes psychological testing, client self-monitoring, and a variety of reading materials. This allows the therapist to individually tailor the training process to the client. Clients learn how to categorize problems into emotion-focused or problem-focused so that they can better treat their negative situations. This phase ultimately prepares the client to eventually confront and reflect upon their current reactions to stressors, before looking at ways to change their reactions and emotions to their stressors. The focus is conceptualization. The second phase emphasizes the aspect of skills acquisition and rehearsal that continues from the earlier phase of conceptualization. The client is taught skills that help them cope with their stressors. These skills are then practiced in the space of therapy. These skills involve self-regulation, problem-solving, interpersonal communication skills, etc. The third and final phase is the application and following through of the skills learned in the training process. This gives the client opportunities to apply their learned skills to a wide range of stressors. Activities include role-playing, imagery, modeling, etc. In the end, the client will have been trained on a preventive basis to inoculate personal, chronic, and future stressors by breaking down their stressors into problems they will address in long-term, short-term, and intermediate coping goals. Activity-guided CBT: Group-knitting A recently developed group therapy model, based on CBT, integrates knitting into the therapeutic process and has been proven to yield reliable and promising results. The foundation for this novel approach to CBT is the frequently emphasized notion that therapy success depends on how embedded the therapy method is in the patients' natural routine. Similar to standard group-based CBT, patients meet once a week in a group of 10 to 15 patients and knit together under the instruction of a trained psychologist or mental health professional. Central for the therapy is the patient's imaginative ability to assign each part of the wool to a certain thought. During the therapy, the wool is carefully knitted, creating a knitted piece of any form. This therapeutic process teaches the patient to meaningfully align thought, by (physically) creating a coherent knitted piece. Moreover, since CBT emphasizes the behavior as a result of cognition, the knitting illustrates how thoughts (which are tried to be imaginary tight to the wool) materialize into the reality surrounding us. Mindfulness-based cognitive behavioral hypnotherapy Mindfulness-based cognitive behavioral hypnotherapy (MCBH) is a form of CBT that focuses on awareness in a reflective approach, addressing subconscious tendencies. It is more the process that contains three phases for achieving wanted goals and integrates the principles of mindfulness and cognitive-behavioral techniques with the transformative potential of hypnotherapy. Unified Protocol The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a form of CBT, developed by David H. Barlow and researchers at Boston University, that can be applied to a range of anxiety disorders. The rationale is that anxiety and depression disorders often occur together due to common underlying causes and can efficiently be treated together. The UP includes a common set of components: Psycho-education Cognitive reappraisal Emotion regulation Changing behaviour The UP has been shown to produce equivalent results to single-diagnosis protocols for specific disorders, such as OCD and social anxiety disorder. Several studies have shown that the UP is easier to disseminate as compared to single-diagnosis protocols. Culturally adapted CBT The study of psychotherapy across races, religions, and cultures, or "ethno-psycho-therapy", is a relatively new discipline Criticisms Relative effectiveness The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments, many other researchers and practitioners have questioned the validity of such claims. For example, one study determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority. In cases where CBT has been reported to be statistically better than other psychological interventions in terms of primary outcome measures, effect sizes were small and suggested that those differences were clinically meaningless and insignificant. Moreover, on secondary outcomes (i.e., measures of general functioning) no significant differences have been typically found between CBT and other treatments. A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., either the subjects or the therapists in psychotherapy studies are not blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in. The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindness were factored in. Pooled data from published trials of CBT in schizophrenia, major depressive disorder (MDD), and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates; treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low. Declining effectiveness Additionally, a 2015 meta-analysis revealed that the positive effects of CBT on depression have been declining since 1977. The overall results showed two different declines in effect sizes: 1) an overall decline between 1977 and 2014, and 2) a steeper decline between 1995 and 2014. Additional sub-analysis revealed that CBT studies where therapists in the test group were instructed to adhere to the Beck CBT manual had a steeper decline in effect sizes since 1977 than studies where therapists in the test group were instructed to use CBT without a manual. The authors reported that they were unsure why the effects were declining but did list inadequate therapist training, failure to adhere to a manual, lack of therapist experience, and patients' hope and faith in its efficacy waning as potential reasons. The authors did mention that the current study was limited to depressive disorders only. High drop-out rates Furthermore, other researchers write that CBT studies have high drop-out rates compared to other treatments. One meta-analysis found that CBT drop-out rates were 17% higher than those of other therapies. This high drop-out rate is also evident in the treatment of several disorders, particularly the eating disorder anorexia nervosa, which is commonly treated with CBT. Those treated with CBT have a high chance of dropping out of therapy before completion and reverting to their anorexia behaviors. Other researchers analyzing treatments for youths who self-injure found similar drop-out rates in CBT and DBT groups. In this study, the researchers analyzed several clinical trials that measured the efficacy of CBT administered to youths who self-injure. The researchers concluded that none of them were found to be efficacious. Philosophical concerns with CBT methods The methods employed in CBT research have not been the only criticisms; some individuals have called its theory and therapy into question. Slife and Williams write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will. They argue that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states: nowhere in CBT theory is agency, or free will, accounted for. Another criticism of CBT theory, especially as applied to major depressive disorder (MDD), is that it confounds the symptoms of the disorder with its causes. Side effects CBT is generally regarded as having very few if any side effects. Calls have been made by some for more appraisal of possible side effects of CBT. Many randomized trials of psychological interventions like CBT do not monitor potential harms to the patient. In contrast, randomized trials of pharmacological interventions are much more likely to take adverse effects into consideration. A 2017 meta-analysis revealed that adverse events are not common in children receiving CBT and, furthermore, that CBT is associated with fewer dropouts than either placebo or medications. Nevertheless, CBT therapists do sometimes report 'unwanted events' and side effects in their outpatients with "negative wellbeing/distress" being the most frequent. Socio-political concerns The writer and group analyst Farhad Dalal questions the socio-political assumptions behind the introduction of CBT. According to one reviewer, Dalal connects the rise of CBT with "the parallel rise of neoliberalism, with its focus on marketization, efficiency, quantification and managerialism", and he questions the scientific basis of CBT, suggesting that "the 'science' of psychological treatment is often less a scientific than a political contest". In his book, Dalal also questions the ethical basis of CBT. Society and culture The UK's National Health Service announced in 2008 that more therapists would be trained to provide CBT at government expense as part of an initiative called Improving Access to Psychological Therapies (IAPT). The NICE said that CBT would become the mainstay of treatment for non-severe depression, with medication used only in cases where CBT had failed. Therapists complained that the data does not fully support the attention and funding CBT receives. Psychotherapist and professor Andrew Samuels stated that this constitutes "a coup, a power play by a community that has suddenly found itself on the brink of corralling an enormous amount of money ... Everyone has been seduced by CBT's apparent cheapness." The UK Council for Psychotherapy issued a press release in 2012 saying that the IAPT's policies were undermining traditional psychotherapy and criticized proposals that would limit some approved therapies to CBT, claiming that they restricted patients to "a watered-down version of cognitive behavioural therapy (CBT), often delivered by very lightly trained staff". References Further reading External links Association for Behavioral and Cognitive Therapies (ABCT) British Association for Behavioural and Cognitive Psychotherapies National Association of Cognitive-Behavioral Therapists International Association of Cognitive Psychotherapy Information on Research-based CBT Treatments Associated Counsellors & Psychologists CBT Therapists Addiction Addiction medicine Treatment of obsessive–compulsive disorder

Mental health first aid

Mental health first aid is an extension of the concept of traditional first aid to cover mental health conditions. Mental health first aid is the first and immediate assistance given to any person experiencing or developing a mental health condition, such as depression or anxiety disorders, or experiencing a mental health crisis situation such as suicidal ideation or panic attack. Mental health first aid training Mental health first aid training teaches members of the public how to help a person who is experiencing varying degrees of worsening mental health issues. Like traditional first aid training, mental health first aid training does not teach people to treat or diagnose mental health or substance use conditions. Instead, the training teaches people how to offer initial support until appropriate professional help is received or until the crisis resolves. History The first mental health first aid training program was developed in Australia in 2001 by a research team led by Betty Kitchener and Anthony Jorm. The program was created to teach members of the general public how to provide initial support to people experiencing mental health problems, as well as to connect them with appropriate professional help and community resources. They tested the idea that giving first aid for mental health could lessen the effects of mental health problems, speed up recovery, and make suicide less likely by educating students on common mental health crises including feelings of suicide, deliberate self-harm, panic attacks, or symptoms of psychosis, and how to deal with these situations. The idea was to reduce the stigma associated with mental illness and make it more likely that people with mental health problems would seek help, which would reduce the risk of the person coming to harm. Mental health first aid training programs are provided by different organizations around the world, many of them non-profit. They have been implemented in countries such as the United States, Canada, the United Kingdom, Ireland, and a number of other European, Asian, and African countries. Public reception General media articles and videos indicate that mental health first aid training has political and celebrity proponents, such as former US president Barack Obama, former US first lady Michelle Obama, and singer/actress Lady Gaga. A few bills of law have been proposed by politicians in countries such as Australia and the United Kingdom to make mental health first aid training compulsory in schools and other organizations. Although considered good practice in several countries, mental health first aid training is not legally imposed for organizations anywhere in the world. Curriculum The curriculum for mental health first aid training typically includes the following topics: Symptoms associated with common mental health conditions such as depression, anxiety, schizophrenia, bipolar disorder, and eating disorders, as well as a general overview of mental health and mental illnesses. Common warning signs of mental illnesses, such as mood, behavior, and cognitive changes. Information about local counseling and psychiatric services, and how to help others gain access to them. Using the knowledge from those topics, participants are trained on a step-by-step action plan for providing mental health first aid, including how to: Evaluate the risk of suicide or harm Approach safely and appropriately Listen non-judgmentally Provide reassurance Encourage appropriate professional assistance Promote self-help Additional support strategies Depending on the program, there may be additional modules that target specific populations, such as children and adolescents, the elderly, or veterans. or conditions such as substance use disorder and its related issues and challenges. All of these topics are covered in order to develop participants' mental health literacy which consists of the knowledge, skills, and confidence necessary to recognize and respond appropriately to signs of mental illness and substance use disorders. Research on mental health first aid training A number of systematic reviews and meta-analyses have been carried out to review data concerning the effectiveness of mental health first aid training on participants' knowledge of mental health conditions and subsequent helping behaviors. A meta-analysis conducted in 2014 concluded that mental health first aid training increases participants' knowledge of mental health, reduces their negative views, and increases their supportive behaviors toward people with mental health issues. A meta-analysis conducted in 2018 concluded that mental health first aid training enhances participants' knowledge, awareness, and beliefs about successful treatments for mental diseases. At follow-up, there were slight improvements in the amount of assistance provided to a person with a mental health problem, but the nature of the change in the offered behaviors was unclear. A systematic review conducted in 2020 showed that mental health first aid training had conflicting effects on how trainees applied the skills they learned, but no influence on how beneficial their actions were for the mental health of the recipients. A systematic review conducted in 2020 focused on youth and adolescent mental health first aid training and found significant improvements in the understanding, recognition, stigmatizing perceptions, helping motivations, and helping behavior of youth and adolescent participants. The most frequently stated improvement was in knowledge and confidence, while the least frequently reported improvement was in helping behavior. As of 2024, the mental health first aid programme has been exported to over 25 countries and trained up over 6 million people worldwide, with over 1 million trained within Australia See also Emotional First Aid First aid Mental health Mental disorder Mental health triage – A brief overview of the Australian concept for dealing with psychiatric emergencies, similar to regular triage References and notes Clinical psychology First aid Mental disorders Mental health Emergency mental health services

Schema therapy

Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies (for example, traditional cognitive behavioral therapy). Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy. Introduction Four main theoretical concepts in schema therapy are early maladaptive schemas (or simply schemas), coping styles, modes, and basic emotional needs: In cognitive psychology, a schema is an organized pattern of thought and behavior. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. In schema therapy, a schema specifically refers to an early maladaptive schema, defined as a pervasive self-defeating or dysfunctional theme or pattern of memories, emotions, and physical sensations, developed during childhood or adolescence and elaborated throughout one's lifetime. Often they have the form of a belief about the self or the world. For instance, a person with an Abandonment schema could be hypersensitive (have an "emotional button" or "trigger") about their perceived value to others, which in turn could make them feel sad and panicky in their interpersonal relationships. Coping styles are a person's behavioral responses to schemas. There are three potential coping styles. In "avoidance" the person tries to avoid situations that activate the schema. In "surrender" the person gives into the schema, doesn't try to fight against it, and changes their behavior in expectation that the feared outcome is inevitable. In "counterattack", also called "overcompensation", the person puts extra work into not allowing the schema's feared outcome to happen. These maladaptive coping styles (overcompensation, avoidance, or surrender) very often wind up reinforcing the schemas. Continuing the Abandonment example: having imagined a threat of abandonment in a relationship and feeling sad and panicky, a person using an avoidance coping style might then behave in ways to limit the closeness in the relationship to try to protect themself from being abandoned. The resulting loneliness or even actual loss of the relationship could easily reinforce the person's Abandonment schema. Another example can be given for the Defectiveness schema: A person using an avoidance coping style might avoid situations that make them feel defective, or might try to numb the feeling with addictions or distractions. A person using a surrender coping style might tolerate unfair criticism without defending themself. A person using the counterattack/overcompensation coping style might put extra effort into being superhuman. Modes are mind states that cluster schemas and coping styles into a temporary "way of being" that a person can shift into occasionally or more frequently. For example, a Vulnerable Child mode might be a state of mind encompassing schemas of Abandonment, Defectiveness, Mistrust/Abuse and a coping style of surrendering (to the schemas). If a patient's basic emotional needs are not met in childhood, then schemas, coping styles, and modes can develop. Some basic needs that have been identified are: connection, mutuality, reciprocity, flow, and autonomy. For example, a child with unmet needs around connection—perhaps due to parental loss to death, divorce, or addiction—might develop an Abandonment schema. The goal of schema therapy is to help patients meet their basic emotional needs by helping the patient learn how to: heal schemas by diminishing the intensity of emotional memories comprising the schema and the intensity of bodily sensations, and by changing the cognitive patterns connected to the schema; replace maladaptive coping styles and responses with adaptive patterns of behavior. Techniques used in schema therapy including limited reparenting and Gestalt therapy psychodrama techniques such as imagery re-scripting and empty chair dialogues. See , below. Early maladaptive schemas Early maladaptive schemas are self-defeating emotional and cognitive patterns established from childhood and repeated throughout life. They may be made up of emotional memories of past hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or lack of normal human affection in general. Early maladaptive schemas can also include bodily sensations associated with such emotional memories. Early maladaptive schemas can have different levels of severity and pervasiveness: the more severe the schema, the more intense the negative emotion when the schema is triggered and the longer it lasts; the more pervasive the schema, the greater the number of situations that trigger it. Schema domains Schema domains are five broad categories of unmet needs into which are grouped 18 early maladaptive schemas identified by : Disconnection/Rejection includes 5 schemas: Abandonment/Instability Mistrust/Abuse Emotional Deprivation Defectiveness/Shame Social Isolation/Alienation Impaired Autonomy and/or Performance includes 4 schemas: Dependence/Incompetence Vulnerability to Harm or Illness Enmeshment/Undeveloped Self Failure Impaired Limits includes 2 schemas: Entitlement/Grandiosity Insufficient Self-Control and/or Self-Discipline Other-Directedness includes 3 schemas: Subjugation Self-Sacrifice Approval-Seeking/Recognition-Seeking Overvigilance/Inhibition includes 4 schemas: Negativity/Pessimism Emotional Inhibition Unrelenting Standards/Hypercriticalness Punitiveness did a primary and a higher-order factor analysis of data from a large clinical sample and smaller non-clinical population. The higher-order factor analysis indicated four schema domains—Emotional Dysregulation, Disconnection, Impaired Autonomy/Underdeveloped Self, and Excessive Responsibility/Overcontrol—that overlap with the five domains (listed above) proposed earlier by . The primary factor analysis indicated that the Emotional Inhibition schema could be split into Emotional Constriction and Fear of Losing Control, and the Punitiveness schema could be split into Punitiveness (Self) and Punitiveness (Other). Schema modes Schema modes are momentary mind states which every human being experiences at one time or another. A schema mode consists of a cluster of schemas and coping styles. Life situations that a person finds disturbing or offensive, or arouse bad memories, are referred to as "triggers" that tend to activate schema modes. In psychologically healthy persons, schema modes are mild, flexible mind states that are easily pacified by the rest of their personality. In patients with personality disorders, schema modes are more severe, rigid mind states that may seem split off from the rest of their personality. Identified schema modes identified 10 schema modes, further described by , and grouped into four categories. The four categories are: Child modes, Dysfunctional Coping modes, Dysfunctional Parent modes, and the Healthy Adult mode. The four Child modes are: Vulnerable Child, Angry Child, Impulsive/Undisciplined Child, and Happy Child. The three Dysfunctional Coping modes are: Compliant Surrenderer, Detached Protector, and Overcompensator. The two Dysfunctional Parent modes are: Punitive Parent and Demanding Parent. Vulnerable Child is the mode in which a patient may feel defective in some way, thrown aside, unloved, obviously alone, or may be in a "me against the world" mindset. The patient may feel as though peers, friends, family, and even the entire world have abandoned them. Behaviors of patients in Vulnerable Child mode may include (but are not limited to) falling into major depression, pessimism, feeling unwanted, feeling unworthy of love, and perceiving personality traits as irredeemable flaws. Rarely, a patient's self-perceived flaws may be intentionally withheld on the inside; when this occurs, instead of showing one's true self, the patient may appear to others as "egotistical", "attention-seeking", selfish, distant, and may exhibit behaviors unlike their true nature. The patient might create a narcissistic alter-ego/persona in order to escape or hide the insecurity from others. Due to fear of rejection, of feeling disconnected from their true self and poor self-image, these patients, who truly desire companionship/affection, may instead end up pushing others away. Angry Child is fueled mainly by feelings of victimization or bitterness, leading towards negativity, pessimism, jealousy, and rage. While experiencing this schema mode, a patient may have urges to yell, scream, throw/break things, or possibly even injure themself or harm others. The Angry Child schema mode is enraged, anxious, frustrated, self-doubting, feels unsupported in ideas and vulnerable. Impulsive Child is the mode where anything goes. Behaviors of the Impulsive Child schema mode may include reckless driving, substance abuse, cutting oneself, suicidal thoughts, gambling, or fits of rage, such as punching a wall when "triggered" or laying blame of circumstantial difficulties upon innocent people. Unsafe sex, rash decisions to run away from a situation without resolution, tantrums perceived by peers as infantile, and so forth are a mere few of the behaviors which a patient in this schema mode might display. Impulsive Child is the rebellious and careless schema mode. Happy Child occurs when one feels like their needs are being met. When people experience the Happy Child mode, they feel safe, loved, and content. They experience a joyful sense of wonder and playfulness about the world. This mode is healthy as it represents the absence of activation of maladaptive schemas. While healthy adults spend most of their time in the Healthy Adult mode, they also cultivate their Happy Child to balance the demands of life with a sense of lightheartedness. Compliant Surrenderer is a coping mode where one experiences the schema that triggered it as true. This in turn leads to feelings such as helplessness, sadness, guilt, or anger about the situation. People in this mode often believe it is pointless to challenge their schema, and that it must simply be accepted. They also often adopt an interpersonally passive and dependent style, seeking to please people in their lives, to minimize conflict, and therefore avoid further harm or abuse. Detached Protector is based in escape. Patients in Detached Protector schema mode withdraw, dissociate, alienate, or hide in some way. This may be triggered by numerous stress factors or feelings of being overwhelmed. When a patient with insufficient skills is in a situation involving excessive demands, it can trigger a Detached Protector response mode. Stated simply, patients become numb in order to protect themselves from the harm or stress of what they fear is to come, or to protect themselves from fear of the unknown in general. Overcompensator is marked by attempts to fight off schemas in a way that is rigid and extreme. It often involves aggressiveness, rebelliousness, violating the rights of other people, and an attempt to dominate them. In this mode, a person who feels emotionally deprived demands affection from others, while a person who believes others cannot be trusted will try to preemptively hurt them before they do. It may also involve obsessiveness in an excessive attempt to control the environment, or forced behaviors, such as extreme forgiveness for someone with a Punitiveness schema. Punitive Parent is identified by beliefs of a patient that they should be harshly punished, perhaps due to feeling "defective", or making a simple mistake. The patient may feel that they should be punished for even existing. Sadness, anger, impatience, and judgment are directed to the patient and from the patient. The Punitive Parent has great difficulty in forgiving themself even under average circumstances in which anyone could fall short of their standards. The Punitive Parent does not wish to allow for human error or imperfection, thus punishment is what this mode seeks. Demanding Parent is associated with a strong sense of pressure to achieve. When experiencing this mode, people often feel like their performance is inadequate, no matter how well they do or how much effort they make. Common beliefs also involve the idea that rest, fun, and relaxation are not acceptable and that one's attention should remain focused on achieving more. It is important to note that while this mode is often accompanied by Punitive Parent, this is not always the case. Clients with the Demanding Parent mode feel pressure and dissatisfaction with their achievements, but not necessarily guilt, shame or feelings of worthlessness. Healthy Adult is the mode that schema therapy aims to help a patient achieve as the long-lasting state of well-being. The Healthy Adult is comfortable making decisions, is a problem-solver, thinks before acting, is appropriately ambitious, sets limits and boundaries, nurtures self and others, forms healthy relationships, takes on all responsibility, sees things through, and enjoys/partakes in enjoyable adult activities and interests with boundaries enforced, takes care of their physical health, and values themself. In this schema mode the patient focuses on the present day with hope and strives toward the best tomorrow possible. The Healthy Adult forgives the past, no longer sees themself as a victim (but as a survivor), and expresses all emotions in ways which are healthy and cause no harm. Techniques in schema therapy Treatment plans in schema therapy generally encompass three basic classes of techniques: cognitive, experiential, and behavioral (in addition to the basic healing components of the therapeutic relationship). Cognitive strategies expand on standard cognitive behavioral therapy techniques such as listing pros and cons of a schema, testing the validity of a schema, or conducting a dialogue between the "schema side" and the "healthy side". Experiential and emotion focused strategies expand on standard Gestalt therapy psychodrama and imagery techniques. Behavioral pattern-breaking strategies expand on standard behavior therapy techniques, such as role playing an interaction and then assigning the interaction as homework. One of the most central techniques in schema therapy is the use of the therapeutic relationship, specifically through a process called "limited reparenting". Specific techniques often used in schema therapy include flash cards with important therapeutic messages, created in session and used by the patient between sessions, and the schema diary—a template or workbook that is filled out by the patient between sessions and that records the patient's progress in relation to all the theoretical concepts in schema therapy. Schema therapy and psychoanalysis From an integrative psychotherapy perspective, limited reparenting and the experiential techniques, particularly around changing modes, could be seen as actively changing what psychoanalysis has described as object relations. Historically, mainstream psychoanalysis tended to reject active techniques—such as Fritz Perls' Gestalt therapy work or Franz Alexander's "corrective emotional experience"—but contemporary relational psychoanalysis (led by analysts such as Lewis Aron, and building on the ideas of earlier unorthodox analysts such as Sándor Ferenczi) is more open to active techniques. It is notable that in a head-to-head comparison of a psychoanalytic object relations treatment (Otto F. Kernberg's transference focused psychotherapy) and schema therapy, the latter has been demonstrated to be more effective in treating Borderline Personality Disorder. Outcome studies on schema therapy Schema therapy vs transference focused psychotherapy outcomes Dutch investigators, including Josephine Giesen-Bloo and Arnoud Arntz (the project leader), compared schema therapy (also known as schema focused therapy or SFT) with transference focused psychotherapy (TFP) in the treatment of borderline personality disorder. 86 patients were recruited from four mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for three years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving "clinically significant and relevant improvement". Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP. Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with schema therapy clearly more successful. Less intensive outpatient, individual schema therapy Dutch investigators, including Marjon Nadort and Arnoud Arntz, assessed the effectiveness of schema therapy in the treatment of borderline personality disorder when utilized in regular mental health care settings. A total of 62 patients were treated in eight mental health centers located in the Netherlands. The treatment was less intensive along a number of dimensions including a shift from twice weekly to once weekly sessions during the second year. Despite this, there was no lessening of effectiveness with recovery rates that were at least as high and similarly low dropout rates. Pilot study of group schema therapy for borderline personality disorder Investigators Joan Farrell, Ida Shaw and Michael Webber at the Indiana University School of Medicine Center for BPD Treatment & Research tested the effectiveness of adding an eight-month, 30-session schema therapy group to treatment-as-usual (TAU) for borderline personality disorder (BPD) with 32 patients. The dropout rate was 0% for those patients who received group schema therapy in addition to TAU and 25% for those who received TAU alone. At the end of treatment, 94% of the patients who received group schema therapy in addition to TAU compared to 16% of the patients receiving TAU alone no longer met BPD diagnostic criteria. The schema therapy group treatment led to significant reductions in symptoms and global improvement in functioning. The large positive treatment effects found in the group schema therapy study suggest that the group modality may augment or catalyze the active ingredients of the treatment for BPD patients. As of 2014, a collaborative randomized controlled trial is under way at 14 sites in six countries to further explore this interaction between groups and schema therapy. See also Cognitive therapy Dynamic-maturational model of attachment and adaptation Personal construct theory Schema (psychology) Notes References Further reading Professional literature Self-help literature Psychotherapy by type Cognitive behavioral therapy Cognitive therapy Borderline personality disorder

Nursing process

The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or health informatics. The diagnosis phase was added later. The nursing process uses clinical judgement to strike a balance of epistemology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. Nursing knowledge has embraced pluralism since the 1970s. Some authors refer to a mind map or abductive reasoning as a potential alternative strategy for organizing care. Intuition plays a part for experienced nurses. Phases The nursing process is goal-oriented method of caring that provides a framework to nursing care. It involves seven major steps: A Assess (what data is collected?) D Diagnose (what is the problem?) O Outcome Identification - (Was originally a part of the Planning phase, but has recently been added as a new step in the complete process). P Plan (how to manage the problem) I Implement (putting plan into action) R Rationale (Scientific reason of the implementations) E Evaluate (did the plan work?) According to some theorists, this seven-steps description of the nursing process is outdated and misrepresents nursing as linear and atomic. Assessing phase The nurse completes a holistic nursing assessment of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective data and objective data using a nursing framework, such as Marjory Gordon's functional health patterns. Models for data collection Nursing assessments provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessment framework is best practice. Methods Client Interview Physical Examination Obtaining a health history (including dietary data) Family history/report Diagnosing phase Nursing diagnoses represent the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patients assessment. Multiple nursing diagnoses may be made for one client. Planning phase In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. When there are multiple nursing diagnoses to be addressed, the nurse prioritizes which diagnoses will receive the most attention first according to their severity and potential for causing more serious harm. The most common terminology for standardized nursing diagnosis is that of the evidence-based terminology developed and refined by NANDA International, the oldest and one of the most researched of all standardized nursing languages. For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome, which are aimed at the related factors (etiologies) not merely at symptoms (defining characteristics). A common method of formulating the expected outcomes is to use the evidence-based Nursing Outcomes Classification to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan. Implementing phase The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established. Delegated tasks and the monitoring of them is included here as well. Activities pre-assessment of the client-done before just carrying out implementation to determine if it is relevant determine need for assistance implementation of nursing orders delegating and supervising-determines who to carry out what action Evaluating phase The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely, if the goal has been achieved then the care can cease. New problems may be identified at this stage, and thus the process will start all over again. Characteristics The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well. The entire process is recorded or documented in order to inform all members of the health care team. Variations and documentation The PIE method is a system for documenting actions, especially in the field of nursing. The name comes from the acronym PIE, meaning Problem, Intervention, Evaluation. See also Clinical Care Classification System Decision cycle Nursing Nursing theory Nursing diagnosis NANDA OODA loop References Nursing Critical thinking Scientific method

Hikikomori

, also known as severe social withdrawal, is total withdrawal from society and seeking extreme degrees of social isolation and confinement. Hikikomori refers to both the phenomenon in general and the recluses themselves, described as loners or "modern-day hermits". The phenomenon is primarily recognized in Japan, although similar concepts exist in other languages and cultures, especially South Korea. Estimates suggest that in Japan, half a million youths have become social recluses, as well as more than half a million middle-aged individuals. In South Korea, the estimates vary from around 350,000-500,000. Definition The Japanese Ministry of Health, Labour, and Welfare defines hikikomori as a condition in which the affected individuals refuse to leave their parents' house, do not work or go to school, and isolate themselves from society and family in a single room for a period exceeding six months. The psychiatrist Tamaki Saitō defines hikikomori as "a state that has become a problem by the late twenties, that involves cooping oneself up in one's own home and not participating in society for six months or longer, but that does not seem to have another psychological problem as its principal source". More recently, researchers have developed more specific criteria to more accurately identify hikikomori. During a diagnostic interview, trained clinicians evaluate for: spending most of the day and nearly every day confined to home, marked and persistent avoidance of social situations, and social relationships, social withdrawal symptoms causing significant functional impairment, duration of exceeding six months, no apparent physical or mental etiology to account for the social withdrawal symptoms. The psychiatrist Alan Teo first characterized hikikomori in Japan as modern-day hermits, while the literary and communication scholar Flavio Rizzo similarly described hikikomori as "post-modern hermits" whose solitude stems from ancestral desires for withdrawal. While the degree of the phenomenon varies on an individual basis, in the most extreme cases, some people remain in isolation for years or even decades. Often hikikomori start out as school refusers, or in Japanese (an older term is ). Hikikomori has been defined by a Japanese expert group as having the following characteristics: Spending most of the time at home No interest in going to school or working Persistence of withdrawal for more than 6 months Exclusion of schizophrenia, intellectual disability, and bipolar disorder Exclusion of those who maintain personal relationships (e.g., friendships) Common traits While many people feel the pressures of the outside world, hikikomori react by complete social withdrawal. In some more severe cases, they isolate themselves in their bedrooms for months or years at a time. They usually have few or no friends. In interviews with current or recovering hikikomori, media reports and documentaries have captured the strong levels of psychological distress and fear felt by these individuals. While hikikomori favor indoor activities, some venture outdoors occasionally. The withdrawal from society usually starts gradually. Affected people may appear unhappy, lose their friends, become insecure and shy, and talk less. Prevalence According to Japanese government figures released in 2010, there were at that time 700,000 individuals living as hikikomori within Japan, with an average age of 31. (Population of Japan in 2014 was 127.3 million.) Still, the numbers vary widely among experts. These included the hikikomori who were at that time in their 40s and had spent 20 years in isolation. This group is generally referred to as the "first-generation hikikomori". There is concern about their reintegration into society in what is known as "the 2030 Problem", when they will be in their 60s and their parents begin to die. Additionally, the government estimates that 1.55 million people are on the verge of becoming hikikomori. Tamaki Saitō, who first coined the phrase, originally estimated that there may be over one million hikikomori in Japan, although this was not based on national survey data. Nonetheless, considering that hikikomori adolescents are hidden away and their parents are often reluctant to talk about the problem, it is extremely difficult to gauge the number accurately. A 2015 Cabinet Office survey estimated that 541,000 recluses aged 15 to 39 existed. In 2019, another survey showed that there are roughly 613,000 people aged 40 to 64 that fall into the category of "adult hikikomori", which Japan's welfare minister Takumi Nemoto referred to as a "new social issue". While the terminology hikikomori is of Japanese origin, the phenomenon is not unique to Japan. There have been cases found in the United States, the United Kingdom, Oman, Spain, Germany, Italy, India, Sweden, Brazil, China, Hong Kong, Taiwan, Singapore, South Korea, France and Russia. Hypotheses on cause Developmental and psychiatric conditions Hikikomori is similar to the social withdrawal exhibited by some people with autism spectrum disorder. This has led some psychiatrists to suggest that hikikomori may be affected by autism spectrum disorder and other disorders that affect social integration, but that their disorders are altered from their typical Western presentation because of Japanese sociocultural pressures. Suwa and Hara (2007) discovered that 5 of 27 cases of hikikomori had a high-functioning pervasive developmental disorder (HPDD), and 12 more had other disorders or mental diseases (6 cases of personality disorders, 3 cases of obsessive-compulsive disorder, 2 cases of depression, 1 case of slight intellectual impairment); 10 out of 27 had primary hikikomori. The researchers used a vignette to illustrate the difference between primary hikikomori (without any obvious mental disorder) and hikikomori with HPDD or other disorder. Alan Teo and colleagues conducted detailed diagnostic evaluations of 22 individuals with hikikomori and found that while the majority of cases fulfilled criteria for multiple psychiatric conditions, about 1 in 5 cases were primary hikikomori. To date, however, hikikomori is not included in the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders), due to insufficient data. According to Michael Zielenziger's book Shutting Out the Sun: How Japan Created Its Own Lost Generation, the syndrome is more closely related to posttraumatic stress disorder. The author claimed that the hikikomori interviewed for the book had discovered independent thinking and a sense of self that the current Japanese environment could not accommodate. The syndrome also closely parallels the terms avoidant personality disorder, schizoid personality disorder, schizotypal personality disorder, agoraphobia or social anxiety disorder (also known as "social phobia"). Social and cultural influence Sometimes referred to as a social problem in Japanese discourse, hikikomori has a number of possible contributing factors. Alan Teo has summarized a number of potential cultural features that may contribute to its predominance in Japan. These include tendencies toward conformity and collectivism, overprotective parenting, and particularities of the educational, housing and economic systems. Severe social withdrawal in Japan appears to affect men and women equally. However, because of differing social expectations for maturing boys and girls, the most widely reported cases of hikikomori are from middle- and upper-middle-class families; sons, typically their eldest, refuse to leave the home, often after experiencing one or more traumatic episodes of social or academic failure. In The Anatomy of Dependence, Takeo Doi identifies the symptoms of hikikomori, and explains its prevalence as originating in the Japanese psychological construct of amae (in Freudian terms, "passive object love", typically of the kind between mother and infant). Other Japanese commentators such as academic Shinji Miyadai and novelist Ryū Murakami, have also offered analysis of the hikikomori phenomenon, and find distinct causal relationships with the modern Japanese social conditions of anomie, amae and atrophying paternal influence in nuclear family child pedagogy. Young adults may feel overwhelmed by modern Japanese society, or be unable to fulfill their expected social roles as they have not yet formulated a sense of personal honne and tatemae – one's "true self" and one's "public façade" – necessary to cope with the paradoxes of adulthood. The dominant nexus of hikikomori centres on the transformation from youth to the responsibilities and expectations of adult life. Indications are that advanced industrialized societies such as modern Japan fail to provide sufficient meaningful transformation rituals for promoting certain susceptible types of youth into mature roles. As do many societies, Japan exerts a great deal of pressure on adolescents to be successful and perpetuate the existing social status quo. A traditionally strong emphasis on complex social conduct, rigid hierarchies and the resulting, potentially intimidating multitude of social expectations, responsibilities and duties in Japanese society contribute to this pressure on young adults. Historically, Confucian teachings de-emphasizing the individual and favouring a conformist stance to ensure social harmony in a rigidly hierarchical society have shaped much of East Asia, possibly explaining the emergence of the hikikomori phenomenon in other East Asian countries. In general, the prevalence of hikikomori tendencies in Japan may be encouraged and facilitated by three primary factors: Middle class affluence in a post-industrial society such as Japan allows parents to support and feed an adult child in the home indefinitely. Lower-income families do not have hikikomori children because a socially withdrawing youth is forced to work outside the home. The inability of Japanese parents to recognize and act upon the youth's slide into isolation; soft parenting; or codependency between mother and son, known as amae in Japanese. A decade of flat economic indicators and a shaky job market in Japan makes the pre-existing system requiring years of competitive schooling for elite jobs appear like a pointless effort to many. Role of modern technology Although the connection between modern communication technologies (such as the Internet, social media and video games) and the phenomenon is not conclusively established, those technologies are considered at least an exacerbating factor that can deepen and nurture withdrawal. Previous studies of hikikomori in South Korea and Spain found that some of them showed signs of Internet addiction, though researchers do not consider this to be the main issue. However, according to associate professor of psychiatry at Kyushu University in Fukuoka, Takahiro Kato, video games and social media have reduced the amount of time that people spent outside and in social environments that require direct face to face interaction. The emergence of mobile phones and then smartphones may also have deepened the issue, given that people can continue their addiction to gaming and online surfing anywhere, even in bed. Japanese education system The Japanese education system puts great demands upon youth. There is high competition to pass entrance exams into the next tier of education in what could be termed a rigid pass-or-fail ideology, which could induce a high level of stress. Echoing the traditional Confucian values of society, the educational system is viewed as playing an important part in society's overall productivity and success. In this social frame, students often face significant pressure from parents and society in general to conform to its dictates and doctrines. These doctrines, while part of modern Japanese society, are increasingly being rejected by Japanese youth in varying ways such as hikikomori, freeter, NEET (Not currently engaged in Employment, Education, or Training), and parasite singles. The term "Hodo-Hodo zoku" (the "So-So tribe") applies to younger workers who refuse promotion to minimize stress and maximize free time. Beginning in the 1960s, the pressure on Japanese youth to succeed began successively earlier in their lives, sometimes starting before pre-school, where even toddlers had to compete through an entrance exam for the privilege of attending one of the best pre-schools. This was said to prepare children for the entrance exam of the best kindergarten, which in turn prepared the child for the entrance exam of the best elementary school, junior high school, high school, and eventually for their university entrance exam. Many adolescents take one year off after high school to study exclusively for the university entrance exam, and are known as ronin. More prestigious universities have more difficult exams. The most prestigious university with the most difficult exam is the University of Tokyo. Since 1996, the Japanese Ministry of Education has taken steps to address this 'pressure-cooker' educational environment and instill greater creative thought in Japanese youth by significantly relaxing the school schedule from six-day weeks to five-day weeks and dropping two subjects from the daily schedule, with new academic curricula more comparable to Western educational models. However, Japanese parents are sending their children to private cram schools, known as juku, to 'make up' for lost time. After graduating from high school or university, Japanese youth also have to face a very difficult job market in Japan, often finding only part-time employment and ending up as freeters with little income, unable to start a family. Another source of pressure is from their co-students, who may harass and bully (ijime) some students for a variety of reasons, including physical appearance, wealth, or educational or athletic performance. Refusal to participate in society makes hikikomori an extreme subset of a much larger group of younger Japanese that includes freeters. Impact Japanese financial burden Some organizations, such as the non-profit Japanese organization NPO lila, have been trying to combat the financial burden the hikikomori phenomenon has had on Japan's economy. The Japanese CD and DVD producer Avex Group produces DVDs of live-action women staring into a camera to help hikikomori learn to cope with eye contact and long spans of human interaction. The goal is to ultimately help hikikomori reintegrate into society by personal choice, thereby realizing an economic contribution and reducing the financial burden on parents or guardians. "80–50 problem" The "80–50 problem" refers to hikikomori children from earlier days now entering their 50s, as their parents on whom they rely, enter their 80s. It was first described in Japanese publications and media in the late 2010s. In 2019, Japanese psychiatrist Tamaki Saitō held a press briefing at the Foreign Press Center Japan on the subject of hikikomori. In view of their rising age, he recommended practical advice to parents with older hikikomori, such as drawing up a lifetime financial plan for them, so they will be able to get by after the parents are gone. He also recommended that parents should not fear embarrassment or be concerned about appearances as they look at the options, including disability pensions or other forms of public assistance for their children. Tamaki emphasized the urgency and necessity for families in these situations to plan ahead; the Japanese government failed to see the urgency of the problem and demonstrated no motion toward developing substantive policies or systems like special safety nets related to the ageing group of hikikomori. Treatment programs When it comes to psychosocial support, it is hard for therapists to attain direct access to hikikomori; research to find different and effective treatment plans to aid hikikomori has been ongoing. One such treatment plan is focused on the families of hikikomori. Such focus primarily includes educational intervention programs (e.g. lectures, role-play, etc.) that are geared towards reducing any averse stigma that family members have towards psychiatric disorders like hikikomori. These educational programs are derived from other established family support programs, specifically Mental Health First Aid (MHFA) and Community Reinforcement and Family Training (CRAFT). CRAFT specifically trains family members to express positive and functional communication, whereas MHFA provides skills to support hikikomori with depression/suicidal like behaviour. Studies so far that have modified the family unit's behavioral response to a hikikomori has yielded positive results, indicating that family behavior is essential for recovery, however further research is still needed. Although there has been a primary emphasis on educating family members, there are also therapy programs for the hikikomori themselves to participate in, like exercise therapy. The individual psychotherapy methods that are being stressed in current research are primarily directed towards cultivating self-confidence within the hikikomori. However, studies have delineated that efficacious treatment of hikikomori requires a multifaceted approach rather than the utilization of one individual approach, such as individual psychotherapy or family therapy. In South Korea hikikomori in low income families can get up to ₩650,000 (equivalent to $490 or £390) as a monthly living allowance. They can also apply for subsidies for various services, including (but not limited to): health, education, counselling, legal services and cultural activities. This is in order to attempt to recover the daily lives of the hikikomori and attempt to reintegrate them into society. A "rental sister" is a system whereby hikikomori are regularly visited, encouraged to try and leave their bedrooms and integrate back into society. This can come through various methods, such as talking through a door and/or eating out, among other methods. COVID-19 pandemic impact Based on prior outbreaks (e.g. SARS, MERS), studies have shown that due to increased loneliness, quarantined individuals have heightened stress-related mental disturbances. Considering that political, social, and/or economical challenges already bring people to express hikikomori-like behavior, researchers theorize that since all the aforementioned factors are by-products of a pandemic, a hikikomori phenomenon may become more common in a post-pandemic world. In fact, people who do experience mental disturbances in Japan generally view seeking the help of a psychiatrist as shameful or a reason for them to be socially shunned. Experts predict an increase in focus on issues such as the mental health problems now affecting youth, and specifically through effective telemedicine services to either the affected individual and/or their respective family unit. Furthermore, with hikikomori becoming more prevalent amid a pandemic, experts theorize that it will bring out more empathy and constructive attention towards the issue. See also Acedia Asociality Avolition Fushūgaku School refusal Herbivore men Jōhatsu Monasticism Recluse literature Tang ping Tokyo!, 2008 movie in three parts, the third part of which, Shaking Tokyo, shows the life of a hikikomori Welcome to the N.H.K., a Japanese novel, manga, and anime series about a young man who is a hikikomori References Notes Bibliography Further reading Media External links Academic pressure in East Asian culture Autism spectrum disorders Demographics of Japan Economy of Japan Education in Japan Culture of Japan Japanese family structure Japanese words and phrases Society of Japan Words and phrases describing personality

Avolition

Avolition or amotivation as a symptom of various forms of psychopathology, is the decrease in the ability to initiate and persist in self-directed purposeful activities. Such activities that appear to be neglected usually include routine activities, including hobbies, going to work or school, and most notably, engaging in social activities. A person experiencing avolition may stay at home for long periods of time, rather than seeking out work or peer relations. It is a disorder of diminished motivation. Psychopathology People with avolition often want to complete certain tasks but lack the ability to initiate behaviors necessary to complete them. Avolition is most commonly seen as a symptom of some other disorder, but might be considered a primary clinical disturbance of itself (or as a coexisting second disorder) related to disorders of diminished motivation. In 2006, avolition was identified as a negative symptom of schizophrenia by the National Institute of Mental Health (NIMH), and has been observed in patients with bipolar disorder as well as resulting from trauma. Avolition is sometimes mistaken for other, similar symptoms also affecting motivation, such as abulia, anhedonia and asociality, or strong general disinterest. For example, abulia is also a restriction in motivation and initiation, but characterized by an inability to set goals or make decisions and considered a disorder of diminished motivation. In order to provide effective treatment, the underlying cause of avolition (if any) has to be identified and it is important to properly differentiate it from other symptoms, even though they might reflect similar aspects of mental illness. Social and clinical implications Implications from avolition often result in social deficits. Not being able to initiate and perform purposeful activities can have many implications for a person with avolition. By disrupting interactions with both familiar and unfamiliar people, it jeopardizes the patient's social relations. When part of a severe mental illness, avolition has been reported, in first person accounts, to lead to physical and mental inability to both initiate and maintain relationships, as well as work, eat, drink or even sleep. Clinically, it may be difficult to engage an individual experiencing avolition in active participation of psychotherapy. Patients are also faced with the stresses of coping with and accepting a mental illness and the stigma that often accompanies such a diagnosis and its symptoms. Regarding schizophrenia, the American Psychiatric Association reported in 2013 that there currently are "no treatments with proven efficacy for primary negative symptoms" (such as avolition). Together with schizophrenia's chronic nature, such facts added to the outlook of never getting well, might further implicate feelings of hopelessness and similar in patients as well as their friends and family. Treatment Antipsychotics are less effective in the treatment of negative symptoms of schizophrenia such as avolition than for positive symptoms. Low dose amisulpride has shown to be more effective than placebo for treating the negative symptoms of schizophrenia, which includes avolition. It works by blocking pre-synaptic dopamine receptors, causing a release of dopamine into the synapse. Compared with social skills training (SST), cognitive behavioural therapy (CBT) shows more promise in treating the negative symptoms of schizophrenia, including avolition. According to a 2015 article, aripiprazole may be useful for treatment of apathy syndrome (avolition). However, its role and efficacy in treatment of apathy requires further investigation in clinical trials. A comparison to amisulpride published in 2022, found that aripiprazole was effective in treating negative symptoms, while amisulpride was not. According to a 2020 study, mitragynine contained in kratom may have the ability to reduce avolition. See also Athymhormia ADHD Akrasia Amotivational syndrome Apathy Autism spectrum disorder Hikikomori Incontinence (philosophy) Learned helplessness Lethargy Major depressive disorder Schizoid personality disorder Volition (psychology) References Symptoms and signs of mental disorders symptoms of schizophrenia Personality traits Motivation Disorders of diminished motivation

Life skills

Life skills are abilities for adaptive and positive behavior that enable humans to deal effectively with the demands and challenges of life. This concept is also termed as psychosocial competency. The subject varies greatly depending on social norms and community expectations but skills that function for well-being and aid individuals to develop into active and productive members of their communities are considered as life skills. Enumeration and categorization The UNICEF Evaluation Office suggests that "there is no definitive list" of psychosocial skills; nevertheless UNICEF enumerates psychosocial and interpersonal skills that are generally well-being oriented, and essential alongside literacy and numeracy skills. Since it changes its meaning from culture to culture and life positions, it is considered a concept that is elastic in nature. But UNICEF acknowledges social and emotional life skills identified by Collaborative for Academic, Social and Emotional Learning (CASEL). Life skills are a product of synthesis: many skills are developed simultaneously through practice, like humor, which allows a person to feel in control of a situation and make it more manageable in perspective. It allows the person to release fears, anger, and stress & achieve a qualitative life. For example, decision-making often involves critical thinking ("what are my options?") and values clarification ("what is important to me?"), ("How do I feel about this?"). Ultimately, the interplay between the skills is what produces powerful behavioral outcomes, especially where this approach is supported by other strategies. Life skills can vary from financial literacy, through substance-abuse prevention, to therapeutic techniques to deal with disabilities such as autism. Core skills The World Health Organization in 1999 identified the following core cross-cultural areas of life skills: decision-making and problem-solving; creative thinking (see also: lateral thinking) and critical thinking; communication and interpersonal skills; self-awareness and empathy; assertiveness and equanimity; and resilience and coping with emotions and coping with stress. UNICEF listed similar skills and related categories in its 2012 report. Life skills curricular designed for K-12 often emphasize communications and practical skills needed for successful independent living as well as for developmental-disabilities/special-education students with an Individualized Education Program (IEP). There are various courses being run based on WHO's list supported by UNFPA. In Madhya Pradesh, India, the programme is being run with Government to teach these through Government Schools. Skills for work and life Skills for work and life, known as technical and vocational education and training (TVET) is comprising education, training and skills development relating to a wide range of occupational fields, production, services and livelihoods. TVET, as part of lifelong learning, can take place at secondary, post-secondary and tertiary levels, and includes work-based learning and continuing training and professional development which may lead to qualifications. TVET also includes a wide range of skills development opportunities attuned to national and local contexts. Learning to learn and the development of literacy and numeracy skills, transversal skills and citizenship skills are integral components of TVET. Parenting: a venue of life skills nourishment Life skills are often taught in the domain of parenting, either indirectly through the observation and experience of the child, or directly with the purpose of teaching a specific skill. Parenting itself can be considered as a set of life skills which can be taught or comes natural to a person. Educating a person in skills for dealing with pregnancy and parenting can also coincide with additional life skills development for the child and enable the parents to guide their children in adulthood. Many life skills programs are offered when traditional family structures and healthy relationships have broken down, whether due to parental lapses, divorce, psychological disorders or due to issues with the children (such as substance abuse or other risky behavior). For example, the International Labour Organization is teaching life skills to ex-child laborers and at-risk children in Indonesia to help them avoid and to recover from worst forms of child abuse. Models: behavior prevention vs. positive development While certain life skills programs focus on teaching the prevention of certain behaviors, they can be relatively ineffective. Based upon their research, the Family and Youth Services Bureau, a division of the U.S. Department of Health and Human Services advocates the theory of positive youth development (PYD) as a replacement for the less effective prevention programs. PYD focuses on the strengths of an individual as opposed to the older decrepit models which tend to focus on the "potential" weaknesses that have yet to be shown. "..life skills education, have found to be an effective psychosocial intervention strategy for promoting positive social, and mental health of adolescents which plays an important role in all aspects such as strengthening coping strategies and developing self-confidence and emotional intelligence..." See also Sources Further reading People Skills & Self-Management (free online guide), Alliances for Psychosocial Advancements in Living: Communication Connections (APAL-CC) Reaching Your Potential: Personal and Professional Development, 4th Edition Life Skills: A Course in Applied Problem Solving., Saskatchewan NewStart Inc., First Ave and River Street East, Prince Albert, Saskatchewan, Canada. References

Chronic traumatic encephalopathy

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease linked to repeated trauma to the head. The encephalopathy symptoms can include behavioral problems, mood problems, and problems with thinking. The disease often gets worse over time and can result in dementia. Most documented cases have occurred in athletes involved in striking-based combat sports, such as boxing, kickboxing, mixed martial arts, and Muay Thai and contact sports such as American football, rugby league, rugby union, Australian rules football, professional wrestling, and ice hockey. It is also an issue in association football (soccer), but largely as a result of heading the ball rather than player contact. Other risk factors include being in the military (combat arms), prior domestic violence, and repeated banging of the head. The exact amount of trauma required for the condition to occur is unknown, and as of 2022 definitive diagnosis can only occur at autopsy. The disease is classified as a tauopathy. There is no specific treatment for the disease. Rates of CTE have been found to be about 30% among those with a history of multiple head injuries; however, population rates are unclear. Research in brain damage as a result of repeated head injuries began in the 1920s, at which time the condition was known as dementia pugilistica or "boxer's dementia", "boxer's madness", or "punch drunk syndrome". It has been proposed that the rules of some sports be changed as a means of prevention. Signs and symptoms Symptoms of CTE, which occur in four stages, generally appear eight to ten years after an individual experiences repetitive mild traumatic brain injuries. First-stage symptoms are confusion, disorientation, dizziness, and headaches. Second-stage symptoms include memory loss, social instability, impulsive behavior, and poor judgment. Third and fourth stages include progressive dementia, movement disorders, hypomimia, speech impediments, sensory processing disorder, tremors, vertigo, deafness, depression and suicidality. Additional symptoms include dysarthria, dysphagia, cognitive disorders such as amnesia, and ocular abnormalities, such as ptosis. The condition manifests as dementia, or declining mental ability, problems with memory, dizzy spells or lack of balance to the point of not being able to walk under one's own power for a short time and/or Parkinsonism, or tremors and lack of coordination. It can also cause speech problems and an unsteady gait. Patients with CTE may be prone to inappropriate or explosive behavior and may display pathological jealousy or paranoia. Cause Most documented cases have occurred in athletes with mild repetitive head impacts (RHI) over an extended period of time. Evidence indicates that repetitive concussive and subconcussive blows to the head cause CTE. In particular, it is associated with contact sports such as boxing, American football, Australian rules football, wrestling, mixed martial arts, ice hockey, rugby, and association football. In association football (soccer), whether this is just associated with prolific headers or other injuries is unclear as of 2017. Other potential risk factors include military personnel (repeated exposure to explosive charges or large caliber ordnance), domestic violence, and repeated impact to the head. The exact amount of trauma required for the condition to occur is unknown although it is believed that it may take years to develop. Pathology The neuropathological appearance of CTE is distinguished from other tauopathies, such as Alzheimer's disease. The four clinical stages of observable CTE disability have been correlated with tau pathology in brain tissue, ranging in severity from focal perivascular epicenters of neurofibrillary tangles in the frontal neocortex to severe tauopathy affecting widespread brain regions. The primary physical manifestations of CTE include a reduction in brain weight, associated with atrophy of the frontal and temporal cortices and medial temporal lobe. The lateral ventricles and the third ventricle are often enlarged, with rare instances of dilation of the fourth ventricle. Other physical manifestations of CTE include anterior cavum septi pellucidi and posterior fenestrations, pallor of the substantia nigra and locus ceruleus, and atrophy of the olfactory bulbs, thalamus, mammillary bodies, brainstem and cerebellum. As CTE progresses, there may be marked atrophy of the hippocampus, entorhinal cortex, and amygdala. On a microscopic scale, a pathognomonic CTE lesion involves p-tau aggregates in neurons, with or without thorn-shaped astrocytes, at the depths of the cortical sulcus around a small blood vessel, deep in the parenchyma, and not restricted to the subpial and superficial region of the sulcus; the pathognomonic lesion must include p-tau in neurons to distinguish CTE from aging-related tau astrogliopathy (ARTAG). Supporting features of CTE are: superficial neurofibrillary tangles (NFTs); p–tau in CA2 and CA4 hippocampus; p-tau in: mammillary bodies, hypothalamic nuclei, amygdala, nucleus accumbens, thalamus, midbrain tegmentum, nucleus basalis of Meynert, raphe nuclei, substantia nigra and locus coeruleus; p-tau thorn-shaped astrocytes (TSA) in the subpial region; p-tau dot-like neurites. Purely astrocytic perivascular p-tau pathology represents ARTAG and does not meet the criteria for CTE. A small group of individuals with CTE have chronic traumatic encephalomyopathy (CTEM), which is characterized by symptoms of motor-neuron disease and which mimics amyotrophic lateral sclerosis (ALS). Progressive muscle weakness and balance and gait problems (problems with walking) seem to be early signs of CTEM. Exosome vesicles created by the brain are potential biomarkers of TBI, including CTE. Loss of neurons, scarring of brain tissue, collection of proteinaceous senile plaques, hydrocephalus, attenuation of the corpus callosum, diffuse axonal injury, neurofibrillary tangles, and damage to the cerebellum are implicated in the syndrome. Neurofibrillary tangles have been found in the brains of dementia pugilistica patients, but not in the same distribution as is usually found in people with Alzheimer's. One group examined slices of brain from patients having had multiple mild traumatic brain injuries and found changes in the cells' cytoskeletons, which they suggested might be due to damage to cerebral blood vessels. Increased exposure to concussions and subconcussive blows is regarded as the most important risk factor. In boxing, this exposure can depend on the total number of fights, number of knockout losses, the duration of career, fight frequency, age of retirement, and boxing style. Diagnosis Diagnosis of CTE cannot be made in living individuals; a clear diagnosis is only possible during an autopsy. Though there are signs and symptoms some researchers associate with CTE, there is no definitive test to prove the existence in a living person. Signs are also very similar to those of other neurological conditions, such as Alzheimer's. The lack of distinct biomarkers is the reason CTE cannot typically be diagnosed while a person is alive. Concussions are non-structural injuries and do not result in brain bleeding, which is why most concussions cannot be seen on routine neuroimaging tests such as CT or MRI. Acute concussion symptoms (those that occur shortly after an injury) should not be confused with CTE. Differentiating between prolonged post-concussion syndrome (PCS, where symptoms begin shortly after a concussion and last for weeks, months, and sometimes even years) and CTE symptoms can be difficult. Research studies are examining whether neuroimaging can detect subtle changes in axonal integrity and structural lesions that can occur in CTE. By the early 2010s, more progress in in-vivo diagnostic techniques for CTE had been made, using DTI, fMRI, MRI, and MRS imaging; however, more research needs to be done before any such techniques can be validated. PET tracers that bind specifically to tau protein are desired to aid diagnosis of CTE in living individuals. One candidate is the tracer , which is retained in the brain in individuals with a number of dementing disorders such as Alzheimer's disease, Down syndrome, progressive supranuclear palsy, corticobasal degeneration, familial frontotemporal dementia, and Creutzfeldt–Jakob disease. In a small study of 5 retired NFL players with cognitive and mood symptoms, the PET scans revealed accumulation of the tracer in their brains. However, binds to beta-amyloid and other proteins as well. Moreover, the sites in the brain where the tracer was retained were not consistent with the known neuropathology of CTE. A more promising candidate is the tracer [18F]-T807, which binds only to tau. It is being tested in several clinical trials. A putative biomarker for CTE is the presence in serum of autoantibodies against the brain. The autoantibodies were detected in football players who experienced a large number of head hits but no concussions, suggesting that even sub-concussive episodes may be damaging to the brain. The autoantibodies may enter the brain by means of a disrupted blood-brain barrier, and attack neuronal cells which are normally protected from an immune onslaught. Given the large numbers of neurons present in the brain (86 billion), and considering the poor penetration of antibodies across a normal blood-brain barrier, there is an extended period of time between the initial events (head hits) and the development of any signs or symptoms. Nevertheless, autoimmune changes in blood of players may constitute the earliest measurable event predicting CTE. According to 2017 study on brains of deceased gridiron football players, 99% of tested brains of NFL players, 88% of CFL players, 64% of semi-professional players, 91% of college football players, and 21% of high school football players had various stages of CTE. Players still alive are not able to be tested. Imaging Although the diagnosis of CTE cannot be determined by imaging, the effects of head trauma may be seen with the use of structural imaging. Imaging techniques include the use of magnetic resonance imaging, nuclear magnetic resonance spectroscopy, CT scan, single-photon emission computed tomography, Diffusion MRI, and Positron emission tomography (PET). One specific use of imaging is the use of a PET scan is to evaluate for tau deposition, which has been conducted on retired NFL players. Prevention The use of helmets and mouth guards has been put forward as a possible preventative measure; though neither has significant research to support its use, both have been shown to reduce direct head trauma. Although there is no significant research to support the use of helmets to reduce the risk of concussions, there is evidence to support that helmet use reduces impact forces. The sports in which a helmet was effective in preventing TBI and concussions were skiing and snowboarding. Mouth guards have been shown to decrease dental injuries, but again have not shown significant evidence to reduce concussions. Because repeated impacts are thought to increase the likelihood of CTE development, a growing area of practice is improved recognition and treatment for concussions and other head trauma; removal from sport participation during recovery from these traumatic injuries is essential. Proper return-to-play protocol after possible brain injuries is also important in decreasing the significance of future impacts. Efforts are being made to change the rules of contact sports to reduce the frequency and severity of blows to the head. Examples of these rule changes are the evolution of tackling technique rules in American football, such as the banning of helmet-first tackles, and the addition of rules to protect defenseless players. Likewise, another growing area of debate is better implementation of rules already in place to protect athletes. Because of the concern that boxing may cause CTE, there is a movement among medical professionals to ban the sport. Medical professionals have called for such a ban as early as the 1950s. Management No cure exists for CTE, and because it cannot be tested for until an autopsy is performed, people cannot know if they have it. Treatment is supportive as with other forms of dementia. Those with CTE-related symptoms may receive medication and non-medication related treatments. Epidemiology Rates of disease have been found to be about 30% among those with a history of multiple head injuries. Population rates, however, are unclear. Professional level athletes are the largest group with CTE, due to frequent concussions and sub-concussive impacts from play in contact sport. These contact-sports include American football, Australian rules football, ice hockey, Rugby football (Rugby union and Rugby league), boxing, kickboxing, mixed martial arts, association football, and wrestling. In association football, only prolific headers are known to have developed CTE. Cases of CTE were also recorded in baseball. According to a 2017 study on brains of deceased gridiron football players, 99% of tested brains of NFL players, 88% of CFL players, 64% of semi-professional players, 91% of college football players, and 21% of high school football players had various stages of CTE. Other individuals diagnosed with CTE were those involved in military service, had a previous history of chronic seizures, were domestically abused, or were involved in activities resulting in repetitive head collisions. History CTE was originally studied in boxers in the 1920s as "punch-drunk syndrome." Punch-drunk syndrome was first described in 1928 by a forensic pathologist, Harrison Stanford Martland, who was the chief medical examiner of Essex County in Newark, New Jersey, in a Journal of the American Medical Association article, in which he noted the tremors, slowed movement, confusion and speech problems typical of the condition. The term "punch-drunk" was replaced with "dementia pugilistica" in 1937 by J.A. Millsbaugh, as he felt the term was condescending to former boxers. The initial diagnosis of dementia pugilistica was derived from the Latin word for boxer, pugil (akin to pugnus 'fist', pugnāre 'to fight'). Other terms for the condition have included chronic boxer's encephalopathy, traumatic boxer's encephalopathy, boxer's dementia, pugilistic dementia, chronic traumatic brain injury associated with boxing (CTBI-B), and punch-drunk syndrome. British neurologist, Macdonald Critchley, wrote a 1949 paper titled "Punch-drunk syndromes: the chronic traumatic encephalopathy of boxers". CTE was first recognized as affecting individuals who took considerable blows to the head, but was believed to be confined to boxers and not other athletes. As evidence pertaining to the clinical and neuropathological consequences of repeated mild head trauma grew, it became clear that this pattern of neurodegeneration was not restricted to boxers, and the term chronic traumatic encephalopathy became most widely used. In October 2022, the United States National Institutes of Health formally acknowledged there was a causal link between repeated blows to the head and CTE. Research In 2005, forensic pathologist Bennet Omalu, along with colleagues in the Department of Pathology at the University of Pittsburgh, published a paper, "Chronic Traumatic Encephalopathy in a National Football League Player", in the journal Neurosurgery, based on analysis of the brain of deceased former NFL center Mike Webster. This was then followed by a paper on a second case in 2006 describing similar pathology, based on findings in the brain of former NFL player Terry Long. In 2008, the Center for the Study of Traumatic Encephalopathy at the BU School of Medicine (now the BU CTE Center) started the VA-BU-CLF Brain Bank at the Bedford Veterans Administration Hospital to analyze the effects of CTE and other neurodegenerative diseases on the brain and spinal cord of athletes, military veterans, and civilians. To date, the VA-BU-CLF Brain Bank is the largest CTE tissue repository in the world, with over 1000 brain donors. On December 21, 2009, the National Football League Players Association announced that it would collaborate with the BU CTE Center to support the center's study of repetitive brain trauma in athletes. Additionally, in 2010 the National Football League gave the BU CTE Center a $1 million gift with no strings attached. In 2008, twelve living athletes (active and retired), including hockey players Pat LaFontaine and Noah Welch as well as former NFL star Ted Johnson, committed to donate their brains to VA-BU-CLF Brain Bank after their deaths. In 2009, NFL Pro Bowlers Matt Birk, Lofa Tatupu, and Sean Morey pledged to donate their brains to the VA-BU-CLF Brain Bank. In 2010, 20 more NFL players and former players pledged to join the VA-BU-CLF Brain Donation Registry, including Chicago Bears linebacker Hunter Hillenmeyer, Hall of Famer Mike Haynes, Pro Bowlers Zach Thomas, Kyle Turley, and Conrad Dobler, Super Bowl Champion Don Hasselbeck and former pro players Lew Carpenter, and Todd Hendricks. In 2010, professional wrestlers Mick Foley, Booker T and Matt Morgan also agreed to donate their brains upon their deaths. Also in 2010, MLS player Taylor Twellman, who had to retire from the New England Revolution because of post-concussion symptoms, agreed to donate his brain upon his death. As of 2010, the VA-BU-CLF Brain Donation Registry consists of over 250 current and former athletes. In 2011, former North Queensland Cowboys player Shaun Valentine became the first Australian National Rugby League player to agree to donate his brain upon his death, in response to recent concerns about the effects of concussions on Rugby League players, who do not use helmets. Also in 2011, boxer Micky Ward, whose career inspired the film The Fighter, agreed to donate his brain upon his death. In 2018, NASCAR driver Dale Earnhardt Jr., who retired in 2017 citing multiple concussions, became the first auto racing competitor agreeing to donate his brain upon his death. In related research, the Center for the Study of Retired Athletes, which is part of the Department of Exercise and Sport Science at the University of North Carolina at Chapel Hill, is conducting research funded by National Football League Charities to "study former football players, a population with a high prevalence of exposure to prior Mild Traumatic Brain Injury (MTBI) and sub-concussive impacts, in order to investigate the association between increased football exposure and recurrent MTBI and neurodegenerative disorders such as cognitive impairment and Alzheimer's disease (AD)". In February 2011, former NFL player Dave Duerson committed suicide via a gunshot to his chest, thus leaving his brain intact. Duerson left text messages to loved ones asking that his brain be donated to research for CTE. The family got in touch with representatives of the Boston University center studying the condition, said Robert Stern, the co-director of the research group. Stern said Duerson's gift was the first time of which he was aware that such a request had been made by someone who had committed suicide that was potentially linked to CTE. Stern and his colleagues found high levels of the protein tau in Duerson's brain. These elevated levels, which were abnormally clumped and pooled along the brain sulci, are indicative of CTE. In July 2010, NHL enforcer Bob Probert died of heart failure. Before his death, he asked his wife to donate his brain to CTE research because it was noticed that Probert experienced a mental decline in his 40s. In March 2011, researchers at Boston University concluded that Probert had CTE upon analysis of the brain tissue he donated. He was the second NHL player from the program at the BU CTE Center to be diagnosed with CTE postmortem. The BU CTE Center has also found indications of links between amyotrophic lateral sclerosis (ALS) and CTE in athletes who have participated in contact sports. Tissue for the study was donated by twelve athletes and their families to the VA-BU-CLF Brain Bank at the Bedford, Massachusetts VA Medical Center. In 2013, President Barack Obama announced the creation of the Chronic Effects of Neurotrauma Consortium or CENC, a federally funded research project devised to address the long-term effects of mild traumatic brain injury in military service personnel (SMs) and veterans. The CENC is a multi-center collaboration linking premiere basic science, translational, and clinical neuroscience researchers from the DoD, VA, academic universities, and private research institutes to effectively address the scientific, diagnostic, and therapeutic ramifications of mild TBI and its long-term effects. Nearly 20% of the more than 2.5 million U.S. service members (SMs) deployed since 2003 to Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have sustained at least one traumatic brain injury (TBI), predominantly mild TBI (mTBI), and almost 8% of all OEF/OIF Veterans demonstrate persistent post-TBI symptoms more than six months post-injury. Unlike those head injuries incurred in most sporting events, recent military head injuries are most often the result of blast wave exposure. After a competitive application process, a consortium led by Virginia Commonwealth University was awarded funding to study brain injuries in military veterans. The project principal investigator for the CENC is David Cifu, chairman and Herman J. Flax professor of the Department of Physical Medicine and Rehabilitation (PM&R) at Virginia Commonwealth University (VCU) in Richmond, Virginia, with co-principal investigators Ramon Diaz-Arrastia, Professor of Neurology, Uniformed Services University of the Health Sciences, and Rick L. Williams, statistician at RTI International. In 2017, Aaron Hernandez, a former professional football player and convicted murderer, committed suicide at the age of 27 while in prison. His family donated his brain to the BU CTE Center. Ann McKee, the head of Center, concluded that "Hernandez had Stage 3 CTE, which researchers had never seen in a brain younger than 46 years old." In 2022, former NRL player and coach Paul Green died by suicide at the age of 49. Green's brain was donated to the Australian Sports Brain Bank, with his family posting on the website "In memory of our beloved Paul, we ask that you support the pioneering work of the Australian Sports Brain Bank" with a goal of raising money for further understanding of CTE. A post-mortem examination revealed that Green was suffering from one of the most "severe forms" of CTE. Professor Michael Buckland said Green had "an organic brain disease which robbed him of his decision-making and impulse control." He added Green would likely have been "symptomatic for some time." Research into the genetic component of CTE is evolving, and well summarized in a recent review. Interestingly, the minor allele of TMEM106B has been found to be associated with a protective phenotype. In 2023, Australian rules football player Heather Anderson became the first female athlete diagnosed with CTE after her death by suicide on 13 November 2022, at the age of 28. Her brain, which was donated to the Australian Sports Brain Bank, was found to contain multiple CTE lesions, and abnormalities were found "nearly everywhere" in the cortex. Also in 2023, a study was published on August 28 in JAMA Neurology regarding brain autopsies of athletes, one of whom was the first American female athlete diagnosed with CTE; her name is unknown, but she died at age 28 and was a collegiate soccer player. In March 2024, former rugby union player Billy Guyton became the first New Zealand-based athlete diagnosed with CTE following his forced retirement in 2018, due to the complications of multiple concussions, and his death by suspected suicide in 2023. His brain had been donated by his family to the Neurological Foundation Human Brain Bank at the University of Auckland, with post-mortem analyses conducted in New Zealand and Australia eventually finding "background changes consistent with global hypoxic ischaemic encephalopathy", as well as trauma-induced cavum septum pellucidum and age-related tau deposits. See also Acquired brain injury Brain damage Chronic traumatic encephalopathy in sports Concussions in American football Concussions in rugby union Health issues in American football List of NFL players with chronic traumatic encephalopathy Chuck Bednarik The Hit (Chuck Bednarik) Traumatic brain injury References External links Association football controversies Motor neuron diseases National Football League controversies Neurotrauma Overuse injuries Professional wrestling controversies Sports controversies Sports injuries Wikipedia medicine articles ready to translate

Intellectual disability

Intellectual disability (ID), also known as general learning disability (in the United Kingdom) and formerly mental retardation (in the United States), is a generalized neurodevelopmental disorder characterized by significant impairment in intellectual and adaptive functioning that is first apparent during childhood. Children with intellectual disabilities typically have an intelligence quotient (IQ) below 70 and deficits in at least two adaptive behaviors that affect everyday living. According to the DSM-5, intellectual functions include reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. Deficits in these functions must be confirmed by clinical evaluation and individualized standard IQ testing. On the other hand, adaptive behaviors include the social, developmental, and practical skills people learn to perform tasks in their everyday lives. Deficits in adaptive functioning often compromises an individual's independence and ability to meet their social responsibility. Intellectual disability is subdivided into syndromic intellectual disability, in which intellectual deficits associated with other medical and behavioral signs and symptoms are present, and non-syndromic intellectual disability, in which intellectual deficits appear without other abnormalities. Down syndrome and fragile X syndrome are examples of syndromic intellectual disabilities. Intellectual disability affects about 2–3% of the general population. Seventy-five to ninety percent of the affected people have mild intellectual disability. Non-syndromic, or idiopathic cases account for 30–50% of these cases. About a quarter of cases are caused by a genetic disorder, and about 5% of cases are inherited. Cases of unknown cause affect about 95 million people . Signs and symptoms Intellectual disability (ID) becomes apparent during childhood and involves deficits in mental abilities, social skills, and core activities of daily living (ADLs) when compared to same-aged peers. There often are no physical signs of mild forms of ID, although there may be characteristic physical traits when it is associated with a genetic disorder (e.g., Down syndrome). The level of impairment ranges in severity for each person. Some of the early signs can include: Delays in reaching, or failure to achieve milestones in motor skills development (sitting, crawling, walking) Slowness learning to talk, or continued difficulties with speech and language skills after starting to talk Difficulty with self-help and self-care skills (e.g., getting dressed, washing, and feeding themselves) Poor planning or problem-solving abilities Difficulty following verbal instructions Behavioral and social problems Failure to grow intellectually, or continued infant childlike behavior Problems keeping up in school Failure to adapt or adjust to new situations Difficulty understanding and following social rules In early childhood, mild ID (IQ 50–69) may not be obvious or identified until children begin school. Even when poor academic performance is recognized, it may take expert assessment to distinguish mild intellectual disability from specific learning disability or emotional/behavioral disorders. People with mild ID are capable of learning reading and mathematics skills to approximately the level of a typical child aged nine to twelve. They can learn self-care and practical skills, such as cooking or using the local mass transit system. As individuals with intellectual disabilities reach adulthood, many learn to live independently and maintain gainful employment. About 85% of persons with ID are likely to have mild ID. Moderate ID (IQ 35–49) is nearly always apparent within the first years of life. Speech delays are particularly common signs of moderate ID. People with moderate intellectual disabilities need considerable support in school, at home, and in the community in order to fully participate. While their academic potential is limited, they can learn simple health and safety skills and to participate in simple activities. As adults, they may live with their parents, in a supportive group home, or even semi-independently with significant supportive services to help them, for example, manage their finances. As adults, they may work in a sheltered workshop. About 10% of persons with ID are likely to have moderate ID. People with Severe ID (IQ 20–34), accounting for 3.5% of persons with ID, or Profound ID (IQ 19 or below), accounting for 1.5% of persons with ID, need more intensive support and supervision for their entire lives. They may learn some ADLs, but an intellectual disability is considered severe or profound when individuals are unable to independently care for themselves without ongoing significant assistance from a caregiver throughout adulthood. Individuals with profound ID are completely dependent on others for all ADLs and to maintain their physical health and safety. They may be able to learn to participate in some of these activities to a limited degree. Co-morbidity Autism and intellectual disability Intellectual disability and autism spectrum disorder (ASD) share clinical characteristics which can result in confusion while diagnosing. Overlapping these two disorders, while common, can be detrimental to a person's well-being. Those with ASD that hold symptoms of ID may be grouped into a co-diagnosis in which they are receiving treatment for a disorder they do not have. Likewise, those with ID that are mistaken to have ASD may be treated for symptoms of a disorder they do not have. Differentiating between these two disorders will allow clinicians to deliver or prescribe the appropriate treatments. Comorbidity between ID and ASD is very common; it was estimated that roughly 40% of those with ID also have ASD, and roughly 70% of those with ASD also have ID. More recently, research has indicated a prevalence of roughly 30% for ID in individuals with ASD. Both ASD and ID require shortfalls in communication and social awareness as defining criteria. In a study conducted in 2016 surveying 2816 cases, it was found that the top subsets that help differentiate between those with ID and ASD are, "impaired non-verbal social behavior and lack of social reciprocity, [...] restricted interests, strict adherence to routines, stereotyped and repetitive motor mannerisms, and preoccupation with parts of objects". Those with ASD tend to show more deficits in non-verbal social behavior such as body language and understanding social cues. In a study done in 2008 of 336 individuals with varying levels of ID, it was found that those with ID display fewer instances of repetitive or ritualistic behaviors. It also recognized that those with ASD, when compared to those with ID, were more likely to isolate themselves and make less eye contact. When it comes to classification ID and ASD have very different guidelines. ID has a standardized assessment called the Supports Intensity Scale (SIS); this measures severity on a system built around how much support an individual will need. While ASD also classifies severity by support needed, there is no standard assessment; clinicians are free to diagnose severity at their own judgment. Epilepsy and intellectual disability Around 22% of individuals with ID suffer from Epilepsy. The incidence of epilepsy is associated with level of ID; epilepsy affects around half of individuals with profound ID. Proper epilepsy management is particularly crucial in this population, as individuals are at increased risk of sudden unexpected death in epilepsy. Nonetheless, epilepsy management in the ID population can be challenging due to high levels of polypharmacy prescribing, drug interactions, and increased vulnerability to adverse effects. It is thought that 70% of individuals with ID are pharmaco-resistant, however only around 10% of individuals are prescribed Anti-Seizure Medications (ASMs) licenced for pharmaco-resistant epilepsy. Research shows that certain ASMs, including Levetiracetam and Brivaracetam, show similar efficacy and tolerability in individuals with ID as compared to those without. There is much ongoing research into epilepsy management in the ID population. Causes Among children, the cause of intellectual disability is unknown for one-third to one-half of cases. About 5% of cases are inherited. Genetic defects that cause intellectual disability, but are not inherited, can be caused by accidents or mutations in genetic development. Examples of such accidents are development of an extra chromosome 18 (trisomy 18) and Down syndrome, which is the most common genetic cause. DiGeorge syndrome and fetal alcohol spectrum disorders are the next most common causes. Some other frequently observed causes include: Genetic conditions. Sometimes disability is caused by abnormal genes inherited from parents, errors when genes combine, or other reasons like de novo mutations in genes associated with intellectual disability. The most prevalent genetic conditions include Down syndrome, Klinefelter syndrome, Fragile X syndrome (common among boys), neurofibromatosis, congenital hypothyroidism, Williams syndrome, phenylketonuria (PKU), and Prader–Willi syndrome. Other genetic conditions include Phelan–McDermid syndrome (22q13del), Mowat–Wilson syndrome, genetic ciliopathy, and Siderius type X-linked intellectual disability as caused by mutations in the PHF8 gene. In the rarest of cases, abnormalities with the X or Y chromosome may also cause disability. Tetrasomy X and pentasomy X syndrome affect a small number of girls worldwide, while boys may be affected by 49, XXXXY, or 49, XYYYY. 47, XYY is not associated with significantly lowered IQ though affected individuals may have slightly lower IQs than non-affected siblings on average. Problems during pregnancy. Intellectual disability can result when the fetus does not develop properly. For example, there may be a problem with the way the fetus's cells divide as it grows. A pregnant woman who drinks alcohol (see fetal alcohol spectrum disorder) or gets an infection like rubella during pregnancy may also have a baby with an intellectual disability. Problems at birth. If a baby has problems during labor and birth, such as not getting enough oxygen, they may have a developmental disability due to brain damage. The group of proteins known as histones have an essential part in gene regulation, and sometimes these proteins become modified and are prevented from working properly. When the genes responsible for the development of neurons are affected, it affects the brain and behavior in the individual. Exposure to certain types of disease or toxins. Diseases like whooping cough, measles, or meningitis can cause intellectual disability if medical care is delayed or inadequate. Exposure to poisons like lead or mercury may also affect mental ability. Iodine deficiency, affecting approximately 2 billion people worldwide, is the leading preventable cause of intellectual disability in areas of the developing world where iodine deficiency is endemic. Iodine deficiency also causes goiter, an enlargement of the thyroid gland. More common than full-fledged congenital iodine deficiency syndrome (formerly cretinism), as intellectual disability caused by severe iodine deficiency is called, is mild impairment of intelligence. Residents of certain areas of the world, due to natural deficiency and governmental inaction, are severely affected by iodine deficiency. India has 500 million people with a deficiency, 54 million with goiter, and 2 million with congenital iodine deficiency. Among other nations affected by iodine deficiency, China and Kazakhstan have instituted widespread salt iodization programs. But, as of 2006, Russia had not. Malnutrition is a common cause of reduced intelligence in parts of the world affected by famine, such as Ethiopia and nations struggling with extended periods of warfare that disrupt agriculture production and distribution. Absence of the arcuate fasciculus. Furthermore, lack of stimulation of sensory pathways in infants can also cause developmental and cognitive delays. Diagnosis According to both the American Association on Intellectual and Developmental Disabilities and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), three criteria must be met for a diagnosis of intellectual disability: significant limitation in general mental abilities (intellectual functioning), significant limitations in one or more areas of adaptive behavior across multiple environments (as measured by an adaptive behavior rating scale, i.e. communication, self-help skills, interpersonal skills, and more), and evidence that the limitations became apparent in childhood or adolescence (onset during developmental phase). In general, people with intellectual disabilities have an IQ below 70, but clinical discretion may be necessary for individuals who have a somewhat higher IQ but severe impairment in adaptive functioning. It is formally diagnosed by an assessment of IQ and adaptive behavior. A third condition requiring onset during the developmental period is used to distinguish intellectual disability from other conditions, such as traumatic brain injuries and dementias (including Alzheimer's disease). Intelligence quotient The first English-language IQ test, the Stanford–Binet Intelligence Scales, was adapted from a test battery designed for school placement by Alfred Binet in France. Lewis Terman adapted Binet's test and promoted it as a test measuring "general intelligence". Terman's test was the first widely used mental test to report scores in "intelligence quotient" form ("mental age" divided by chronological age, multiplied by 100). Current tests are scored in "deviation IQ" form, with a performance level by a test-taker two standard deviations below the median score for the test-takers age group defined as IQ 70. Until the most recent revision of diagnostic standards, an IQ of 70 or below was a primary factor for intellectual disability diagnosis, and IQ scores were used to categorize degrees of intellectual disability. Since the current diagnosis of intellectual disability is not based on IQ scores alone, but must also take into consideration a person's adaptive functioning, the diagnosis is not made rigidly. It encompasses intellectual scores, adaptive functioning scores from an adaptive behavior rating scale based on descriptions of known abilities provided by someone familiar with the person, and also the observations of the assessment examiner, who is able to find out directly from the person what they can understand, communicate, and such like. IQ assessment must be based on a current test. This enables a diagnosis to avoid the pitfall of the Flynn effect, which is a consequence of changes in population IQ test performance changing IQ test norms over time. Distinction from other disabilities Clinically, intellectual disability is a subtype of cognitive deficit or disabilities affecting intellectual abilities, which is a broader concept and includes intellectual deficits that are too mild to properly qualify as intellectual disability, or too specific (as in specific learning disability), or acquired later in life through acquired brain injuries or neurodegenerative diseases like dementia. Cognitive deficits may appear at any age. Developmental disability is any disability that is due to problems with growth and development. This term encompasses many congenital medical conditions that have no mental or intellectual components, although it, too, is sometimes used as a euphemism for intellectual disability. Limitations in more than one area Adaptive behavior, or adaptive functioning, refers to the skills needed to live independently (or at the minimally acceptable level for age). To assess adaptive behavior, professionals compare the functional abilities of a child to those of other children of similar age. To measure adaptive behavior, professionals use structured interviews, with which they systematically elicit information about persons' functioning in the community from people who know them well. There are many adaptive behavior scales, and accurate assessment of the quality of someone's adaptive behavior requires clinical judgment as well. Certain skills are important to adaptive behavior, such as: Daily living skills, such as getting dressed, using the bathroom, and feeding oneself Communication skills, such as understanding what is said and being able to answer Social skills with peers, family members, spouses, adults, and others Other specific skills can be critical to an individual's inclusion in the community and to develop appropriate social behaviors, as for example being aware of the different social expectations linked to the principal lifespan stages (i.e., childhood, adulthood, old age). The results of a Swiss study suggest that the performance of adults with ID in recognizing different lifespan stages is related to specific cognitive abilities and to the type of material used to test this performance. Management By most definitions, intellectual disability is more accurately considered a disability rather than a disease. Intellectual disability can be distinguished in many ways from mental illness, such as schizophrenia or depression. Currently, there is no "cure" for an established disability, though with appropriate support and teaching, most individuals can learn to do many things. Causes, such as congenital hypothyroidism, if detected early may be treated to prevent the development of an intellectual disability. There are thousands of agencies around the world that provide assistance for people with developmental disabilities. They include state-run, for-profit, and non-profit, privately run agencies. Within one agency there could be departments that include fully staffed residential homes, day rehabilitation programs that approximate schools, workshops wherein people with disabilities can obtain jobs, programs that assist people with developmental disabilities in obtaining jobs in the community, programs that provide support for people with developmental disabilities who have their own apartments, programs that assist them with raising their children, and many more. There are also many agencies and programs for parents of children with developmental disabilities. Beyond that, there are specific programs that people with developmental disabilities can take part in wherein they learn basic life skills. These "goals" may take a much longer amount of time for them to accomplish, but the ultimate goal is independence. This may be anything from independence in tooth brushing to an independent residence. People with developmental disabilities learn throughout their lives and can obtain many new skills even late in life with the help of their families, caregivers, clinicians and the people who coordinate the efforts of all of these people. There are four broad areas of intervention that allow for active participation from caregivers, community members, clinicians, and of course, the individual(s) with an intellectual disability. These include psychosocial treatments, behavioral treatments, cognitive-behavioral treatments, and family-oriented strategies. Psychosocial treatments are intended primarily for children before and during the preschool years as this is the optimum time for intervention. This early intervention should include encouragement of exploration, mentoring in basic skills, celebration of developmental advances, guided rehearsal and extension of newly acquired skills, protection from harmful displays of disapproval, teasing, or punishment, and exposure to a rich and responsive language environment. A great example of a successful intervention is the Carolina Abecedarian Project that was conducted with over 100 children from low socioeconomic status families beginning in infancy through pre-school years. Results indicated that by age 2, the children provided the intervention had higher test scores than control group children, and they remained approximately 5 points higher 10 years after the end of the program. By young adulthood, children from the intervention group had better educational attainment, employment opportunities, and fewer behavioral problems than their control-group counterparts. Core components of behavioral treatments include language and social skills acquisition. Typically, one-to-one training is offered in which a therapist uses a shaping procedure in combination with positive reinforcements to help the child pronounce syllables until words are completed. Sometimes involving pictures and visual aids, therapists aim at improving speech capacity so that short sentences about important daily tasks (e.g. bathroom use, eating, etc.) can be effectively communicated by the child. In a similar fashion, older children benefit from this type of training as they learn to sharpen their social skills such as sharing, taking turns, following instruction, and smiling. At the same time, a movement known as social inclusion attempts to increase valuable interactions between children with an intellectual disability and their non-disabled peers. Cognitive-behavioral treatments, a combination of the previous two treatment types, involves a strategical-metastrategical learning technique that teaches children math, language, and other basic skills pertaining to memory and learning. The first goal of the training is to teach the child to be a strategical thinker through making cognitive connections and plans. Then, the therapist teaches the child to be metastrategical by teaching them to discriminate among different tasks and determine which plan or strategy suits each task. Finally, family-oriented strategies delve into empowering the family with the skill set they need to support and encourage their child or children with an intellectual disability. In general, this includes teaching assertiveness skills or behavior management techniques as well as how to ask for help from neighbors, extended family, or day-care staff. As the child ages, parents are then taught how to approach topics such as housing/residential care, employment, and relationships. The ultimate goal for every intervention or technique is to give the child autonomy and a sense of independence using the acquired skills they have. In a 2019 Cochrane review on beginning reading interventions for children and adolescents with intellectual disability, small to moderate improvements in phonological awareness, word reading, decoding, expressive and receptive language skills, and reading fluency were noted when these elements were part of the teaching intervention. Although there is no specific medication for intellectual disability, many people with developmental disabilities have further medical complications and may be prescribed several medications. For example, autistic children with developmental delay may be prescribed antipsychotics or mood stabilizers to help with their behavior. Use of psychotropic medications such as benzodiazepines in people with intellectual disability requires monitoring and vigilance as side effects occur commonly and are often misdiagnosed as behavioral and psychiatric problems. Epidemiology Intellectual disability affects about 2–3% of the general population. 75–90% of the affected people have mild intellectual disability. Non-syndromic or idiopathic ID accounts for 30–50% of cases. About a quarter of cases are caused by a genetic disorder. Cases of unknown cause affect about 95 million people . It is more common in males and in low to middle income countries. History Intellectual disability has been documented under a variety of names throughout history. Throughout much of human history, society was unkind to those with any type of disability, and people with intellectual disability were commonly viewed as burdens on their families. Greek and Roman philosophers, who valued reasoning abilities, disparaged people with intellectual disability as barely human. The oldest physiological view of intellectual disability is in the writings of Hippocrates in the late fifth century BCE, who believed that it was caused by an imbalance in the four humors in the brain. In ancient Rome people with intellectual disabilities had limited rights and were generally looked down upon. They were considered property and could be kept slaves by their father. These people could also not marry, hold office, or raise children. Many of them were killed early in the childhood, and then dumped into the Tiber in order to avoid them burdening society. However, they were exempt from their crimes under Roman law, and they were also used to perform menial labor. Caliph Al-Walid (r. 705–715) built one of the first care homes for individuals with intellectual disabilities and built the first hospital which accommodated intellectually disabled individuals as part of its services. In addition, Al-Walid assigned each intellectually disabled individual a caregiver. Until the Enlightenment in Europe, care and asylum was provided by families and the church (in monasteries and other religious communities), focusing on the provision of basic physical needs such as food, shelter, and clothing. Negative stereotypes were prominent in social attitudes of the time. In the 13th century, England declared people with intellectual disabilities to be incapable of making decisions or managing their affairs. Guardianships were created to take over their financial affairs. In the 17th century, Thomas Willis provided the first description of intellectual disability as a disease. He believed that it was caused by structural problems in the brain. According to Willis, the anatomical problems could be either an inborn condition or acquired later in life. The first known person in the British colonies with an intellectual disability was Benoni Buck, son of Richard Buck, whose life and guardianship battles provide significant insight into the early legal and social treatment of people with disabilities. In the 18th and 19th centuries, housing and care moved away from families and towards an asylum model. People were placed by, or removed from, their families (usually in infancy) and housed in large professional institutions, many of which were self-sufficient through the labor of the residents. Some of these institutions provided a very basic level of education (such as differentiation between colors and basic word recognition and numeracy), but most continued to focus solely on the provision of basic needs of food, clothing, and shelter. Conditions in such institutions varied widely, but the support provided was generally non-individualized, with aberrant behavior and low levels of economic productivity regarded as a burden to society. Individuals of higher wealth were often able to afford higher degrees of care such as home care or private asylums. Heavy tranquilization and assembly-line methods of support were the norm, and the medical model of disability prevailed. Services were provided based on the relative ease to the provider, not based on the needs of the individual. A survey taken in 1891 in Cape Town, South Africa shows the distribution between different facilities. Out of 2,046 persons surveyed, 1,281 were in private dwellings, 120 in jails, and 645 in asylums, with men representing nearly two-thirds of the number surveyed. In situations of scarcity of accommodation, preference was given to white men and Black men (whose insanity threatened white society by disrupting employment relations and the taboo sexual contact with white women). In the late 19th century, in response to Charles Darwin's On the Origin of Species, Francis Galton proposed selective breeding of humans to reduce intellectual disability. Early in the 20th century, the eugenics movement became popular throughout the world. This led to forced sterilization and prohibition of marriage in most of the developed world and was later used by Adolf Hitler as a rationale for the mass murder of people with intellectual disability during the Holocaust. Eugenics was later abandoned as a violation of human rights, and the practice of forced sterilization and prohibition from marriage was discontinued by most of the developed world by the mid-20th century. In 1905, Alfred Binet produced the first standardized test for measuring intelligence in children. Although ancient Roman law had declared people with intellectual disability to be incapable of the deliberate intent to harm that was necessary for a person to commit a crime, during the 1920s, Western society believed they were morally degenerate. Ignoring the prevailing attitude, U.S.-based Civitans adopted service to people with developmental disabilities as a major organizational emphasis in 1952. Their earliest efforts included workshops for special education teachers and daycamps for children with disabilities, all at a time when such training and programs were almost nonexistent. The segregation of people with developmental disabilities was not widely questioned by academics or policy-makers until the 1969 publication of Wolf Wolfensberger's seminal work "The Origin and Nature of Our Institutional Models", drawing on some of the ideas proposed by S. G. Howe 100 years earlier. This study posited that society characterizes people with disabilities as deviant, sub-human and burdens of charity, resulting in the adoption of that "deviant" role. Wolfensberger argued that this dehumanization, and the segregated institutions that result from it, ignored the potential productive contributions that all people can make to society. He pushed for a shift in policy and practice that recognized the human needs of those with intellectual disability and provided the same basic human rights as for the rest of the population. This publication may be regarded as the first move towards the widespread adoption of the social model of disability in regard to these types of disabilities, and was the impetus for the development of government strategies for desegregation. Successful lawsuits against governments and increasing awareness of human rights and self-advocacy also contributed to this process, resulting in the passing in the U.S. of the Civil Rights of Institutionalized Persons Act in 1980. From the 1960s to the present, most states have moved towards the elimination of segregated institutions. Normalization and deinstitutionalization are dominant. Along with the work of Wolfensberger and others including Gunnar and Rosemary Dybwad, a number of scandalous revelations around the horrific conditions within state institutions created public outrage that led to change to a more community-based method of providing services. By the mid-1970s, most governments had committed to de-institutionalization and had started preparing for the wholesale movement of people into the general community, in line with the principles of normalization. In most countries, this was essentially complete by the late 1990s, although the debate over whether or not to close institutions persists in some states, including Massachusetts. In the past, lead poisoning and infectious diseases were significant causes of intellectual disability. Some causes of intellectual disability are decreasing, as medical advances, such as vaccination, increase. Other causes are increasing as a proportion of cases, perhaps due to rising maternal age, which is associated with several syndromic forms of intellectual disability. Along with the changes in terminology, and the downward drift in acceptability of the old terms, institutions of all kinds have had to repeatedly change their names. This affects the names of schools, hospitals, societies, government departments, and academic journals. For example, the Midlands Institute of Mental Sub-normality became the British Institute of Mental Handicap and is now the British Institute of Learning Disability. This phenomenon is shared with mental health and motor disabilities, and seen to a lesser degree in sensory disabilities. Terminology Over the past two decades, the term intellectual disability has become preferred by most advocates and researchers in most English-speaking countries. In a 2012 survey of 101 Canadian healthcare professionals, 78% said they would use the term developmental delay with parents over intellectual disability (8%). Expressions like developmentally disabled, special, special needs, or challenged are sometimes used, but have been criticized for "reinforc[ing] the idea that people cannot deal honestly with their disabilities". The term mental retardation, which stemmed from the understanding that such conditions arose as a result of delays or retardation of a child's natural development, was used in the American Psychiatric Association's DSM-IV (1994) and in the World Health Organization's ICD-10 (codes F70–F79). In the next revision, ICD-11, it was replaced by the term "disorders of intellectual development" (codes 6A00–6A04; 6A00.Z for the "unspecified" diagnosis code). The term "intellectual disability (intellectual developmental disorder)" is used in the DSM-5 (2013). The term "mental retardation" is still used in some professional settings such as governmental aid programs or health insurance paperwork, where "mental retardation" is specifically covered but "intellectual disability" is not. Historical terms for intellectual disability eventually become perceived as an insult, in a process commonly known as the euphemism treadmill. The terms mental retardation and mentally retarded became popular in the middle of the 20th century to replace the previous set of terms, which included "imbecile", "idiot", "feeble-minded", and "moron", among others, and are now considered offensive. By the end of the 20th century, retardation and retard become widely seen as disparaging, politically incorrect, and in need of replacement. Usage has changed over the years and differed from country to country. For example, mental retardation in some contexts covers the whole field, but it previously applied to people with milder impairments. Feeble-minded used to mean mild impairments in the UK, and once applied in the US to the whole field. "Borderline intellectual functioning" is not currently defined, but the term may be used to apply to people with IQs in the 70s. People with IQs of 70 to 85 used to be eligible for special consideration in the US public education system on grounds of intellectual disability. United States In North America, intellectual disability is subsumed into the broader term developmental disability, which also includes epilepsy, autism, cerebral palsy, and other disorders that develop during the developmental period (birth to age 18). Because service provision is tied to the designation "developmental disability", it is used by many parents, direct support professionals, and physicians. In the United States, however, in school-based settings, the more specific term mental retardation or, more recently (and preferably), intellectual disability, is still typically used, and is one of 13 categories of disability under which children may be identified for special education services under Public Law 108–446. The phrase intellectual disability is increasingly being used as a synonym for people with significantly below-average cognitive ability. These terms are sometimes used as a means of separating general intellectual limitations from specific, limited deficits as well as indicating that it is not an emotional or psychological disability. It is not specific to congenital disorders such as Down syndrome. The American Association on Mental Retardation changed its name to the American Association on Intellectual and Developmental Disabilities (AAIDD) in 2007, and soon thereafter changed the names of its scholarly journals to reflect the term "intellectual disability". In 2010, the AAIDD released its 11th edition of its terminology and classification manual, which also used the term intellectual disability. United Kingdom In the UK, mental handicap had become the common medical term, replacing mental subnormality in Scotland and mental deficiency in England and Wales, until Stephen Dorrell, Secretary of State for Health for the United Kingdom from 1995 to 1997, changed the NHS's designation to learning disability. The new term is not yet widely understood, and is often taken to refer to problems affecting schoolwork (the American usage), which are known in the UK as "learning difficulties". British social workers may use "learning difficulty" to refer to both people with intellectual disability and those with conditions such as dyslexia. In education, "learning difficulties" is applied to a wide range of conditions: "specific learning difficulty" may refer to dyslexia, dyscalculia or developmental coordination disorder, while "moderate learning difficulties", "severe learning difficulties" and "profound learning difficulties" refer to more significant impairments. The term "Profound and Multiple Learning Disability/ies" (PMLD) is used: the NHS describes PMLD as "when a person has a severe learning disability and other disabilities that significantly affect their ability to communicate and be independent". In England and Wales between 1983 and 2008, the Mental Health Act 1983 defined "mental impairment" and "severe mental impairment" as "a state of arrested or incomplete development of mind which includes significant/severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned." As behavior was involved, these were not necessarily permanent conditions: they were defined for the purpose of authorizing detention in hospital or guardianship. The term mental impairment was removed from the Act in November 2008, but the grounds for detention remained. However, English statute law uses mental impairment elsewhere in a less well-defined manner—e.g. to allow exemption from taxes—implying that intellectual disability without any behavioral problems is what is meant. A 2008 BBC poll conducted in the United Kingdom came to the conclusion that 'retard' was the most offensive disability-related word. On the reverse side of that, when a contestant on Celebrity Big Brother live used the phrase "walking like a retard", despite complaints from the public and the charity Mencap, the communications regulator Ofcom did not uphold the complaint saying "it was not used in an offensive context [...] and had been used light-heartedly". It was, however, noted that two previous similar complaints from other shows were upheld. Australia In the past, Australia has used British and American terms interchangeably, including "mental retardation" and "mental handicap". Today, "intellectual disability" is the preferred and more commonly used descriptor. Society and culture People with intellectual disabilities are often not seen as full citizens of society. Person-centered planning and approaches are seen as methods of addressing the continued labeling and exclusion of socially devalued people, such as people with disabilities, encouraging a focus on the person as someone with capacities and gifts as well as support needs. The self-advocacy movement promotes the right of self-determination and self-direction by people with intellectual disabilities, which means allowing them to make decisions about their own lives. Until the middle of the 20th century, people with intellectual disabilities were routinely excluded from public education, or educated away from other typically developing children. Compared to peers who were segregated in special schools, students who are mainstreamed or included in regular classrooms report similar levels of stigma and social self-conception, but more ambitious plans for employment. As adults, they may live independently, with family members, or in different types of institutions organized to support people with disabilities. About 8% currently live in an institution or a group home. In the United States, the average lifetime cost of a person with an intellectual disability amounts to $223,000 per person, in 2003 US dollars, for direct costs such as medical and educational expenses. The indirect costs were estimated at $771,000, due to shorter lifespans and lower than average economic productivity. The total direct and indirect costs, which amount to a little more than a million dollars, are slightly more than the economic costs associated with cerebral palsy, and double that associated with serious vision or hearing impairments. Of the costs, about 14% is due to increased medical expenses (not including what is normally incurred by the typical person), and 10% is due to direct non-medical expenses, such as the excess cost of special education compared to standard schooling. The largest amount, 76%, is indirect costs accounting for reduced productivity and shortened lifespans. Some expenses, such as ongoing costs to family caregivers or the extra costs associated with living in a group home, were excluded from this calculation. Human rights and legal status The law treats person with intellectual disabilities differently than those without intellectual disabilities. Their human rights and freedoms, including the right to vote, the right to conduct business, enter into a contract, enter into marriage, right to education, are often limited. The courts have upheld some of these limitations and found discrimination in others. The UN Convention on the Rights of Persons with Disabilities, which sets minimum standards for the rights of persons with disabilities, has been ratified by more than 180 countries. In several U.S. states, and several European Union states, persons with intellectual disabilities are disenfranchised. The European Court of Human Rights ruled in Alajos Kiss v. Hungary (2010) that Hungary cannot restrict voting rights only on the basis of guardianship due to a psychosocial disability. Health disparities People with intellectual disabilities are usually at a higher risk of living with complex health conditions such as epilepsy and neurological disorders, gastrointestinal disorders, and behavioral and psychiatric problems compared to people without disabilities. Adults also have a higher prevalence of poor social determinants of health, behavioral risk factors, depression, diabetes, and poor or fair health status than adults without intellectual disability. In the United Kingdom people with intellectual disability live on average 16 years less than the general population. Some of the barriers that exist for people with ID accessing quality healthcare include: communication challenges, service eligibility, lack of training for healthcare providers, diagnostic overshadowing, and absence of targeted health promotion services. Key recommendations from the CDC for improving the health status for people with intellectual disabilities include: improve access to health care, improve data collection, strengthen the workforce, include people with ID in public health programs, and prepare for emergencies with people with disabilities in mind. See also Future planning History of psychiatric institutions IQ classification Intermediate Care Facilities for Individuals with Intellectual Disabilities Secondary handicap Severe mental impairment Intellectual disability and higher education in the United States References Further reading Adkins, B.; Summerville, J.; Knox, M.; Brown, A. R.; Dillon, S. (2012). "Digital technologies and musical participation for people with intellectual disabilities". New Media & Society. 15 (4): 501–518. . . . Carey C. Allison (2010). On the Margins of Citizenship: Intellectual Disability and Civil Rights in Twentieth-Century America. Temple University Press. Rights of People with Intellectual Disabilities: Access to Education and Employment, bilingual reports on 14 European countries Dalton, A. J.; Janicki, Matthew P., editors (1999). Dementia, aging, and intellectual disabilities: a handbook. Philadelphia: Brunner/Mazel. p. 12. . . The Definition and Prevalence of Intellectual Disability in Australia. Australian Institute of Health and Welfare paper. Harris, James C. (2010). Intellectual Disability: A Guide for Families and Professionals. Oxford University Press. 2001 New Zealand Snapshot of Intellectual Disability Kovago, Emese (2003). People with Intellectual Disabilities: from Invisible to Visible Citizens of the EU Accession Countries; archived copy. Smith, Philip (2010). Whatever Happened to Inclusion?: The Place of Students with Intellectual Disabilities in Education. New York: Peter Lang Publishing. . . . Wehmeyer, Michael L. (2013). The Story of Intellectual Disability: An Evolution of Meaning, Understanding, and Public Perception. Brookes Publishing. External links Facts about intellectual disabilities from the US Centers for Disease Control's National Center on Birth Defects and Developmental Disabilities Let's Work! A documentary about eight young people with IDD in California and their experiences with competitive integrated employment. Funded by the California State Council on Developmental Disabilities Developmental disabilities Learning disabilities Neurodevelopmental disorders

Autonomy

In developmental psychology and moral, political, and bioethical philosophy, autonomy is the capacity to make an informed, uncoerced decision. Autonomous organizations or institutions are independent or self-governing. Autonomy can also be defined from a human resources perspective, where it denotes a (relatively high) level of discretion granted to an employee in his or her work. In such cases, autonomy is known to generally increase job satisfaction. Self-actualized individuals are thought to operate autonomously of external expectations. In a medical context, respect for a patient's personal autonomy is considered one of many fundamental ethical principles in medicine. Sociology In the sociology of knowledge, a controversy over the boundaries of autonomy inhibited analysis of any concept beyond relative autonomy, until a typology of autonomy was created and developed within science and technology studies[citation needed]. According to it, the institution of science's existing autonomy is "reflexive autonomy": actors and structures within the scientific field are able to translate or to reflect diverse themes presented by social and political fields, as well as influence them regarding the thematic choices on research projects. Institutional autonomy Institutional autonomy is having the capacity as a legislator to be able to implant and pursue official goals. Autonomous institutions are responsible for finding sufficient resources or modifying their plans, programs, courses, responsibilities, and services accordingly. But in doing so, they must contend with any obstacles that can occur, such as social pressure against cut-backs or socioeconomic difficulties. From a legislator's point of view, to increase institutional autonomy, conditions of self-management and institutional self-governance must be put in place. An increase in leadership and a redistribution of decision-making responsibilities would be beneficial to the research of resources. Institutional autonomy was often seen as a synonym for self-determination, and many governments feared that it would lead institutions to an irredentist or secessionist region. But autonomy should be seen as a solution to self-determination struggles. Self-determination is a movement toward independence, whereas autonomy is a way to accommodate the distinct regions/groups within a country. Institutional autonomy can diffuse conflicts regarding minorities and ethnic groups in a society. Allowing more autonomy to groups and institutions helps create diplomatic relationships between them and the central government. Politics In governmental parlance, autonomy refers to self-governance. An example of an autonomous jurisdiction was the former United States governance of the Philippine Islands. The Philippine Autonomy Act of 1916 provided the framework for the creation of an autonomous government under which the Filipino people had broader domestic autonomy than previously, although it reserved certain privileges to the United States to protect its sovereign rights and interests. Other examples include Kosovo (as the Socialist Autonomous Province of Kosovo) under the former Yugoslav government of Marshal Tito and Puntland Autonomous Region within Federal Republic of Somalia. Although often being territorially defined as self-governments, autonomous self-governing institutions may take a non-territorial form. Such non-territorial solutions are, for example, cultural autonomy in Estonia and Hungary, national minority councils in Serbia or Sámi parliaments in Nordic countries. Philosophy Autonomy is a key concept that has a broad impact on different fields of philosophy. In metaphysical philosophy, the concept of autonomy is referenced in discussions about free will, fatalism, determinism, and agency. In moral philosophy, autonomy refers to subjecting oneself to objective moral law. According to Kant Immanuel Kant (1724–1804) defined autonomy by three themes regarding contemporary ethics. Firstly, autonomy as the right for one to make their own decisions excluding any interference from others. Secondly, autonomy as the capacity to make such decisions through one's own independence of mind and after personal reflection. Thirdly, as an ideal way of living life autonomously. In summary, autonomy is the moral right one possesses, or the capacity we have in order to think and make decisions for oneself providing some degree of control or power over the events that unfold within one's everyday life. The context in which Kant addresses autonomy is in regards to moral theory, asking both foundational and abstract questions. He believed that in order for there to be morality, there must be autonomy. "Autonomous" is derived from the Greek word autonomos where 'auto' means self and 'nomos' means to govern (nomos: as can be seen in its usage in nomárchēs which means chief of the province). Kantian autonomy also provides a sense of rational autonomy, simply meaning one rationally possesses the motivation to govern their own life. Rational autonomy entails making your own decisions but it cannot be done solely in isolation. Cooperative rational interactions are required to both develop and exercise our ability to live in a world with others. Kant argued that morality presupposes this autonomy in moral agents, since moral requirements are expressed in categorical imperatives. An imperative is categorical if it issues a valid command independent of personal desires or interests that would provide a reason for obeying the command. It is hypothetical if the validity of its command, if the reason why one can be expected to obey it, is the fact that one desires or is interested in something further that obedience to the command would entail. "Don't speed on the freeway if you don't want to be stopped by the police" is a hypothetical imperative. "It is wrong to break the law, so don't speed on the freeway" is a categorical imperative. The hypothetical command not to speed on the freeway is not valid for you if you do not care whether you are stopped by the police. The categorical command is valid for you either way. Autonomous moral agents can be expected to obey the command of a categorical imperative even if they lack a personal desire or interest in doing so. It remains an open question whether they will, however. The Kantian concept of autonomy is often misconstrued, leaving out the important point about the autonomous agent's self-subjection to the moral law. It is thought that autonomy is fully explained as the ability to obey a categorical command independently of a personal desire or interest in doing so—or worse, that autonomy is "obeying" a categorical command independently of a natural desire or interest; and that heteronomy, its opposite, is acting instead on personal motives of the kind referenced in hypothetical imperatives. In his Groundwork of the Metaphysic of Morals, Kant applied the concept of autonomy also to define the concept of personhood and human dignity. Autonomy, along with rationality, are seen by Kant as the two criteria for a meaningful life. Kant would consider a life lived without these not worth living; it would be a life of value equal to that of a plant or insect. According to Kant autonomy is part of the reason that we hold others morally accountable for their actions. Human actions are morally praise- or blame-worthy in virtue of our autonomy. Non- autonomous beings such as plants or animals are not blameworthy due to their actions being non-autonomous. Kant's position on crime and punishment is influenced by his views on autonomy. Brainwashing or drugging criminals into being law-abiding citizens would be immoral as it would not be respecting their autonomy. Rehabilitation must be sought in a way that respects their autonomy and dignity as human beings. According to Nietzsche Friedrich Nietzsche wrote about autonomy and the moral fight. Autonomy in this sense is referred to as the free self and entails several aspects of the self, including self-respect and even self-love. This can be interpreted as influenced by Kant (self-respect) and Aristotle (self-love). For Nietzsche, valuing ethical autonomy can dissolve the conflict between love (self-love) and law (self-respect) which can then translate into reality through experiences of being self-responsible. Because Nietzsche defines having a sense of freedom with being responsible for one's own life, freedom and self-responsibility can be very much linked to autonomy. According to Piaget The Swiss philosopher Jean Piaget (1896–1980) believed that autonomy comes from within and results from a "free decision". It is of intrinsic value and the morality of autonomy is not only accepted but obligatory. When an attempt at social interchange occurs, it is reciprocal, ideal and natural for there to be autonomy regardless of why the collaboration with others has taken place. For Piaget, the term autonomous can be used to explain the idea that rules are self-chosen. By choosing which rules to follow or not, we are in turn determining our own behaviour. Piaget studied the cognitive development of children by analyzing them during their games and through interviews, establishing (among other principles) that the children's moral maturation process occurred in two phases, the first of heteronomy and the second of autonomy: Heteronomous reasoning: Rules are objective and unchanging. They must be literal because the authority are ordering it and do not fit exceptions or discussions. The base of the rule is the superior authority (parents, adults, the State), that it should not give reason for the rules imposed or fulfilled them in any case. Duties provided are conceived as given from oneself. Any moral motivation and sentiments are possible through what one believes to be right. Autonomous reasoning: Rules are the product of an agreement and, therefore, are modifiable. They can be subject to interpretation and fit exceptions and objections. The base of the rule is its own acceptance, and its meaning has to be explained. Sanctions must be proportionate to the absence, assuming that sometimes offenses can go unpunished, so that collective punishment is unacceptable if it is not the guilty. The circumstances may not punish a guilty. Duties provided are conceived as given from the outside. One follows rules mechanically as it is simply a rule, or as a way to avoid a form of punishment. According to Kohlberg The American psychologist Lawrence Kohlberg (1927–1987) continues the studies of Piaget. His studies collected information from different latitudes to eliminate the cultural variability, and focused on the moral reasoning, and not so much in the behavior or its consequences. Through interviews with adolescent and teenage boys, who were to try and solve "moral dilemmas", Kohlberg went on to further develop the stages of moral development. The answers they provided could be one of two things. Either they choose to obey a given law, authority figure or rule of some sort or they chose to take actions that would serve a human need but in turn break this given rule or command. The most popular moral dilemma asked involved the wife of a man approaching death due to a special type of cancer. Because the drug was too expensive to obtain on his own, and because the pharmacist who discovered and sold the drug had no compassion for him and only wanted profits, he stole it. Kohlberg asks these adolescent and teenage boys (10-, 13- and 16-year-olds) if they think that is what the husband should have done or not. Therefore, depending on their decisions, they provided answers to Kohlberg about deeper rationales and thoughts and determined what they value as important. This value then determined the "structure" of their moral reasoning. Kohlberg established three stages of morality, each of which is subdivided into two levels. They are read in progressive sense, that is, higher levels indicate greater autonomy. Level 1: Premoral/Preconventional Morality: Standards are met (or not met) depending on the hedonistic or physical consequences. [Stage 0: Egocentric Judgment: There is no moral concept independent of individual wishes, including a lack of concept of rules or obligations.] Stage 1: Punishment-Obedience Orientation: The rule is obeyed only to avoid punishment. Physical consequences determine goodness or badness and power is deferred to unquestioningly with no respect for the human or moral value, or the meaning of these consequences. Concern is for the self. Stage 2: Instrumental-Relativist Orientation: Morals are individualistic and egocentric. There is an exchange of interests but always under the point of view of satisfying personal needs. Elements of fairness and reciprocity are present but these are interpreted in a pragmatic way, instead of an experience of gratitude or justice. Egocentric in nature but beginning to incorporate the ability to see things from the perspective of others. Level 2: Conventional Morality/Role Conformity: Rules are obeyed according to the established conventions of a society. Stage 3: Good Boy–Nice Girl Orientation: Morals are conceived in accordance with the stereotypical social role. Rules are obeyed to obtain the approval of the immediate group and the right actions are judged based on what would please others or give the impression that one is a good person. Actions are evaluated according to intentions. Stage 4: Law and Order Orientation: Morals are judged in accordance with the authority of the system, or the needs of the social order. Laws and order are prioritized. Level 3: Postconventional Morality/Self-Accepted Moral Principles: Standards of moral behavior are internalized. Morals are governed by rational judgment, derived from a conscious reflection on the recognition of the value of the individual inside a conventionally established society. Stage 5: Social Contract Orientation: There are individual rights and standards that have been lawfully established as basic universal values. Rules are agreed upon by through procedure and society comes to consensus through critical examination in order to benefit the greater good. Stage 6: Universal Principle Orientation: Abstract ethical principles are obeyed on a personal level in addition to societal rules and conventions. Universal principles of justice, reciprocity, equality and human dignity are internalized and if one fails to live up to these ideals, guilt or self-condemnation results. According to Audi Robert Audi characterizes autonomy as the self-governing power to bring reasons to bear in directing one's conduct and influencing one's propositional attitudes. Traditionally, autonomy is only concerned with practical matters. But, as Audi's definition suggests, autonomy may be applied to responding to reasons at large, not just to practical reasons. Autonomy is closely related to freedom but the two can come apart. An example would be a political prisoner who is forced to make a statement in favor of his opponents in order to ensure that his loved ones are not harmed. As Audi points out, the prisoner lacks freedom but still has autonomy since his statement, though not reflecting his political ideals, is still an expression of his commitment to his loved ones. Autonomy is often equated with self-legislation in the Kantian tradition. Self-legislation may be interpreted as laying down laws or principles that are to be followed. Audi agrees with this school in the sense that we should bring reasons to bear in a principled way. Responding to reasons by mere whim may still be considered free but not autonomous. A commitment to principles and projects, on the other hand, provides autonomous agents with an identity over time and gives them a sense of the kind of persons they want to be. But autonomy is neutral as to which principles or projects the agent endorses. So different autonomous agents may follow very different principles. But, as Audi points out, self-legislation is not sufficient for autonomy since laws that do not have any practical impact do not constitute autonomy. Some form of motivational force or executive power is necessary in order to get from mere self-legislation to self-government. This motivation may be inherent in the corresponding practical judgment itself, a position known as motivational internalism, or may come to the practical judgment externally in the form of some desire independent of the judgment, as motivational externalism holds. In the Humean tradition, intrinsic desires are the reasons the autonomous agent should respond to. This theory is called instrumentalism. Audi rejects instrumentalism and suggests that we should adopt a position known as axiological objectivism. The central idea of this outlook is that objective values, and not subjective desires, are the sources of normativity and therefore determine what autonomous agents should do. Child development Autonomy in childhood and adolescence is when one strives to gain a sense of oneself as a separate, self-governing individual. Between ages 1–3, during the second stage of Erikson's and Freud's stages of development, the psychosocial crisis that occurs is autonomy versus shame and doubt. The significant event that occurs during this stage is that children must learn to be autonomous, and failure to do so may lead to the child doubting their own abilities and feel ashamed. When a child becomes autonomous it allows them to explore and acquire new skills. Autonomy has two vital aspects wherein there is an emotional component where one relies more on themselves rather than their parents and a behavioural component where one makes decisions independently by using their judgement. The styles of child rearing affect the development of a child's autonomy. Autonomy in adolescence is closely related to their quest for identity. In adolescence parents and peers act as agents of influence. Peer influence in early adolescence may help the process of an adolescent to gradually become more autonomous by being less susceptible to parental or peer influence as they get older. In adolescence the most important developmental task is to develop a healthy sense of autonomy. Religion In Christianity, autonomy is manifested as a partial self-governance on various levels of church administration. During the history of Christianity, there were two basic types of autonomy. Some important parishes and monasteries have been given special autonomous rights and privileges, and the best known example of monastic autonomy is the famous Eastern Orthodox monastic community on Mount Athos in Greece. On the other hand, administrative autonomy of entire ecclesiastical provinces has throughout history included various degrees of internal self-governance. In ecclesiology of Eastern Orthodox Churches, there is a clear distinction between autonomy and autocephaly, since autocephalous churches have full self-governance and independence, while every autonomous church is subject to some autocephalous church, having a certain degree of internal self-governance. Since every autonomous church had its own historical path to ecclesiastical autonomy, there are significant differences between various autonomous churches in respect of their particular degrees of self-governance. For example, churches that are autonomous can have their highest-ranking bishops, such as an archbishop or metropolitan, appointed or confirmed by the patriarch of the mother church from which it was granted its autonomy, but generally they remain self-governing in many other respects. In the history of Western Christianity the question of ecclesiastical autonomy was also one of the most important questions, especially during the first centuries of Christianity, since various archbishops and metropolitans in Western Europe have often opposed centralizing tendencies of the Church of Rome. , the Catholic Church comprises 24 autonomous (sui iuris) Churches in communion with the Holy See. Various denominations of Protestant churches usually have more decentralized power, and churches may be autonomous, thus having their own rules or laws of government, at the national, local, or even individual level. Sartre brings the concept of the Cartesian god being totally free and autonomous. He states that existence precedes essence with god being the creator of the essences, eternal truths and divine will. This pure freedom of god relates to human freedom and autonomy; where a human is not subjected to pre-existing ideas and values. According to the first amendment, In the United States of America, the federal government is restricted in building a national church. This is due to the first amendment's recognizing people's freedom's to worship their faith according to their own belief's. For example, the American government has removed the church from their "sphere of authority" due to the churches' historical impact on politics and their authority on the public. This was the beginning of the disestablishment process. The Protestant churches in the United States had a significant impact on American culture in the nineteenth century, when they organized the establishment of schools, hospitals, orphanages, colleges, magazines, and so forth. This has brought up the famous, however, misinterpreted term of the separation of church and state. These churches lost the legislative and financial support from the state. The disestablishment process The first disestablishment began with the introduction of the bill of rights. In the twentieth century, due to the great depression of the 1930s and the completion of the second world war, the American churches were revived. Specifically the Protestant churches. This was the beginning of the second disestablishment when churches had become popular again but held no legislative power. One of the reasons why the churches gained attendance and popularity was due to the baby boom, when soldiers came back from the second world war and started their families. The large influx of newborns gave the churches a new wave of followers. However, these followers did not hold the same beliefs as their parents and brought about the political, and religious revolutions of the 1960s. During the 1960s, the collapse of religious and cultural middle brought upon the third disestablishment. Religion became more important to the individual and less so to the community. The changes brought from these revolutions significantly increased the personal autonomy of individuals due to the lack of structural restraints giving them added freedom of choice. This concept is known as "new voluntarism" where individuals have free choice on how to be religious and the free choice whether to be religious or not. Medicine In a medical context, respect for a patient's personal autonomy is considered one of many fundamental ethical principles in medicine. Autonomy can be defined as the ability of the person to make his or her own decisions. This faith in autonomy is the central premise of the concept of informed consent and shared decision making. This idea, while considered essential to today's practice of medicine, was developed in the last 50 years. According to Tom Beauchamp and James Childress (in Principles of Biomedical Ethics), the Nuremberg trials detailed accounts of horrifyingly exploitative medical "experiments" which violated the subjects' physical integrity and personal autonomy. These incidences prompted calls for safeguards in medical research, such as the Nuremberg Code which stressed the importance of voluntary participation in medical research. It is believed that the Nuremberg Code served as the premise for many current documents regarding research ethics. Respect for autonomy became incorporated in health care and patients could be allowed to make personal decisions about the health care services that they receive. Notably, autonomy has several aspects as well as challenges that affect health care operations. The manner in which a patient is handled may undermine or support the autonomy of a patient and for this reason, the way a patient is communicated to becomes very crucial. A good relationship between a patient and a health care practitioner needs to be well defined to ensure that autonomy of a patient is respected. Just like in any other life situation, a patient would not like to be under the control of another person. The move to emphasize respect for patient's autonomy rose from the vulnerabilities that were pointed out in regards to autonomy. However, autonomy does not only apply in a research context. Users of the health care system have the right to be treated with respect for their autonomy, instead of being dominated by the physician. This is referred to as paternalism. While paternalism is meant to be overall good for the patient, this can very easily interfere with autonomy. Through the therapeutic relationship, a thoughtful dialogue between the client and the physician may lead to better outcomes for the client, as he or she is more of a participant in decision-making. There are many different definitions of autonomy, many of which place the individual in a social context. Relational autonomy, which suggests that a person is defined through their relationships with others, is increasingly considered in medicine and particularly in critical and end-of-life care. Supported autonomy suggests instead that in specific circumstances it may be necessary to temporarily compromise the autonomy of the person in the short term in order to preserve their autonomy in the long-term. Other definitions of the autonomy imagine the person as a contained and self-sufficient being whose rights should not be compromised under any circumstance. There are also differing views with regard to whether modern health care systems should be shifting to greater patient autonomy or a more paternalistic approach. For example, there are such arguments that suggest the current patient autonomy practiced is plagued by flaws such as misconceptions of treatment and cultural differences, and that health care systems should be shifting to greater paternalism on the part of the physician given their expertise.  On the other hand, other approaches suggest that there simply needs to be an increase in relational understanding between patients and health practitioners to improve patient autonomy. One argument in favor of greater patient autonomy and its benefits is by Dave deBronkart, who believes that in the technological advancement age, patients are capable of doing a lot of their research on medical issues from their home. According to deBronkart, this helps to promote better discussions between patients and physicians during hospital visits, ultimately easing up the workload of physicians. deBronkart argues that this leads to greater patient empowerment and a more educative health care system. In opposition to this view, technological advancements can sometimes be viewed as an unfavorable way of promoting patient autonomy. For example, self-testing medical procedures which have become increasingly common are argued by Greaney et al. to increase patient autonomy, however, may not be promoting what is best for the patient. In this argument, contrary to deBronkart, the current perceptions of patient autonomy are excessively over-selling the benefits of individual autonomy, and is not the most suitable way to go about treating patients. Instead, a more inclusive form of autonomy should be implemented, relational autonomy, which factors into consideration those close to the patient as well as the physician. These different concepts of autonomy can be troublesome as the acting physician is faced with deciding which concept he/she will implement into their clinical practice. It is often references as one of the four pillars of medicine, alongside beneficence, justice and nonmaleficence Autonomy varies and some patients find it overwhelming especially the minors when faced with emergency situations. Issues arise in emergency room situations where there may not be time to consider the principle of patient autonomy. Various ethical challenges are faced in these situations when time is critical, and patient consciousness may be limited. However, in such settings where informed consent may be compromised, the working physician evaluates each individual case to make the most professional and ethically sound decision. For example, it is believed that neurosurgeons in such situations, should generally do everything they can to respect patient autonomy. In the situation in which a patient is unable to make an autonomous decision, the neurosurgeon should discuss with the surrogate decision maker in order to aid in the decision-making process. Performing surgery on a patient without informed consent is in general thought to only be ethically justified when the neurosurgeon and his/her team render the patient to not have the capacity to make autonomous decisions. If the patient is capable of making an autonomous decision, these situations are generally less ethically strenuous as the decision is typically respected. Not every patient is capable of making an autonomous decision. For example, a commonly proposed question is at what age children should be partaking in treatment decisions. This question arises as children develop differently, therefore making it difficult to establish a standard age at which children should become more autonomous. Those who are unable to make the decisions prompt a challenge to medical practitioners since it becomes difficult to determine the ability of a patient to make a decision. To some extent, it has been said that emphasis of autonomy in health care has undermined the practice of health care practitioners to improve the health of their patient as necessary. The scenario has led to tension in the relationship between a patient and a health care practitioner. This is because as much as a physician wants to prevent a patient from suffering, they still have to respect autonomy. Beneficence is a principle allowing physicians to act responsibly in their practice and in the best interests of their patients, which may involve overlooking autonomy. However, the gap between a patient and a physician has led to problems because in other cases, the patients have complained of not being adequately informed. The seven elements of informed consent (as defined by Beauchamp and Childress) include threshold elements (competence and voluntariness), information elements (disclosure, recommendation, and understanding) and consent elements (decision and authorization). Some philosophers such as Harry Frankfurt consider Beauchamp and Childress criteria insufficient. They claim that an action can only be considered autonomous if it involves the exercise of the capacity to form higher-order values about desires when acting intentionally. What this means is that patients may understand their situation and choices but would not be autonomous unless the patient is able to form value judgements about their reasons for choosing treatment options they would not be acting autonomously. In certain unique circumstances, government may have the right to temporarily override the right to bodily integrity in order to preserve the life and well-being of the person. Such action can be described using the principle of "supported autonomy", a concept that was developed to describe unique situations in mental health (examples include the forced feeding of a person dying from the eating disorder anorexia nervosa, or the temporary treatment of a person living with a psychotic disorder with antipsychotic medication). While controversial, the principle of supported autonomy aligns with the role of government to protect the life and liberty of its citizens. Terrence F. Ackerman has highlighted problems with these situations, he claims that by undertaking this course of action physician or governments run the risk of misinterpreting a conflict of values as a constraining effect of illness on a patient's autonomy. Since the 1960s, there have been attempts to increase patient autonomy including the requirement that physician's take bioethics courses during their time in medical school. Despite large-scale commitment to promoting patient autonomy, public mistrust of medicine in developed countries has remained. Onora O'Neill has ascribed this lack of trust to medical institutions and professionals introducing measures that benefit themselves, not the patient. O'Neill claims that this focus on autonomy promotion has been at the expense of issues like distribution of healthcare resources and public health. One proposal to increase patient autonomy is through the use of support staff. The use of support staff including medical assistants, physician assistants, nurse practitioners, nurses, and other staff that can promote patient interests and better patient care. Nurses especially can learn about patient beliefs and values in order to increase informed consent and possibly persuade the patient through logic and reason to entertain a certain treatment plan. This would promote both autonomy and beneficence, while keeping the physician's integrity intact. Furthermore, Humphreys asserts that nurses should have professional autonomy within their scope of practice (35–37). Humphreys argues that if nurses exercise their professional autonomy more, then there will be an increase in patient autonomy (35–37). International human rights law After the Second World War, there was a push for international human rights that came in many waves. Autonomy as a basic human right started the building block in the beginning of these layers alongside liberty. The Universal declarations of Human rights of 1948 has made mention of autonomy or the legal protected right to individual self-determination in article 22. Documents such as the United Nations Declaration on the Rights of Indigenous Peoples reconfirm international law in the aspect of human rights because those laws were already there, but it is also responsible for making sure that the laws highlighted when it comes to autonomy, cultural and integrity; and land rights are made within an indigenous context by taking special attention to their historical and contemporary events The United Nations Declaration on the Rights of Indigenous Peoples article 3 also through international law provides Human rights for Indigenous individuals by giving them a right to self-determination, meaning they have all the liberties to choose their political status, and are capable to go and improve their economic, social, and cultural statuses in society, by developing it. Another example of this, is article 4 of the same document which gives them autonomous rights when it comes to their internal or local affairs and how they can fund themselves in order to be able to self govern themselves. Minorities in countries are also protected as well by international law; the 27th article of the United Nations International covenant on Civil and Political rights or the ICCPR does so by allowing these individuals to be able to enjoy their own culture or use their language. Minorities in that manner are people from ethnic religious or linguistic groups according to the document. The European Court of Human rights, is an international court that has been created on behalf of the European Conventions of Human rights. However, when it comes to autonomy they did not explicitly state it when it comes to the rights that individuals have. The current article 8 has remedied to that when the case of Pretty v the United Kingdom, a case in 2002 involving assisted suicide, where autonomy was used as a legal right in law. It was where Autonomy was distinguished and its reach into law was marked as well making it the foundations for legal precedent in making case law originating from the European Court of Human rights. The Yogyakarta Principles, a document with no binding effect in international human rights law, contend that "self-determination" used as meaning of autonomy on one's own matters including informed consent or sexual and reproductive rights, is integral for one's self-defined or gender identity and refused any medical procedures as a requirement for legal recognition of the gender identity of transgender. If eventually accepted by the international community in a treaty, this would make these ideas human rights in the law. The Convention on the Rights of Persons with Disabilities also defines autonomy as principles of rights of a person with disability including "the freedom to make one's own choices, and independence of persons". Celebrity culture on teenage autonomy A study conducted by David C. Giles and John Maltby conveyed that after age-affecting factors were removed, a high emotional autonomy was a significant predictor of celebrity interest, as well as high attachment to peers with a low attachment to parents. Patterns of intense personal interest in celebrities was found to be conjunction with low levels of closeness and security. Furthermore, the results suggested that adults with a secondary group of pseudo-friends during development from parental attachment, usually focus solely on one particular celebrity, which could be due to difficulties in making this transition. Various uses In computing, an autonomous peripheral is one that can be used with the computer turned off. Within self-determination theory in psychology, autonomy refers to 'autonomy support versus control', "hypothesizing that autonomy-supportive social contexts tend to facilitate self-determined motivation, healthy development, and optimal functioning." In mathematical analysis, an ordinary differential equation is said to be autonomous if it is time-independent. In linguistics, an autonomous language is one which is independent of other languages, for example, has a standard variety, grammar books, dictionaries or literature, etc. In robotics, "autonomy means independence of control. This characterization implies that autonomy is a property of the relation between two agents, in the case of robotics, of the relations between the designer and the autonomous robot. Self-sufficiency, situatedness, learning or development, and evolution increase an agent's degree of autonomy.", according to Rolf Pfeifer. In spaceflight, autonomy can also refer to crewed missions that are operating without control by ground controllers. In economics, autonomous consumption is consumption expenditure when income levels are zero, making spending autonomous to income. In politics, autonomous territories are States wishing to retain territorial integrity in opposition to ethnic or indigenous demands for self-determination or independence (sovereignty). In anti-establishment activism, an autonomous space is another name for a non-governmental social center or free space (for community interaction). In social psychology, autonomy is a personality trait characterized by a focus on personal achievement, independence, and a preference for solitude, often labeled as an opposite of sociotropy. Limits to autonomy Autonomy can be limited. For instance, by disabilities, civil society organizations may achieve a degree of autonomy albeit nested within—and relative to—formal bureaucratic and administrative regimes. Community partners can therefore assume a hybridity of capture and autonomy—or a mutuality—that is rather nuanced. Semi-autonomy The term semi-autonomy (coined with prefix semi- / "half") designates partial or limited autonomy. As a relative term, it is usually applied to various semi-autonomous entities or processes that are substantially or functionally limited, in comparison to other fully autonomous entities or processes. Quasi-autonomy The term quasi-autonomy (coined with prefix quasi- / "resembling" or "appearing") designates formally acquired or proclaimed, but functionally limited or constrained autonomy. As a descriptive term, it is usually applied to various quasi-autonomous entities or processes that are formally designated or labeled as autonomous, but in reality remain functionally dependent or influenced by some other entity or process. An example for such use of the term can be seen in common designation for quasi-autonomous non-governmental organizations. See also Autonomism List of autonomous areas by country Autonomy Day Cornelius Castoriadis Counterdependency Direct democracy Equality of autonomy Essential facilities doctrine Flat organization Takis Fotopoulos Home rule Job autonomy Personal boundaries Self-governing colony Self-sufficiency Teaching for social justice Viable system model Workplace democracy Notes References Citations Sources External links Kastner, Jens. "Autonomy" (2015). University Bielefeld – Center for InterAmerican Studies. "Self-sustainability strategies for Development Initiatives: What is self-sustainability and why is it so important?" Ethical principles Individualism Organizational cybernetics

Psychiatric assessment

A psychiatric assessment, or psychological screening, is the process of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist, but it can be a multi-disciplinary process involving nurses, psychologists, occupational therapist, social workers, and licensed professional counselors. Purpose Clinical assessment A psychiatric assessment is most commonly carried out for clinical and therapeutic purposes, to establish a diagnosis and formulation of the individual's problems, and to plan their care and treatment. This may be done in a hospital, in an out-patient setting, or as a home-based assessment. Forensic assessment A forensic psychiatric assessment may have a number of purposes. A forensic assessment may be required of an individual who has been charged with a crime, to establish whether the person has the legal competence to stand trial. If a person with a mental illness is convicted of an offense, a forensic report may be required to inform the Court's sentencing decision, as a mental illness at the time of the offense may be a mitigating factor. A forensic assessment may also take the form of a risk assessment, to comment on the relationship between the person's mental illness and the risk of further violent offenses. Medico-legal assessment A medico-legal psychiatric assessment is required when a psychiatric report is used as evidence in civil litigation, for example in relation to compensation for work-related stress or after a traumatic event such as an accident. The psychiatric assessment may be requested in order to establish a link between the trauma and the victim's psychological condition, or to determine the extent of psychological harm and the amount of compensation to be awarded to the victim. Medico-legal psychiatric assessments are also utilized in the context of child safety and child protection services. A child psychiatrist's assessment can provide information on the psychological impact of abuse or neglect on a child. A child psychiatrist can carry out an assessment of parenting capacity, taking into consideration the mental state of both the child and the parents, and this may be used by child protective services to decide whether a child should be placed in an alternative care arrangement such as foster care. History A standard part of any psychiatric assessment is the obtaining of a body of social, demographic and biographical data known as the history. The standard psychiatric history consists of biographical data (name, age, marital and family contact details, occupation, and first language), the presenting complaint (an account of the onset, nature and development of the individual's current difficulties) and personal history (including birth complications, childhood development, parental care in childhood, educational and employment history, relationship and marital history, and criminal background). The history also includes an enquiry about the individual's current social circumstances, family relationships, current and past use of alcohol and illicit drugs, and the individual's past treatment history (current and past diagnoses, and use of prescribed medication). The psychiatric history includes an exploration of the individual's culture and ethnicity, as cultural values can influence the way a person and their family communicates psychological distress and responds to a diagnosis of mental illness. Certain behaviors and beliefs may be misinterpreted as features of mental illness by a clinician who is from a different cultural background than the individual being assessed. This assessment also includes information from related people. Mental status examination The mental status examination (MSE) is another core part of any psychiatric assessment. The MSE is a structured way of describing a patient's current state of mind, under the domains of appearance, attitude, behavior, speech, mood and affect, thought process, thought content, perception, cognition (including for example orientation, memory and concentration), insight and judgement. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalized psychological tests. As with the psychiatric history, the MSE is prone to errors if cultural differences between the examiner and the patient are not taken into account, as different cultural backgrounds may be associated with different norms of interpersonal behavior and emotional expression. The MSE differs from a mini-mental state examination (MMSE) which is a brief neuro-psychological screening test for dementia. Physical examination A thorough physical examination is regarded as an integral part of a comprehensive psychiatric assessment. This is because physical illnesses are more common in people with mental disorders, because neurological and other medical conditions may be associated with psychiatric symptoms, and to identify side effects of psychiatric medication. The physical examination would include measurement of body mass index, vital signs such as pulse, blood pressure, temperature and respiratory rate, observation for pallor and nutritional deficiencies, palpation for lymph nodes, palpation of the abdomen for organ enlargement, and examination of the cardiovascular, respiratory and neurological systems. Physical investigations Although there are no physiological tests that confirm any mental illness, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes, serum calcium and liver enzymes to rule out a metabolic disturbance, and a full blood count to rule out a systemic infection or chronic disease. The investigation of dementia could include measurement of serum vitamin B-12 levels, serology to exclude syphilis or HIV infection, EEG, and a CT scan or MRI scan. People receiving antipsychotic medication require measurement of plasma glucose and lipid levels to detect a medication-induced metabolic syndrome, and an electrocardiogram to detect iatrogenic cardiac arrhythmias. Assessment tools Clinical assessment can be supplemented by the use of symptom scales for specific disorders, such as the Beck Depression Inventory for depression, or the Brief Psychiatric Rating Scale (BPRS) or Positive and Negative Syndrome Scale (PANSS) for psychotic disorders. Scales such as HoNOS or the Global Assessment of Functioning are used to measure global level of functioning and to monitor response to treatment. Multidisciplinary assessment Psychiatric assessment in hospital settings is typically a multidisciplinary process, with contributions from psychiatric nurses, occupational therapists, psychologists and social workers. A psychiatrist takes a history and carries out a mental state examination and physical examination as described above. A nursing assessment includes risk assessment (risk of suicide, aggression, absconding from hospital, self-harm, sexual safety in hospital and medication compliance), physical health screening, and obtaining background personal and health information from the person being admitted and their carers. The immediate purpose of the nursing assessment is to determine the required level of care and supervision, and to have a plan to manage disturbed behavior. Assessment could include a visit to the person's home, for direct observation of the social and living environment. The role of a psychologist includes the use of psychological tests: structured diagnostic instruments such as the Millon Clinical Multiaxial Inventory or psychometric tests such as the WISC or WAIS, to assist with diagnosis and formulation of the person's problems. A psychologist might contribute to the team's assessment by providing a psychological formulation or behavioral analysis, which is an analysis, through systematic observation, of the factors which trigger or perpetuate the presenting problems. Other perspectives This article describes the assessment process within a medical model, with the collection of supposedly objective data, identification of problems, formulation of a diagnosis leading to a specific treatment, but there are other approaches to the assessment of people with social and emotional difficulties. A family therapy or systemic therapy approach is not concerned with diagnoses but seeks to understand the problem in terms of relationships and communication patterns. The systemic tradition is suspicious of the objectivity of medical assessment, sees the individual's account as a subjective narrative, and sees diagnosis as a socially constructed phenomenon. From a solution focused perspective, the assessment deliberately avoids identification of problems, and seeks to elicit strengths and solutions. Criticism Psychiatric assessments have recently been under heavy criticism from a community of experts. Some go as far as saying that. "Yet they are just subjective opinions with no scientific basis and can change over time." See also List of diagnostic classification and rating scales used in psychiatry Medical history Mental disorder Psychiatry Seasonal Pattern Assessment Questionnaire Psychiatrist Notes References External links American Psychiatric Association Practice Guidelines: Psychiatric Evaluation of Adults Medical diagnosis

Mini–mental state examination

The mini–mental state examination (MMSE) or Folstein test is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment. It is commonly used in medicine and allied health to screen for dementia. It is also used to estimate the severity and progression of cognitive impairment and to follow the course of cognitive changes in an individual over time; thus making it an effective way to document an individual's response to treatment. The MMSE's purpose has been not, on its own, to provide a diagnosis for any particular nosological entity. Administration of the test takes between 5 and 10 minutes and examines functions including registration (repeating named prompts), attention and calculation, recall, language, ability to follow simple commands and orientation. It was originally introduced by Folstein et al. in 1975, in order to differentiate organic from functional psychiatric patients but is very similar to, or even directly incorporates, tests which were in use previous to its publication. This test is not a mental status examination. The standard MMSE form which is currently published by Psychological Assessment Resources is based on its original 1975 conceptualization, with minor subsequent modifications by the authors. Advantages to the MMSE include requiring no specialized equipment or training for administration, and has both validity and reliability for the diagnosis and longitudinal assessment of Alzheimer's disease. Due to its short administration period and ease of use, it is useful for cognitive assessment in the clinician's office space or at the bedside. Disadvantages to the utilization of the MMSE is that it is affected by demographic factors; age and education exert the greatest effect. The most frequently noted disadvantage of the MMSE relates to its lack of sensitivity to mild cognitive impairment and its failure to adequately discriminate patients with mild Alzheimer's disease from normal patients. The MMSE has also received criticism regarding its insensitivity to progressive changes occurring with severe Alzheimer's disease. The content of the MMSE is highly verbal, lacking sufficient items to adequately measure visuospatial and/or constructional praxis. Hence, its utility in detecting impairment caused by focal lesions is uncertain. Other tests are also used, such as the Hodkinson abbreviated mental test score (1972), Geriatric Mental State Examination (GMS), or the General Practitioner Assessment of Cognition, bedside tests such as the 4AT (which also assesses for delirium), and computerised tests such as CoPs and Mental Attributes Profiling System, as well as longer formal tests for deeper analysis of specific deficits. Test features The MMSE test includes simple questions and problems in a number of areas: the time and place of the test, repeating lists of words, arithmetic such as the serial sevens, language use and comprehension, and basic motor skills. For example, one question, derived from the older Bender-Gestalt Test, asks to copy a drawing of two pentagons (shown on the right or above). A version of the MMSE questionnaire can be found on the British Columbia Ministry of Health website. Although consistent application of identical questions increases the reliability of comparisons made using the scale, the test can be customized (for example, for use on patients that are blind or partially immobilized.) Also, some have questioned the use of the test on the deaf. However, the number of points assigned per category is usually consistent: Interpretations Any score of 24 or more (out of 30) indicates a normal cognition. Below this, scores can indicate severe (≤9 points), moderate (10–18 points) or mild (19–23 points) cognitive impairment. The raw score may also need to be corrected for educational attainment and age. Even a maximum score of 30 points can never rule out dementia and there is no strong evidence to support this examination as a stand-alone one-time test for identifying high risk individuals who are likely to develop Alzheimer's. Low to very low scores may correlate closely with the presence of dementia, although other mental disorders can also lead to abnormal findings on MMSE testing. The presence of purely physical problems can also interfere with interpretation if not properly noted; for example, a patient may be physically unable to hear or read instructions properly or may have a motor deficit that affects writing and drawing skills. In order to maximize the benefits of the MMSE the following recommendations from Tombaugh and McIntyre (1992) should be employed: The MMSE should be used as a screening device for cognitive impairment or a diagnostic adjunct in which a low score indicates the need for further evaluation. It should not serve as the sole criterion for diagnosing dementia or to differentiate between various forms of dementia. However, the MMSE scores may be used to classify the severity of cognitive impairment or to document serial change in dementia patients. The following four cut-off levels should be employed to classify the severity of cognitive impairment: no cognitive impairment 24–30; mild cognitive impairment 19–23; moderate cognitive impairment 10–18; and severe cognitive impairment ≤9. The MMSE should not be used clinically unless the person has at least a grade-eight education and is fluent in English. While this recommendation does not discount the possibility that future research may show that number of years of education constitutes a risk factor for dementia, it does acknowledge the weight of evidence showing that low educational levels substantially increase the likelihood of misclassifying normal subjects as cognitively impaired. Serial sevens and WORLD should not be considered equivalent items. Both items should be administered and the higher of the two should be used. In scoring serial sevens, each number must be independently compared to the prior number to ensure that a single mistake is not unduly penalized. WORLD should be spelled forward (and corrected) prior to spelling it backward. The words "apple", "penny", and "table" should be used for registration and recall. If necessary, the words may be administered up to three times in order to obtain perfect registration, but the score is based on the first trial. The "county" and "where are you" orientation to place questions should be modified: the name of the county where a person lives should be asked rather than the county of the testing site, and the name of the street where the individual lives should be asked rather than the name of the floor where the testing is taking place. The MMSE may help differentiate different types of dementias. People with Alzheimer's disease may score significantly lower on orientation to time and place as well as recall, compared to those who have dementia with Lewy bodies, vascular dementia, or Parkinson's disease dementia. Copyright issues The MMSE was first published in 1975 as an appendix to an article written by Marshal F. Folstein, Susan Folstein, and Paul R. McHugh. It was published in Volume 12 of the Journal of Psychiatric Research, published by Pergamon Press. While the MMSE was attached as an appendix to the article, the copyright ownership of the MMSE (to the extent that it contains copyrightable content) remained with the three authors. Pergamon Press was subsequently taken over by Elsevier, who also took over copyright of the Journal of Psychiatric Research. The authors later transferred all their intellectual property rights, including the copyright of the MMSE, to MiniMental registering the transfer with the U.S. Copyright Office on June 8, 2000. In March 2001, MiniMental entered into an exclusive agreement with Psychological Assessment Resources granting PAR the exclusive rights to publish, license, and manage all intellectual property rights to the MMSE in all media and languages in the world. Despite the many free versions of the test that are available on the internet, PAR claims that the official version is copyrighted and must be ordered only through it. At least one legal expert has claimed that PAR's copyright claims are weak. The enforcement of copyright on the MMSE has been compared to the phenomenon of "stealth" or "submarine" patents, in which a patent applicant waited until an invention gained widespread popularity before allowing the patent to issue, and only then commenced enforcement. Such applications are no longer possible, given changes in patent law. The enforcement of the copyright has led to researchers looking for alternative strategies in assessing cognition. PAR have also asserted their copyright against an alternative diagnostic test, "Sweet 16", which was designed to avoid the copyright issues surrounding the MMSE. Sweet 16 was a 16-item assessment developed and validated by Tamara Fong and published in March 2011; like the MMSE it included orientation and three-object recall. Assertion of copyright forced the removal of this test from the Internet. Editions In February 2010, PAR released a second edition of the MMSE; 10 foreign language translations (French, German, Dutch, Spanish for the US, Spanish for Latin America, European Spanish, Hindi, Russian, Italian, and Simplified Chinese) were also created. See also Abbreviated mental test score (AMTS) Addenbrooke's Cognitive Examination (ACE) Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) Mental status examination (MSE) Montreal Cognitive Assessment (MoCA) NIH stroke scale (NIHSS) Saint Louis University Mental Status Exam (SLUMS) Self-administered Gerocognitive Examination (SAGE) References Cognitive impairment and dementia screening and assessment tools Cognitive tests Neuropsychological tests Memory tests Geriatrics

Makaton

Makaton is a communication tool with speech, signs, and symbols to enable people with disabilities or learning disabilities to communicate. Makaton supports the development of essential communication skills such as attention, listening, comprehension, memory and expressive speech and language. The Makaton language programme has been used with individuals who have cognitive impairments, autism, Down syndrome, specific language impairment, multisensory impairment and acquired neurological disorders that have negatively affected the ability to communicate, including stroke and dementia patients. The name "Makaton" is derived from the names of three members of the original teaching team at Botleys Park Hospital in Chertsey, Surrey: Margaret Walker (the designer of the programme and speech therapist at Botleys Park), Katherine Johnston and Tony Cornforth (psychiatric hospital visitors from the Royal Association for Deaf People). Makaton is a registered trademark of the Makaton Charity, which was established in 2007 to replace the original charitable trust, the Makaton Vocabulary Development Project, established in 1983. The original trademark application for Makaton was filed in Britain on 28 August 1979, with registration approved as from that date under trademark registration no. 1119745. In 2004 the Oxford University Press included Makaton as a common usage word in the Oxford English Dictionary. The entry states: "Makaton, n. Brit. A proprietary name for: a language programme integrating speech, manual signs, and graphic symbols, developed to help people for whom communication is very difficult, esp. those with learning disabilities." Programme The Makaton Language Programme uses a multimodal approach to teach communication, language and, where appropriate literacy skills, through a combination of speech, signs, and graphic symbols used concurrently, or, only with speech with signs, or, only with speech with graphic symbols as appropriate for the student's needs. It consists of a Core Vocabulary of roughly 450 concepts that are taught in a specific order (there are eight different stages). For example, stage one involves teaching vocabulary for immediate needs, like "eat" and "drink". Later stages contain more complex and abstract vocabulary such as time and emotions. Once basic communication has been established, the student can progress in their language use, using whatever modes are most appropriate. Also, although the programme is organised in stages, it can be modified and tailored to the individual's needs. In addition to the Core Vocabulary, there is a Makaton Resource Vocabulary of over 11,000 concepts which are illustrated with signs and graphic symbols. Development Original research was conducted by Margaret Walker in 1972/73, and resulted in the design of the Makaton Core Vocabulary based on functional need. This research was conducted with institutionalised deaf cognitively impaired adults resident at Botleys Park Hospital in Chertsey, Surrey (which closed in 2008). The aim was to enable them to communicate using signs from British Sign Language. Fourteen deaf and cognitively impaired adults participated in the pilot study, and all were able to learn to use manual signs; improved behaviour was also noted. Shortly after, the Core Vocabulary was revised to include both children and adults with severe communication difficulties (including individuals who could hear), and was used in many schools throughout Britain in order to stimulate communication and language. In the early stages of development, Makaton used only speech and manual signs (without symbols). By 1985, work had begun to include graphic symbols in the Makaton Language Programme and a version including graphic symbols was published in 1986. The Core Vocabulary was revised in 1986 to include additional cultural concepts. The Makaton Vocabulary Development Project was founded in 1976 by Margaret Walker, who worked in a voluntary capacity as director until her retirement in October 2008. The first Makaton training workshop was held in 1976 and supporting resources and further training courses were, and continue to be, developed. In 1983 the Makaton Vocabulary Development Project became a charitable trust, and in 2007 it changed its status to become the Makaton Charity. Use The Makaton Language Programme is used extensively across Britain and has been adapted for use in different countries; signs from each country's deaf community are used, along with culturally relevant Makaton symbols. For example, within Britain, Makaton uses signs from British Sign Language; the signs are mainly from the London and South East England regional dialect. Makaton has also been adapted for use in over 40 countries, including France, Greece, Japan, Kuwait and the Gulf, Russia, South Africa and Switzerland. Using signs from each country's own existing sign language ensures that they reflect each country's unique culture and also provide a bank of further signs if required for use with the Makaton Language Programme. In 1991 the Makaton Charity produced a video/DVD of children's familiar nursery rhymes, signed, spoken and sung by a well-known children's TV presenter, Dave Benson Phillips, who had previously used Makaton with poems and rhymes in the Children's BBC show Playdays. The aim was for it to be enjoyed by children with developmental disabilities and their peers and siblings. Following this major success, in 2003 it became a significant part of the BBC's Something Special programmes on the CBeebies programme thread, presented by Justin Fletcher, which has won numerous awards and is now into its thirteenth series. On 16 November 2018, comedian Rob Delaney read a book on the BBC's children's channel CBeebies entirely in Makaton and English; he had used Makaton to communicate with his late son Henry, who was rendered unable to talk after a tracheotomy. References Further reading Harrison, D: Virden, F (2011). "Assistant practitioners lead way". British Journal of Healthcare Assistants, 5(8),409. Hooper, External links The Makaton Charity website 1970s establishments in the United Kingdom Augmentative and alternative communication Deaf culture in the United Kingdom Sign language Sign systems Speech and language pathology

Community mental health service

Community mental health services (CMHS), also known as community mental health teams (CMHT) in the United Kingdom, support or treat people with mental disorders (mental illness or mental health difficulties) in a domiciliary setting, instead of a psychiatric hospital (asylum). The array of community mental health services vary depending on the country in which the services are provided. It refers to a system of care in which the patient's community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment. Community services include supported housing with full or partial supervision (including halfway houses), psychiatric wards of general hospitals (including partial hospitalization), local primary care medical services, day centers or clubhouses, community mental health centers, and self-help groups for mental health. The services may be provided by government organizations and mental health professionals, including specialized teams providing services across a geographical area, such as assertive community treatment and early psychosis teams. They may also be provided by private or charitable organizations. They may be based on peer support and the consumer/survivor/ex-patient movement. The World Health Organization states that community mental health services are more accessible and effective, lessen social exclusion, and are likely to have fewer possibilities for the neglect and violations of human rights that were often encountered in mental hospitals. However, WHO notes that in many countries, the closing of mental hospitals has not been accompanied by the development of community services, leaving a service vacuum with far too many not receiving any care. New legal powers have developed in some countries, such as the United States, to supervise and ensure compliance with treatment of individuals living in the community, known as outpatient commitment or assisted outpatient treatment or community treatment orders. History Origins Community mental health services began as an effort to contain those who were "mad" or considered "lunatics". Understanding the history of mental disorders is crucial in understanding the development of community mental health services. As medical psychology developed as a science and shifted toward the treatment of the mentally ill, psychiatric institutions began to develop around the world, and laid the groundwork for modern day community mental health services. Pre-deinstitutionalization On July 3, 1946, President Harry Truman signed the National Mental Health Act which, for the first time in the history of the United States, generated a large amount of federal funding for both psychiatric education and research. The passing of this Act eventually led to the founding of the National Institute of Mental Health (NIMH) in 1949. At the end of the 1940s and moving into the beginning of the 1950s, the governor of Minnesota Luther Youngdahl initiated the development of numerous community-based mental health services. He also advocated for the humane treatment of people in state institutions. Deinstitutionalization Philippe Pinel played a large role in the ethical and humane treatment of patients and greatly influenced Dorothea Dix. Dix advocated the expansion of state psychiatric hospitals for patients who were at the time being housed in jails and poor houses. Despite her good intentions, rapid urbanization and increased immigration led to a gross overwhelming of the state's mental health systems and because of this, as the 19th century ended and the 20th century began, a shift in focus from treatment to custodial care was seen. As quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers. Mental health movements Post-deinstitutionalization Following deinstitutionalization, many of the mentally ill ended up in jails, nursing homes, and on the streets as homeless individuals. It was at this point in history that modern community mental health services started to grow and become influential. In 1955, following a major period of deinstitutionalization, the Mental Health Study Act was passed. With the passing of this Act, the U.S. Congress called for "an objective, thorough, nationwide analysis and reevaluation of the human and economic problems of mental health." Following Congress' mandate, the Joint Commission on Mental Illness conducted numerous studies. For the next four years this commission made recommendations to establish community mental health centers across the country. In 1963 the Community Mental Health Centers Act was passed, essentially kick-starting the community mental health revolution. This Act contributed further to deinstitutionalization by moving mental patients into their "least restrictive" environments. The Community Mental Health Centers Act funded three main initiatives: Professional training for those working in community mental health centers Improvement of research in the methodology utilized by community mental health centers Improving the quality of care of existing programs until newer community mental health centers could be developed. That same year the Mental Retardation Facilities and Community Mental Health Centers Construction Act was passed. President John F. Kennedy ran part of his campaign on a platform strongly supporting community mental health in the United States. Kennedy's ultimate goal was to reduce custodial care of mental health patients by 50% in ten to twenty years. In 1965, the Community Mental Health Act was amended to ensure a long list of provisions. First, construction and staffing grants were extended to include centers that served patients with substance abuse disorders. Secondly, grants were provided to bolster the initiation and progression of community mental health services in low-SES areas. Lastly, new grants were established to support mental health services aimed at helping children. As the 20th century progressed, even more political influence was exerted on community mental health. In 1965, with the passing of Medicare and Medicaid, there was an intense growth of skilled nursing homes and intermediate-care facilities that alleviated the burden felt by the large-scale public psychiatric hospitals. 20th century From 1965 to 1969, $260 million was authorized for community mental health centers. Compared to other government organizations and programs, this number is strikingly low. The funding drops even further under Richard Nixon from 1970 to 1973 with a total of $50.3 million authorized. Even though the funding for community mental health centers was on a steady decline, deinstitutionalization continued into the 1960s and 1970s. The number of state and county mental hospital resident patients in 1950 was 512,501 and by 1989 had decreased to 101,402. This continuing process of deinstitutionalization without adequate alternative resources led the mentally ill into homelessness, jails, and self-medication through the use of drugs or alcohol. In 1975 Congress passed an Act requiring community mental health centers to provide aftercare services to all patients in the hopes of improving recovery rates. In 1980, just five years later, Congress passed the Mental Health Systems Act of 1980, which provided federal funding for ongoing support and development of community mental health programs. This Act strengthened the connection between federal, state, and local governments with regards to funding for community mental health services. It was the final result of a long series of recommendations by Jimmy Carter's Mental Health Commission. Despite this apparent progress, just a year after the Mental Health Systems Act was passed, the Omnibus Budget Reconciliation Act of 1981 was passed. The Omnibus Act was passed by the efforts of the Reagan administration as an effort to reduce domestic spending. The Act rescinded a large amount of the legislation just passed, and the legislation that was not rescinded was almost entirely revamped. It effectively ended federal funding of community treatment for the mentally ill, shifting the burden entirely to individual state governments. Federal funding was now replaced by granting smaller amounts of money to the individual states. In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program (C.S.P.). The C.S.P.'s goal was to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients. The C.S.P. established the ten elements of a community support system listed below: Responsible team Residential care Emergency care Medicare care Halfway house Supervised (supported) apartments Outpatient therapy Vocational training and opportunities Social and recreational opportunities Family and network attention This conceptualization of what makes a good community program has come to serve as a theoretical guideline for community mental health service development throughout the modern-day United States psychological community. In 1986 Congress passed the Mental Health Planning Act of 1986, which was a Federal law requiring that at the state government level, all states must have plans for establishing case management under Medicaid, improving mental health coverage of community mental health services, adding rehabilitative services, and expanding clinical services to the homeless population. More specifically, community mental health providers could now receive reimbursement for services from Medicare and Medicaid, which allowed for many of the centers to expand their range of treatment options and services. As the 1990s began, many positive changes occurred for people with mental illnesses through the development of larger networks of community-based providers and added innovations with regards to payment options from Medicare and Medicaid. Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care as the 1990s progressed. Managed care as a system focuses on limiting costs by one of two means: either keeping the total number of patients using services low or reducing the cost of the service itself. Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment. The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless. While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbor negative attitudes toward those with mental illnesses. Historically, people with mental illnesses have been portrayed as violent or criminal and because of this, "many American jails have become housing for persons with severe mental illnesses arrested for various crimes." In 1999 the Supreme Court ruled on the case Olmstead v. L.C. The Court ruled that it was a violation of the Americans with Disabilities Act of 1990 to keep an individual in a more restrictive inpatient setting, such as a hospital, when a more appropriate and less restrictive community service was available to the individual. 21st century and modern trends In 2002 President George W. Bush increased funding for community health centers. The funding aided in the construction of additional centers and increased the number of services offered at these centers, which included healthcare benefits. In 2003, the New Freedom Commission on Mental Health, established by President Bush, issued a report. The report was in place to "conduct a comprehensive study of the United States mental health delivery system..." Its objectives included assessing the efficiency and quality of both public and private mental health providers and identifying possible new technologies that could aid in treatment. As the 20th century came to a close and the 21st century began, the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centers grew from 210,000 to approximately 800,000. This nearly four-fold increase shows just how important community mental health centers are becoming to the general population's wellbeing. This drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population. The staggering new numbers of patients then are being forced to seek specialized treatment from their primary care providers or hospital emergency rooms. The result of this trend is that a patient who is working with a primary care provider is more likely to receive less care than with a specialized clinician. Politics and funding have always been and continue to be a topic of contention when it comes to funding of community health centers. Political views aside, it is clear that these community mental health centers exist largely to aid areas painfully under resourced with psychiatric care. In 2008, over 17 million people utilized community mental health centers with 35% being insured through Medicaid, and 38% being uninsured. Networks like Open Path Collective, established in 2015, offer discounted rates to uninsured and underinsured people who cannot otherwise afford psychotherapy. As the 2000s continued, the rate of increase of patients receiving mental health treatment in community mental health centers stayed steady. Purpose and examples Cultural knowledge and attitude is passed from generation to generation. For example, the stigma with therapy may be passed from mother to daughter. San Diego county has a diverse range of ethnicities. Thus, the population diversity in San Diego include many groups with historical trauma and trans-generational trauma within those populations. For example, witnesses of war can pass down certain actions and patterns of survival mechanism to generations. Refugee groups have trans-generational trauma around war and PTSD. Providing services and therapy to these communities is important because it affects their day-to-day lives, where their experiences lead to trauma or the experiences are traumatic themselves. Knowledge and access to mental health resources are limited in these multicultural communities. Government agencies fund community groups that provide services to these communities. Therefore, this creates a power hierarchy. If their missions do not align with each other, it will be hard to provide benefits for the community, even though the services are imperative to the wellbeing of its residents. The combination of a mental illness as a clinical diagnosis, functional impairment with one or more major life activities, and distress is highest in ages 18–25 years old. Despite the research showing the necessity of therapy for this age group, only one fifth of emerging adults receive treatment. Psychosocial interventions that encourage self-exploration and self-awareness, such as acceptance and mindfulness-based therapies, is useful in preventing and treating mental health concerns. At the Center for Community Counseling and Engagement, 39% of their clients are ages 1–25 years old and 40% are in ages 26–40 years old as well as historically underrepresented people of color. The center serves a wide range of ethnicities and socio-economic statuses in the City Heights community with counselors who are graduate student therapists getting their Master's in Marriage and Family Therapy or Community Counseling from San Diego State University, as well as post-graduate interns with their master's degree, who are preparing to be licensed by the state of California. Counseling fees are based on household incomes, which 69% of the client's annual income is $1–$25,000 essentially meeting the community's needs. Taking into account of San Diego's population, the clinic serves as an example of how resources can be helpful for multicultural communities that have a lot of trauma in their populations. See also American Association of Community Psychiatrists Community health Recovery model References Further reading Mental health in the United Kingdom Mental health in the United States Deinstitutionalisation

Existential crisis

Existential crises are inner conflicts characterized by the impression that life lacks meaning and confusion about one's personal identity. They are accompanied by anxiety and stress, often to such a degree that they disturb one's normal functioning in everyday life and lead to depression. Their negative attitude towards meaning reflects characteristics of the philosophical movement of existentialism. The components of existential crises can be divided into emotional, cognitive, and behavioral aspects. Emotional components refer to the feelings, such as emotional pain, despair, helplessness, guilt, anxiety, or loneliness. Cognitive components encompass the problem of meaninglessness, the loss of personal values or spiritual faith, and thinking about death. Behavioral components include addictions, and anti-social and compulsive behavior. Existential crises may occur at different stages in life: the teenage crisis, the quarter-life crisis, the mid-life crisis, and the later-life crisis. Earlier crises tend to be forward-looking: the individual is anxious and confused about which path in life to follow regarding education, career, personal identity, and social relationships. Later crises tend to be backward-looking. Often triggered by the impression that one is past one's peak in life, they are usually characterized by guilt, regret, and a fear of death. If an earlier existential crisis was properly resolved, it is easier for the individual to resolve or avoid later crises. Not everyone experiences existential crises in their life. The problem of meaninglessness plays a central role in all of these types. It can arise in the form of cosmic meaning, which is concerned with the meaning of life at large or why we are here. Another form concerns personal secular meaning, in which the individual tries to discover purpose and value mainly for their own life. Finding a source of meaning may resolve a crisis, like altruism, dedicating oneself to a religious or political cause, or finding a way to develop one's potential. Other approaches include adopting a new system of meaning, learning to accept meaninglessness, cognitive behavioral therapy, and the practice of social perspective-taking. Negative consequences of existential crisis include anxiety and bad relationships on the personal level as well as a high divorce rate and decreased productivity on the social level. Some questionnaires, such as the Purpose in Life Test, measure whether someone is currently undergoing an existential crisis. Outside its main use in psychology and psychotherapy, the term "existential crisis" refers to a threat to the existence of something. Definition In psychology and psychotherapy, the term "existential crisis" refers to a form of inner conflict. It is characterized by the impression that life lacks meaning and is accompanied by various negative experiences, such as stress, anxiety, despair, and depression. This often happens to such a degree that it disturbs one's normal functioning in everyday life. The inner nature of this conflict sets existential crises apart from other types of crises that are mainly due to outward circumstances, like social or financial crises. Outward circumstances may still play a role in triggering or exacerbating an existential crisis, but the core conflict happens on an inner level. The most common approach to resolving an existential crisis consists in addressing this inner conflict and finding new sources of meaning in life. The core issue responsible for the inner conflict is the impression that the individual's desire to lead a meaningful life is thwarted by an apparent lack of meaning, also because they feel much confusion about what meaning really is, and are constantly questioning themselves. In this sense, existential crises are crises of meaning. This is often understood through the lens of the philosophical movement known as existentialism. One important aspect of many forms of existentialism is that the individual seeks to live in a meaningful way but finds themselves in a meaningless and indifferent world. The exact term "existential crisis" is not commonly found in the traditional existentialist literature in philosophy. But various closely related technical terms are discussed, such as existential dread, existential vacuum, existential despair, existential neurosis, existential sickness, anxiety, and alienation. Different authors focus in their definitions of existential crisis on different aspects. Some argue that existential crises are at their core crises of identity. On this view, they arise from a confusion about the question "Who am I?" and their goal is to achieve some form of clarity about oneself and one's position in the world. As identity crises, they involve intensive self-analysis, often in the form of exploring different ways of looking at oneself. They constitute a personal confrontation with certain key aspects of the human condition, like existence, death, freedom, and responsibility. In this sense, the person questions the very foundations of their life. Others emphasize the confrontation with human limitations, such as death and lack of control. Some stress the spiritual nature of existential crises by pointing out how outwardly successful people may still be severely affected by them if they lack the corresponding spiritual development. The term "existential crisis" is most commonly used in the context of psychology and psychotherapy. But it can also be employed in a more literal sense as a crisis of existence to express that the existence of something is threatened. In this sense, a country, a company, or a social institution faces an existential crisis if political tensions, military threats , high debt, or social changes may have as a result that the corresponding entity ceases to exist. Components Existential crises are usually seen as complex phenomena that can be understood as consisting of various components. Some approaches distinguish three types of components belonging to the fields of emotion, cognition, and behavior. Emotional aspects correspond to what it feels like to have an existential crisis. It is usually associated with emotional pain, despair, helplessness, guilt, anxiety, and loneliness. On the cognitive side, the affected are often confronted with a loss of meaning and purpose together with the realization of one's own end. Behaviorally, existential crises may express themselves in addictions and anti-social behavior, sometimes paired with ritualistic behavior, loss of relationships, and degradation of one's health. While manifestations of these three components can usually be identified in every case of an existential crisis, there are often significant differences in how they manifest. Nonetheless, it has been suggested that these components can be used to give a more unified definition of existential crises. Emotional On the emotional level, existential crises are associated with unpleasant experiences, such as fear, anxiety, panic, and despair. They can be categorized as a form of emotional pain whereby people lose trust and hope. This pain often manifests in the form of despair and helplessness. The despair may be caused by being unable to find meaning in life, which is associated both with a lack of motivation and the absence of inner joy. The impression of helplessness arises from being unable to find a practical response to deal with the crisis and the associated despair. This helplessness concerns specifically a form of emotional vulnerability: the individual is not just subject to a wide range of negative emotions, but these emotions often seem to be outside the person's control. This feeling of vulnerability and lack of control can itself produce further negative impressions and may lead to a form of panic or a state of deep mourning. But on the other hand, there is also often an impression in the affected that they are in some sense responsible for their predicament. This is the case, for example, if the loss of meaning is associated with bad choices in the past for which the individual feels guilty. But it can also take the form of a more abstract type of bad conscience as existential guilt. In this case, the agent carries a vague sense of guilt that is free-floating in the sense that it is not tied to any specific wrongdoing by the agent. Especially in existential crises in the later parts of one's life, this guilt is often accompanied by a fear of death. But just as in the case of guilt, this fear may also take a more abstract form as an unspecific anxiety associated with a sense of deficiency and meaninglessness. As crises of identity, existential crises often lead to a disturbed sense of personal integrity. This can be provoked by the apparent meaninglessness of one's life together with a general lack of motivation. Central to the sense of personal integrity are close relationships with oneself, others, and the world. The absence of meaning usually has a negative impact on these relationships. As a lack of a clear purpose, it threatens one's personal integrity and can lead to insecurity, alienation, and self-abandonment. The negative impact on one's relationships with others is often experienced as a form of loneliness. Depending on the person and the crisis they are suffering, some of these emotional aspects may be more or less pronounced. While they are all experienced as unpleasant, they often carry within them various positive potentials as well that can push the person in the direction of positive personal development. Through the experience of loneliness, for example, the person may achieve a better understanding of the substance and importance of relationships. Cognitive The main cognitive aspect of existential crises is the loss of meaning and purpose. In this context, the term "meaninglessness" refers to the general impression that there is no higher significance, direction, or purpose in our actions or in the world at large. It is associated with the question of why one is doing what one is doing and why one should continue. It is a central topic in existentialist psychotherapy, which has as one of its main goals to help the patient find a proper response to this meaninglessness. In Viktor Frankl's logotherapy, for example, the term existential vacuum is used to describe this state of mind. Many forms of existentialist psychotherapy aim to resolve existential crises by assisting the patient in rediscovering meaning in their life. Closely related to meaninglessness is the loss of personal values. This means that things that seemed valuable to the individual before, like the relation to a specific person or success in their career, may now appear insignificant or pointless to them. If the crisis is resolved, it can lead to the discovery of new values. Another aspect of the cognitive component of many existential crises concerns the attitude to one's personal end, i.e. the realization that one will die one day. While this is not new information as an abstract insight, it takes on a more personal and concrete nature when one sees oneself confronted with this fact as a concrete reality one has to face. This aspect is of particular relevance for existential crises occurring later in life or when the crisis was triggered by the loss of a loved one or by the onset of a terminal disease. For many, the issue of their own death is associated with anxiety. But it has also been argued that the contemplation of one's death may act as a key to resolving an existential crisis. The reason for this is that the realization that one's time is limited can act as a source of meaning by making the remaining time more valuable and by making it easier to discern the bigger issues that matter in contrast to smaller everyday issues that can act as distractions. Important factors for dealing with imminent death include one's religious outlook, one's self-esteem, and social integration as well as one's future prospects. Behavioral Existential crises can have various effects on the individual's behavior. They often lead a person to isolate themself and engage less in social interactions. For example, one's communication to one's housemates may be limited to very brief responses like a simple "yes" or "no" in order to avoid a more extended exchange or the individual reduces various forms of contact that are not strictly speaking necessary. This can result in a long-term deterioration and loss of one's relationships. In some cases, existential crises may also express themselves in overtly anti-social behavior, like hostility or aggression. These negative impulses can also be directed at the person themselves, leading to self-injury and, in the worst case, suicide. Addictive behavior is also seen in people going through an existential crisis. Some turn to drugs in order to lessen the impact of the negative experiences whereas others hope to learn through the non-ordinary drug experiences to cope with the existential crisis. While this type of behavior can succeed in providing a short-term relief of the effects of the existential crisis, it has been argued that it is usually maladaptive and fails on the long-term level. This way, the crises may even be further exacerbated. For the affected, it is often difficult to distinguish the need for pleasure and power from the need for meaning, thereby leading them on a wrong track in their efforts to resolve the crisis. The addictions themselves or the stress associated with existential crises can result in various health problems, ranging from high blood pressure to long-term organ damage and increased likelihood of cancer. Existential crises may also be accompanied by ritualistic behavior. In some cases, this can have positive effects to help the affected transition to a new outlook on life. But it might also take the form of compulsive behavior that acts more as a distraction than as a step towards a solution. Another positive behavioral aspect concerns the tendency to seek therapy. This tendency reflects the awareness of the affected of the gravity of the problem and their desire to resolve it. Types Different types of existential crises are often distinguished based on the time in one's life when they occur. This approach rests on the idea that, depending on one's stage in life, individuals are faced with different issues connected to meaning and purpose. They lead to different types of crises if these issues are not properly resolved. The stages are usually tied to rough age groups but this correspondence is not always accurate since different people of the same age group may find themselves in different life situations and different stages of development. Being aware of these differences is central for properly assessing the issue at the core of a specific crisis and finding a corresponding response to resolve it. The most well-known existential crisis is the mid-life crisis and a lot of research is directed specifically at this type of crisis. But researchers have additionally discovered various other existential crises belonging to different types. There is no general agreement about their exact number and periodization. Because of this, the categorizations of different theorists do not always coincide but they have significant overlaps. One categorization distinguishes between the early teenage crisis, the sophomore crisis, the adult crisis, the mid-life crisis, and the later-life crisis. Another focuses only on the sophomore crisis, the adult crisis, and the later-life crisis but defines them in wider terms. The sophomore crisis and the adult crisis are often treated together as forms of the quarter-life crisis. There is wide agreement that the earlier crises tend to be more forward-looking and are characterized by anxiety and confusion about the path in life one wants to follow. The later crises, on the other hand, are more backward-looking, often in the form of guilt and regrets, while also concerned with the problem of one's own mortality. These different crises can affect each other in various ways. For example, if an earlier crisis was not properly resolved, later crises may impose additional difficulties for the affected. But even if an earlier crisis was fully resolved, this does not guarantee that later crises will be successfully resolved or avoided altogether. Another approach distinguishes existential crises based on their intensity. Some theorists use the terms existential vacuum and existential neurosis to refer to different degrees of existential crisis. On this view, an existential vacuum is a rather common phenomenon characterized by the frequent recurrence of subjective states like boredom, apathy, and emptiness. Some people experience this only in their free time but are otherwise not troubled by it. The term "Sunday neurosis" is often used in this context. An existential vacuum becomes an existential neurosis if it is paired with overt clinical neurotic symptoms, such as depression or alcoholism. Teenage The early teenage crisis involves the transition from childhood to adulthood and is centered around the issue of developing one's individuality and independence. This concerns specifically the relation to one's family and often leads to spending more time with one's peers instead. Various rebellious and anti-social behavior seen sometimes in this developmental stage, like stealing or trespassing, may be interpreted as attempts to achieve independence. It can also give rise to a new type of conformity concerning, for example, how the teenager dresses or behaves. This conformity tends to be not in relation to one's family or public standards but to one's peer group or adored celebrities. But this may be seen as a temporary step in order to distance oneself from previously accepted standards with later steps emphasizing one's independence also from one's peer group and celebrity influences. A central factor for resolving the early teenage crisis is that meaning and purpose are found in one's new identity since independence without it can result in the feeling of being lost and may lead to depression. Another factor pertains to the role of the parents. By looking for signs of depression, they may become aware that a teenager is going through a crisis. Examples include a change of appetite, sleep behavior is different; sleeps more or less, grades take a dive in a short amount of time, they are less social and more isolated, and start to become easily irritated. If parents regularly talk to their teenagers and ask them questions, it is more likely that they detect the presence of a crisis. Quarter-life, sophomore, and adult The term "quarter-life crisis" is often used to refer to existential crises occurring in early adulthood, i.e. roughly during the ages between 18 and 30. Some authors distinguish between two separate crises that may occur at this stage in life: the sophomore crisis and the adult crisis. The sophomore crisis affects primarily people in their late teenage years or their early 20s. It is also referred to as "sophomore slump", specifically when it affects students. It is the first time that serious questions about the meaning of life and one's role in the world are formulated. At this stage, these questions have a direct practical relation to one's future. They apply to what paths one wants to choose in life, like which career to focus on and how to form successful relationships. At the center of the sophomore crisis is the anxiety over one's future, i.e. how to lead one's life and how to best develop and employ one's abilities. Existential crisis often specifically affect high achievers who fear that they do not reach their highest potential since they lack a secure plan for the future. To solve them, it is necessary to find meaningful answers to these questions. Such answers may result in practical commitments and can inform later life decisions. Some people who have already made their career choices at a very early age may never experience a sophomore crisis. But such decisions can lead to problems later on since they are usually mainly informed by the outlook of one's social environment and less by the introspective insight into one's individual preferences. If there turns out to be a big discrepancy between the two, it can provoke a more severe form of the sophomore crisis later on. James Marcia defines this early commitment without sufficient exploration as identity foreclosure. The adult crisis usually starts in the mid- to late 20s. The issues faced in it overlap to some extent with the ones in the sophomore crisis, but they tend to be more complex issues of identity. As such, they also circle around one's career and one's path in life. But they tend to take more details into account, like one's choice of religion, one's political outlook, or one's sexuality. Resolving the adult crisis means having a good idea of who one is as a person and being comfortable with this idea. It is usually associated with reaching full adulthood, having completed school, working full-time, having left one's home, and being financially independent. Being unable to resolve the adult crisis may result in disorientation, a lack of confidence in one's personal identity, and depression. Mid-life Among the different types of existential crises, the mid-life crisis is the one most widely discussed. It often sets in around the age of 40 and can be triggered by the impression that one's personal growth is obstructed. This may be combined with the sense that there is a significant distance between one's achievement and one's aspirations. In contrast to the earlier existential crises, it also involves a backward-looking component: previous choices in life are questioned and their meaning for one's achievements are assessed. This may lead to regrets and dissatisfaction with one's life choices on various topics, such as career, partner, children, social status, or missed opportunities. The tendency to look backward is often connected to the impression that one is past one's peak period in life. Sometimes five intermediary stages are distinguished: accommodation, separation, liminality, reintegration, and individuation. In these stages, the individual first adapts to changed external demands, then addresses the distance between their innate motives and the external persona, next rejects their previously adaptive persona, later adopts their new persona, and lastly becomes aware of the external consequences associated with these changes. Mid-life crises can be triggered by specific events such as losing a job, forced unemployment, extramarital affairs, separation, death of a loved one, or health problems. In this sense, the mid-life crisis can be understood as a period of transition or reevaluation in which the individual tries to adapt to their changed situation in life, both in response to the particular triggering event and to the more general changes that come with age. Various symptoms are associated with mid-life crises, such as stress, boredom, self-doubt, compulsivity, changes in the libido and sexual preferences, rumination, and insecurity. In public discourse, the mid-life crisis is primarily associated with men, often in direct relation to their career. But it affects women just as well. An additional factor here is the limited time left in their reproductive period or the onset of the menopause. Between 8 and 25 percent of Americans over the age of thirty-five have experienced a mid-life crisis. Both the severity and the length of the mid-life crisis are often affected by whether and how well the earlier crises were resolved. People who managed to resolve earlier crises well tend to feel more fulfilled with their life choices, which also reflects in how their meaningfulness is perceived when looking back on them. But it does not ensure that they still appear meaningful from one's current perspective. Later-life The later-life crisis often occurs around one's late 60s. It may be triggered by events such as retirement, the death of a loved one, serious illness, or imminent death. At its core is a backward-looking reflection on how one led one's life and the choices one made. This reflection is usually motivated by a desire to have lived a valuable and meaningful life paired with an uncertainty of one's success. A contemplation of one's past wrongdoings may also be motivated by a desire to find a way to make up for them while one still can. It can also express itself in a more theoretical form as trying to assess whether one's life made a positive impact on one's more immediate environment or the world at large. This is often associated with the desire to leave a positive and influential legacy behind. Because of its backward-looking nature, there may be less one can do to truly resolve the crisis. This is true especially for people who arrive at a negative assessment of their life. An additional impeding factor in contrast to earlier crises is that individuals are often unable to find the energy and youthfulness necessary to make meaningful changes to their lives. Some suggest that developing an acceptance of the reality of death may help in the process. Other suggestions focus less on outright resolving the crisis but more on avoiding or minimizing its negative impact. Recommendations to this end include looking after one's physical, economic, and emotional well-being as well as developing and maintaining a social network of support. The best way to avoid the crisis as much as possible may be to ensure that one's earlier crises in life are resolved. Meaninglessness Most theorists see meaninglessness as the central issue around which existential crises revolve. In this sense, they may be understood as crises of meaning. The issue of meaning and meaninglessness concerns various closely related questions. Understood in the widest sense, it involves the global questions of the meaning of life in general, why we are here, or for what purpose we live. Answers to this question traditionally take the form of religious explanations, for example, that the world was created by God according to His purpose and that each thing is meaningful because it plays a role for this higher purpose. This is sometimes termed cosmic meaning in contrast to the secular personal meaning an individual seeks when asking in what way their particular life is meaningful or valuable. In this personal sense, it is often connected with a practical confusion about how one should live one's life or why one should continue doing what one does. This can express itself in the feeling that one has nothing to live for or to hope for. Sometimes this is even interpreted in the sense that there is no right and wrong or good and evil. While it may be more and more difficult in the contemporary secular world to find cosmic meaning, it has been argued that to resolve the problem of meaninglessness, it is sufficient for the individual to find a secular personal meaning to hold onto. The issue of meaninglessness becomes a problem because humans seem to have a strong desire or need for meaning. This expresses itself both emotionally and practically since goals and ideals are needed to structure one's life. The other side of the problem is given in the fact that there seems to be no such meaning or that the world is at its bottom contingent and could have existed in a very different way or not at all. The world's contingency and indifference to human affairs are often referred to as the absurd in the existentialist literature. The problem can be summarized through the question "How does a being who needs meaning find meaning in a universe that has no meaning?". Various practitioners of existential psychotherapy have affirmed that the loss of meaning plays a role for the majority of people requiring psychotherapy and is the central issue for a significant number of them. But this loss has its most characteristic expression in existential crises. Various factors affect whether life is experienced as meaningful, such as social relationships, religion, and thoughts about the past or future. Judgments of meaning are quite subjective. They are a form of global assessment since they take one's life as a whole into consideration. It is sometimes argued that the problem of a loss of meaning is particularly associated with modern society. This is often based on the idea that people tended to be more grounded in their immediate social environment, their profession, and their religion in premodern times. Sources of meaning It is usually held that humans have a need for meaning. This need may be satisfied by finding an accessible source of meaning. Religious faith can be a source of meaning and many studies demonstrate that it is associated with self-reported meaning in life. Another important source of meaning is due to one's social relationships. Lacking or losing a source of meaning, on the other hand, often leads to an existential crisis. In some cases, this change is clearly linked to a specific source of meaning that becomes inaccessible. For example, a religious person confronted with the vast extent of death and suffering may find their faith in a benevolent, omnipotent God shattered and thereby lose the ability to find meaning in life. For others, a concrete threat of imminent death, for example, due to the disruption of the social order, can have a similar effect. If the individual is unable to assimilate, reinterpret, or ignore this type of threatening information, the loss of their primary source of meaning may force them to reevaluate their system of meaning in life from the ground up. In this case, the person is entering an existential crisis, which can bring with it the need to question what other sources of meaning are accessible to them or whether there is meaning at all. Many different sources of meaning are discussed in the academic literature. Discovering such a source for oneself is often key to resolving an existential crisis. The sources discussed in the literature can be divided into altruism, dedication to a cause, creativity, hedonism, self-actualization, and finding the right attitude. Altruism refers to the practice or attitude based on the desire to benefit others. Altruists aim to make the world a better place than they found it. This can happen in various ways. On a small scale, one may try to be kinder to the people in one's immediate social environment. It can include the effort to become aware of their problems and try to help them, directly or indirectly. But the altruistic attitude may also express itself in a less personal form towards strangers, for example, by donating money to charities. Effective altruism is an example of a contemporary movement promoting altruism and providing concrete advice on how to live altruistically. It has been argued that altruism can be a strong source of meaning in one's life. This is also reflected in the fact that altruists tend to enjoy higher levels of well-being as well as increased physical and mental health. Dedicating oneself to a cause can act as a closely related source of meaning. In many cases, the two overlap, if altruism is the primary motivation. But this is not always the case since the fascination with a cause may not be explicitly linked to the desire to benefit others. It consists in devoting oneself fully to producing something greater than oneself. A diverse set of causes can be followed this way, ranging from religious goals, political movements, or social institutions to scientific or philosophical ventures. Such causes provide meaning to one's life to the extent that one participates in the meaningfulness of the cause by working towards it and realizing it. Creativity refers to the activity of creating something new and exciting. It can act as a source of meaning even if it is not obvious that the creation serves a specific purpose. This aspect is especially relevant in the field of art, where it is sometimes claimed that the work of art does not need an external justification since it is "its own excuse for being". It has been argued that for many great artists, their keener vision of the existential dilemma of the human condition was the cause of their creative efforts. These efforts in turn may have served them as a form of therapy. But creativity is not limited to art. It can be found and practiced in many different fields, both on a big and a small scale, such as in science, cooking, gardening, writing, regular work, or romantic relationships. The hedonistic approach can also constitute a source of meaning. It is based on the idea that a life enjoyed to the fullest extent is meaningful even if it lacks any higher overarching purpose. For this perspective, it is relevant that hedonism is not understood in a vulgar sense, i.e. as the pursuit of sensory pleasures characterized by a disregard of the long-term consequences. While such a lifestyle may be satisfying in certain respects, a more refined form of hedonism that includes other forms of pleasures and considers their long-term consequences is more commonly recommended in the academic literature. This wider sense also includes more subtle pleasures such as looking at fine art or engaging in a stimulating intellectual conversation. In this way, life can be meaningful to the individual if it is seen as a gift evoking a sense of astonishment at its miracle and a general appreciation of it. According to the perspective of self-actualization, each human carries within themselves a potential of what they may become. The purpose of life then is to develop oneself to realize this potential and successfully doing so increases the individual's well-being and sense of meaningfulness. In this sense, just like an acorn has the potential to become an oak, so an infant has the potential to become a fully actualized adult with various virtues and skills based on their inborn talents. The process of self-actualization is sometimes understood in terms of a hierarchy: certain lower potentials have to be actualized before the actualization of higher potentials becomes possible. Most of the approaches mentioned so far have clear practical implications in that they affect how the individual interacts with the world. The attitudinal approach, on the other hand, identifies different sources of meaning based only on taking the right attitude towards life. This concerns specifically negative situations in which one is faced with a fate that one cannot change. In existential crises, this often expresses itself in the feeling of helplessness. The idea is that in such situations one can still find meaning based on taking a virtuous or admirable attitude towards one's suffering, for example, by remaining courageous. Whether a certain source of meaning is accessible differs from person to person. It may also depend on the stage in life one finds oneself in, similar to how different stages are often associated with different types of existential crises. It has been argued, for example, that the concern with oneself and one's own well-being found in self-actualization and hedonism tends to be associated more with earlier stages in life. The concern with others or the world at large found in altruism and the dedication to a cause, on the other hand, is more likely found in later stages in life, for example, when an older generation aims to pass on their knowledge and improve the lives of a younger generation. Consequences, clinical manifestation, and measurement Going through an existential crisis is associated with a variety of consequences, both for the affected individual and their social environment. On the personal level, the immediate effects are usually negative since experiencing an existential crisis is connected to stress, anxiety, and the formation of bad relationships. This can lead all the way to depression if existential crises are not resolved. On the social level, they cause a high divorce rate and an increased number of people being unable to make significant positive contributions to society, for example, due to a lack of drive resulting from depression. But if resolved properly, they can also have positive effects by pushing the affected to address the underlying issue. Individuals may thereby find new sources of meaning, develop as a person, and thereby improve their way of life. In the sophomore crisis, for example, this can happen by planning ahead and thereby making more conscious choices in how to lead one's life. Being aware of the symptoms and consequences of existential crises on the personal level is important for psychotherapists so they can arrive at an accurate diagnosis. But this is not always easy since the symptoms usually differ from person to person. In this sense, the lack of meaning at the core of existential crises can express itself in several different ways. For some, it may lead them to become overly adventurous and zealous. In their attempt to wrest themselves free from meaninglessness, they are desperate to indiscriminately dedicate themselves to any cause. They might do so without much concern for the concrete content of the cause or for their personal safety. It has been argued that this type of behavior is present in some hardcore activists. This may be understood as a form of defense mechanism in which the individual engages fanatically in activities in response to a deep sense of purposelessness. It can also express itself in a related but less dramatic way as compulsive activity. This may take various forms, such as workaholism or the obsessive pursuit of prestige, or material acquisitions. This is sometimes referred to as false centering or inauthenticity since the activity is pursued more as a distraction and less because it is in itself fulfilling to the agent. It can provide a temporary alleviation by helping the individual drain their energy and thus distract them from the threat of meaninglessness. Another response consists in an overt declaration of nihilism characterized by a pervasive tendency to discredit activities purported by others to have meaning. Such an individual may, for example, dismiss altruism out of hand as a disingenuous form of selfishness or see all leaders as motivated by their lust for power rather than inspired by a grand vision. In some more extreme forms of crisis, the individual's behavior may show severe forms of aimlessness and apathy, often accompanied by depression. Being unable to find good reasons for making an effort, such a person remains inactive for extended periods of time, such as staying in bed all day. If they engage in a behavior, they may do so indiscriminately without much concern for what they are doing. Indirect factors for determining the severeness of an existential crisis include job satisfaction and the quality of one's relationships. For example, physical violence or constant fighting in a relationship may be interpreted as external signs of a serious existential crisis. Various empirical studies have shown that a lack of sense of meaning in life is associated with psychopathology. Having a positive sense of meaning, on the other hand, is associated with deeply held religious beliefs, having a clear life goal, and having dedicated oneself to a cause. Measurement Different suggestions have been made concerning how to measure whether someone has an existential crisis, to what degree it is present, and which approach to resolving it might be promising. These methods can help therapists and counselors to understand both whether their client is going through an existential crisis and, if so, how severe their crisis is. But they can also be used by theorists in order to identify how existential crises correlate with other phenomena, such as depression, gender, or poverty. One way to assess this is through questionnaires focusing on topics like the meaning of life, such as the Purpose in Life Test and the Life Regard Index. The Purpose in Life Test is widely used and consists of 20 items rated on a seven-point scale, such as "In life I have: (1) no goals or aims at all ... (7) very clear goals and aims" or "With regard to death, I am (1) unprepared and frightened ... (7) prepared and unafraid". Resolution Since existential crises can have a crippling effect on people, it is important to find ways to resolve them. Different forms of resolution have been proposed. The right approach often depends on the type of crisis experienced. Many approaches emphasize the importance of developing a new stage of intellectual functioning in order to resolve the inner conflict. But others focus more on external changes. For example, crises related to one's sexual identity and one's level of independence may be resolved by finding a partner matching one's character and preferences. Positive indicators of marital success include having similar interests, engaging in common activities, and having a similar level of education. Crises centering around one's professional path may also be approached more externally by finding the right type of career. In this respect, important factors include that the career matches both one's interests and one's skills to avoid a job that is unfulfilling, lacks engagement, or is overwhelming. But the more common approach aims at changing one's intellectual functioning and inner attitude. Existential psychotherapists, for example, usually try to resolve existential crises by helping the patient to rediscover meaning in their life. Sometimes this takes the form of finding a spiritual or religious purpose in life, such as dedicating oneself to an ideal or discovering God. Other approaches focus less on the idea of discovering meaning and more on the idea of creating meaning. This is based on the idea that meaning is not something independent of the agent out there but something that has to be created and maintained. However, there are also types of existentialist psychotherapy that accept the idea that the world is meaningless and try to develop the best way of coping with this fact. The different approaches to resolving the issue of meaninglessness are sometimes divided into a leap of faith, the reasoned approach, and nihilism. Another classification categorizes possible resolutions as isolation, anchoring, distraction, and sublimation. Methods from cognitive behavior therapy have also been used to treat existential crises by bringing about a change in the individual's intellectual functioning. Leap of faith, reasoned approach, and nihilism Since existential crises circle around the idea of being unable to find meaning in life, various resolutions focus on specifically this aspect. Sometimes three different forms of this approach are distinguished. On the one hand, the individual may perform a leap of faith and affirm a new system of meaning without a previous in-depth understanding of how secure it is as a source of meaning. Another method consists in carefully considering all the relevant factors and thereby rebuilding and justifying a new system of meaning. A third approach goes against these two by denying that there is actual meaning. It consists in accepting the meaninglessness of life and learning how to deal with it without the illusion of meaning. A leap of faith implies committing oneself to something one does not fully understand. In the case of existential crises, the commitment involves the faith that life is meaningful even though the believer lacks a reasoned justification. This leap is motivated by the strong desire that life is meaningful and triggered as a response to the threat posed to the fulfillment of this desire by the existential crisis. For whom this is psychologically possible, this may be the fastest way to bypass an existential crisis. This option may be more available to people oriented toward intuitive processing and less to people who favor a more rational approach since it has less need for a thorough reflection and introspection. It has been argued that the meaning acquired through a leap of faith may be more robust than in other cases. One reason for this is that since it is not based on empirical evidence for it, it is also less vulnerable to empirical evidence against it. Another reason concerns the flexibility of intuition to selectively disregard threatening information on the one hand and to focus instead on validating cues. More rationally inclined persons tend to focus more on a careful evaluation of the sources of meaning based on solid justification through empirical evidence. If successful, this approach has the advantage of providing the individual with a concrete and realistic understanding of how their life is meaningful. It can also constitute a very robust source of meaning if it is based on solid empirical evidence and thorough understanding. The system of meaning arrived at may be very idiosyncratic by being based on the individual's values, preferences, and experiences. On a practical level, it often leads to a more efficient realization of this meaning since the individual can focus more exclusively on this factor. If someone determines that family life is their main source of meaning, for example, they may focus more intensely on this aspect and take a less involved stance towards other areas in life, such as success at work. In comparison to the leap of faith, this approach offers more room for personal growth due to the cognitive labor in the form of reflection and introspection involved in it and the self-knowledge resulting from this process. One of the drawbacks of this approach is that it can take a considerable amount of time to complete and rid oneself of the negative psychological consequences. If successful, the foundations arrived at this way may provide a solid basis to withstand future existential crises. But success is not certain and even after a prolonged search, the individual might still be unable to identify a significant source of meaning in their life. If the search for meaning in either way fails, there is still another approach to resolving the issue of meaninglessness in existential crises: to find a way to accept that life is meaningless. This position is usually referred to as nihilism. One can distinguish a local and a global version of this approach, depending on whether the denial of meaningfulness is only directed at a certain area of life or at life as a whole. It becomes necessary if the individual arrives at the justifiable conclusion that life is, after all, meaningless. This conclusion may be intolerable initially, since humans seem to have a strong desire to lead a meaningful life, sometimes referred to as the will to meaning. Some theorists, such as Viktor Frankl, see this desire even as the primary motivation of all individuals. One difficulty with this negative stance towards meaning is that it seems to provide very little practical guidance in how to live one's life. So even if an individual has resolved their existential crises this way, they may still lack an answer to the question of what they should do with their life. Positive aspects of this stance include that it can lead to a heightened sense of freedom by being unbound from any predetermined purpose. It also exemplifies the virtue of truthfulness by being able to acknowledge an inconvenient truth instead of escaping into the convenient illusion of meaningfulness. Isolation, anchoring, distraction, and sublimation According to Peter Wessel Zapffe, life is essentially meaningless but this does not mean that we are automatically doomed to unresolvable existential crises. Instead, he identifies four ways of dealing with this fact without falling into an existential depression: isolation, anchoring, distraction, and sublimation. Isolation involves a dismissal of destructive thoughts and feelings from consciousness. Physicians and medical students, for example, may adopt a detached and technical stance in order to better deal with the tragic and disgusting aspects of their vocation. Anchoring involves a dedication to certain values and practical commitments that give the individual a sense of assurance. This often happens collectively, for example, through devotion to a common religion, but it can also happen individually. Distraction is a more temporary form of withdrawing one's attention from the meaninglessness of certain life situations that do not provide any significant contributions to the construction of our self. Sublimation is the rarest of these mechanisms. Its essential characteristic setting it apart from the other mechanisms is that it uses the pain of living and transforms it into a work of art or another creative expression. Cognitive behavioral therapy and social perspective-taking Some approaches from the field of cognitive behavioral therapy adjust and employ treatments for depression to resolve existential crises. One fundamental idea in cognitive behavior theory is that various psychological problems arise due to inaccurate core beliefs about oneself, such as beliefs that one is worthless, helpless, or incompetent. These problematic core beliefs may lie dormant for extended periods. But when activated by certain life events, they may express themselves in the form of recurrent negative and damaging thoughts. This can lead, among other things, to depression. Cognitive behavioral therapy then consists in raising the awareness of the affected person in regards to these toxic thought patterns and the underlying core beliefs while training to change them. This can happen by focusing on one's immediate present, being goal-oriented, role-playing, or behavioral experiments. A closely related method employs the practice of social perspective-taking. Social perspective-taking involves the ability to assess one's situation and character from the point of view of a different individual. This enables the individual to step outside their own immediate perspective while taking into consideration how others see the individual and thus reach a more integral perspective. Unresolved crises Existential crises sometimes pass even if the underlying issue is not resolved. This may happen, for example, if the issue is pushed into the background by other concerns and thus remains present only in a masked or dormant state. But even in this state, it may have unconscious effects on how people lead their life, like career choices. It can also increase the likelihood of suffering another existential crisis later on in life and might make resolving these later crises more difficult. It has been argued that many existential crises in contemporary society are not resolved. The reason for this may be a lack of clear awareness of the nature, importance, and possible treatments of existential crises. Cultural context In the 19th century, Thomas Carlyle wrote of how the loss of faith in God results in an existential crisis which he called the "Centre of Indifference", wherein the world appears cold and unfeeling and the individual considers himself to be without worth. Søren Kierkegaard considered that angst and existential despair would appear when an inherited or borrowed world-view (often of a collective nature) proved unable to handle unexpected and extreme life-experiences. Friedrich Nietzsche extended his views to suggest that the death of God—the loss of collective faith in religion and traditional morality—created a more widespread existential crisis for the philosophically aware. Existential crisis has indeed been seen as the inevitable accompaniment of modernism (1890–1945). Whereas Émile Durkheim saw individual crises as the by-product of social pathology and a (partial) lack of collective norms, others have seen existentialism as arising more broadly from the modernist crisis of the loss of meaning throughout the modern world.<ref>M. Hardt/K. Weeks, The Jameson Reader (2000) p. 265</ref> Its twin answers were either a religion revivified by the experience of anomie (as with Martin Buber), or an individualistic existentialism based on facing directly the absurd contingency of human fate within a meaningless and alien universe, as with Sartre and Camus. Irvin Yalom, an emeritus professor of psychiatry at Stanford University, has made fundamental contributions to the field of existential psychotherapy. Rollo May is another of the founders of this approach. Fredric Jameson has suggested that postmodernism, with its saturation of social space by a visual consumer culture, has replaced the modernist angst of the traditional subject, and with it the existential crisis of old, by a new social pathology of flattened affect and a fragmented subject. Historical context Existential crises are often seen as a phenomenon associated specifically with modern society. One important factor in this context is that various sources of meaning, such as religion or being grounded in one's local culture and immediate social environment, are less important in the contemporary context. Another factor in modern society is that individuals are faced with a daunting number of decisions to make and alternatives to choose from, often without any clear guidelines on how to make these choices. The high difficulty for finding the best alternative and the importance of doing so are often the cause of anxiety and may lead to an existential crisis. For example, it was very common for a long time in history for a son to simply follow his father's profession. In contrast to this, the modern schooling system presents students with different areas of study and interest, thereby opening a wide range of career opportunities to them. The problem brought about by this increased freedom is sometimes referred to as the agony of choice. The increased difficulty is described in Barry Schwartz's law, which links the costs, time, and energy needed to make a well-informed choice to the number of alternatives available. See also Absurdism Why there is anything at all Antinatalism "Dark Night of the Soul" Depersonalization Duḥkha Ego death Limit situation Scholarly approaches to mysticism Positive disintegration The Sickness unto Death Spiritual crisis References Further reading J. Watson, Caring Science as Sacred Science 2005. Chapter 4: "Existential Crisis in Science and Human Sciences". T.M. Cousineau, A. Seibring, M.T. Barnard, P-673 Making meaning of infertility: Existential crisis or personal transformation? Fertility and Sterility, 2006. Sanders, Marc, Existential Depression. How to recognize and cure life-related sadness in gifted people'', 2013. External links Alan Watts on meaningless life, and its resolution Crisis Personal life Philosophy of life Popular psychology Psychological concepts Psychotherapy Religion and mental health Suffering

History of autism

The history of Autism spans over a century; Autism has been subject to varying treatments, being pathologized or being viewed as a beneficial part of human neurodiversity. The understanding of Autism has been shaped by cultural, scientific, and societal factors, and its perception and treatment change over time as scientific understanding of Autism develops. The term Autism was first introduced by Eugen Bleuler in his description of Schizophrenia in 1911. The diagnosis of Schizophrenia was broader than its modern equivalent; autistic children were often diagnosed with Childhood Schizophrenia. The earliest research that focused on children who would today be considered autistic was conducted by Grunya Sukhareva starting in the 1920s. In the 1930s and 1940s, Hans Asperger and Leo Kanner described two related syndromes, later termed infantile Autism and Asperger Syndrome. Kanner thought that the condition he had described might be distinct from Schizophrenia, and in the following decades, research into what would become known as Autism accelerated. Formally, however, autistic children continued to be diagnosed under various terms related to Schizophrenia in both the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD), but by the early 1970s, it had become more widely recognized that Autism and Schizophrenia were in fact distinct mental disorders, and in 1980, this was formalized for the first time with new diagnostic categories in the DSM-III. Asperger syndrome was introduced to the DSM as a formal diagnosis in 1994, but in 2013, Asperger Syndrome and infantile autism were reunified into a single diagnostic category, Autism Spectrum Disorder (ASD). Autistic individuals often struggle with understanding non-verbal social cues and emotional sharing. The development of the web has given many autistic people a way to form online communities, work remotely, and attend school remotely which can directly benefit those experiencing communicating typically. Societal and cultural aspects of Autism have developed: some in the community seek a cure, while others believe that autism is simply another way of being. Although the rise of organizations and charities relating to advocacy for autistic people and their caregiver and efforts to destigmatize ASD have affected how ASD is viewed, Autistic individuals and their caregivers continue to experience social stigma in situations where autistic peoples' behaviour is thought of negatively and many primary care physicians and medical specialists express beliefs consistent with outdated Autism research. The discussion of Autism has brought about much controversy. Without researchers being able to meet a consensus on the varying forms of the condition, there was for a time a lack of research being conducted on what is now classed as autism. Discussing the syndrome and its complexity frustrated researchers. Controversies have surrounded various claims regarding the etiology of Autism. Autism before the term "autism" (until 1908) Autistic people before autism There are few examples of people now understood to be autistic were described long before autism was named. The Table Talk of Martin Luther, compiled by his note taker, Mathesius, contains the story of a 12-year-old boy who may have been autistic with high support needs. The earliest well-documented case of autism is that of Hugh Blair of Borgue, as detailed in a 1747 court case in which his brother successfully petitioned to annul Blair's marriage to gain Blair's inheritance. Henry Cavendish was a prolific natural philosopher, first published in 1766. During his life, Cavendish was considered eccentric and his behaviour was described as "peculiarly shy" by contemporaries. When researching Cavendish as a subject for a 2001 article in the journal Neurology, neurologist Oliver Sacks determined that evidence for an ASD diagnosis was "almost overwhelming". The Wild Boy of Aveyron, a feral child found in 1798, showed several signs of autism. He was non-verbal during his teenage years, and his case was widely popular among society for its time. Such cases brought awareness to autism and related disabilities, and more research was conducted on the natural dimensions of human behaviour. The medical student Jean Itard treated him with a behavioural program designed to help him form social attachments and to induce speech via imitation. Early descriptions of autistic symptoms Around 1810, French psychiatrist Jean-Étienne Dominique Esquirol defined the condition of monomania. He published about it in 1827. It was centred on the contemporary concept of the fixed idea (idée fixe), a single subject of obsession in an otherwise healthy mind. Autistic people often will have strong fixations on certain topics or objects. In 1877, British doctor John Down used the term developmental retardation to describe conditions including what would be considered autism today. Also in 1877, German doctor Adolf Kussmaul defined the condition aphasia voluntaria - when people choose not to speak. Some people considered to have aphasia voluntaria may have been autistic and non-verbal. In 1887, John Down gave a lecture which describes idiots savants, people whose mental abilities were generally poor, but who had strong abilities in a particular area. He notes that "In none of the cases of "idiot savant" have I been able to trace any history of a like faculty in the parents or in the brothers and sisters..." French psychiatrist Pierre Janet published the book Lés Obsessions et la Psychasthénie (The obsessions and psychasthenia) in 1903. It included the newly defined condition of psychasthenia, which became a prototype of Carl Jung's later introverted personality type, and was believed by Grunya Sukhareva to be a component of schizoid psychopathy in childhood. Dementia praecox and related disorders The term dementia praecox (premature dementia) was first used by German psychiatrist Heinrich Schüle in 1880, and also by 1891 by Arnold Pick, a Czech professor of psychiatry at Charles University in Prague. Scottish psychiatrist Thomas Clouston in his 1883 book Clinical Lectures on Mental Diseases, described a new condition he called psychoneurosis. His description covered what is today considered the schizophrenia and autism spectrums - what others had considered "dementia praecox". The term "dementia praecox" was greatly popularised in 1899 through the sixth edition of German Psychiatrist Emil Kraepelin's book Psychiatrie. Ein Lehrbuch für Studirende und Aerzte (Psychiatry. A text-book for students and physicians). This condition was defined very broadly by today's standards. The primary disturbance in dementia praecox was seen to be a disruption in cognitive or mental functioning in attention, memory, and goal-directed behaviour. Autistic people often have these attributes and some people diagnosed with this condition would have been considered autistic today. Italian psychiatrist Sante De Sanctis briefly mentioned a condition in a 1906 paper he called dementia praecocissima (very premature dementia), which was a form of dementia praecox that started very early in people's lives. He wrote about it in more detail in a 1908 paper. It was a very broadly defined condition he considered "very similar to the hebephrenic or catatonic symptom complex of puberty and adolescence." Austrian educator Theodor Heller defined a condition called dementia infantilis (infantile dementia) in 1908. This condition would go on to be called Heller's syndrome and childhood disintegrative disorder. The DSM currently considers it part of autism spectrum disorder. It is a rare genetic condition. Autism as a symptom of schizophrenia (1908–1924) Eugen Bleuler Eugen Bleuler was a Swiss psychiatrist who was the director of the Burghölzli mental hospital, which was associated with the University of Zurich. In April 1908 he gave a lecture explaining that dementia praecox was very different to other forms of dementia. He proposed that it be given the unique name schizophrenia - a split mind. The term would be increasingly adopted over the next fifty years. What is now known as "schizophrenia" is different from what Bleuler described. He included what is today considered as autism, schizoid personality disorder and various schizophrenia spectrum and other psychotic disorders in his definition. The Neo-Latin word autismus (English translation autism) was coined by Bleuler in July 1910. He first used it in print to describe a symptom of schizophrenia in the scientific paper "Zur Theorie des schizophrenen Negativismus" (On the theory of schizophrenic negativism). He derived autismus from the , and used it to mean morbid self-admiration, referring to "autistic withdrawal of the patient to his fantasies, against which any influence from outside becomes an intolerable disturbance". Bleuler believed that the idiosyncratic behaviours of people displaying autistic behaviour were due to them engaging with personal fantasy rather than with the world as it is. He believed they drew on an early childhood mental state that was unable to form theory of mind. August Hoch: the shut-in personality In two papers first publicly presented in November 1908 and May 1910, and published in 1909 and 1910 respectively, Swiss-American psychiatrist August Hoch of the New York State Psychiatric Institute defined the concept of the shut-in personality. It was characterised by reticence, seclusiveness, shyness and a preference for living in fantasy worlds, among other things. Hoch also said they had "a poorly balanced sexual instinct [and] strikingly fruitless love affairs". This personality was identified because a high proportion of patients with dementia praecox had shut-in behaviour before more serious symptoms appeared. Children's rights In 1913, the Mental Deficiency Act was passed in England and Wales, ensuring institutional care for all children identified as "mental defectives". Gannushkin and Kraepelin Both Russian psychiatrist Pyotr Gannushkin's 1914 paper "The state of the question of the schizophrenic constitution", and the verschrobene (eccentric) type of the eighth edition of Emil Kraepelin's psychiatry textbook (1915), detailed character types that would later be considered schizoid by Grunya Sukhareva. Kraepelin writes of an as-of-yet poorly understood group of patients who may be intellectually well-endowed, yet are "absent-minded, forgetful, and show fluctuations in their intellectual capacity." They are eccentric in the sense that they tend to hold "extravagant and unworldly ideas," have a rambling or confused mode of expression, and tend to not to adjust themselves to others' experiences and instead "occupy themselves with completely hopeless and out-of-the-way plans". While Sukhareva saw a strong connection between Kraepelin's eccentric type and the children she saw a common pattern in, Kraepelin's description could equally describe many people in the schizophrenia spectrum. Introduction of the term schizoid The term schizoid began to be used just before 1920. It was used to describe people who had symptoms similar to "schizophrenia", but were not as pronounced. German psychiatrist of the University of Tübingen, Ernst Kretschmer's 1921 paper "Körperbau und Charakter" was expanded in 1922. This expanded version was published as the book Physique and Character in English in 1925, and used the terms schizoid and schizothmes (the latter being like schizoid, but more neurotypical). He included the schizothmic artistic temperament as one of two varieties of genius, and defined the socially withdrawn schizothymia as a personality type. In 1924, Bleuler said schizoid people were:At this time Bleuler also believed that everyone had a schizoid element, writing "Every man then has one syntonic [in harmony with one's environment] and one schizoid component, and through closer observation one can determine its force and direction". In 1925, Sante De Sanctis published another paper about "dementia praecocissima". It had some overlap with Heller's syndrome. Carl Jung: Introversion In September 1909, Swiss psychiatrist Carl Jung used the term introverted in a lecture at Clark University. A transcript of this lecture was then published with two others in a journal in 1910, the first time the term appeared in print. In the lecture he mentions that love that is "introverted", "is turned inward into the subject and there produces increased imaginative activity". Jung had earlier worked under Bleuler at Burghölzli. Carl Jung's 1921 book Psychologische Typen was published as Personality Types in English in 1923. It described the "introverted" in detail for the first time. (Various new editions were published until 1949). A more concise definition of the introverted type was given by Jung in February 1936, in his paper "Psychologische Typologie" (Psychological Typology). It included: The International Council for the Education of Exceptional Children The International Council for the Education of Exceptional Children was established in the United States on August 10, 1922. The group was founded by Elizabeth Farrell to bring together teachers of disabled children. The group later became known as the Council for Exceptional Children. Moritz Tramer In 1924, Austrian-Swiss psychiatrist Moritz Tramer published the paper "Einseitig Talentierte und Begabte Schwachsinnige" (Singularly talented and gifted mental defectives). It described idiot savants. Leo Kanner would later claim Tramer's autism work as an antecedent of his own. Pioneering research (1925–1949) Grunya Sukhareva Soviet child psychiatrist Grunya Sukhareva (Груня Сухарева) was the first person to comprehensively define what is now considered autism. She was born in Kyiv to a Jewish family, and between 1917 and 1921 worked in a psychiatric hospital in Kyiv. In 1921, she founded a school for children with psychological problems at the Psychoneurological Department for Children in Moscow, and worked there for some time. She was supervised by Mikhail Gurevich, who had previously worked under Emil Kraepelin. In 1925 she published a pioneering paper containing six case studies and a detailed description of schizoid personality disorder in children, titled "Шизоидные псиxопатии в детском возрасте" (Schizoid Psychopathies in Childhood). This was revised slightly and published in German in 1926, as "Die schizoiden Psychopathien im Kindesalter" (The Schizoid Psychopathies in Childhood). Her definition aligned well with that for ASD in the DSM-5. She summarised the condition as being made up of five factors: A peculiar type of thought, with a tendency towards the abstract and schematic. This often combined with a tendency to reason and engage in absurd pondering. The latter often makes them seen as being eccentric. Autistic attitude. All children in this group remained aloof from their environment, adapt to their environment with difficulty and never fully integrate into it. Cases 1, 2 and 3 immediately become the object of general ridicule among the other children upon admission to school. Cases 4 and 5 had no authority among their classmates and are nicknamed "talking machines", although their general level put them significantly above the rest of the children. Case 6 even avoided the company of children, which traumatized him. The tendency to loneliness and the fear of people can be observed in all of these children from early childhood onwards; they stay apart from the others, avoid playing together, they prefer fantastic stories and fairy tales. In the area of the thymopsyche, a certain flatness and superficiality of feelings (cases 2, 3, 5). This is often combined with what Kretschmer described as an aesthetic personality. Special features: tendency to automatism (cases 1, 2, 3, 4 and 6), which is expressed by sticking to work that has been started. Their rigid psyche has difficulty adapting to the new. impulsive absurd actions (cases 1, 2, 3), a silly demeanor, the tendency to rhyme, and to create stereotypical new words (cases 1, 2, 3, 5). tendency to obsessive states (cases 1, 2, 3, 4) and increased suggestibility (cases 1, 3 and 6). A pronounced motor insufficiency could be observed: clumsiness, angularity of movements, many superfluous movements, synkinesis (cases 1, 2, 3 and 4). Inadequacy of facial expressions and expressive movements (cases 1, 4 and 5), slack posture (cases 2, 4, 6), linguistic peculiarities, and insufficiently modulated speech (cases 1, 2, 3). Sukhareva concluded that "there is a group of personality disorders whose clinical picture shares certain features with schizophrenia, but which yet differs profoundly from schizophrenia in terms of its pathogenesis". Speculating about the etiology of the condition, she attributed these to "an inborn deficiency of those systems which are also affected in schizophrenia". Sukhareva followed this paper with one the next year that focused on girls with the condition. She found that there were four main sex-related differences. (New Zealand translator Charlotte Simmonds translated this paper into English in 2020.) In 1930, Sukhareva published the paper K probleme struktury i dinamiki detskikh konstitutsionnykh psikhopatiĭ (shizoidnye formy) (On the problem of the structure and dynamics of children's constitutional psychopathy (schizoid form)). It was translated into English by William New and Hristo Kyuchukov in 2022. In this paper she notes the presence of psychomotor disorders, disorder of affect and emotional responses and issues with associative work and thinking. Between 1932 and 1936, Sukhareva went on to publish several papers about childhood schizophrenia. In one she notes that even from early childhood, these children showed a "lack of adaptability to life in the collective, a certain autism and unreliability". In 1939, Sukhareva published the three book collection Клинические лекции по психиатрии детского возраста, (Clinical lectures on child psychiatry). The second volume included her findings about schizoid/schizophrenic children. New editions were published in 1959 and 1965. While Sukhareva's writings would be read and referenced by American child psychology researchers like Louise Despert, Charles Bradley, and Leo Kanner in the 1930s and 40s, her work was subsequently largely unknown in the Anglosphere and Western Europe. Sukhareva would not become well known in the West until much later. In September 1996, British child psychiatrist Sula Wolff published her translation of Grunya Sukhareva's 1925 paper, starting the process of increasing awareness of Sukhareva's work in the West. Hans Asperger The Austrian psychiatrist Hans Asperger was born in Vienna in 1906. In 1929, German psychiatrist Erich Rudolf Jaensch (of the University of Marburg) published his book Grundformen menschlichen Seins (Basic forms of human existence). Asperger would later say his autism thinking was influenced by its explanation of schizothyms. In May 1931, Asperger joined the Vienna University's Children's Clinic, and the following year had joined its department of curative education. He learnt from those already working there, including the Austrians psychiatrist , psychologist Anni Weiss, and nurse Viktorine Zak. In 1935, Asperger went on to become the head of the department. In April 1935, Anni Weiss published the paper "Qualitative intelligence testing as a means of diagnosis in the examination of psychopathic children", which includes a case study about an autistic boy. In August that year, the Jewish Weiss migrated from Europe to the United States. She would go on to work at Johns Hopkins Hospital in Baltimore. George Frankl was working at the clinic long before Asperger, and had taught Asperger much about child psychiatry. Already in 1934, Frankl had published the paper "Befehlen und Gehorchen" (Command and Obey), which identified a group of children with particular language difficulties that some have subsequently considered autistic. As a Jew, Frankl was in danger from his country's Nazi regime. So he left Vienna in 1937 and migrated to the United States in November that year. He went to work with his friend Leo Kanner at Johns Hopkins Hospital. Asperger used the terms autistic psychopath and autism in a 3 October 1938 lecture to describe a pattern he had seen in his patients and elsewhere. The lecture was published later that year as Das Psychisch Abnormale Kind (The Mentally Abnormal Child). The lecture included two case studies, and analysis. It instructed its predominantly Viennese listeners and readers that people who are a bit strange may also be very intelligent, and that knowing this will become important "when the 'Law for the Prevention of Hereditary Diseased Offspring' comes into force in our country". Describing a particular kind of mentally abnormal child, Asperger wrote about the struggles that many children with autism face, including "disturbance of relationships, clumsiness in 'pure' motor skills, and poor practical understanding." He also spoke of the presence of restricted interests in autistic people. Hans Asperger submitted a postdoctoral habilitation thesis on the topic of autism to the University of Vienna in October 1942, which would be published with very few changes in June 1944. The paper "Die "Autistischen Psychopathen" im Kindesalter" (The "Autistic Psychopaths" in Childhood) included four cases studies and related analysis. This work offered the most detailed description of autism as yet published. Asperger identified a typical behaviour pattern seen among autistic children, and with extensive detail outlined his observations. He concludes that "...the individual personalities [of autistic people] stand out from one another not only through the degree of the contact disorder, through the level of intellectual and character strengths, but also through numerous individual traits, special ways of reacting, and special interests." Asperger also details his lack of finding autistic traits in young girls. In regards to his work's academic antecedents, Asperger frequently acknowledges Bleuler, and also said:It has been suggested that Asperger was also likely aware of Sukhareva's work. The particular patterns Asperger identified later became known as "Asperger syndrome", particularly those that differed from the children later described by Leo Kanner. Asperger served Germany's National Socialist regime in a number of capacities. On multiple occasions he publicly advocated for the legitimacy of its race hygiene policies such as forced sterilization, and he also took part in its child 'euthanasia' program. Despite many important English-publishing autism researchers being fluent in German, and his work being covered in some English language works, Asperger's concept of autism would be almost unknown by non-German-speaking psychological professionals until the 1970s. It would take yet longer for substantial numbers of non-German-speaking people it describes to hear about it. Leo Kanner Leo Kanner was born in 1894 to a Jewish family in what is Ukraine today, and what was then the Austro-Hungarian Empire. He went on to study and work in Berlin. He then immigrated to the United States in 1924. In 1930, the first child psychiatry clinic in the United States was established at Johns Hopkins Hospital, and Kanner was appointed to run it. In 1933, Kanner became associate professor of psychiatry at Johns Hopkins University. In May 1933, American psychiatrist Howard Potter, (assistant director of the New York State Psychiatric Institute and Hospital), published a paper titled "Schizophrenia in Children". Potter defined six diagnostic criteria for childhood schizophrenia, which Kanner would later say was important when thinking about autism: A generalized retraction of interests from the environment. Dereistic thinking, feeling and acting. Disturbances of thought, manifested through blocking, symbolization, condensation, perseveration, incoherence and diminution, sometimes to the extent of mutism. Defect in emotional rapport. Diminution, rigidity and distortion of affect. Alterations of behavior with either an increase of motility, leading to incessant activity, or a diminution of motility, reacting to complete immobility or bizarre behavior with a tendency to perseveration or stereotypy. In 1934, Soviet psychiatrist Evgenia Grebelskaya-Albatz (Евгения Гребельская-Альбац) of Moscow published the paper "Zur Klinik der Schizophrenie des frühen Kindesalters" (On the clinic of early childhood schizophrenia). It divided people with childhood "schizophrenia" into two groups, those with intelligence within the normal range, and those with below average intelligence. Kanner would later say that she was one of the three people to identify autism before he did. Leo Kanner published the first American textbook on child psychiatry in 1935, titled Child Psychiatry. (While many sources say he published the first English-language book of that kind, Kanner himself credits this to William Ireland). In 1937, Swiss psychiatrist Jakob Lutz of University of Zurich published a short book reviewing the available material on childhood schizophrenia, including the work of Sukhareva, Potter, Grebelskaja-Albatz and others. It was republished in a journal later in 1937. Lutz visited Kanner's department at Johns Hopkins in early 1938. Lutz would also publish a chapter on the topic in a book that year. Kanner later acknowledged Lutz's influence on his work. In June 1938, American psychiatrist Louise Despert of the New York State Psychiatric Institute published the paper Schizophrenia in Children. It included case studies of people that have subsequently been identified as having autism. The paper referenced two researchers, Sukhareva and Grebelskaya-Albatz. It has been suggested that this paper was a major influence on Kanner. Kanner would later also claim Despert's autism work as an antecedent of his own. By this time, two of Hans Asperger's close colleagues, psychiatrist (and friend of Kanner) and psychologist Anni Weiss, were now working at Johns Hopkins, having fled the Nazis. Leo Kanner visited the autistic child Donald Triplett on 27 October 1938. Kanner would later say that this was the first time he saw the pattern of autism. In April 1941, Kanner presented a paper titled "Autistic Disturbances of Affective Contact" to a staff conference in The Henry Phipps Psychiatric Clinic in Baltimore. This would be published in April 1943. It includes case studies of eleven children and their families who have particular things in common. He did not use the term autism as the name of the children's condition. In the paper he notices a pattern of children with childhood schizophrenia have a "combination of extreme autism, obsessiveness, stereotypy, and echolalia..." that differ greatly from other people with childhood schizophrenia. He also notes that these children often present with "the powerful desire for aloneness and sameness..." and "between the ages of 6 and 8 do not play with other children but instead along side them." He adds that "reading skill is acquired quickly, but the children read monotonously, and a story or moving picture is experienced in unrelated portions rather than in its coherent totality..." Also, "in the whole group, there are few really warmhearted fathers and mothers. For the most part, the parents, grandparents, and collaterals are persons strongly preoccupied with abstractions of a scientific, literary, or artistic nature, and limited in genuine interest in people." Almost all the characteristics described in this paper, notably "autistic aloneness" and "insistence on sameness", are still regarded as typical of autistic spectrum disorder. As for the cause of the condition, it states:The term Kanner's syndrome was later coined to describe the children's condition, in particular to distinguish them from the differing symptoms of Asperger's children. This syndrome has also sometimes been known as classic autism. Kanner and Asperger's colleague George Frankl published the paper "Language and Affective Contact" in the same journal edition as Kanner's 1943 paper. It describes different kinds of speech problems children have. In particular, he identifies a group of speech-troubled children defined by having a "lack of contact with persons", which can considered to be an autistic group. Frankl's precise role in the development of the concept of autism is not clear. In September 1944, Kanner published the paper "Early Infantile Autism", giving his newly identified condition a new name. The paper has much in common with Kanner's 1943 paper. It included only two case studies, but had a much more detailed introduction. Other research German child psychiatrist August Homberger released the book Vorlesungen über Psychopathologie des Kindesalters (Lectures on childhood psychopathology) in 1926, which included a chapter called "Die Schizophrenie" (The schizophrenia). Charles Bradley would later quote from it extensively. Russian-French psychiatrist Eugène Minkowski submitted a thesis in 1926, "La notion de perte de contact avec la réalité et ses applications en psychopathologie" (The Notion of Loss of Contact with Reality and its Applications in Psychopathology). He thought that autism was the patient's loss of contact with reality, and was the core component of "schizophrenia". He thought autism was of two types, "rich" (full of fantasy/psychosis) and "poor" (with few thoughts and feelings). Contrary to Bleuer, he thought that the vast majority of autistic cases were of the "poor" type. R. Niedenthal published the paper "Schizophrenia in childhood" in 1932. It was devoted to defining the symptoms of childhood schizophrenia. In 1934, Moritz Tramer published the paper "Elktiver Mutismus bei Kindern" (Elective Mutism in Children), coining the term elective mutism. During this period, the term autism came to be used quite widely, with a variety of related meanings. In 1936, Swiss psychologist Jean Piaget first published about centration - the ability to focus on only one salient aspect of a situation. In December 1937, British psychiatrist Mildred Creak of Maudsley Hospital presented a paper titled "Psychoses in Children". One part of it identified a group of five children that might today be considered autistic. The paper was published in March 1938. In 1939 and 1940, Dutch psychiatrist Alfons Chorus of Nijmegen's Pedological Institute published a pair of papers describing children that were autists and schizoid, which today would be considered autistic. In late 1938 or early 1939, the Institute created a category for its child students called "autists", representing those who were particularly self-centred. (The institute's work with the autistic would later be explained by senior Sister and psychologist Ida Frye in her doctoral desertion in 1968). In November 1940, husband-and-wife psychiatrists the American Lauretta Bender and Austrian-American Paul Schilder of New York University and Bellevue Hospital published the paper "Impulsions: A specific disorder of behaviour of children". This paper describes in detail children with what would earlier be considered monomania, and later be considered "special interests":American psychiatrist Charles Bradley of the Emma Pendleton Bradley Home, published the book Schizophrenia in Childhood in March 1941, which described in extensive detail what is today considered childhood autism. He cited dozens of other early researchers on the topic, predominantly Lutz, Sukhareva, Potter and Homberger. In 1942, Lauretta Bender described the condition of childhood schizophrenia as a "definite syndrome", a "pathology at every level and in every field of integration within the functioning of the central nervous system". American Academy of Speech Correction The American Academy of Speech Correction (AASC) was founded in 1925, bringing together people working to correct serious communication problems some people had. This included some autistic people. Speech correctionists later became known as "speech therapists" and "speech pathologists", amongst other terms. The AASC changed its name to the American Speech–Language–Hearing Association (ASHA) in 1978. In 2022, the US Centers for Disease Control and Prevention (CDC) noted that "The most common developmental therapy for people with ASD is Speech and Language Therapy." Similar bodies later formed in other parts of the world, including the UK's College of Speech Therapists (now Royal College of Speech and Language Therapists) in 1945, the Australian College of Speech Therapists (now Speech Pathology Australia) in 1949 and Speech-Language & Audiology Canada (SAC). Fragile X syndrome In July 1943, the British neurologist James Martin and geneticist Julia Bell described a pedigree of X-linked intellectual disability. This would later be called Fragile X syndrome, and is now considered one of the genetic causes of autism. ICD-6 On 7 April 1948, the newly formed United Nations established the World Health Organization (WHO). One of its first tasks was to create a global standard list of all health conditions, which was approved by an international conference at the end of April. The WHO adopted and greatly expanded an earlier list of fatal conditions, the ILCD-5. The first International Classification of Diseases (ICD-6) soon became widely used in Europe and elsewhere. It included "primary childhood behaviour disorders" (324), which was used to categorise all children with what was considered disordered behaviour. There was also the condition of "specific learning defects" (326.0). One of its "disorders of character, behaviour, and intelligence" was the "pathological personality" of "schizoid personality" (320.0). Various categories of schizophrenia (300) were additionally represented, though not specifically "childhood" schizophrenia. (The DSM-II would later explicitly state that its concept of childhood schizophrenia had no ICD equivalent). The ICD would not substantially change its representation of autism-related conditions until the ICD-9 in 1978. Increasing awareness (1950–1978) Starting in the 1950s, awareness of "autism" as a distinct condition began to spread to psychiatrists and the wider culture. Parents of autistic children began to group together around the condition, and advocate for their children and themselves. Applied Behavioral Analysis (ABA) became adopted as a method of treatment. The League for Emotionally Disturbed Children The League for Emotionally Disturbed Children was founded in New York in 1950 by 20 parents of emotionally disturbed children, including doctor and researcher Jacques May. The group established the League School in Brooklyn in 1953. Enrolment was limited to children diagnosed with "childhood schizophrenia". The school helped establish a new method of teaching, led by teacher Carl Fenichel and assisted by psychiatrists Alfred Freedman and Zelda Klapper. In 1955, it changed its name to the National Organization for Mentally Ill Children. Leo Kanner noted in 1956 that the organisation had sponsored research that was "attempting to uncover metabolic and electrophysiologic abnormalities" in autistic children. In 1966, Fenichel established the League School of Boston. Refrigerator mother theory In the early 1950s, the refrigerator mother theory emerged as an accepted explanation for Kanner's early infantile autism. The hypothesis was based on the idea that autistic behaviours stem from the emotional frigidity, lack of warmth, and cold, distant, rejecting demeanour of a child's mother. Parents of children with an ASD experienced blame, guilt and self-doubt, especially as the theory was embraced by the medical establishment and went largely unchallenged into the mid-1960s. (While an inspiration for it, Leo Kanner himself eventually rejected the theory.) Austrian-British psychologist Anna Freud and British psychologist Sophie Dann published a paper in 1951 that found that the extreme conditions of deprivation of affection of the Nazi concentration camps did not induce autistic pathology in children. This was later used as an argument against the refrigerator mother theory. DSM-I The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) was released in 1952. The DSM was created to give each of America's mental disorders a clear definition. Two of the conditions it defined included reference to Bleuler's understanding of "autism" - the symptom of keeping-to-oneself. Each was named primarily using another of Bleuler's terms, and defined with a paragraph. One was "Schizophrenic reaction, childhood type" (000-x28), used in cases of "psychotic reactions", including those manifesting primarily autism. This diagnosis was used in cases where there were intellectual disturbances, repetitive behaviour, or a retreat from reality. The other was "Schizoid personality" (000-x42), which was characterized by avoidance of close relations with others, inability to express ordinary aggressive feelings, and autistic thinking. Kanner and Eisenberg's 1956-57 work In February 1956, American psychiatrist Leon Eisenberg published the paper "The Autistic Child in Adolescence", which compared the childhood and adolescence of 63 autistic people. He found that almost one third had achieved at least a moderate social adjustment over the period, predominantly those who had possessed "meaningful language" by the age of 5. He also found that "the fundamental feature [of autism] is a disturbance in social perception." In July that year, Kanner and fellow Johns Hopkins researcher Eisenberg published the paper "Early infantile autism, 1943-1955". Providing Kanner's most concise definition of the condition yet published, the paper says:Supporting the refrigerator mother hypothesis, the paper notes: "The emotional frigidity in the typical autistic family suggests a dynamic experiential factor in the genesis of the disorder in the child." Kanner released the third edition of his textbook Child Psychiatry in 1957. It included an extensive chapter on "early infantile autism", which he categorised as a type of schizophrenia. Regarding the treatment of child schizophrenia as a whole, he wrote: "Whenever possible, frequent sessions with a psychiatrist may enhance the child's ability to form relationships and wean him away from the temptation to schizophrenic withdrawal." Kanner published a number of other papers about autism in the 1950s and 60s. Mildred Creak's nine point definition Until 1961, autistic children in the UK were often institutionalised from a young age. Poor disease control in these institutions often led to a quick death. At this time, the British government sought to discover exactly how many psychotic children there were in the UK. They commissioned Mildred Creak of Great Ormond Street Hospital to lead a group to define the symptoms of childhood psychosis/schizophrenia, and the group completed their work the same year. They came up with a nine-point definition that soon became widely used in that country, and in time would form the definition of the condition used in most of the world. The nine points were more detailed than Sukhareva's similar definition. They lacked the earlier definition's mention of OCD and clumsiness, and added the inclusion of anxiety. A major difference came in Creak's ninth point: "A background of serious retardation in which islets of normal, near normal, or exceptional intellectual function or skill may appear." As the new definition took off, the autistic condition began to be seen as involving a lack of fantasy rather than an excess of it. In the United Kingdom British teacher Sybil Elgar began a school for autistic children in the basement of her London home in 1962. Later that year Elgar, Lorna Wing and others established the UK's Society for Autistic Children. (It became known as the National Autistic Society in 1982.) The Society proposed the "puzzle piece" as a symbol for autism in 1963, because it reflected their view of autism as a "puzzling condition". In 1965, the group set up The Society School for Autistic Children, which was later named after Sybil Elgar. As of 2023, the society operates seven schools across England. Representative organisation Scottish Autism began in 1968, and continues independently today. (Autism Northern Ireland would follow in 1991.) In the United States Austrian-American psychologist Bruno Bettelheim at the University of Chicago published an article in 1959 in Scientific American, "Joey the Mechanical Boy", about a 9-year-old with autism. This increased public awareness of the condition in the United States. Rosemary Kennedy, sister of US President John F Kennedy, was autistic. Her sister Eunice Kennedy Shriver made the public aware of this through an article in the New York Post in September 1962. Rosemary's treatment with brain surgery severely impacted her. The US Community Mental Health Act (CMHA) of 1963 prompted the closure of most of the country's residential institutions for the mentally unwell. The intent was that as many people as possible would be enabled to live freely in homes without full time professional supervision, but could draw on support from community mental health centres. The introduction of Medicaid in 1965 increased the rate of institutional closure. In 1963, the Council for Exceptional Children established the Association for Children with Learning Disabilities (now the Division on Autism and Developmental Disabilities). In 1966, the Association established the journal Education and Training of the Mentally Retarded. (In 2010, the publication became known as Education and Training in Autism and Developmental Disabilities.) In 1964, Bernard Rimland published the book Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behavior, which refuted the refrigerator theory. Instead, Rimland suggested, autism was a result of biochemical defects "triggered by environmental assaults". It included a foreword by Leo Kanner. The book challenged the medical establishment's perceptions of autism. Rimland's message resonated with parents, who wanted to share their stories with him and ask for advice. (The book also includes a reference to "Asperger Syndrome".) Philip K. Dick published the science fiction book Martian Time-Slip in 1964, which features an autistic boy with special powers. In February 1965, American TV aired an episode of the series Directions entitled "Conall", the story of a boy with autism told by his family. In May that year, Life magazine published an article on the work led by Norwegian-American behaviourist psychologist Ivar Lovaas at UCLA's Young Autism Project. "Screams, Slaps and Love" showed how the adults working with autistic children hit them as part of their training. Both this TV episode and magazine article led to further awareness of the condition in the United States. Later in 1965, this newfound awareness coalesced as Rimland, Lovaas, nurse Ruth C. Sullivan and others founded the National Society for Autistic Children (NSAC). Leo Kanner and Carl Fenichel soon joined its Professional Advisory Board. Bettelheim countered Rimland's assertions about the causes of autism in his 1967 book Empty Fortress: Infantile Autism and the Birth of the Self. It greatly popularised the refrigerator theory. Bettelheim subsequently appeared multiple times on The Dick Cavett Show in the 70s to discuss theories of autism and psychoanalysis. (Refrigerator theory has since been refuted in the scientific literature, including a 2015 systematic review which showed absolutely no association between caregiver interaction and language outcomes in ASD patients.) Another notable book of 1967 was The Siege: The First Eight Years of an Autistic Child by American teacher Clara Claiborne Park. It told the story of Clara's daughter and Clara's efforts to help her. (An updated version was released in 1982). Bernard Rimland left his central role at the NSAC in 1967, founding the Autism Research Institute. However, he remained attached to the NSAC. Starting in the late 1960s, "autism" started to be considered as a separate syndrome from "schizophrenia", just as Bleuler had separated schizophrenia from dementia. The Rehabilitation Act of 1973 stated, “No otherwise qualified handicapped individual in the United States, shall solely by reason of his handicap, be subject to discrimination under any program or activity receiving federal financial assistance.” The Education for All Handicapped Children Act (EHA) was passed in November 1975, after a series of related Supreme Court decisions. In 1970, US schools educated only one in five children with disabilities. Many states had laws excluding emotionally disturbed and intellectual disabled children from public education. The EHA guaranteed each disabled child a free and appropriate public education. (The act became the Individuals with Disabilities Education Act (IDEA) in 1990). Newly defined commonly comorbid conditions Sensory processing disorder is a condition in which multisensory input is not adequately processed in order to provide appropriate responses to the demands of the environment. The concept was developed by American occupational therapist Anna Jean Ayres in the 1960s. The disorder continues to be recognised by some major occupational therapy bodies. Studies by the STAR Institute suggest that at least three-quarters of autistic children have significant symptoms of the condition. American psychiatrist Peter Sifneos identified that some people without brain lesions experienced emotional agnosia in 1967, they not being able to recognise the emotions expressed by others. Hyperlexia is when a child can read at an early age. This can be a symptom of autism, particularly when their reading ability is much better than their speaking ability. The term was coined by Norman E. Silberberg and Margaret C. Silberberg, and first published in September 1967. Hyperkinetic reaction of childhood was newly included in the DSM-II in 1968. This condition later became known as attention deficit hyperactivity disorder (ADHD). It's symptoms were first described by German doctor Melchior Adam Weikard in 1775. The concept of child hyperactivity or hyperkinetic behaviour became established in the United States in the 1930s. Around 50-70% of people with ASD also have ADHD. The term alexithymia was conceptualised by Peter Sifneos and fellow American psychiatrist John Case Nemiah in 1973. It refers to people having difficulties in understanding the emotions experienced by themselves or others. This is common in autistic people, but is not always the case. By the early 2000s it was found that about half of autistic people have at least some alexithymia traits. During the 1970s, Anna Jean Ayres developed the sensory integration theory, which proposes that sensory-processing is linked to emotional regulation, learning, behaviour, and participation in daily life. Sensory integration is the process of organizing sensations from the body and from environmental stimuli. In conjunction with her theory, Ayres developed sensory integration therapy (SIT) to help children with sensory-processing difficulties. America's CDC notes that this therapy is used with autistic people to "help improve responses to sensory input that may be restrictive or overwhelming." Asperger's 1968 paper In April 1968, Hans Asperger wrote about the similarities and differences of his and Kanner's concepts of autism in the paper "Zur Differentialdiagnose des kindlichen Autismus" (On the differential diagnosis of childhood autism), noting:Highlighting his broad use of the term autism, he also remarked:Leo Kanner republished a copy of his 1934 paper in the same journal edition. DSM-II In the DSM-II, published in 1968, the concept of autism was used to describe the symptoms of three different conditions: childhood schizophrenia (295.8), withdrawing reaction of childhood (308.1), and schizoid personality (301.2). Compared to the DSM-I, the description of childhood schizophrenia was more detailed. Applied behavior analysis and related techniques While serving as an assistant professor of psychology at Indiana University from 1957 to 1962, Charles Ferster employed errorless learning to instruct young autistic children how to speak. This was an early example of what would later be known as applied behaviour analysis. From the late 1950s, Ferster and others used the new science of behaviorism to teach autistic people and other mental conditions. This led researchers at the University of Kansas to start the Journal of Applied Behavior Analysis in the northern spring of 1968, establishing the concept of applied behavior analysis (ABA). A concise definition of the concept, still used today, was given in the first issue of the journal. ABA soon came to be used extensively with autistic children in the United States and elsewhere. In the US, ABA became the only autism-specific teaching method insurance companies would typically pay for, thus most autism-specialist teachers there became ABA trained and qualified. (Two major American professional associations would later be founded for ABA practitioners.) The Behavior Research Institute was founded by Matthew Israel in the United States in 1971. It would later become known as the Judge Rotenberg Educational Centre. Six residents have died of preventable causes at the center since it opened. Various bodies have accused the center of repeatedly torturing autistic people in the name of ABA. Matthew Israel invented the graduated electronic decelerator to provide electric shocks as punishment for residents. This includes shocks nine times as powerful as a cattle prod. The MidWestern Association for Behavior Analysis was founded in the United States in 1974. It later became the Association for Behavior Analysis International (ABAI). A 2018 study by Henny Kupferstein showed a significant link between early childhood exposure to ABA and Post-Traumatic Stress Disorder (PTSD), "Nearly half (46 percent) of the ABA-exposed respondents met the diagnostic threshold for PTSD..." Kanner's work in the 1970s The Journal of Autism and Childhood Schizophrenia was established in January 1971, with Leo Kanner as the editor. This was the first scientific journal devoted to autism. Kanner wrote a paper called "Childhood psychosis: A historical overview" for the first issue. It acknowledges the work of a broader range of people than Kanner had previously, but not that of Asperger or Frankl; according to Dirk van Krevelen, Kanner and Asperger were mutually unaware of each other's work. Another paper in the first edition however compares Kanner's syndrome (early infantile autism) with Asperger's syndrome (autistic psychosis). It also differentiates the two conditions through a list of seven differences. For the second edition, Kanner traced the eleven children in his 1943 paper and determined how they had grown up, but the results were inconclusive. Kanner released the fourth and final edition of his textbook Child Psychiatry in 1972. He edited the book Childhood Psychosis: Initial Studies and New Insights in 1973, and wrote three of its chapters. It reviewed 30 years of research into early infantile autism and childhood schizophrenia. In it he bemoaned the diagnosing of intellectually disabled children with a few autistic features as singularly having autism. The "First International Leo Kanner Colloquium on Child Development, Deviations, and Treatment" was held in October 1973. The papers tabled were published as the popular academic book Psychopathology and child development: research and treatment in April 1976. Many of the papers were about autism. It was edited by Eric Schopler and American psychiatrist Robert J. Reichler. Eric Schopler would become the second editor of the Journal of Autism and Childhood Schizophrenia in 1974, staying in that role until 1997. Other scientific contributions Dirk van Krevelen published the paper "Een geval van 'early infantil autism'" (A case of early infantile autism) in 1952. It was the first European paper about "early infantile autism". In it, van Krevelen notes that while the condition is well known by United States child psychiatrists, it is virtually unknown in Europe. In 1952, British psychiatrist Ronald Fairbairn published the paper "Schizoid Factors in the Personality" as part of a book. (An early form of it had been given as a lecture in November 1940). It included Fairbairn's belief that the schizoid type was defined by "(1) an attitude of omnipotence, (2) an attitude of isolation and detachment and, (3) a preoccupation with inner reality", with last being by far the most important. Fairbairn believed that people became schizoid because they had been unable to get the parental love they sought when they were small children. He also saw an equivalency between being "schizoid" and being "introverted". 1962 saw a number of notable scientific publications about autism published: In January, Charles Ferster and American psychiatrist Marian DeMyer published the paper "A method for the experimental analysis of the behavior of autistic children". This was possibly the first paper to show how behaviorism could be used to teach autistic students. Also in January, Dirk van Krevelen and Christine Kuipers published a paper in English regarding the work of Hans Asperger, "The psychopathology of autistic psychopathy". Also in 1962, German psychiatrist Gerhard Bosch published the book Der Frühkindliche Autismus: Eine Klinische und Phänomenologisch-Anthropologische Untersuchung am Leitfaden der Sprache (Early Childhood Autism: A Clinical and Phenomenological-Anthropological Study Using Language as a Guide). Among other things, it briefly compared the work of Asperger and Kanner and suggested both men had described variants of the same condition. In 1965, Kanner said he had read this book. Bruno Bettleheim cited it substantially in his later work. British psychiatrist John K Wing edited the first edition of Early Childhood Autism; Clinical, Educational and Social Aspects in 1966, which included chapters from both Ivar Lovaas and Lorna Wing. Later editions would contain different chapters. British psychiatrist Michael Rutter's extensive research in the 1960s provided statistically robust evidence that the syndrome of "early infantile autism" existed. His most cited paper of the period was published in October 1968. 1970 saw the release of the English translation of Gerhard Bosch's 1962 book as Infantile autism: a clinical and phenomenological-anthropological investigation taking language as the guide. It was translated by Derek and Inge Jordan, and included an introduction from Bruno Bettelheim. The English language edition included a large appendix about Asperger and Kanner not included in the German one. It used the term Asperger's syndrome to describe the symptoms of Asperger's patients. American psychiatrist Stella Chess conducted studies on the potential link between rubella and autism. In 1971, she found that children with congenital rubella syndrome developed autism at rates 200 times higher than the general population at the time. She followed this up with a 1977 study. South African-British psychiatrist Israel Kolvin provided much evidence that "early infantile autism" was a very different condition to later onset schizophrenia through two studies published in 1971. In 1975, American-British psychologist Donald Meltzer released his book Explorations in Autism: a psychoanalytic study, documenting the treatment of childhood autism following the thinking of Melanie Klein. Hans Asperger gave a lecture in Fribourg in 1977, of which a translation in English titled "Problems of Infantile Autism" was published in 1979. American psychiatrist Susan Folstein and British psychiatrist Micheal Rutter published a significant twin study establishing the genetic basis of autism in September 1977. The popular academic book Language of autistic children was published in 1978, and was written by American psychiatrist Don W. Churchill. Other treatment programmes, self-advocacy and books American social worker, teacher and dramatist Viola Spolin released the book Improvisation for the Theater in 1963, based on her decades of experience teaching people how to more effectively communicate with each other. The book contained a series of exercises for teaching people how to understand other people's thoughts about their shared situation, and how to react to them effectively. This kicked off the theatre games set of practices, which form an important part of drama therapy. (A second edition was published in 1983, and a third in 1999.) The University of North Carolina's TEACCH Autism Program was founded by German-American psychologist Eric Schopler in 1971, building on work started by Schopler and a colleague in 1964. It recognizes autism as a lifelong condition and does not aim to cure but to respond to autism as a culture. It uses behaviourism in a small group setting. Its methods have been adopted by many practitioners. British researcher Lorna Wing of the Institute of Psychiatry, London published the book Autistic children - a guide for parents in 1971. Louise Despert endorsed the book, and provided its forewords. In 1972, German-American Wolf Wolfensberger released his book Normalisation. It advocated that society should provide opportunities to people with disabilities so that they can do what people without those disabilities can do. The popular book A child called Noah: a family journey was written about the autistic boy Noah Greenfield by his father the American playwright Josh Greenfeld, and was published in 1972. Josh Greenfield was to write two other books about Noah, and Noah's brother would write an additional one. In 1975, Canadian speech pathologist Ayala Hanen Manolson founded The Hanen Centre. Here she developed a new program for groups of parents whose children had significant language delays, known as the "Hanen Approach." Previously, speech pathology was largely delivered by professional pathologists - this approach trained parents to provide the same guidance to children. Over decades, this approach further developed into programs such as More Than Words and Talkability. In November 1975, two British organisations, the Union of the Physically Impaired Against Segregation and the Disability Alliance, held a discussion about the "fundamental principles of disability." The published summary of that discussion advanced a new definition of disability. "In our view, it is society which disables physically impaired people. Disability is something imposed on top of our impairments, by the way we are unnecessarily isolated and excluded from full participation in society." This sentiment later became the basis of the social model of disability, and was important in disability self-advocacy. The home-based autism treatment program Son-Rise, was developed by American couple Barry Kaufman and Samahria Kaufman in the early 1970s. Barry published a book on the method in 1976, (Son-Rise), claiming that it cured his son of autism. An American TV movie based on the book, Son-Rise: A Miracle of Love, was released in 1979. It was influential in Brazil, and was repeatedly aired there during the 1980s. In 1990, the BBC in the UK aired a documentary about one boy's treatment using the Son-Rise program, titled I Want My Little Boy Back, as part of the series Q.E.D.: Challenging Children. An updated and expanded Son-Rise book, Son-Rise: The Miracle Continues was released in 1994. Establishment of new organizations In addition to new scientific and cultural developments, the period from 1950 to 1978 also saw the establishment of various new associations, foundations, and other organizations related to autism: The first French national autism organisation, the ASITP (Association au service des inadaptés présentant des troubles de la personnalité), was founded in Paris in 1963. (Since 1990, it has been known as (FFSA)). Kfar Tikva was established in Israel as a village for people with "cognitive, developmental and emotional disabilities" in 1964. This includes autistic people. (The similar Kishorit community opened in 1997.) In 1964–7, Australian autistic people and their parents founded what is now Autism SA (1964), the Autistic Children's Association of New South Wales (now Aspect, 1966), Victorian Autistic Children's and Adult's Association (now Amaze, 1967), Autistic Children's Association of Queensland (now Autism Queensland, 1967), and what is now the Autism Association of Western Australia (1967). These organisations continue today. (Later, Autism Tasmania (1992) and Autism NT (2002) would be founded.) In Brazil, the Comunidade Terapêutica Leo Kanner (Leo Kanner Therapeutic Community) was founded in Porto Alegre in 1965. 40 parents of autistic children met in Tokyo in December 1966. In February 1967, they and others formed the Association of Autistic Children's Parents. A national body was established in 1968. In time, this would become (日本自閉症協会). In 1970, NSAC launched an ongoing national autism awareness campaign in the US. In 1972, it started the first National Autistic Children's week, which later evolved into Autism Awareness Month. In Italy, (AIABA, The Italian Association for Assistance to Autistic Children) was founded by parents of children with autism in 1970. In Germany, what is now (Autism Germany) was founded in 1970. In Canada's most populous province, the Ontario Society for Autistic Children was founded by parents in 1973. (After a number of name changes, it became Autism Ontario in 2006.) Division 33 of the American Psychological Association was established in 1973, bringing together American psychologists interested in "Mental Retardation and Developmental Disabilities", including autism. As of 2023, the group covers "Intellectual and Developmental Disabilities/Autism Spectrum Disorder" (IDD/ASD). The Israeli Society for Children and Adults with Autism (ALUT) was founded in 1974. As of 2023 it has over 2,500 employees, providing services to over 15,000 families. In January 1975, Autismus Deutsche Schweiz (Autism German Switzerland) began in German-speaking Switzerland. (This was followed with an allied body in French-speaking Switzerland in 1985, and one in Italian-speaking Switzerland in 1989. The three groups now form a confederation called Autism Switzerland.) Autism Society Canada was established in 1976. Autism support group APAFAC was founded in Catalonia in 1976. It was joined by Aspanaes in Galacia in 1979, and similar bodies in other parts of Spain after that. The (NVA) (Dutch Association for Autism) was founded in 1978 by parents of children with autism. Formal recognition (1978–1993) Autism became recognized as a developmental disorder distinct from schizophrenia for the first time by a major psychiatric body, the WHO, in 1978. This and the APA's adoption of a similar definition in 1980, was a major milestone in enabling research into autism. Asperger's work became known to a wider audience, thanks in part to new publications by Lorna Wing. Awareness of autism in the public culture increased with the release of Rain Man and other media productions, and stronger self-advocacy by autistic people laid the foundations of the neurodiversity movement and helped secure better legal rights for autistic people. ICD-9 The international medical condition classification system, the ICD, greatly changed the way it categorised autism-related conditions in 1978, with the release of the ICD-9. "Infantile autism" (299.0) was now recognised as a condition, with separate sub-categories for it having a "current or active state" or "residual state". Its definition of this condition was based on the criteria devised by Mildred Creak for "childhood schizophrenia" in the early 1960s. In the category of "disturbance of emotions specific to childhood and adolescence", the ICD now included "sensitivity, shyness and social withdrawal disorder" (313.2), which included the subcategories "shyness disorder of childhood", "introverted disorder of childhood" and "elective mutism". "Schizoid personality disorder" (301.2) now had two varieties, a general one, and "introverted personality". DSM-III and DSM-III-R DSM-III Under advisement from the NSAC, the DSM-III (1980) turned what was previously defined as childhood schizophrenia into three kinds of "pervasive developmental disorder" (PDD). "Infantile autism" began before a child was 30 months old, and "childhood onset pervasive developmental disorder" began between 30 months and 12 years. A third variety, "atypical pervasive developmental disorder" was similar but lesser than the other two, and could begin at any time. "Elective mutism" was now categorised as in independent condition. "Withdrawing reaction of childhood (or adolescence)" became "schizoid disorder of childhood or adolescence". The DSM-III notes that people with this condition have qualifying symptoms "Not due to Pervasive Developmental Disorder; Conduct Disorder, Undersocialized, Nonaggressive; or any psychotic disorder, such as Schizophrenia." "Schizoid personality" in adults was split into "schizoid personality disorder", "avoidant personality disorder" and "schizotypal personality disorder". The first two differed by the motivation of the diagnosed person - "avoidant" people had social difficulties but wanted to be social, while "schizoid" people had social difficulties and were happy to stay that way. "Schizotypal" people were on the schizophrenia spectrum - the condition was not well aligned with conceptions of autism. The DSM-III gave much more detail for its conditions than previous editions had done, providing comprehensive diagnostic criteria for the first time. DSM-III-R In 1987, the revised DSM-III-R was released. In this edition of the DSM, "infantile autism" was merged with "childhood onset pervasive developmental disorder" to create the new "autistic disorder". The new definition broadened the range of neurotypes that were considered "autistic" by clinicians. The DSM's third PDD category became "pervasive developmental disorder not otherwise specified" (PDDNOS, later PDD-NOS). "Schizoid disorder of childhood or adolescence" was absorbed by the PDD category as a whole. "Schizoid personality disorder" in adults, "avoidant personality disorder" and "elective mutism" continued to exist. The DSM-III-R noted that "The evidence suggests, however, that [autistic disorder] is merely the most severe and prototypical form of the general category Pervasive Developmental Disorders ... Whereas in clinical settings Autistic Disorder is more commonly seen than PDDNOS, studies in England and the United States, using criteria similar to those in this manual, suggest that PDDNOS is more common than Autistic Disorder in the general population." The book also stated that "In Schizoid and Schizotypal Personality Disorders there are deficits in interpersonal relatedness. The diagnosis of Autistic Disorder preempts the diagnosis of these personality disorders. However, these personality disorders preempt the diagnosis of Pervasive Developmental Disorder Not Otherwise Specified." Lorna Wing on the autism spectrum and Asperger's syndrome Considering the wide difference of autistic traits in different people, British psychiatrist Lorna Wing and British psychologist Judith Gould coined the term autism spectrum in their March 1979 paper "Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification." Lorna Wing's February 1981 publication of the paper "Asperger's Syndrome: A Clinical Account" greatly increased awareness of the existence of Hans Asperger's autism work. Wing summarised Asperger's autism syndrome, and made two challenges to points he had made. She also provided six case studies of her own, and much additional analysis. The paper brought the concept of "Asperger's disorder" into the spotlight, leading to it being recognised by many psychological practitioners. Regarding the breadth of people with the condition, Wing notes:As to the relationship between schizoid personality disorder and Asperger's syndrome, Wing writes: Start of the neurodiversity movement The United Nations declared 1981 the International Year of Disabled Persons. This gave increased focus on people with disabilities in many countries. The physically disabled British musician Ian Dury released the song Spasticus Autisticus in protest to elements of the year. In 1983, building on developments over the previous twenty years, the disabled British academic Mike Oliver coined the term "social model of disability," which posits that "disability" is caused by a lack of acceptance by society of people's non-typical natures. This was contrasted with the "medical model of disability", which posits that disability is that non-typical nature itself. American Jim Sinclair is credited as the first person to communicate the "anti-cure" or "autism rights" perspective in the late 1980s. In 1992, Sinclair co-founded the Autism Network International (ANI) with Kathy Grant and Donna Williams. ANI is an organization that publishes newsletters "written by and for autistic people". This grew into the autism rights movement. Neurodiversity is the idea that people can think differently to the norm without those differences being a medical problem. Australian sociologist Judy Singer and American self-advocate Jane Meyerdin coined the term in 1998. It was used by the group known as the "Institute for the Study of the Neurologically Typical" (INST). The term first appeared in print in the September 1998 article Neurodiviersity in The Atlantic, by American journalist Harvey Blume. The term neurodivergent was later coined in 2000 by American neurodiversity activist Kassiane Asasumasu. Mirror neurons Researchers Giacomo Rizzolatti, Giuseppe Di Pellegrino, Luciano Fadiga, Leonardo Fogassi, and Vittorio Gallese at the University of Parma published a paper announcing the existence of mirror neurons in 1992. They found that when a monkey watches another monkey doing something, specialised neurons in the first monkey's brain fire in a way that mirrors the firing of the neurons in the acting monkey. The same scientists later found the same thing in human brains. It has been proposed that differences in the mirror neuron system could in part explain differences between autistic and neurotypical people. A well-cited study in 2006 by American psychiatrist Mirella Dapretto and others found such a connection. Later research, however, did not support this connection. Scientific developments The opioid excess theory hypothesis of autism was first proposed by Estonian-American neuroscientist Jaak Panksepp in a 1979 paper. The Childhood Autism Rating Scale (CARS) was released in March 1980 by Americans Eric Schopler, Robert Jay Reichler, Robert F DeVellis and Kenneth Daly. In 1981, Jakob Lutz published the paper "Hans Asperger und Leo Kanner zum Gedenken" (Hans Asperger and Leo Kanner in memoriam). The Minspeak image-based language was first implemented on a computer in 1981. It was developed by American linguist Bruce R Baker. It has gone on to become popular on augmentative and alternative communication devices. In 1983, Swiss-American neurologist Isabelle Rapin and psycholinguist Doris A Allen coined the term semantic pragmatic disorder to describe the communicative behavior of children who presented traits such as pathological talkativeness, deficient access to vocabulary and discourse comprehension, atypical choice of terms and inappropriate conversational skills. They referred to a group of children who presented with mild autistic features and specific semantic pragmatic language problems. (In the late 1990s, the term "pragmatic language impairment" (PLI) was proposed to cover this situation.) The popular academic book Educating and understanding autistic children was edited by Americans Robert L. Koegel (psychiatrist), Arnold Rincover (psychologist) and Andrew L. Egel (educationalist), and released in 1983. In September 1985, Felix F. de la Cruz outlined extensively the physical, psychological, and cytogenetic characteristics of people with Fragile X syndrome in addition to their prospects for therapy. A controversial claim suggested that watching extensive amounts of television may cause autism. This hypothesis was largely based on research suggesting that the increasing rates of autism in the 1970s and 1980s were linked to the growth of cable television at the time. Multiplex developmental disorder was conceptualised by American Yale University researchers Donald J. Cohen (psychiatrist), Rhea Paul (speech pathologist) and Fred Volkmar (psychiatrist) in March 1986. They proposed that it be recognised as a variety of autism in the DSM, however this did not occur. The Handbook of autism and pervasive developmental disorders is a popular academic book about autism that was first released in 1987. The first edition was edited by Americans Donald J. Cohen (psychiatrist), Anne M. Donnellan (educational psychologist) and Rhea Paul (speech pathologist). New editions were published in 1997, 2005 and 2014. Additional editors included the Americans Fred Volkmar (psychiatrist), Ami Klin (psychologist), Sally J. Rogers (psychologist) and Kevin A. Pelphrey (neuroscientist). Mind-blindness is a term first published in early 1990 by British psychologist Simon Baron-Cohen at the University of Cambridge. It refers to the idea that "autistic people are impaired in their ability to attribute mental states (such as beliefs, knowledge states, etc.) to themselves and other people". This is otherwise known as an impaired theory of mind (ToM). Baron-Cohen believed that a lack of ability to read eyes was a particularly important deficit, and developed a training program to develop this. It is now thought that all autistic people have some ToM ability. Baron-Cohen, Scottish psychologist Alan M Leslie and Uta Frith released another well-cited paper on the topic in 1985. Baron-Cohen's book Mindblindness: An Essay on Autism and Theory of Mind was released in 1995. The Autism Diagnostic Observation Schedule (ADOS) was developed in 1989 by Catherine Lord, Michael Rutter, Susan Goode, Jacquelyn Heemsbergen, Heather Jordan, Lynn Mawhood and Eric Schopler. It became commercially available in 2001. (A revised version, ADOS-2, was released in 2012). The Autism Diagnostic Interview (ADI) was also developed in 1989 by Ann Le Couteur, Michael Rutter, Catherine Lord, Patricia Rios, Sarah Robertson, Mary Holdgrafer and John McLennan. An updated version, the ADI-R, was commercially released in 2003. Hans Asperger's early papers were first published in English in 1991, as part of the book Autism and Asperger Syndrome. They were translated by the book's editor, Uta Frith. This further increased awareness of Asperger's work, and of the concept of "Asperger syndrome". Applied behavior analysis The Early Start Denver Model of autism treatment for young children was developed in 1981 by American psychologists Sally J Rogers and Geraldine Dawson. It was initially called the "play school model", because its main actions happened during children's play. It is considered a variety of ABA. Positive behavior support (PBS, PBIS, SWPBS or SWPBIS) emerged from the University of Oregon in the mid-1980s. It is a type of ABA that is typically used in schools. Tim Lewis is a noted practitioner of the concept, and is often credited as a co-founder. The Association for Positive Behaviour Support was founded in 2003. Pivotal response treatment (PRT) was pioneered by Americans Robert Koegel, Mary O'Dell and Lynn Kern Koegel in 1987. It is a "naturalistic" form of ABA used with young children. PRT aims to teach a few “pivotal skills”, that will help the student learn many other skills. Initiating communication with others is deemed one such pivotal skill. Ivar Lovaas released a major report on the decades established UCLA Young Autism Project in 1987, defining a new method of ABA. Lovaas controversially reported that half his pre-school patients that received intensive therapy now had an IQ level equal to their non-autistic peers, and had "recovered" from their autism. It is sometimes called the "Lovaas method/model/program" and sometimes the "UCLA model/intervention". It has become the primary form of Early Intensive Behavior Intervention (EIBI), and now is often referred to by that name as well. One methodology it developed was discrete trial training, which has become a well-used ABA technique. The commonly-used textbook Applied Behavior Analysis was first released by American educationalists John O Cooper, Timothy E Heron, and William Lee Heward at Ohio State University in 1987. New editions were published in 2007 and 2019. Non-ABA treatment and support The "developmental, individual-difference, relationship-based model" (DIR) of autism diagnosis and treatment was developed by American psychiatrist Stanley Greenspan in 1979. This was later further developed into the Floortime program. In a February 1981 publication, Lorna Wing noted that although she believed there was currently no treatment for autism, "handicaps can be diminished by appropriate management and education" and that "techniques of behaviour modification used with autistic children can possibly be helpful if applied with sensitivity". The LEAP (Learning Experiences - An Alternative Program for Preschoolers and Parents) curriculum model was developed by American psychologist Phillip Strain of the University of Pittsburgh in 1981. The first paper explaining it was published in 1984. The program has autistic and non-autistic pre-schoolers share a classroom, with the latter assisting the former. It is considered a more-cognitive rather than a more-behaviourist form of teaching. It is also considered one of the best researched forms of training for autistic pre-schoolers. The Picture Exchange Communication System (PECS) was developed in 1985 at the Delaware Autism Program by Andy Bondy and Lori Frost. It is a communication teaching method for people with limited speech. In the late 1980s, the field of Developmental Education developed at the Sturt campus of SACAE in Adelaide, Australia. It brought together the concept of "normalisation" from the social model of disability with ideas from ABA. Developmental Education aims to teach life skills to disabled people who need them. The Autism CRC believes practitioners may be of help to autistic children and their families. Social skill teaching method, Social Stories, began its development in 1989 by American teacher Carol Gray. A survey of Ontario autism support workers in 2011 found that 58% had support programs influenced by her. Diagnostic tools for toddlers The Checklist for Autism in Toddlers (CHAT), a tool for diagnosing autism in children aged 18–24 months, was first published in December 1992 by Simon Baron-Cohen, Jane Allen and Christopher Gillberg. Simon Baron-Cohen and others also developed another test for autism in 18-month-olds, which was published in February 1996. The Modified Checklist for Autism in Toddlers (M-CHAT) was developed in 1999 by American psychologists Diana Robins, Deborah Fein and Marianne Barton. Revised versions, the M-CHAT-R (2009) and M-CHAT-R/F were later released. In specific countries In China Autism was first diagnosed in the People's Republic of China in 1982 by Professor Tao Guotai (陶国泰) from the Nanjing Brain Hospital. He presented the case in a Chinese journal. In the late 1980s, he introduced his findings to the global audience in English. The "China Compulsory Education Law" (中华人民共和国义务教育法) was enacted in 1986. Like the American EHA, it required public schools to accept students with disabilities. In the United States The US congress endorsed Autism Awareness Month in 1984. The Americans with Disabilities Act of 1990 made it illegal to discriminate against people based on their disability, in a number of important categories. It also required covered employers to provide reasonable accommodations to employees with disabilities, and imposed accessibility requirements on public accommodations. In Finland Autism found its way into the Finnish disease classification in 1987. (It was only in 1996 that it was finally removed from the category of psychosis in the Finnish version of the ICD-10.) Newly established organizations The Sensory Processing Disorder Foundation was founded in America in 1979 by occupational therapist Lucy Jane Miller. It is now known as the STAR Institute. Domus Instituto de Autismo was established in Mexico in May 1980 by parents of children with autism. Autism-Europe began in 1983, co-ordinating autism organisations across Europe. In Brazil, (AMA, Association of Friends of the Autistic) was founded in 1983. Within a year of this, they were running a school. They soon became their country's main autism association. The Autism Society of Taiwan (中華民國自閉症總會) was founded in January 1985. Eleven mothers of autistic children in the Philippines held a gathering in 1987. In March 1989, they and others founded the Autistic Children and Adults of the Philippines (ACAP) Foundation. The group became the country's predominant autism organisation. It is now known as Autism Society Philippines. 1987 saw America's National Association for Autistic Children became the Autism Society of America. A new national French autism organisation, , was founded in February 1989. Representative organisation Autism South Africa (A;SA) was founded in 1989 by concerned parents and professionals. In Saudi Arabia, the Saudi Autistic Society (الجمعية السعودية الخيرية للتوح) was founded in January 1990. In India, Action for Autism (AFA) began in 1991 as a parent support group. It soon became India's foremost autism organisation. In Turkey, a support group for parents of children with autism began in 1991. It reformed as the Turkish Autistic Support and Education Foundation (TODEV) in 1997. It is Turkey's pre-eminent autism group. Popular books and other media Popular American movie Rain Man was released in 1988. Its titular character was an autistic man. Bernard Rimland was consulted on how the character was portrayed. The movie did much to define public understanding of the condition. The book Autism: Explaining the Enigma was released by Uta Frith in 1989. It explained to non-autistic people how autistic people thought. A second edition was published in 2003. The popular book Children with autism: a parents' guide was also released in 1989. It was edited by American psychologist Michael D. Powers. A second edition was published in 2000. The similar Asperger's syndrome and your child: a parents' guide was released in 2002. Asperger syndrome recognised (1994–2012) The 1990s saw the continued popularization of autism both in popular culture and in the scientific community. The newly ICD and DSM endorsed condition "Asperger syndrome" saw a particularly strong increase in attention. ICD and DSM changes The 1990s saw the release of both the ICD-10 and the DSM-IV, as well as the revised version DSM-IV-TR. Notably, Asperger syndrome came to be recognized as condition distinct from, but related to, autistic disorder/childhood autism. ICD-10 The ICD-10 was first published in 1992, for use beginning in 1994. It made a number of changes to its categorisation of autism-related conditions. It newly included "Asperger syndrome" (F84.5) - its first recognition by a major mental health body. It also included "childhood autism" (F84.0), and a category for "atypical autism" (F84.1, similar to the DSM's PDD-NOS). The ICD-10 categorised all of these as "pervasive developmental disorders", as the DSM had done since 1980. The ICD childhood shyness conditions were incorporated into the new section "disorders of social functioning with onset specific to childhood and adolescence", with a category for elective mutism (F94.0) and various categories not specifically aligning with common autism symptoms. "Schizoid personality disorder" would remain, though its subcategories would not. (The ICD-9 would continue to be used for coding by some organisations in the United States until 2015.) DSM-IV: autistic disorder, Asperger syndrome and other conditions In 1994, reflecting the better understood diversity of autistic experience, the DSM-IV included a number of newly defined PDD conditions. "Autistic disorder" was redefined, and supplemented with the new conditions Asperger syndrome, Rett syndrome and childhood disintegrative disorder (CDD). PDD-NOS remained. The definition of Asperger syndrome required those with it to have speech and language difficulties. This edition also saw the defining of developmental coordination disorder (DCD), a condition featuring "a marked impairment in the development of motor coordination." The DSM acknowledged that these symptoms were common in people with PDDs, and excluded such people from being diagnosed with DCD. In October 1994, the International Consensus Meeting on Children and Clumsiness adopted the concept of DCD, choosing to use it in place of earlier descriptions of child clumsiness. This led to the adoption of the concept by occupational therapists and physiotherapists as covering all abnormal child clumsiness. Schizoid personality disorder and avoidant personality disorder also remained in the manual. "Elective mutism" became "selective mutism". American psychiatrist Fred Volkmar was the lead author of the autism section in the DSM-IV. (From 2007, Volkmar would later be the fourth editor of the Journal of Autism and Developmental Disorders). DSM-IV TR The DSM-IV TR (2000) contained an almost complete rewrite of the definition of Asperger syndrome. Notably, it now no longer included speech and language difficulties. This greatly increased the number of people deemed to have the condition. Temple Grandin American animal behaviourist Temple Grandin came to prominence in 1996, with the publishing of her popular book Thinking in Pictures: My Life with Autism in November 1995. She would later become a board member of the Autism Society of America. Together with Catherine Johnson, she coauthored the popular book Animals in Translation: Using the Mysteries of Autism to Decode Animal Behavior, which was published in December 2004. In February 2010, a movie titled Temple Grandin about her life was released. Fraudulent vaccine study In February 1998, British doctor Andrew Wakefield published a controversial paper claiming a link between some vaccines and autism. This finding gained much public attention. The paper was subsequently found to be fraudulent. He would go on to retract the work in 2010, and he subsequently lost his license to practice medicine. Treatment and support Leadership of the TEACCH Autism Program passed from Eric Schopler to American psychologist Gary Mesibov in 1992. Mesibov subsequently also succeeded Schopler as editor of the Journal of Autism and Developmental Disorders from 1997 to 2007. American speech therapist Michelle Garcia Winner began to develop the Social Thinking Methodology in the mid-1990s, and established the Social Thinking company shortly afterwards. The organisation has subsequently developed a wide range of resources for teaching social skills to autistic people. Winner's works were a substantial influence on Ontario autism support workers in 2011. The developmental social-pragmatic (DSP) model of autism teaching emerged in the late 1990s. It aims to work with and strengthen autistic children's desires to successfully communicate (as well as their ability to), with parents and teachers conversing with children in as non-contrived ways as possible. It emphasises cognitive psychology more than typical, behaviourism focused, varieties of ABA. The influential book Asperger's Syndrome: A Guide for Parents and Professionals was published by British-Australian psychologist Tony Attwood in 1998. Attwood went on to publish widely on autistic topics. A survey of Ontario autism support workers in 2011 found that 52% had support programs influenced by him. Relationship Development Intervention was developed by American psychologist Steven Gutstein in the 1990s. It is designed to increase someone's desire and ability to be social. It became better known after the publishing of books on the topic in 2002. Fred Frankel and Robert Myatt developed the Children's Friendship Training (CFT) model over two decades at UCLA, publishing a book on it in 2002. The SCERTS Model: A Comprehensive Educational Approach for Children with Autism Spectrum Disorders was published in June 2004 by five American authors. The model covers children's social communication (SC), emotional regulation (ER), and transactional support (TS). The model continues to be developed. Tony Attwood released the program Exploring Feelings: Cognitive Behaviour Therapy to Manage Anxiety in 2004. It is recommended for use with autistic children by the ASHA. "Paediatric Autism Communication Therapy" (PACT), a technique for teaching parents of young autistic children how to better communicate with them, was first released through a paper in November 2004. It was written by three British researchers, speech therapist Catherine Aldred, psychiatrist Jonathan Green, and speech therapist Catherine Adams. The Raising Children Network launched raisingchildren.net.au in May 2006, with the endorsement and financial support of the Australian government. This website provides extensive information for raising autistic children. Simon Baron-Cohen and others released an animated series for autistic pre-schoolers called The Transporters in 2006. Its creators claimed that autistic children could learn to read facial emotions as well as non-autistic children after repeated viewing, addressing their social-emotional agnosia and alexithymia. The series was nominated for a BAFTA. The British-voiced version of the series is available for free under a Creative Commons licence. The notable book No More Meltdowns was published by American Jed Baker in April 2008. This and his other works were substantially influential on Ontario autism support workers in 2011. American teacher Brenda Smith Myles at the University of Kansas began writing well-received books to help people with Asperger syndrome in the late 1990s. These books were also a substantial influence on Ontario autism support workers in 2011. Pathological demand avoidance In July 2003, British child psychologist Elizabeth Newson at the University of Nottingham published an article in the Archives of Disease in Childhood journal arguing that pathological demand avoidance (PDA) be recognised as a unique profile within the autism spectrum. She had first seen the pattern of PDA in children in 1980. She believed that autistic people with pronounced PDA symptoms tend to behave quite differently to those that do not, and that people with PDA symptoms often do not have common autistic symptoms. New diagnostic tools The "Reading the Mind in the Eyes Test" was first published in 1997 by Simon Baron-Cohen and others. A very well-cited revised version was released in February 2001, which also involved British experimental psychologist Sally Wheelwright. Also in February 2001, the autism-spectrum quotient (AQ), a measure of autism within an individual, was released by a Simon Baron-Cohen-led team from the University of Cambridge. The "Diagnostic Interview for Social and Communication Disorders" (DISCO) was released in March 2002 by Lorna Wing and others. It was a further development of the child-specific "Handicaps Behaviour and Skills" (HBS) schedule Wing had developed in the 1970s. As of 2023, it is still in use in the UK. The "Social Communication Questionnaire" (SCQ) is a commonly used tool for measuring autism social symptoms. It was released as the "Autism Screening Questionnaire" (ASQ), by British psychiatrists Michael Rutter and Anthony Bailey, and American psychologist Catherine Lord, in 2003. The empathy quotient measure was released in April 2004 by Simon Baron-Cohen and Sally Wheelwright. The paper it was published in also introduced the terms "affective empathy" (feeling what someone else is feeling) and "cognitive empathy" (understanding what someone else is feeling). In February 2008, American psychiatrist Riva Ariella Ritvo of Yale University and others released the Ritvo Autism and Asperger Diagnostic Scale (RAADS). A revised version, RAADS-R, was released in 2011. In the United States The atypical antipsychotic drug risperidone was approved in the United States for treating autism-associated aggressive and self-injurious behaviors in October 2006. The similar but less problematic drug aripiprazole was approved in 2009. The United States passed its Combating Autism Act in December 2006, providing US$1 billion for autism services and research in that country, over five years. The US state of South Carolina enacted Ryan's Law in July 2008. This requires health insurers to provide up to $50,000 of behavioral therapy each year for autistic people aged 16 and younger. Autism Speaks American advocacy organisation Autism Speaks was founded in 2005 by businessman Bob Wright and his wife Suzanne Wright, grandparents of a child with autism. In 2023, the organisation claimed it had so far provided more than 18 million people with free autism information and resources. It adopted a puzzle piece as part of its logo. Simons Foundation Autism Research Initiative The Simons Foundation established the Simons Foundation Autism Research Initiative (SFARI) in 2006. As of 2023, the foundation has a research budget of over US$100 million per year. The SFARI website launched a "News & Opinion" section in 2008. This grew, and was given its own identity as Spectrum in 2015. This has become an important autism research news website. Recognition in China China's Eleventh Five Year Development Programme for the Disabled (中国残疾人事业"十一五"发展纲要) was released in 2006. It officially recognised autism as a neurological disability. Autistic Self Advocacy Network (ASAN) The Autistic Self Advocacy Network (ASAN) was co-founded in November 2006 by Americans Ari Ne'eman and Scott Michael Robertson. It has positioned itself as America's foremost body of autistic people representing the interests of autistic people. In early 2017, Julia Bascom became the second president of ASAN. Affiliated bodies were later formed in Australia/New Zealand, Canada and Portugal. The Academic Autistic Spectrum Partnership In Research and Education (AASPIRE) was also founded in the United States in 2006. It focuses on improving the lives of autistic adults. It has come to work closely with ASAN. ASAN's activities have included organising the first Disability Day of Mourning on 1 March 2012, which commemorates disabled people who were killed by their parents. The organisation also assisted in the production of the 2020 Pixar short film Loop by Erica Milsom, which features a non-verbal autistic teenage girl. World Autism Awareness Day World Autism Awareness Day was first held by the United Nations in April 2007. Lighting buildings with blue light at night is a common means of awareness raising on this day. Autism Speaks quickly embraced it. This had led some neurodiversity-embracing autistic people to shun using the colour blue to represent autism. Great National Cause in France Each year, the French government assigns a "Great National Cause" for the country to focus on. This includes much free publicity on state television and radio. Autism was the cause for 2012. Other scientific developments "Executive Functions and Developmental Psychopathology" is a well-cited paper published in January 1996. In it, the Americans Bruce F Pennington (psychiatrist) and Sally Ozonoff (psychologist) explored the effects of various conditions (including autism) on executive function. The first edition of the scientific journal Autism was published in July 1997 by the British National Autistic Society. The 2000 Simpsonwood CDC conference in the United States examined evidence of the effect of thimerosol in vaccines on neurological development. There are certain specialised parts of the brain that non-autistic people use to process face information. American psychiatrist Karen Pierce and others found that autistic people do not use these parts of the brain for this task. They also found that the fusiform face area in individuals with autism has a reduced volume. They published a paper on these and related findings in October 2001. The empathising–systemising theory of autism was released by Simon Baron-Cohen in June 2002. He and others would go on to develop it in subsequent years. The theory of monotropism was developed by three autistic activists, the British linguist and teacher Dinah Murray, British-Australian psychologist and social worker Wenn Lawson and British mathematician Mike Lesser. They started their formulation in the 1990s, and first published the theory in May 2005. British psychiatrist Chris Frifth and his wife Uta Frifth published a well-cited short description of theory of mind in September 2005. In October 2006, N. Carolyn Schanen (of the University of Delaware), found two chromosomes with a strong epigenetic association with autism. The journal Research in Autism Spectrum Disorders was first published in January 2007 by Elsevier. The well-cited paper "Strong Association of De Novo Copy Number Mutations with Autism" was published in April 2007 by 32 people including Jonathan Sebat and Daniel Geschwind. It found that de novo germline mutation was a more significant causative factor for ASD than was previously recognised. The journal Autism Research was founded in February 2008 as the US-based journal of the International Society of Autism Research (INSAR), partnering with publishers Wiley-Blackwell. The imprinted brain hypothesis of autism was first presented by Bernard Crespi and Christopher Badcock of Canada's Simon Fraser University in June 2008. "Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample" is a well-cited paper published in August 2008. Its six authors included the Britons Emily Simonoff (psychiatrist) and Andrew Pickles (biostatistician). It found that seventy percent of its autistic sample had at least one other recognised psychiatric condition, and that 41% had two or more. The most common comorbid diagnoses were social anxiety disorder (29%), ADHD (28%), and oppositional defiant disorder (28%). The open access scientific journal Molecular Autism was founded in the UK by BioMed Central in 2010. In May 2011, American neuroscientist Jared Reser proposed that autistic traits, including increased abilities for spatial intelligence, concentration and memory, could have been naturally selected to enable self-sufficient foraging in a more (although not completely) solitary environment, referred to as the "Solitary Forager Hypothesis". The concept of the double empathy problem was first described as such in October 2012 by British psychologist Damian Milton. The idea proposes that the interaction issues between autistic and non-autistic people are at least in part because these two types of people think differently from each other, understand other people in their own group, but have difficulty understanding people that think differently. This contrasts with the idea that the interaction issues are due to autistic people having lesser social understanding abilities than non-autistic people. The Australian government established its national autism research organisation Autism CRC in March 2013. The April 2013 paper "Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism" showed that taking the psychiatric drug valproate greatly increased the chance of a woman giving birth to a child with autism. Its lead author was Danish neurologist Jakob Christensen. Organizations The first International Conference on Autism was held in Toronto, Canada, in July 1993. It was organised by the Autism Society of America and Autism Society Canada. 2300 delegates from 47 countries attended. In 1999, the Autism Society of America adopted the puzzle ribbon as a sign of autism awareness. This period also saw the establishment of various new autism-related organizations: Stars and Rain was the first non-governmental organization established for autism in China. It was founded in March 1993 by Tian Huiping (田慧萍), a mother of a child with autism. The institution runs training programs for both parents and children, and overall has a focus on ABA. The nation-wide (Autism Spain) was established in Spain in January 1994 by the coming together of autonomous community based organisations. The Korean Autism Society (한국자폐학회) was founded in South Korea in 1994. It has focused on professionals who treat those with the condition. The US National Alliance for Autism Research was founded in 1994. (It merged with Autism Speaks in early 2006). (Indonesian Autism Foundation) was founded in by five doctors and eight parents of autistic people in 1997. The Behavior Analyst Certification Board was founded in May 1998 in the United States to provide accreditation for ABA practitioners. It quickly became an established international authority. On November 21, 1998, the World Autism Organisation (WAO) began. It was set up by Autism-Europe to prompt the UN to do more about autism, and to increase autism support in countries with few services of that kind. The United States' Interagency Autism Coordinating Committee was set up in 2000. It coordinates US government autism actions. The Autism Resource Centre (Singapore) was established in 2000. Autism Awareness Campaign UK was founded in 2000. It held a UK "Autism Awareness Year" in 2002, which in February included the first annual Autism Sunday religious observance. In 2001, the autistic daughter of Israeli Major General Gabi Ophir inspired him and others to establish Special in Uniform, an organisation that supports a squad of teens with disabilities or autism in the Israel Defense Forces. (PAS, Persons on the Autism Spectrum) was founded in the Netherlands in 2001. It represents autistic people with normal or higher IQs. The International Society for Autism Research (INSAR) was formed in 2001 in the United States. Autistic-specialist employment services company Specialisterne was founded by Danish IT worker Thorkil Sonne in 2003. It has gone on to operate in various parts of Europe, North America and Australia. Aspies For Freedom (AFF) was established in 2004 as a global online organisation by Welsh husband-and-wife Gareth Nelson and Amy Nelson. AFF celebrated the first Autistic Pride Day on 18 June 2005. The autism community website Wrong Planet was started in 2004 by Dan Grover and Alex Plank. The British autism research charity Autistica was founded in 2004 by German-British software entrepreneur Dame Stephanie Shirley. (한국자폐인사랑협회는) was founded in South Korea in January 2006. It has focused on representing autistic people and their parents. Israeli people-with-autism representative organisation began in early 2006. The UK's Autism Education Trust was established by the National Autistic Society and the UK's Department for Children, Schools and Families in 2007. It is tasked with ensuring that all British children with autism are educated appropriately, through better education of their teachers. Autism Spectrum News began as a quarterly print publication in the United States in 2008. It became online-only in 2021. The Autism Science Foundation was founded in the United States in April 2009, by Alison Singer and Karen Margulis London. Its founders broke away from Autism Speaks due to its focus on funding research into possible links between vaccines and autism. Other popular self-help books A popular book of 1998 was sensory processing guide The Out-of-Sync Child by American music and movement teacher Carol Stock Kranowitz. New editions were published in 2005 and 2022. The Introvert Advantage: How to Thrive in an Extrovert World was a popular book released by American psychologist Marti Olsen Laney in February 2002. August 2002 saw the publishing of Freaks, Geeks, and Asperger Syndrome: A User Guide to Adolescence by 13-year-old British adolescent with Asperger syndrome, Luke Jackson. The book was praised by Sula Wolff. In January 2004, Luke and his family featured in the BBC documentary feature My Family and Autism. In 2005, a fictional movie based on the family, Magnificent 7, was aired on the BBC. It included a character based on Luke's mother, fellow autistic subject author Jacqui Jackson. Another book first published in August 2002 was A Parent's Guide to Asperger Syndrome and High-Functioning Autism by American psychologist Sally Ozonoff. A second edition, A Parent's Guide to High-Functioning Autism Spectrum Disorder: How to Meet the Challenges and Help Your Child Thrive, was published in 2014 by Ozonoff and fellow American psychologists, Geraldine Dawson and James C. McPartland. Over 125,000 copies of the books have been printed. Raising a Sensory Smart Child was first released in March 2005 by two Americans, the occupational therapist Lindsey Biel and the writer Nancy Peske. New editions were released in 2009 and 2018. Ten Things Every Child with Autism Wishes You Knew was first published by American speech therapist Ellen Notbohm in 2005. New editions were published in 2012 and 2019. Over 250,000 copies have been sold. ABA book The Verbal Behavior Approach: How to Teach Children With Autism and Related Disorders was released in May 2007 by two Americans, nurse Mary Barbera and writer Tracy Rasmussen. Released in September 2007 was the book Louder Than Words: A Mother's Journey in Healing Autism by American mother Jenny McCarthy. Smart but Scattered: The Revolutionary "Executive Skills" Approach to Helping Kids Reach Their Potential was released in January 2009. Written by American psychologists Peg Dawson and Richard Guare, it has over 375,000 copies in print. Other books and media Other popular books and other media were published during this period, most notably the following: Personal memoir Nobody Nowhere: The Extraordinary Autobiography of an Autistic Girl by Australian Donna Williams was published in 1992, and was on the New York Times Bestsellers list in 1993. The Hollywood action movie Mercury Rising (1998) featured an autistic boy. Pretending to Be Normal: Living with Asperger's Syndrome was an autobiography published by American researcher Liane Holliday Willey in 1999. She also coined the term aspie. She released an updated edition in 2014. (The book was praised by Sula Wolff). She went on to write a number of other books on autism topics. The book The Fear of Game Brain (ゲーム脳の恐怖) was released by Japanese physiologist Akio Mori in 2002, and sold over 100,000 copies in Japan. In a related speaking engagement, Mori was believed to say that autism is at least in part caused by people spending too much time playing video games. However, Mori refuted this assertion to Autism Society Japan. The British fiction book The Curious Incident of the Dog in the Night-Time was published in May 2003 by Mark Haddon. It features a protagonist that the publishers have said has Asperger's syndrome, but was not specifically written that way. In 2012, it was made into a successful West End play, which then went to Broadway in 2014. Mozart and the Whale, an American romantic comedy-drama film about two people with Asperger's syndrome, was first released in September 2005. It was based on a true story. The documentary feature Normal People Scare Me: A Film About Autism was produced by American actor Joey Travolta in 2006. The popular photo-book All Cats have Asperger Syndrome was released in October 2006 by Australian teacher Kathy Hoopmann. A second edition (retitled All Cats have Autism) was released in 2020. She also wrote other books about autism and related conditions. 2007 also saw the publishing of The Reason I Jump, a bestselling memoir attributed to Naoki Higashida, a Japanese 13-year-old boy with autism. It was released in English in 2013, and has been translated into over 30 languages. Children of the Stars (来自星星的孩子) is a 2007 documentary about lives of autistic children in China. Another popular book of 2007 was Look Me in the Eye: My Life with Asperger's by American John Elder Robison, first released in September that year. Robison would later become a board member of Autism Speaks. The character Sheldon Cooper first appeared on American television in September 2007, in the popular sitcom The Big Bang Theory. While he is not explicitly autistic, according to the actor who plays him as an adult, the character "couldn't display more traits" of Asperger's syndrome. The soap opera Aapki Antara first went on air in India in June 2009. The title character of the series is an autistic girl. The book A history of autism: a conversation with the pioneers was released in October 2010 by British autism researcher Adam Feinstein, having been commissioned by Autistica founder Dame Stephanie Shirley. Neurodiversity and autism as a spectrum (since 2013) In 2013, the DSM-5 eliminated Asperger syndrome as a separate diagnosis, instead considering autism to be a spectrum disorder referred to as autism spectrum disorder (ASD). Both in the research community and among autistic people, there is ongoing debate about whether autism should be considered a disorder, or whether it should be thought of as merely a different way of being. DSM-5 In May 2013, the DSM-5 was released. It combined "autistic disorder", "Asperger's disorder", "CDD" and "PDD-NOS" into the broader concept of "autism spectrum disorder" (ASD), and discontinued the four earlier conditions. It also grouped the symptoms of ASD into two groups - impaired social communication and/or interaction, and restricted and/or repetitive behaviors. The new definition was narrower than the collective definitions of its DSM-IV predecessors had been, reducing the number of neurodiverse people covered by it. The DSM-5 assigned three "severity levels" for ASD, with people in level 1 "requiring support", level 2 "requiring substantial support" and level 3 "requiring very substantial support". Some autism activists believe the autistic spectrum should not be measured in this way, as it does not take into account the greatly varying attributes the people in the different DSM severity levels have, or that support needs can be context-dependent. DSM publishers, the American Psychiatric Association, said that "The revised diagnosis represents a new, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders." It also noted that the conditions that the new ASD condition replaced "were not consistently applied across different clinics and treatment centers". A new condition of social (pragmatic) communication disorder (SCD) was added. This does not apply to people who fulfil all of the ASD criteria, but to those who only have the social communication difficulties found in the ASD definition. (It drew on the earlier concepts of "semantic pragmatic disorder" and "pragmatic language impairment.") "Schizoid personality disorder", "avoidant personality disorder" and "selective mutism" remained. Another major change in this edition of the DSM was allowing individuals to be diagnosed with both ASD and ADHD. Previously, under the DSM's rules people could only be diagnosed as having one of their antecedent conditions. There is evidence to suggest that a majority of people with ASD also have ADHD. Similarly, people diagnosed with ASD could now also be diagnosed with other commonly co-morbid psychiatric syndromes such as social anxiety disorder, oppositional defiant disorder and developmental coordination disorder. ICD-11 January 2022 saw the first official use of the ICD-11. This version of the ICD combined all PDD conditions as "autistic spectrum disorder" (following the DSM's practice). However, unlike the DSM-5, the ICD-11 included a number of ASD subdivisions. Science Diagnostic test, the "Aspie Quiz", was released by Leif Ekblad of Sweden in July 2013. The Review Journal of Autism and Developmental Disorders was established in the United States by Springer in March 2014. Autism Speaks, Hospital for Sick Children (Toronto) and Google Genomics began the AUT10K project in 2014. It created one of the world's largest collections of autism related genetic material, and had open access to researchers, called AGRE. The project later evolved into the similar MSSNG project. MSSNG aims to "provide the best resources to enable the identification of many subtypes of autism". The MSSNG project was quickly met with criticism from autistic self-advocates. The journal Advances in Autism was launched by British publisher Emerald Publishing in January 2015. Brazilian researcher Alysson Muotri and others founded the company Tismoo in 2015, which aims to develop genetic treatments for autism and other conditions. The open access journal Autism & Developmental Language Impairments was launched by American publisher Sage Journals in January 2016. An October 2016 paper by three researchers from the University of York examines Asperger syndrome as "an alternative prosocial adaptive strategy" which may have developed as a result of the emergence of "collaborative morality" in the context of small-scale hunter-gathering, i.e. where "a positive social reputation for making a contribution to group wellbeing and survival" becomes more important than complex social understanding. A study by American psychologist Henny Kupferstein published in January 2018 found that autistics that had been given ABA therapy were 86% more likely to have PTSD than those that hadn't. The well-cited study "Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014" was released in April 2018 by 26 US-based authors. It found that one in 59 US children aged 8 years had ASD (nearly 2%). It found that 56% of autistic children had an intellectual disability (with an IQ of 85 or less), and 44% had IQ scores in the average to above average range. A National Guideline for the Assessment and Diagnosis of Autism Spectrum Disorders in Australia was released by Autism CRC in August 2018. The journal Autism in Adulthood was launched by American publisher Mary Ann Liebert, Inc. in March 2019. The Camouflaging Autistic Traits Questionnaire (CAT-Q) was released by British psychologist Laura Hull, Simon Baron-Cohen and others in March 2019. An ABA tool, the graduated electric decelarator, became the third device ever banned by the United States' Food and Drug Administration (FDA) in March 2020. Its main user, the Judge Rotenberg Center, filed a lawsuit against the FDA, and in July 2021, the DC Circuit Court overturned the ban, meaning that the centre can still use the device. The report Interventions for children on the autism spectrum: A synthesis of research evidence was released by the Autism CRC in November 2020. It compared dozens of different interventions. American psychiatrist Lynn Kern Koegel of Stanford University became the sixth editor of the Journal of Autism and Developmental Disorders in 2022. She and her husband had earlier developed pivotal response treatment. Support The ASEAN Autism Network was created in January 2010, linking together autism organisations in South East Asia. It held the ASEAN Autism Games athletic competition in 2016 and 2018. The Program for the Education and Enrichment of Relational Skills (PEERS) was developed by Americans Elizabeth Laugeson and Fred Frankel in 2010, drawing on Frankel's earlier CFT work. Laugeson later established the UCLA PEERS Clinic. PEERS programs are used to teach social skills to autistic and other people in many countries of the world. Autism Parenting Magazine was founded in the UK in 2012. In December 2012, Brazil passed the Berenice Piana Law, which created the National Policy for the Protection of the Rights of Persons with Autism Spectrum Disorder. This officially classified autism as a disability under Brazilian law, and increased the condition's profile in the country. The Iran Autism Association was founded in 2013 by treatment professionals, the autistic and their families. The United States government passed the Autism CARES Act of 2014, authorising the spending of US$1.3 billion between 2015 and 2019. This extended the work of the Combating Autism Act. The Act was reauthorised in 2019. The first Social Communication Intervention Programme (SCIP) manual was published in 2015 by British speech and language therapist Catherine Adams. SCIP was based on research she and others had conducted since 2005. The program teaches social communication skills to children. It involves social understanding and social interpretation, pragmatics and language processing. In 2015, representative body Autism Canada was created through the merger of Autism Society Canada and Autism Canada Foundation. 2016 saw Australia's main state-based and other autism representative organisations group together as the Australian Autism Alliance. In March 2017, the Russian peak parents-of-autistic-children representative body Autism Regions (Аутизм Регионы) was founded. Neurodiversity employment services organisation Untapped Group was co-founded by Australian accountant Andrew Eddy in 2017. It operates in the United States and Australia, and notably organises the prominent Autism at Work conferences. In the United States, the National Council on Severe Autism was founded in January 2019. It is concerned with autistic people who have an IQ of 85 or less. Australia's National Disability Insurance Scheme went into full operation in 2020. It provides many autistic people in that country with substantial amounts of money to help them live fuller lives. In April 2021, the American Autism Awareness Month became Autism Acceptance Month. The National Guideline for Supporting the Learning, Participation, and Wellbeing of Autistic Children and Their Families in Australia was released by Autism CRC in February 2023. People British singer Susan Boyle mentioned in a December 2013 interview that she had been diagnosed with Asperger's syndrome. Swedish activist Greta Thunberg's mother told a national newspaper of her daughter's Asperger's diagnosis in May 2015. Greta would become globally prominent as an activist in 2018. British actor Anthony Hopkins mentioned in a January 2017 interview that he had been diagnosed with Asperger's syndrome. Popular books for helping autistic people and their parents Aspergirls: Empowering Females with Asperger Syndrome was published by American writer Rudy Simone in 2010. She went on to write a number of other books on autistic subjects. Emotional control guidebook Zones of Regulation was published by American occupational therapist Leah Kuypers in 2011, to help autistic people and others who needed it. It has since sold over 100,000 copies. Various other products helping people understand and use the Zones concept have since been created. Understanding Your Child's Sensory Signals: A Practical Daily Use Handbook for Parents and Teachers was released in September 2011 by American occupational therapist Angie Voss. Two further editions have subsequently been published. Bestselling book Quiet: The Power of Introverts in a World That Can't Stop Talking was published by American writer Susan Cain in January 2012. The Survival Guide for Kids with Autism Spectrum Disorders (And Their Parents) was released in March 2012 by Americans Elizabeth Verdick (a writer) and Elizabeth Reeve (a psychiatrist). A new edition was released in 2021. Denver Early Start Model book, An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn was released by Americans Sally J. Rogers, Geraldine Dawson and Laurie A. Vismara in May 2012. It has sold over 100,000 copies. The Asperkids' (Secret) Book of Social Rules: The Handbook of Not-So-Obvious Guidelines for Teens and Tweens was published by American social worker Jennifer Cook O'Toole in September 2012. It sold many copies, and won the Autism Society of America's Temple Grandin Outstanding Literary Work of the Year. Jennifer would go on to write a number of other books about autism. Quiet influence: the introvert's guide to making a difference by American counsellor Jennifer B. Kahnweiler, was released in 2013. Speech therapist Barry Prizant (one of the SCERTS authors), also released a popular book in August 2015 - Uniquely Human: A Different Way of Seeing Autism. The book explains autism from a neurodiversity perspective. A new edition was published in 2022, with the help of writer Tom Fields-Meyer. The ABA Visual Language: Applied Behavior Analysis by Japanese ABA practitioner Makoto Shibutani, was published in May 2017. ABA book Positive Parenting for Autism: Powerful Strategies to Help Your Child Overcome Challenges and Thrive was released by American speech therapist Victoria Boone in December 2018. Divergent Mind: Thriving in a World That Wasn't Designed for You was released by American journalist Jenara Nerenberg in February 2021. It explores how ADHD, autism, synaesthesia, high sensitivity, and sensory processing disorder manifest in women. Unmasking Autism: Discovering the New Faces of Neurodiversity was a popular book written by American psychologist Devon Price, and published in April 2022. Notable autism history books Bestselling book NeuroTribes: The Legacy of Autism and the Future of Neurodiversity was published by American writer Steve Silberman in August 2015. It did much to spread the concept of neurodiversity, and explain the history of autism. The book Asperger's Children: The Origins of Autism in Nazi Vienna was released by American historian Edith Sheffer in Mary 2018. The book Our autistic lives: personal accounts from autistic adults aged 20 to 70+ was compiled by British autism writer Alex Ratcliffe, and was released in January 2020. Autism in popular culture See also History of Asperger syndrome Autism in China Autism in Brazil Autism in France References Autism Autism

Psychotherapy

Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience. There are hundreds of psychotherapy techniques, some being minor variations; others are based on very different conceptions of psychology. Most involve one-to-one sessions, between the client and therapist, but some are conducted with groups, including families. Psychotherapists may be mental health professionals such as psychiatrists, psychologists, mental health nurses, clinical social workers, marriage and family therapists, or professional counselors. Psychotherapists may also come from a variety of other backgrounds, and depending on the jurisdiction may be legally regulated, voluntarily regulated or unregulated (and the term itself may be protected or not). Definitions The term psychotherapy is derived from Ancient Greek psyche (ψυχή meaning "breath; spirit; soul") and therapeia (θεραπεία "healing; medical treatment"). The Oxford English Dictionary defines it as "The treatment of disorders of the mind or personality by psychological means...", however, in earlier use, it denoted the treatment of disease through hypnotic suggestion. Psychotherapy is often dubbed as a "talking therapy" or "talk therapy", particularly for a general audience, though not all forms of psychotherapy rely on verbal communication. Children or adults who do not engage in verbal communication (or not in the usual way) are not excluded from psychotherapy; indeed some types are designed for such cases. The American Psychological Association adopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed by American psychologist John C. Norcross: "Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable". Influential editions of a work by psychiatrist Jerome Frank defined psychotherapy as a healing relationship using socially authorized methods in a series of contacts primarily involving words, acts and rituals—which Frank regarded as forms of persuasion and rhetoric. Historically, psychotherapy has sometimes meant "interpretative" (i.e. Freudian) methods, namely psychoanalysis, in contrast with other methods to treat psychiatric disorders such as behavior modification. Some definitions of counseling overlap with psychotherapy (particularly in non-directive client-centered approaches), or counseling may refer to guidance for everyday problems in specific areas, typically for shorter durations with a less medical or "professional" focus. Somatotherapy refers to the use of physical changes as injuries and illnesses, and sociotherapy to the use of a person's social environment to effect therapeutic change. Psychotherapy may address spirituality as a significant part of someone's mental / psychological life, and some forms are derived from spiritual philosophies, but practices based on treating the spiritual as a separate dimension are not necessarily considered as traditional or 'legitimate' forms of psychotherapy. Delivery Psychotherapy may be delivered in person (one on one, or with couples, or in groups) or via telephone counseling or online counseling (see also ). There have also been developments in computer-assisted therapy, such as virtual reality therapy for behavioral exposure, multimedia programs to teach cognitive techniques, and handheld devices for improved monitoring or putting ideas into practice (see also ). Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story or music. Psychotherapy with children and their parents often involves play, dramatization (i.e. role-play), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting. Regulation Psychotherapists traditionally may be mental health professionals like psychologists and psychiatrists; professionals from other backgrounds (family therapists, social workers, nurses, etc.) who have trained in a specific psychotherapy; or (in some cases) academic or scientifically trained professionals. Psychiatrists are trained first as physicians, and as such they may prescribe prescription medication; and specialist psychiatric training begins after medical school in psychiatric residencies: however, their specialty is in mental disorders or forms of mental illness. Clinical psychologists have specialist doctoral degrees in psychology with some clinical and research components. Other clinical practitioners, social workers, mental health counselors, pastoral counselors, and nurses with a specialization in mental health, also often conduct psychotherapy. Many of the wide variety of psychotherapy training programs and institutional settings are multi-professional. In most countries, psychotherapy training is completed at a postgraduate level, often at a master's degree (or doctoral) level, over four years, with significant supervised practice and clinical placements. Mental health professionals that choose to specialize in psychotherapeutic work also require a program of continuing professional education after basic professional training. A listing of the extensive professional competencies of a European psychotherapist was developed by the European Association of Psychotherapy (EAP) in 2013. As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of client confidentiality—and the limited circumstances in which it may need to be broken for the protection of clients or others—is enshrined in the regulatory psychotherapeutic organizations' codes of ethical practice. Examples of when it is typically accepted to break confidentiality include when the therapist has knowledge that a child or elder is being physically abused; when there is a direct, clear and imminent threat of serious physical harm to self or to a specific individual. Europe As of 2015, there are still a lot of variations between different European countries about the regulation and delivery of psychotherapy. Several countries have no regulation of the practice or no protection of the title. Some have a system of voluntary registration, with independent professional organizations, while other countries attempt to restrict the practice of psychotherapy to 'mental health professionals' (psychologists and psychiatrists) with state-certified training. The titles that are protected also vary. The European Association for Psychotherapy (EAP) established the 1990 Strasbourg Declaration on Psychotherapy, which is dedicated to establishing an independent profession of psychotherapy in Europe, with pan-European standards. The EAP has already made significant contacts with the European Union & European Commission towards this end. Given that the European Union has a primary policy about the free movement of labor within Europe, European legislation can overrule national regulations that are, in essence, forms of restrictive practices. In Germany, the practice of psychotherapy for adults is restricted to qualified psychologists and physicians (including psychiatrists) who have completed several years of specialist practical training and certification in psychotherapy. As psychoanalysis, psychodynamic therapy, and cognitive behavioral therapy meet the requirements of German health insurance companies, mental health professionals regularly opt for one of these three specializations in their postgraduate training. For psychologists, this includes three years of full-time practical training (4,200 hours), encompassing a year-long internship at an accredited psychiatric institution, six months of clinical work at an outpatient facility, 600 hours of supervised psychotherapy in an outpatient setting, and at least 600 hours of theoretical seminars. Social workers may complete the specialist training for child and teenage clients. Similarly in Italy, the practice of psychotherapy is restricted to graduates in psychology or medicine who have completed four years of recognised specialist training. Sweden has a similar restriction on the title "psychotherapist", which may only be used by professionals who have gone through a post-graduate training in psychotherapy and then applied for a licence, issued by the National Board of Health and Welfare. Legislation in France restricts the use of the title "psychotherapist" to professionals on the National Register of Psychotherapists, which requires a training in clinical psychopathology and a period of internship which is only open to physicians or titulars of a master's degree in psychology or psychoanalysis. Austria and Switzerland (2011) have laws that recognize multi-disciplinary functional approaches. In the United Kingdom, the government and Health and Care Professions Council considered mandatory legal registration but decided that it was best left to professional bodies to regulate themselves, so the Professional Standards Authority for Health and Social Care (PSA) launched an Accredited Voluntary Registers scheme. Counseling and psychotherapy are not protected titles in the United Kingdom. Counsellors and psychotherapists who have trained and qualify to a certain standard (usually a level 4 Diploma) can apply to be members of the professional bodies who are listed on the PSA Accredited Registers. United States In some states, counselors or therapists must be licensed to use certain words and titles on self-identification or advertising. In some other states, the restrictions on practice are more closely associated with the charging of fees. Licensing and regulation are performed by various states. Presentation of practice as licensed, but without such a license, is generally illegal. Without a license, for example, a practitioner cannot bill insurance companies. Information about state licensure of psychologists is provided by the American Psychological Association. In addition to state laws, the American Psychological Association requires its members to adhere to its published Ethical Principles of Psychologists and Code of Conduct. The American Board of Professional Psychology examines and certifies "psychologists who demonstrate competence in approved specialty areas in professional psychology". Canada Regulation of psychotherapy is in the jurisdiction of, and varies among, the provinces and territories. In Quebec, psychotherapy is a regulated activity which is restricted to psychologists, medical doctors, and holders of a psychotherapy permit issued by the Ordre des psychologues du Québec, the Quebec order of psychologists. Members of certain specified professions, including social workers, couple and family therapists, occupational therapists, guidance counsellors, criminologists, sexologists, psychoeducators, and registered nurses may obtain a psychotherapy permit by completing certain educational and practice requirements; their professional oversight is provided by their own professional orders. Some other professionals who were practising psychotherapy before the current system came into force continue to hold psychotherapy permits alone. On 1 July 2019, Ontario's Missing Persons Act came into effect, with the purpose of giving police more power to investigate missing persons. It allows police to require (as opposed to permit) health professionals, including psychotherapists, to share otherwise confidential documents about their client, if there is reason to believe their client is missing. Some have expressed concern that this legislation undermines psychotherapy confidentiality and could be abused maliciously by police, while others have praised the act for how it respects privacy and includes checks and balances. History Psychotherapy can be said to have been practiced through the ages, as medics, philosophers, spiritual practitioners and people in general used psychological methods to heal others. In the Western tradition, by the 19th century, a moral treatment movement (then meaning morale or mental) developed based on non-invasive non-restraint therapeutic methods. Another influential movement was started by Franz Mesmer (1734–1815) and his student Armand-Marie-Jacques de Chastenet, Marquis of Puységur (1751–1825). Called Mesmerism or animal magnetism, it would have a strong influence on the rise of dynamic psychology and psychiatry as well as theories about hypnosis. In 1853, Walter Cooper Dendy introduced the term "psycho-therapeia" regarding how physicians might influence the mental states of patients and thus their bodily ailments, for example by creating opposing emotions to promote mental balance. Daniel Hack Tuke cited the term and wrote about "psycho-therapeutics" in 1872, in which he also proposed making a science of animal magnetism. Hippolyte Bernheim and colleagues in the "Nancy School" developed the concept of "psychotherapy" in the sense of using the mind to heal the body through hypnotism, yet further. Charles Lloyd Tuckey's 1889 work, Psycho-therapeutics, or Treatment by Hypnotism and Suggestion popularized the work of the Nancy School in English. Also in 1889 a clinic used the word in its title for the first time, when Frederik van Eeden and Albert Willem van Renterghem in Amsterdam renamed theirs "Clinique de Psycho-thérapeutique Suggestive" after visiting Nancy. During this time, travelling stage hypnosis became popular, and such activities added to the scientific controversies around the use of hypnosis in medicine. Also in 1892, at the second congress of experimental psychology, van Eeden attempted to take the credit for the term psychotherapy and to distance the term from hypnosis. In 1896, the German journal Zeitschrift für Hypnotismus, Suggestionstherapie, Suggestionslehre und verwandte psychologische Forschungen changed its name to Zeitschrift für Hypnotismus, Psychotherapie sowie andere psychophysiologische und psychopathologische Forschungen, which is probably the first journal to use the term. Thus psychotherapy initially meant "the treatment of disease by psychic or hypnotic influence, or by suggestion". Sigmund Freud visited the Nancy School and his early neurological practice involved the use of hypnotism. However following the work of his mentor Josef Breuer—in particular a case where symptoms appeared partially resolved by what the patient, Bertha Pappenheim, dubbed a "talking cure"—Freud began focusing on conditions that appeared to have psychological causes originating in childhood experiences and the unconscious mind. He went on to develop techniques such as free association, dream interpretation, transference and analysis of the id, ego and superego. His popular reputation as the father of psychotherapy was established by his use of the distinct term "psychoanalysis", tied to an overarching system of theories and methods, and by the effective work of his followers in rewriting history. Many theorists, including Alfred Adler, Carl Jung, Karen Horney, Anna Freud, Otto Rank, Erik Erikson, Melanie Klein and Heinz Kohut, built upon Freud's fundamental ideas and often developed their own systems of psychotherapy. These were all later categorized as psychodynamic, meaning anything that involved the psyche's conscious/unconscious influence on external relationships and the self. Sessions tended to number into the hundreds over several years. Behaviorism developed in the 1920s, and behavior modification as a therapy became popularized in the 1950s and 1960s. Notable contributors were Joseph Wolpe in South Africa, M.B. Shapiro and Hans Eysenck in Britain, and John B. Watson and B.F. Skinner in the United States. Behavioral therapy approaches relied on principles of operant conditioning, classical conditioning and social learning theory to bring about therapeutic change in observable symptoms. The approach became commonly used for phobias, as well as other disorders. Some therapeutic approaches developed out of the European school of existential philosophy. Concerned mainly with the individual's ability to develop and preserve a sense of meaning and purpose throughout life, major contributors to the field (e.g., Irvin Yalom, Rollo May) and Europe (Viktor Frankl, Ludwig Binswanger, Medard Boss, R.D.Laing, Emmy van Deurzen) attempted to create therapies sensitive to common "life crises" springing from the essential bleakness of human self-awareness, previously accessible only through the complex writings of existential philosophers (e.g., Søren Kierkegaard, Jean-Paul Sartre, Gabriel Marcel, Martin Heidegger, Friedrich Nietzsche). The uniqueness of the patient-therapist relationship thus also forms a vehicle for therapeutic inquiry. A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based also on the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centered psychotherapy into mainstream focus. The primary requirement was that the client receive three core "conditions" from his counselor or therapist: unconditional positive regard, sometimes described as "prizing" the client's humanity; congruence [authenticity/genuineness/transparency]; and empathic understanding. This type of interaction was thought to enable clients to fully experience and express themselves, and thus develop according to their innate potential. Others developed the approach, like Fritz and Laura Perls in the creation of Gestalt therapy, as well as Marshall Rosenberg, founder of Nonviolent Communication, and Eric Berne, founder of transactional analysis. Later these fields of psychotherapy would become what is known as humanistic psychotherapy today. Self-help groups and books became widespread. During the 1950s, Albert Ellis originated rational emotive behavior therapy (REBT). Independently a few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included relatively short, structured and present-focused techniques aimed at identifying and changing a person's beliefs, appraisals and reaction-patterns, by contrast with the more long-lasting insight-based approach of psychodynamic or humanistic therapies. Beck's approach used primarily the socratic method, and links have been drawn between ancient stoic philosophy and these cognitive therapies. Cognitive and behavioral therapy approaches were increasingly combined and grouped under the umbrella term cognitive behavioral therapy (CBT) in the 1970s. Many approaches within CBT are oriented towards active/directive yet collaborative empiricism (a form of reality-testing), and assessing and modifying core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders. A "third wave" of cognitive and behavioral therapies developed, including acceptance and commitment therapy and dialectical behavior therapy, which expanded the concepts to other disorders and/or added novel components and mindfulness exercises. However the "third wave" concept has been criticized as not essentially different from other therapies and having roots in earlier ones as well. Counseling methods developed include solution-focused therapy and systemic coaching. Postmodern psychotherapies such as narrative therapy and coherence therapy do not impose definitions of mental health and illness, but rather see the goal of therapy as something constructed by the client and therapist in a social context. Systemic therapy also developed, which focuses on family and group dynamics—and transpersonal psychology, which focuses on the spiritual facet of human experience. Other orientations developed in the last three decades include feminist therapy, brief therapy, somatic psychology, expressive therapy, applied positive psychology and the human givens approach. A survey of over 2,500 US therapists in 2006 revealed the most utilized models of therapy and the ten most influential therapists of the previous quarter-century. Types There are hundreds of psychotherapy approaches or schools of thought. By 1980 there were more than 250; by 1996 more than 450; and at the start of the 21st century there were over a thousand different named psychotherapies—some being minor variations while others are based on very different conceptions of psychology, ethics (how to live) or technique. In practice therapy is often not of one pure type but draws from a number of perspectives and schools—known as an integrative or eclectic approach. The importance of the therapeutic relationship, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy. Common factors theory addresses this and other core aspects thought to be responsible for effective psychotherapy. Sigmund Freud (1856–1939), a Viennese neurologist who studied with Jean-Martin Charcot in 1885, is often considered the father of modern psychotherapy. His methods included analyzing his patient's dreams in search of important hidden insights into their unconscious minds. Other major elements of his methods, which changed throughout the years, included identification of childhood sexuality, the role of anxiety as a manifestation of inner conflict, the differentiation of parts of the psyche (id, ego, superego), transference and countertransference (the patient's projections onto the therapist, and the therapist's emotional responses to that). Some of his concepts were too broad to be amenable to empirical testing and invalidation, and he was critiqued for this by Jaspers. Numerous major figures elaborated and refined Freud's therapeutic techniques including Melanie Klein, Donald Winnicott, and others. Since the 1960s, however, the use of Freudian-based analysis for the treatment of mental disorders has declined substantially. Different types of psychotherapy have been created along with the advent of clinical trials to test them scientifically. These incorporate subjective treatments (after Beck), behavioral treatments (after Skinner and Wolpe) and additional time-constrained and centered structures, for example, interpersonal psychotherapy. In youth issue and in schizophrenia, the systems of family treatment hold esteem. A portion of the thoughts emerging from therapy are presently pervasive and some are a piece of the tool set of ordinary clinical practice. They are not just medications, they additionally help to understand complex conduct. Therapy may address specific forms of diagnosable mental illness, or everyday problems in managing or maintaining interpersonal relationships or meeting personal goals. A course of therapy may happen before, during or after pharmacotherapy (e.g. taking psychiatric medication). Psychotherapies are categorized in several different ways. A distinction can be made between those based on a medical model and those based on a humanistic model. In the medical model, the client is seen as unwell and the therapist employs their skill to help the client back to health. The extensive use of the DSM-IV, the diagnostic and statistical manual of mental disorders in the United States is an example of a medically exclusive model. The humanistic or non-medical model in contrast strives to depathologise the human condition. The therapist attempts to create a relational environment conducive to experiential learning and help build the client's confidence in their own natural process resulting in a deeper understanding of themselves. The therapist may see themselves as a facilitator/helper. Another distinction is between individual one-to-one therapy sessions, and group psychotherapy, including couples therapy and family therapy. Therapies are sometimes classified according to their duration; a small number of sessions over a few weeks or months may be classified as brief therapy (or short-term therapy), others, where regular sessions take place for years, may be classified as long-term. Some practitioners distinguish between more "uncovering" (or "depth") approaches and more "supportive" psychotherapy. Uncovering psychotherapy emphasizes facilitating the client's insight into the roots of their difficulties. The best-known example is classical psychoanalysis. Supportive psychotherapy by contrast stresses strengthening the client's coping mechanisms and often providing encouragement and advice, as well as reality-testing and limit-setting where necessary. Depending on the client's issues and situation, a more supportive or more uncovering approach may be optimal. Humanistic These psychotherapies, also known as "experiential", are based on humanistic psychology and emerged in reaction to both behaviorism and psychoanalysis, being dubbed the "third force". They are primarily concerned with the human development and needs of the individual, with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. Some posit an inherent human capacity to maximize potential, "the self-actualizing tendency"; the task of therapy is to create a relational environment where this tendency might flourish. Humanistic psychology can, in turn, be rooted in existentialism—the belief that human beings can only find meaning by creating it. This is the goal of existential therapy. Existential therapy is in turn philosophically associated with phenomenology. Person-centered therapy, also known as client-centered, focuses on the therapist showing openness, empathy and "unconditional positive regard", to help clients express and develop their own self. Humanistic Psychodrama (HPD) is based on the human image of humanistic psychology. So all rules and methods follow the axioms of humanistic psychology. The HPD sees itself as development-oriented psychotherapy and has completely moved away from the psychoanalytic catharsis theory. Self-awareness and self-realization are essential aspects in the therapeutic process. Subjective experiences, feelings and thoughts and one's own experiences are the starting point for a change or reorientation in experience and behavior in the direction of more self-acceptance and satisfaction. Dealing with the biography of the individual is closely related to the sociometry of the group. Gestalt therapy, originally called "concentration therapy", is an existential/experiential form that facilitates awareness in the various contexts of life, by moving from talking about relatively remote situations to action and direct current experience. Derived from various influences, including an overhaul of psychoanalysis, it stands on top of essentially four load-bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom. A briefer form of humanistic therapy is the human givens approach, introduced in 199899. It is a solution-focused intervention based on identifying emotional needs—such as for security, autonomy and social connection—and using various educational and psychological methods to help people meet those needs more fully or appropriately. Insight-oriented Insight-oriented psychotherapies focus on revealing or interpreting unconscious processes. Most commonly referring to psychodynamic therapy, of which psychoanalysis is the oldest and most intensive form, these applications of depth psychology encourage the verbalization of all the patient's thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the nature of the past and present unconscious conflicts which are causing the patient's symptoms and character problems. There are six main schools of psychoanalysis, which all influenced psychodynamic theory: Freudian, ego psychology, object relations theory, self psychology, interpersonal psychoanalysis, and relational psychoanalysis. Techniques for analytic group therapy have also developed. Cognitive-behavioral Behavior therapies use behavioral techniques, including applied behavior analysis (also known as behavior modification), to change maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others. Functional analytic psychotherapy is one form of this approach. By nature, behavioral therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behavior ultimately has), probabilistic (viewing behavior as statistically predictable), monistic (rejecting mind-body dualism and treating the person as a unit), and relational (analyzing bidirectional interactions). Cognitive therapy focuses directly on changing the thoughts, in order to improve the emotions and behaviors. Cognitive behavioral therapy attempts to combine the above two approaches, focused on the construction and reconstruction of people's cognitions, emotions and behaviors. Generally in CBT, the therapist, through a wide array of modalities, helps clients assess, recognize and deal with problematic and dysfunctional ways of thinking, emoting and behaving. The concept of "third wave" psychotherapies reflects an influence of Eastern philosophy in clinical psychology, incorporating principles such as meditation into interventions such as mindfulness-based cognitive therapy, acceptance and commitment therapy, and dialectical behavior therapy for borderline personality disorder. Interpersonal psychotherapy (IPT) is a relatively brief form of psychotherapy (deriving from both CBT and psychodynamic approaches) that has been increasingly studied and endorsed by guidelines for some conditions. It focuses on the links between mood and social circumstances, helping to build social skills and social support. It aims to foster adaptation to current interpersonal roles and situations. Exposure and response prevention (ERP) is primarily deployed by therapists in the treatment of OCD. The American Psychiatric Association (APA) state that CBT drawing primarily on behavioral techniques (such as ERP) has the "strongest evidence base" among psychosocial interventions. By confronting feared scenarios (i.e., exposure) and refraining from performing rituals (i.e., responsive prevention), patients may gradually feel less distress in confronting feared stimuli, while also feeling less inclination to use rituals to relieve that distress. Typically, ERP is delivered in "hierarchical fashion", meaning patients confront increasingly anxiety-provoking stimuli as they progress through a course of treatment. Other types include reality therapy/choice theory, multimodal therapy, and therapies for specific disorders including PTSD therapies such as cognitive processing therapy, substance abuse therapies such as relapse prevention and contingency management; and co-occurring disorders therapies such as Seeking Safety. Systemic Systemic therapy seeks to address people not just individually, as is often the focus of other forms of therapy, but in relationship, dealing with the interactions of groups, their patterns and dynamics (includes family therapy and marriage counseling). Community psychology is a type of systemic psychology. The term group therapy was first used around 1920 by Jacob L. Moreno, whose main contribution was the development of psychodrama, in which groups were used as both cast and audience for the exploration of individual problems by reenactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the US, such as Paul Schilder, who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably Wilfred Bion and Rickman, followed by S. H. Foulkes, Main, and Bridger. The Northfield Hospital in Birmingham gave its name to what came to be called the two "Northfield Experiments", which provided the impetus for the development since the war of both social therapy, that is, the therapeutic community movement, and the use of small groups for the treatment of neurotic and personality disorders. Today group therapy is used in clinical settings and in private practice settings. Expressive Expressive psychotherapy is a form of therapy that utilizes artistic expression (via improvisational, compositional, re-creative, and receptive experiences) as its core means of treating clients. Expressive psychotherapists use the different disciplines of the creative arts as therapeutic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy, writing therapy, among others. This may include techniques such as affect labeling. Expressive psychotherapists believe that often the most effective way of treating a client is through the expression of imagination in creative work and integrating and processing what issues are raised in the act. Postmodernist Also known as post-structuralist or constructivist. Narrative therapy gives attention to each person's "dominant story" through therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful. Coherence therapy posits multiple levels of mental constructs that create symptoms as a way to strive for self-protection or self-realization. Feminist therapy does not accept that there is one single or correct way of looking at reality and therefore is considered a postmodernist approach. Other Transpersonal psychology addresses the client in the context of a spiritual understanding of consciousness. Positive psychotherapy (PPT) (since 1968) is a method in the field of humanistic and psychodynamic psychotherapy and is based on a positive image of humans, with a health-promoting, resource-oriented and conflict-centered approach. Hypnotherapy is undertaken while a subject is in a state of hypnosis. Hypnotherapy is often applied in order to modify a subject's behavior, emotional content, and attitudes, as well as a wide range of conditions including: dysfunctional habits, anxiety, stress-related illness, pain management, and personal development. Psychedelic therapy are therapeutic practices involving psychedelic drugs, such as LSD, psilocybin, DMT, and MDMA. In psychedelic therapy, in contrast to conventional psychiatric medication taken by the patient regularly or as needed, patients generally remain in an extended psychotherapy session during the acute psychedelic activity with additional sessions both before and after in order to help integrate experiences with the psychedelics. Psychedelic therapy has been compared with the shamanic healing rituals of indigenous people. Researchers identified two main differences: the first is the shamanic belief that multiple realities exist and can be explored through altered states of consciousness, and second the belief that spirits encountered in dreams and visions are real. The charitable initiative Founders Pledge has written a research report on cost-effective giving opportunities for funding psychedelic-assisted mental health treatments. Body psychotherapy, part of the field of somatic psychology, focuses on the link between the mind and the body and tries to access deeper levels of the psyche through greater awareness of the physical body and emotions. There are various body-oriented approaches, such as Reichian (Wilhelm Reich) character-analytic vegetotherapy and orgonomy; neo-Reichian bioenergetic analysis; somatic experiencing; integrative body psychotherapy; Ron Kurtz's Hakomi psychotherapy; sensorimotor psychotherapy; Biosynthesis psychotherapy; and Biodynamic psychotherapy. These approaches are not to be confused with body work or body-therapies that seek to improve primarily physical health through direct work (touch and manipulation) on the body, rather than through directly psychological methods. Some non-Western indigenous therapies have been developed. In African countries this includes harmony restoration therapy, meseron therapy and systemic therapies based on the Ubuntu philosophy. Integrative psychotherapy is an attempt to combine ideas and strategies from more than one theoretical approach. These approaches include mixing core beliefs and combining proven techniques. Forms of integrative psychotherapy include multimodal therapy, the transtheoretical model, cyclical psychodynamics, systematic treatment selection, cognitive analytic therapy, internal family systems model, multitheoretical psychotherapy and conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time. Child Psychotherapy needs to be adapted to meet the developmental needs of children. Depending on age, it is generally held to be one part of an effective strategy to help the needs of a child within the family setting. Child psychotherapy training programs necessarily include courses in human development. Since children often do not have the ability to articulate thoughts and feelings, psychotherapists will use a variety of media such as musical instruments, sand and toys, crayons, paint, clay, puppets, bibliocounseling (books), or board games. The use of play therapy is often rooted in psychodynamic theory, but other approaches also exist. In addition to therapy for the child, sometimes instead of it, children may benefit if their parents work with a therapist, take parenting classes, attend grief counseling, or take other action to resolve stressful situations that affect the child. Parent management training is a highly effective form of psychotherapy that teaches parenting skills to reduce their child's behavior problems. In many cases a different psychotherapist will work with the care taker of the child, while a colleague works with the child. Therefore, contemporary thinking on working with the younger age group has leaned towards working with parent and child simultaneously, as well as individually as needed. Computer-supported Research on computer-supported and computer-based interventions has increased significantly over the course of the last two decades. The following applications frequently have been investigated: Virtual reality: VR is a computer-generated scenario that simulates experience. The immersive environment, used for simulated exposure, can be similar to the real world or it can be fantastical, creating a new experience. Computer-based interventions (or online interventions or internet interventions): These interventions can be described as interactive self-help. They usually entail a combination of text, audio or video elements. Computer-supported therapy (or blended therapy): Classical psychotherapy is supported by means of online or software application elements. The feasibility of such interventions has been investigated for individual and group therapy. Telepsychotherapy Effects Efficacy There is considerable controversy about whether, or when, psychotherapy efficacy is best evaluated by randomized controlled trials or more individualized idiographic methods. One issue with trials is what to use as a placebo treatment group or non-treatment control group. Often, this group includes patients on a waiting list, or those receiving some kind of regular non-specific contact or support. Researchers must consider how best to match the use of inert tablets or sham treatments in placebo-controlled studies in pharmaceutical trials. Several interpretations and differing assumptions and language remain. Another issue is the attempt to standardize and manualize therapies and link them to specific symptoms of diagnostic categories, making them more amenable to research. Some report that this may reduce efficacy or gloss over individual needs. Fonagy and Roth's opinion is that the benefits of the evidence-based approach outweighs the difficulties. There are several formal frameworks for evaluating whether a psychotherapist is a good fit for a patient. One example is the Scarsdale Psychotherapy Self-Evaluation (SPSE). However, some scales, such as the SPS, elicit information specific to certain schools of psychotherapy alone (e.g. the superego). Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice. Psychodynamic therapists increasingly believe that evidence-based approaches are appropriate to their methods and assumptions, and have increasingly accepted the challenge to implement evidence-based approaches in their methods. A pioneer in investigating the results of different psychological therapies was psychologist Hans Eysenck, who argued that psychotherapy does not produce any improvement in patients. He held that behavior therapy is the only effective one. However, it was revealed that Eysenck (who died in 1997) falsified data in his studies about this subject, fabricating data that would indicate that behavioral therapy enables achievements that are impossible to believe. Fourteen of his papers were retracted by journals in 2020, and journals issued 64 statements of concern about publications by him. Rod Buchanan, a biographer of Eysenck, has argued that 87 publications by Eysenck should be retracted. The response rate of psychotherapy varies, no reliable changes due to psychotherapy can be found in up to 33% of patients. Comparison with other treatments Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions. A 2022 meta-analysis of meta-analyses found that effect sizes reported for both psychotherapies and pharmacotherapies, compared to treatment-as-usual or placebo, were small for most disorders and treatments, and concluded that a "paradigm shift in research" was needed to advance the field and improve treatment strategies for mental disorders. One line of research consistently found that supposedly different forms of psychotherapy show similar effectiveness. According to the 2008 edition of The Handbook of Counseling Psychology: "Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments". The handbook stated that "little evidence suggests that any one treatment consistently outperforms any other for any specific psychological disorders". This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes. Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions. Outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalize from them to practicing therapists. However, specific therapies have been tested for use with specific disorders, and regulatory organizations in both the UK and US make recommendations for different conditions. The Helsinki Psychotherapy Study was one of several large long-term clinical trials of psychotherapies that have taken place. Anxious and depressed patients in two short-term therapies (solution-focused and brief psychodynamic) improved faster, but five years long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies. Meta-analyses have established that cognitive behavioural therapy (CBT) and psychodynamic psychotherapy are equally effective in treating depression. A 2014 meta analysis over 11,000 patients reveals that Interpersonal Psychotherapy (IPT) is of comparable effectiveness to CBT for depression but is inferior to the latter for eating disorders. For children and adolescents, interpersonal psychotherapy and CBT are the best methods according to a 2014 meta analysis of almost 4000 patients. Adverse effects Research on adverse effects of psychotherapy has been limited, yet worsening of symptoms may be expected to occur in 3% to 15% of patients, with variability across patient and therapist characteristics. Potential problems include deterioration of symptoms or developing new symptoms, strains in other relationships, social stigma, and therapy dependence. Some techniques or therapists may carry more risks than others, and some client characteristics may make them more vulnerable. Side-effects from properly conducted therapy should be distinguished from harms caused by malpractice. Adherence Patient adherence to a course of psychotherapy—continuing to attend sessions or complete tasks—is a major issue. The dropout level—early termination—ranges from around 30% to 60%, depending partly on how it is defined. The range is lower for research settings for various reasons, such as the selection of clients and how they are inducted. Early termination is associated on average with various demographic and clinical characteristics of clients, therapists and treatment interactions. The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy. Most psychologists use between-session tasks in their general therapy work, and cognitive behavioral therapies in particular use and see them as an "active ingredient". It is not clear how often clients do not complete them, but it is thought to be a pervasive phenomenon. From the other side, the adherence of therapists to therapy protocols and techniques—known as "treatment integrity" or "fidelity"—has also been studied, with complex mixed results. In general, however, it is a hallmark of evidence-based psychotherapy to use fidelity monitoring as part of therapy outcome trials and ongoing quality assurance in clinical implementation. Mechanisms of change It is not yet understood how psychotherapies can succeed in treating mental illnesses. Different therapeutic approaches may be associated with particular theories about what needs to change in a person for a successful therapeutic outcome. In general, processes of emotional arousal and memory have long been held to play an important role. One theory combining these aspects proposes that permanent change occurs to the extent that the neuropsychological mechanism of memory reconsolidation is triggered and is able to incorporate new emotional experiences. General critiques Some critics are skeptical of the healing power of psychotherapeutic relationships. Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners, instead favoring either nonprofessional help or biomedical treatments. Others have pointed out ways in which the values and techniques of therapists can be harmful as well as helpful to clients (or indirectly to other people in a client's life). Many resources available to a person experiencing emotional distress—the friendly support of friends, peers, family members, clergy contacts, personal reading, healthy exercise, research, and independent coping—all present considerable value. Critics note that humans have been dealing with crises, navigating severe social problems and finding solutions to life problems long before the advent of psychotherapy. On the other hand, some argue psychotherapy is under-utilized and under-researched by contemporary psychiatry despite offering more promise than stagnant medication development. In 2015, the US National Institute of Mental Health allocated only 5.4% of its budget to new clinical trials of psychotherapies (medication trials are largely funded by pharmaceutical companies), despite plentiful evidence they can work and that patients are more likely to prefer them. Further critiques have emerged from feminist, constructionist and discourse-analytical sources. Key to these is the issue of power. In this regard there is a concern that clients are persuaded—both inside and outside the consulting room—to understand themselves and their difficulties in ways that are consistent with therapeutic ideas. This means that alternative ideas (e.g., feminist, economic, spiritual) are sometimes implicitly undermined. Critics suggest that we idealize the situation when we think of therapy only as a helping relationship—arguing instead that it is fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified, and that while it is seldom intended, the therapist–client relationship always participates in society's power relations and political dynamics. A noted academic who espoused this criticism was Michel Foucault. See also References Further reading Two volumes. Two volumes.

Neurosis

Neurosis (: neuroses) is a term mainly used today by followers of Freudian thinking to describe mental disorders caused by past anxiety, often that has been repressed. In recent history, the term has been used to refer to anxiety-related conditions more generally. The term "neurosis" is no longer used in condition names or categories by the World Health Organization's International Classification of Diseases (ICD) or the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). According to the American Heritage Medical Dictionary of 2007, the term is "no longer used in psychiatric diagnosis". Neurosis is distinguished from psychosis, which refers to a loss of touch with reality. Its descendant term, neuroticism, refers to a personality trait of being prone to anxiousness and mental collapse. The term "neuroticism" is also no longer used for DSM or ICD conditions; however, it is a common name for one of the Big Five personality traits. A similar concept is included in the ICD-11 as the condition "negative affectivity". History A broad condition (1769–1879) The term neurosis was coined by Scottish doctor William Cullen to refer to "disorders of sense and motion" caused by a "general affection of the nervous system". The term is derived from the Greek word neuron (νεῦρον, 'nerve') and the suffix -osis (-ωσις, 'diseased' or 'abnormal condition'). It was first used in print in Cullen's System of Nosology, first published in Latin in 1769. Cullen used the term to describe various nervous disorders and symptoms that could not be explained physiologically. Physical features, however, were almost inevitably present, and physical diagnostic tests, such as exaggerated knee-jerks, loss of the gag reflex and dermatographia, were used into the 20th century. French psychiatrist Phillipe Pinnel's Nosographie philosophique ou La méthode de l'analyse appliquée à la médecine (1798) was greatly inspired by Cullen. It divided medical conditions into five categories, with one being "neurosis". This was divided into four basic types of mental disorder: melancholia, mania, dementia, and idiotism. Morphine was first isolated from opium in 1805, by German chemist Friedrich Sertürner. After the publication of his third paper on the topic in 1817, morphine became more widely known, and used to treat neuroses and other kinds of mental distress. After becoming addicted to this highly addictive substance, he warned "I consider it my duty to attract attention to the terrible effects of this new substance I called morphium in order that calamity may be averted." German psychologist Johann Friedrich Herbart used the term repression in 1824, in a discussion of unconscious ideas competing to get into consciousness. The tranquilising properties of potassium bromide were noted publicly by British doctor Charles Locock in 1857. Over the coming decades, this and other bromides were used in great quantities to calm people with neuroses. This led to many cases of bromism. French psychiatrist Henri Legrand du Saulle used exposure therapy to treat phobias. American doctor Weir Mitchell first published an account of his rest cure for non-psychotic mental disorders in 1875. His 1877 book "Fat and Blood: and how to make them" gave a fuller explanation. The cure originally involved women being isolated in bed, only communicating with a nurse trained to talk about unchallenging topics, a fattening diet of milk, plus massage and the application of electricity. Eventually, the cure advocated by the Mitchell family had less strict isolation and diet, and was followed by men as well as women. "Fat and Blood" was revised and reprinted for many decades. Breuer, Freud and contemporaries (1880-1939) Austrian psychiatrist Josef Breuer first used psychoanalysis to treat hysteria in 1880–1882. Bertha Pappenheim was treated for a variety of symptoms that began when her father suddenly fell seriously ill in mid-1880 during a family holiday in Ischl. His illness was a turning point in her life. While sitting up at night at his sickbed she was suddenly tormented by hallucinations and a state of anxiety. At first the family did not react to these symptoms, but in November 1880, Breuer, a friend of the family, began to treat her. He encouraged her, sometimes under light hypnosis, to narrate stories, which led to partial improvement of the clinical picture, although her overall condition continued to deteriorate. According to Breuer, the slow and laborious progress of her "remembering work" in which she recalled individual symptoms after they had occurred, thus "dissolving" them, came to a conclusion on 7 June 1882 after she had reconstructed the first night of hallucinations in Ischl. "She has fully recovered since that time" were the words with which Breuer concluded his case report. Accounts differ on the success of Pappenheim's treatment by Breuer. She did not speak about this episode in her later life, and vehemently opposed any attempts at psychoanalytic treatment of people in her care. Breuer was not quick to publish about this case. (Subsequent research has suggested Pappenheim may have had one of a number of neurological illnesses. This includes temporal lobe epilepsy, tuberculous meningitis, and encephalitis. Whatever the nature of her condition, she went on to run an orphanage, and then found and lead the for twenty years.) The term psychoneurosis was coined by Scottish psychiatrist Thomas Clouston for his 1883 book Clinical Lectures on Mental Diseases. He describes a condition that covers what is today considered the schizophrenia and autism spectrums (a combination of symptoms that would soon become better known as dementia praecox). French neurologist Jean-Martin Charcot came to believe that psychological trauma was a cause of some cases of hysteria. He wrote in his book Leçons sur les maladies du système nerveux, (1885-1887) (and published in English as Clinical Lectures on the Diseases of the Nervous System):Quite recently male hysteria has been studied by Messrs. Putnam [1884] and Walton [1883] in America, principally as it occurs after injuries, and especially after railway accidents. They have recognised, like Mr. Page, [1885] who in England has also paid attention to this subject, that many of those nervous accidents described under the name of Railway-spine, and which according to them would be better described as Railway-brain, are in fact, whether occurring in man or woman, simply manifestations of hysteria.Charcot documented around two dozen cases where psychological trauma appears to have caused hysteria. In some cases, the results are described like the modern concept of PTSD. Austrian psychiatrist Sigmund Freud was a student of Charcot in 1885–6. In 1893 Freud credited Charcot with being the source of "all the modern advances made in the understanding and knowledge of hysteria." French psychiatrist Pierre Janet released his book L'automatisme psychologique (Psychological automatism) in 1889, its third chapter detailing his understanding of hypnosis and the unconscious. At this time, he claimed that the main aspect of psychological trauma is dissociation (a disconnection of the conscious mind from reality). (Freud would later claim Janet as a major influence.) In 1891, Thomas Clouston published Neuroses of Development, which covered a wide range of physical and mental developmental conditions.Breuer came to mentor Freud. The pair released the paper "Ueber den psychischen Mechanismus hysterischer Phänomene. (Vorläufige Mittheilung.)" (known in English as "On the physical mechanism of hysterical phenomena: preliminary communication") in January 1893. It opens with:A chance observation has led us, over a number of years, to investigate a great variety of different forms and symptoms of hysteria, with a view to discovering their precipitating cause the event which provoked the first occurrence, often many years earlier, of the phenomenon in question. In the great majority of cases it is not possible to establish the point of origin by a simple interrogation of the patient, however thoroughly it may be carried out. This is in part because what is in question is often some experience which the patient dislikes discussing; but principally because he is genuinely unable to recollect it and often has no suspicion of the causal connection between the precipitating event and the pathological phenomenon. As a rule it is necessary to hypnotize the patient and to arouse his memories under hypnosis of the time at which the symptom made its first appearance; when this has been done, it becomes possible to demonstrate the connection in the clearest and most convincing fashion... It is of course obvious that in cases of 'traumatic' hysteria what provokes the symptoms is the accident. The causal connection is equally evident in hysterical attacks when it is possible to gather from the patient's utterances that in each attack he is hallucinating the same event which provoked the first one. The situation is more obscure in the case of other phenomena. Our experiences have shown us, however, that the most various symptoms, which are ostensibly spontaneous and, as one might say, idiopathic products of hysteria, are just as strictly related to the precipitating trauma as the phenomena to which we have just alluded and which exhibit the connection quite clearly.This paper was reprinted and supplemented with case studies in the pair's 1895 book Studien über Hysterie (Studies on Hysteria). Of the book's five case studies, the most famous became that of Breuer's patient Bertha Pappenheim (given the pseudonym "Anna O."). This book established the field of psychoanalysis. French neurologist Paul Oulmont was mentored by Charcot. In his 1894 book Thérapeutique des névroses (Therapy of neuroses), he lists the neuroses as being hysteria, neurasthenia, exophthalmic goitre, epilepsy, migraine, Sydenham's chorea, Parkinson's disease and tetany. The fifth edition of German psychiatrist Emil Kraepelin's popular psychiatry textbook in 1896 gave "neuroses" a well-accepted definition:In the following presentation we want to summarize a group of disease states as general neuroses, which are accompanied by more or less pronounced nervous dysfunctions. What is common to these manifestations of insanity is that we are constantly dealing with the morbid processing of vital stimuli; what they also have in common is the occurrence of more transitory, peculiar manifestations of illness, sometimes in the physical, sometimes in the psychic area. These attacks of fluctuations in mental balance are therefore not independent illnesses, but only the occasional increase in a persistent illness... It seems useful to me, for the time being, to distinguish between two main forms of general neuroses, epileptic and hysterical insanity.Pierre Janet published the two volume work Névroses et Idées Fixes (Neuroses and Fixations) in 1898. According to Janet, neuroses could be usefully divided into hysterias and psychasthenias. Hysterias induced such symptoms as anaesthesia, visual field narrowing, paralyses, and unconscious acts. Psychasthenias involved the ability to adjust to one's surroundings, similar to the later concepts of adjustment disorder and executive functions. Janet founded the French "Société de psychologie" in 1901. This later became the "Société française de psychologie", and continues today as France's main psychology body. Barbiturates are a class of highly addictive sedative drugs. The first barbiturate, barbital, was synthesized in 1902 by German chemists Emil Fischer and Joseph von Mering and was first marketed as "Veronal" in 1904. The similar barbiturate phenobarbital was brought to market in 1912 under the name "Luminal". Barbiturates became popular drugs in many countries to reduce neurotic anxiety and displaced the use of bromides. Janet published the book Les Obsessions et la Psychasthénie (The Obsessions and the Psychasthenias) in 1903. Janet followed this with the books The Major Symptoms of Hysteria in 1907, and Les Névroses (The Neuroses) in 1909. According to Janet, one cause of neurosis is when the mental force of a traumatic event is stronger than what someone can counter using their normal coping mechanisms. The Swiss psychiatrist Paul Charles Dubois published the book Les psychonévroses et leur traitement moral in 1904, which was translated into English as "Psychic Treatment of Nervous Disorders (The Psychoneuroses and Their Moral Treatment)" in 1905. Dubois believed that neurosis could be successfully treated by listening carefully to patients, and rationally convincing them of the truth — what he called "rational psychotherapy". This was a form of cognitive behavioural therapy. He also followed Weir Mitchell's rest cure, though with a broad fattening diet and other modifications. Meanwhile, Freud developed a number of different theories of neurosis. The most impactful one was that it referred to mental disorders caused by the brain's defence against past psychological trauma. This redefined the general understanding and use of the word. It came to replace the concept of "hysteria". He held the First Congress for Freudian Psychology in Salzburg in April 1908. Subsequent Congresses continue today. Progressive muscle relaxation (PMR) was first developed by American psychiatrist and physiologist Edmund Jacobson. This began at Harvard University in 1908. PMR involves learning to relieve the tension in specific muscle groups by first tensing and then relaxing each muscle group. When the muscle tension is released, attention is directed towards the differences felt during tension and relaxation so that the patient learns to recognize the contrast between the states. This reduces anxiety and the effect of phobias. Freud published the detailed case study "Bemerkungen über einen Fall von Zwangsneurose" (Notes Upon a Case of Obsessional Neurosis) in 1909, documenting his treatment of "Rat Man". Freud established the International Psychoanalytical Association (IPA) in March 1910. He arranged for Carl Jung to be its first president. This organisation chose to only provide both psychoanalytic training and recognition to medical doctors. The American Psychoanalytic Association was founded in 1911 by Welsh neurologist Ernest Jones, with the support of Freud. It followed the IPA's practice of only supporting psychoanalysis provided by medical doctors. Jung gave a speech explaining his understanding of Freud's work called Psychoanalysis and Neurosis in New York in 1912. It was published in 1916. The journal Internationale Zeitschrift für Psychoanalyse was established in 1913, and continued until 1941. The battlefield stresses of World War I (1914–18) lead to many cases of strong short-term psychological symptoms, known today as "combat stress reaction" (CSR). Other terms for the condition include "combat fatigue", "battle fatigue", "battle neurosis", "shell shock" and "operational stress reaction". The general psychological term acute stress disorder was first used for this condition at this time. The fight-or-flight response was first described by American physiologist Walter Bradford Cannon in 1915. American military psychiatrist Thomas W. Salmon (the chief consultant in psychiatry in the American Expeditionary Force) released the book The care and treatment of mental diseases and war neuroses ("shell shock") in the British army in 1917, dealing primarily with what was considered was the best treatment for hysteria. His recommendations were broadly adopted in the US armed forces. Freud's most explanatory work on neurosis was his lectures later grouped together as "General Theory of the Neuroses" (1916–17), forming part 3 of the book Vorlesungen zur Einführung in die Psychoanalyse (1917), later published in English as A General Introduction to Psychoanalysis (1920). In that work, Freud noted that:The meaning of neurotic symptoms was first discovered by J. Breuer in the study and felicitous cure of a case of hysteria which has since become famous (1880–82). It is true that P. Janet independently reached the same result... The [neurotic] symptom develops as a substitution for something else that has remained suppressed. Certain psychological experiences should normally have become so far elaborated that consciousness would have attained knowledge of them. This did not take place, however, but out of these interrupted and disturbed processes, imprisoned in the unconscious, the symptom arose... Our therapy does its work by means of changing the unconscious into the conscious, and is effective only in so far as it has the opportunity of bringing about this transformation...Freud added to this with his paper "Aus der Geschichte einer infantilen Neurose" (From the History of an Infantile Neurosis) published in 1918, which is a detailed case study of his treatment of the "Wolfman". The International Journal of Psychoanalysis was founded by Ernest Jones in 1920. In response to stress injuries from World War I, the British government produced the Report of the War Office Committee of Inquiry into "Shell-Shock", which was published in 1922. Its recommended course of treatment included: While recognizing that each individual case of war neurosis must be treated on its merits, the Committee are of opinion that good results will be obtained in the majority by the simplest forms of psycho-therapy, i.e., explanation, persuasion and suggestion, aided by such physical methods as baths, electricity and massage. Rest of mind and body is essential in all cases. [The practices of Paul Charles Dubois.] The committee are of opinion that the production of deep hypnotic sleep, while beneficial as a means of conveying suggestions or eliciting forgotten experiences are useful in selected cases, but in the majority they are unnecessary and may even aggravate the symptoms for a time. They do not recommend psycho-analysis in the Freudian sense. In the state of convalescence, re-education and suitable occupation of an interesting nature are of great importance. If the patient is unfit for further military service, it is considered that every endeavor should be made to obtain for him suitable employment on his return to active life.The common neuroses and their treatment by psychotherapy was a book released by British psychiatrist Thomas Arthur Ross in 1923, to instruct medical doctors in general. (A second edition was published in 1937, which was subsequently reprinted many times). He also followed the practice of Paul Charles Dubois, and believed "Freudian analysis" was only necessary for the most difficult cases. Ross would later write the books Introduction to analytical psychotherapy (1932) and An enquiry into prognosis in the neuroses (1936). In April 1923 Freud published his monograph Das Ich und das Es (published in English as The Ego and the Id), which included a revised theory of mental functioning, now considering that repression was only one of many defence mechanisms, and that it occurred to reduce anxiety. Hence, Freud characterised repression as both a cause and a result of anxiety. Austrian literary theorist Otto Rank was a close ally of Freud. His book The Trauma of Birth (1924) focused more on people's choices, rather than Freud's focus on drives. He believed in the idea of psychotherapy as opposed to psychoanalysis — that understanding someone's neuroses wasn't sufficient for effective therapy. Freud released his book Hemmung, Symptom und Angst (Inhibition, Symptom and Anxiety) in 1926, in reaction to Rank's book. It detailed his further developed understanding of neurosis and anxiety. (The book was published in English as The Problem of Anxiety in 1936.) This book expressed his new view that anxiety created repression, rather than the other way around. Freud also published the book Die Frage der Laienanalyse (The Question of Lay Analysis) in 1926, in which he endorsed non-doctors performing psychoanalysis. In 1929, Austrian psychiatrist Alfred Adler published the book Problems of Neurosis: A Book of Case-Histories, furthering the school of individual psychology he had established in 1912. 1929 also saw Edmund Jacobson publishing of the professional instruction book Progressive Relaxation. It explained the benefits of relaxation for addressing neuroses and other mental conditions. He followed this with the more publicly-oriented You Must Relax in 1934. Walter Bradford Cannon's 1932 book The Wisdom of the Body popularised the concept of fight-or-flight. The American Medical Association released its Standard Classified Nomenclature of Diseases in 1933, the first widely accepted such nomenclature in the United States. By the second edition of 1935, its category of "psychoneuroses" included: Hysteria Anxiety hysteria Conversion hysteria Anesthenic type Paralytic type Hyperkinetic type Paresthetic type Autonomic type Amnesic type Mixed hysterical psychoneurosis Psychasthenia or compulsive states Obsession Compulsive tics or spasms Phobia Mixed compulsive states Neurasthenia Hypochondriasis Reactive depression Anxiety state Mixed psychoneurosis The general adaptation syndrome (GAS) theory of stress was developed by Austro-Hungarian physiologist Hans Selye in 1936. In 1937, Austrian-American psychiatrist Adolph Stern proposed that there were many people with conditions that fitted between the definitions of psychoneurosis and psychosis, and called them the "border line group of neuroses". This group would later become known as borderline personality disorder. By 1937, the concept of "occupational neuroses" was known by many American health practitioners. It referred to neuroses caused by any aspect of someone's employment. 1939–1952 Followers of Freud's psychoanalytic thinking, such as Carl Jung, Karen Horney, and Jacques Lacan, continued to discuss the concept of neurosis after Freud's death in 1939. The term continues to be used in the Freudian sense in psychology and philosophy. By 1939, some 120,000 British ex-servicemen had received final awards for primary psychiatric disability or were still drawing pensions – about 15% of all pensioned disabilities – and another 44,000 or so were getting pensions for "soldier's heart" or effort syndrome. British historian Ben Shephard notes, "There is, though, much that statistics do not show, because in terms of psychiatric effects, pensioners were just the tip of a huge iceberg." Approximately 20% of U.S. troops displayed symptoms of combat stress reaction during WWII (1939-1945). It was assumed to be a temporary response of healthy individuals to witnessing or experiencing traumatic events. Symptoms included depression, anxiety, withdrawal, confusion, paranoia, and sympathetic hyperactivity. Thomas W. Salmon's battle neurosis principles were adopted by the U.S. forces during this conflict. The American Journal of Psychoanalysis was founded by Karen Horney in 1941. 1942 saw American psychologist Carl Rogers publish the handbook Counseling and Psychotherapy, which established his school of person-centered therapy. Austrian psychiatrist Otto Fenichel's encyclopaedic textbook The psychoanalytic theory of neurosis (1945) set the post-war Freudian orthodoxy on the subject. It has been heavily cited by academic papers in the years since. Karen Horney's Our Inner Conflicts: A Constructive Theory of Neurosis (1945) was a popular book on the topic. The post-World War II boom in the number of patient-treating psychologists in the United States led to a major restructure of the American Psychological Association in 1945. Carl Rogers became its president in 1947. Austrian psychiatrist Viktor Frankl's best selling book Man's Search for Meaning (1946) launched the psychotherapy school of logotherapy. For his 1947 book, Dimensions of Personality, German-British psychologist Hans Eysenck created the term "neuroticism" to refer to someone whose "constitution may leave them liable to break down [emotionally] with the slightest provocation". The book outlines a two-factor theory of personality, with neuroticism as one of those two factors. This book would be greatly influential on future personality theory. Karen Horney's Neurosis and Human Growth (1950) further expanded the understanding of neuroses. French-Swiss psychologist Germaine Guex's 1950 book La névrose d'abandon proposed the existence of the condition of "abandonment neurosis". It also detailed all the forms of treatment Geux had found effective in treating it. (It was published in English as The Abandonment Neurosis in 2015). In October 1951, the now highly influential Carl Rogers presented a paper in which he described the relationship between neurosis and his understanding of effective therapy. He wrote:The emotionally maladjusted person, the "neurotic", is in difficulty first because communication within himself has broken down, and second because as a result of this his communication with others has been damaged. If this sounds somewhat strange, then let me put it in other terms. In the "neurotic" individual, parts of himself which have been termed unconscious, or repressed, or denied to awareness, become blocked off so that they no longer communicate themselves to the conscious or managing part of himself... The task of psychotherapy is to help the person achieve, through a special relationship with the therapist, good communication within himself.The North American Society of Adlerian Psychology was established in 1952, becoming the predominant society of its cause in the world. DSM-I (1952–1968) The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952 included a category named "Psychoneurotic Disorders". Regarding the definition of this category, the Manual stated:Grouped as Psychoneurotic Disorders are those disturbances in which "anxiety" is a chief characteristic, directly felt and expressed, or automatically controlled by such defenses as depression, conversion, dissociation, displacement, phobia formation, or repetitive thoughts and acts. For this nomenclature, a psychoneurotic reaction may be defined as one in which the personality, in its struggle for adjustment to internal and external stresses, utilizes the mechanisms listed above to handle the anxiety created. The qualifying phrase, x.2 with neurotic reaction, may be used to amplify the diagnosis when, in the presence of another psychiatric disturbance, a symptomatic clinical picture appears which might be diagnosed under Psychoneurotic Disorders in this nomenclature. A specific example may be seen in an episode of acute anxiety occurring in a homosexual.Conditions in the category included: Anxiety reaction Dissociative reaction Conversion reaction Phobic reaction Obsessive compulsive reaction Depressive reaction Psychoneurotic reaction, other The DSM-I also included a category of "transient situational personality disorders". This included the diagnosis of "gross stress reaction". This was defined as a normal personality using established patterns of reaction to deal with overwhelming fear as a response to conditions of great stress. The diagnosis included language which relates the condition to combat as well as to "civilian catastrophe". The other situational disorders were "adult situational reaction" and a variety of time-of-life delineated "adjustment reactions". These referred to short-term reactions to stressors. Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) were developed for the treatment of neurosis and other conditions from the early 1950s. Because of their undesirable adverse-effect profile and high potential for toxicity, their use was limited. The use of modern exposure therapy for neuroses began in the 1950s in South Africa. South African-American Joseph Wolpe was one of the first psychiatrists to spark interest in treating psychiatric problems as behavioral issues. In May 1950, pharmacologist Frank Berger (Czech-American) and chemist Bernard John Ludwig engineered meprobamate to be a non-drowsy tranquiliser. Launched as "Miltown" in 1955, it rapidly became the first blockbuster psychotropic drug in American history, becoming popular in Hollywood and gaining fame for its effects. It is highly addictive. The Meaning of Anxiety was a book released by American psychiatrist Rollo May in 1950. It reviewed the existing research on the subject. It found that some anxiety was a simple reaction to related stimuli, while other anxiety had a more complicated and neurotic beginning. A revised edition of the book was published in 1977. After the Korean War (1950-1953), Thomas W. Salmon's battle neurosis treatment practices became summarised as the PIE principles: Proximity – treat the casualties close to the front and within sound of the fighting. Immediacy – treat them without delay and not wait until the wounded were all dealt with. Expectancy – ensure that everyone had the expectation of their return to the front after a rest and replenishment. The Taylor Manifest Anxiety Scale was created by American psychologist Janet Taylor in 1953. It measures anxiousness as a personality trait. The International Association of Analytical Psychology was founded in 1955. It is the predominant organisation devoted to the psychology of Carl Jung. The American Academy of Psychoanalysis was founded in 1956, for psychiatrists to discuss psychoanalysis in ways that deviated from the orthodoxy of the time. Also in 1956, American psychologist Albert Ellis publicly read his first paper on his methodology "rational psychotherapy". (He took inspiration from, and used the same name as the methodology of Paul Charles Dubois. He claimed additional inspiration from Freud and Epicetus). This and later works defined what is now known as rational emotive behavior therapy (REBT). Ellis believed that people's erroneous beliefs about their adversities was a major cause of neurosis, and his therapy aimed to dissolve these neuroses by correcting people's understandings. Ellis published the first REBT book, How to live with a neurotic, in 1957. Albert Ellis and others founded "The Institute for Rational Living" in April 1959, which later became the Albert Ellis Institute. The concept of "institutional neurosis" was coined by British psychiatrist Russell Barton, and explained in his well-cited 1959 book Institutional Neurosis. Barton believed that many of the mental health symptoms had by people living in mental hospitals and similar institutions were caused by being in those environments, rather than other causes. Barton was a leader in the deinstitutionalisation movement. (This form of neurosis later came to be known as "institutional syndrome"). Benzodiazepines are a class of highly addictive sedative drugs that reduce anxiety by depressing function in certain parts of the brain. The first of these drugs, chlordiazepoxide (Librium), was made available for sale in 1960. (It was discovered by Polish-American chemist Leo Sternbach in 1955.) Librium was followed with the more popular diazepam (Valium) in 1963. These drugs soon displaced Miltown. Spanish history writer Jose M. Lopez Pinero published Origenes historicos del concepto de neurosis in 1963. It was published in English as Historical Origins of the Concept of Neurosis in 1983. Neurotics Anonymous began in February 1964, as a twelve-step program to help the neurotic. It was founded in Washington, D.C. by American psychologist Grover Boydston, and has since spread through the Americas. Also in 1964, Polish psychiatrist Kazimierz Dąbrowski released his book Positive Disintegration. The book argues that developing and resolving psychoneurosis is a necessary part of healthy personality development. The year 1964 also saw the establishment of the American Psychological Association's Division 25, a group of psychologists interested in behaviourism. The popular textbook The causes and cures of neurosis; an introduction to modern behaviour therapy based on learning theory and the principles of conditioning was published in 1965 by Hans Eysenck and South African-British psychologist Stanley Rachman. It aimed to replace the Freudian approach to neurosis with behaviorism. The "Hopkins Symptom Checklist" (HSCL) is a self-report symptom inventory that was developed in the mid-1960s from earlier checklists. It measures somatization, obsession-compulsion, interpersonal sensitivity, anxiety and depression. In 1966, psychologists began to observe large numbers of children of Holocaust survivors seeking mental help in clinics in Canada. The grandchildren of Holocaust survivors were overrepresented by 300% among the referrals to psychiatry clinics in comparison with their representation in the general population. Further study lead to the better understanding of transgenerational trauma. The noted book Psychological stress and the coping process was released by American psychologist Richard Lazarus in 1966. The well-cited book Anxiety and Behaviour was also released in 1966. As with Eysenck and Rachman's book, it aimed to connect neuroses with behaviourism. It was edited by American psychologist Charles Spielberger. The Association for Advancement of Behavioral Therapies was founded in 1966. (In 2005, it became the Association for Behavioral and Cognitive Therapies.) DSM-II (1968–1980) After Freudian thinking became less prominent in psychology, the term "neurosis" came to be used as a near synonym for "anxiety". The second edition of the DSM (DSM-II) in 1968 described neuroses thusly: Anxiety is the chief characteristic of the neuroses. It may be felt and expressed directly, or it may be controlled unconsciously and automatically by conversion [into physical symptoms], displacement [into mental symptoms] and various other psychological mechanisms. Generally, these mechanisms produce symptoms experienced as subjective distress from which the patient desires relief. The neuroses, as contrasted to the psychoses, manifest neither gross distortion or misinterpretation of external reality, nor gross personality disorganization...Included in this category were the conditions: Hysterical neurosis Hysterical neurosis, conversion type Hysterical neurosis, dissociative type Phobic neurosis Obsessive compulsive neurosis Depressive neurosis Neurasthenic neurosis (neurasthenia) Depersonalization neurosis (depersonalization syndrome) Hypochondriacal neurosis Other neurosis Unspecified neurosis What was previously "gross stress reaction" and "adult situational reaction" was combined into the new "adjustment disorder of adult life", a condition covering mild to strong reactions. Other adjustment disorders for other times-of-life were also included. (Also, the category "transient situational personality disorders" was renamed "transient situational disturbances.") Anxiety and Neurosis was a popular mass-market book released in 1968 by British psychologist Charles Rycroft. Neuroses and Personality Disorders was a popular textbook released by American psychologist Elton B McNeil in 1970. The State-Trait Anxiety Inventory (STAI) was developed by Charles Spielberger and others, and first published in 1970. It provides separate "state" and "trait" measures of a person's anxiety. A revised form was released in 1983. The book Primal Scream. Primal Therapy: The Cure for Neurosis by American psychologist Arthur Janov was released in 1970. It established primal therapy as a treatment for neurosis. It is based on the idea that neurosis is caused by the repressed pain of childhood trauma. Janov argued that repressed pain can be sequentially brought to conscious awareness for resolution through re-experiencing specific incidents and fully expressing the resulting pain during therapy. Janov criticizes the talking therapies as they deal primarily with the cerebral cortex and higher-reasoning areas and do not access the source of Pain within the more basic parts of the central nervous system. (A second edition of the book was published in 1999). Chinese-American psychiatrist William WK Zung released his "Anxiety Status Inventory" (ASI) and patient "Self-rating Anxiety Scale" (SAS) in November 1971. Dąbrowski expanded on his earlier book with Psychoneurosis Is Not An Illness: Neuroses And Psychoneuroses From The Perspective Of Positive Disintegration in 1972. Anxiety: Current Trends in Theory and Research is a well-cited series of two books released in 1972, and were edited by Charles Spielberger. American anthropologist Ernst Becker in his Pulitzer-winning book The Denial of Death (1973) argued that the repression of the fear of death had a number of advantages, and that this was a major source of neurosis. The first tetracyclic anti-depressant (TeCA) maprotiline (Ludiomil) was developed by Ciba, and patented in 1966. It was introduced for medical use in 1974. TeCAs mianserin (Tolvon) and amoxapine (Asendin) followed shortly thereafter and mirtazapine (Remeron) being introduced later on. Albert Ellis' work was expanded on by fellow American, psychiatrist Aaron Beck. In 1975, Beck released the greatly influential book Cognitive Therapy and the Emotional Disorders. Beck's cognitive therapy became popular, soon becoming the most popular form of CBT and often being known by that name. American psychiatrist and historian Kenneth Levin's Freud's early psychology of the neuroses: a historical perspective was published in 1978. American-Israeli medical sociologist Aaron Antonovsky in his 1979 book Stress, Health and Coping, stated that an event will not be perceived as stressful when it is appraised as consistent, under some personal control of the outcome, and balanced between underload and overload. Someone resistant to stress will see potential stressors as instead being "meaningful, predictable, and ordered." Antonovsky proposed that stress and a lack of an individual's "resistance resources" (to stressors) may be the main underlying causes of illness and disease, not just mental neuroses. This book established the field of salutogenesis. In January 1980, Stanley Rachman published a well-cited working definition of "emotional processing", aiming to define the "certain psychological experiences" Freud had mentioned in his 1923 book (and had earlier referred to). It included lists of things likely to improve or retard such processing. DSM-III (1980–1994) The DSM replaced its "neurosis" category with an "anxiety disorders" category in 1980, with the release of the DSM-III. It did this because of a decision by its editors to provide descriptions of behavior rather than descriptions of hidden psychological mechanisms. This change was controversial. This edition of the book also included a condition named "post-traumatic stress disorder" for the first time. This was similar in definition to the "gross stress reaction" of the DSM-I. The anxiety disorders were defined as: Phobic disorders (or phobic neuroses) Agoraphobia with panic attacks Agoraphobia without panic attacks Social phobia Simple phobia Anxiety states (or anxiety neuroses) Panic disorder Generalised anxiety disorder Obsessive compulsive disorder (or obsessive compulsive neuroses) Post-traumatic stress disorder, acute Post-traumatic stress disorder, chronic or delayed Atypical anxiety disorder Adjustment disorder remained, and was defined separately. Its time-of-life based subtypes were abolished, replaced with combinations with co-morbid syndromes (such as "Adjustment Disorder with Depressed Mood" and "Adjustment Disorder with Anxious Mood"). Adjustment disorder returned to being a short-term condition. Somatoform disorders, disassociation, depression and hypochondria (all previously considered neuroses) were also treated separately. Neurasthenia (a neurosis that caused otherwise unexplainable fatigue) was loosely mapped to a mild form of depression. The American "National Membership Committee on Psychoanalysis in Clinical Social Work" was established in May 1980. (It became the "American Association for Psychoanalysis in Clinical Social Work" in 2007). American psychiatrist George F. Drinka released the history book Birth of Neurosis: Myth, Malady, and the Victorians in 1984. The World Association of Psychoanalysis was founded in January 1992, and became the largest organisation devoted to the psychotherapy of Jacques Lacan. DSM-5 (2013–current) In 2013, the DSM-5 was released, separating out the "trauma and stress-related disorders" (Freud's etiology for neuroses) from the "anxiety disorders". The former category includes: Reactive attachment disorder Disinhibited social engagement disorder Posttraumatic stress disorder Acute stress disorder Adjustment disorders Other specified trauma- and stressor-related disorder Adjustment-like disorders with a late onset Ataque de nervios Dhat syndrome Khyâl cap Kufungisisa Maladi moun Nervios Shenjing shuairuo Susto Taijin kyofusho Persistent complex bereavement disorder Unspecified trauma- and stressor-related disorder Prevention Stress inoculation training was developed to reduce anxiety in doctors during times of intense stress by Donald Meichenbaum. It is a combination of techniques including relaxation, negative thought suppression, and real-life exposure to feared situations used in PTSD treatment. The therapy is divided into four phases and is based on the principles of cognitive behavioral therapy. The first phase identifies the individual's specific reaction to stressors and how they manifest into symptoms. The second phase helps teach techniques to regulate these symptoms using relaxation methods. The third phase deals with specific coping strategies and positive cognitions to work through the stressors. Finally, the fourth phase exposes the client to imagined and real-life situations related to the traumatic event. This training helps to shape the response to future triggers to diminish impairment in daily life. Patients with acute stress disorder (ASD) have been found to benefit from cognitive behavioral therapy in preventing PTSD, with clinically meaningful outcomes at six-month follow-up consultations. Supportive counseling was outperformed by a regimen of relaxation, cognitive restructuring, imaginal exposure, and in-vivo exposure. Programs based on mindfulness-based stress reduction also seem to be useful at managing stress. Progressive muscle relaxation (PMR) was developed by Edmund Jacobson. PMR involves learning to relieve the tension in specific muscle groups by first tensing and then relaxing each muscle group. When the muscle tension is released, attention is directed towards the differences felt during tension and relaxation so that the patient learns to recognize the contrast between the states. This reduces anxiety. Playing Tetris shortly after a traumatic experience prevents the development of PTSD in some cases. Stanley Rachman compiled lists of factors that promote or impede "emotional processing" in 1980, the former reducing the development of neurosis, the latter making it more likely. Aaron Antonovsky stated that a resilient person is more likely to appraise a situation as "meaningful, predictable, and ordered." Michael Rutter found that resilience could be improved in an individual by the 1) reduction of risk impact, 2) reduction of negative chain reactions, 3) establishment and maintenance of self-esteem and self-efficacy, and 4) opening up of opportunities. The use of pharmaceuticals to mitigate the consequences of ASD has made some progress. The Alpha-1 blocker Prazosin, which controls sympathetic response, can be administered to patients to help them unwind and enable better sleep. It is unclear how it functions in this situation. Following a traumatic experience, hydrocortisone (cortisol) has demonstrated some promise as an early prophylactic intervention, frequently slowing the onset of PTSD. In a systematic literature review in 2014, the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) found that a number of work environment factors could affect the risk of developing exhaustion disorder or depressive symptoms: People who experience a work situation with little opportunity to influence, in combination with too high demands, develop more depressive symptoms. People who experience a lack of compassionate support in the work environment develop more symptoms of depression and exhaustion disorder than others. Those who experience bullying or conflict in their work develop more depressive symptoms than others, but it is not possible to determine whether there is a corresponding connection for symptoms of exhaustion disorder. People who feel that they have urgent work or a work situation where the reward is perceived as small in relation to the effort develops more symptoms of depression and exhaustion disorder than others. This also applies to those who experience insecurity in the employment, for example concerns that the workplace will be closed down. In some work environments, people have less trouble. People who experience good opportunities for control in their own work and those who feel that they are treated fairly develop less symptoms of depression and exhaustion disorder than others. Women and men with similar working conditions develop symptoms of depression as much as exhaustion disorder. Etiology Historic versions of the DSM and ICD The term "neurosis" is no longer used in a professional diagnostic sense, it having been eliminated from the DSM in 1980 with the publication of DSM III, and having the last remnants of being removed from the ICD with the enacting of the ICD-11 in 2022. (In the ICD-10 it was used in section F48.8 to describe certain minor conditions.) According to the "anxiety" concept of the term, there were many different neuroses, including: obsessive–compulsive disorder (OCD) obsessive–compulsive personality disorder impulse control disorder anxiety disorder histrionic personality disorder dissociative disorder a great variety of phobias According to C. George Boeree, professor emeritus at Shippensburg University, the symptoms of neurosis may involve: Psychoanalytic (Freudian) theory According to psychoanalytic theory, neuroses may be rooted in ego defense mechanisms, though the two concepts are not synonymous. Defense mechanisms are a normal way of developing and maintaining a consistent sense of self (i.e., an ego). However, only those thoughts and behaviors that produce difficulties in one's life should be called neuroses. A neurotic person experiences emotional distress and unconscious conflict, which are manifested in various physical or mental illnesses; the definitive symptom being anxiety. Neurotic tendencies are common and may manifest themselves as acute or chronic anxiety, depression, OCD, a phobia, or a personality disorder. Freud's typology of neuroses in "Introduction to Psychoanalysis" (1923) included: Psychoneuroses Transference neuroses Hysteria Anxiety hysteria Various phobias Conversion hysteria Compulsion neuroses Trauma neuroses Narcissistic neuroses True neuroses Neurasthenia Anxiety neurosis Hypochondria Paraphrenia [schizophrenia spectrum] Dementia praecox Paranoia Megalomania Mania of persecution Erotomania Mania of jealousy Jungian theory Carl Jung found his approach particularly effective for patients who are well adjusted by social standards but are troubled by existential questions. Jung claims to have "frequently seen people become neurotic when they content themselves with inadequate or wrong answers to the questions of life". Accordingly, the majority of his patients "consisted not of believers but of those who had lost their faith". A contemporary person, according to Jung, ... is blind to the fact that, with all his rationality and efficiency, he is possessed by 'powers' that are beyond his control. His gods and demons have not disappeared at all; they have merely got new names. They keep him on the run with restlessness, vague apprehensions, psychological complications, an insatiable need for pills, alcohol, tobacco, food — and, above all, a large array of neuroses.Jung found that the unconscious finds expression primarily through an individual's inferior psychological function, whether it is thinking, feeling, sensation, or intuition. The characteristic effects of a neurosis on the dominant and inferior functions are discussed in his Psychological Types. Jung also found collective neuroses in politics: "Our world is, so to speak, dissociated like a neurotic." Horney's theory In her final book, Neurosis and Human Growth, Karen Horney lays out a complete theory of the origin and dynamics of neurosis. In her theory, neurosis is a distorted way of looking at the world and at oneself, which is determined by compulsive needs rather than by a genuine interest in the world as it is. Horney proposes that neurosis is transmitted to a child from their early environment and that there are many ways in which this can occur: The child's initial reality is then distorted by their parents' needs and pretenses. Growing up with neurotic caretakers, the child quickly becomes insecure and develops basic anxiety. To deal with this anxiety, the child's imagination creates an idealized self-image: Once they identify themselves with their idealized image, a number of effects follow. They will make claims on others and on life based on the prestige they feel entitled to because of their idealized self-image. They will impose a rigorous set of standards upon themselves in order to try to measure up to that image. They will cultivate pride, and with that will come the vulnerabilities associated with pride that lacks any foundation. Finally, they will despise themselves for all their limitations. Vicious circles will operate to strengthen all of these effects. Eventually, as they grow to adulthood, a particular "solution" to all the inner conflicts and vulnerabilities will solidify. They will be either: expansive, displaying symptoms of narcissism, perfectionism, or vindictiveness. self-effacing and compulsively compliant, displaying symptoms of neediness or codependence. resigned, displaying schizoid tendencies. In Horney's view, mild anxiety disorders and full-blown personality disorders all fall under her basic scheme of neurosis as variations in the degree of severity and in the individual dynamics. The opposite of neurosis is a condition Horney calls self-realization, a state of being in which the person responds to the world with the full depth of their spontaneous feelings, rather than with anxiety-driven compulsion. Thus, the person grows to actualize their inborn potentialities. Horney compares this process to an acorn that grows and becomes a tree: the acorn has had the potential for a tree inside it all along. See also Individuation Treatments for PTSD Sublimation Post-traumatic growth References Bibliography External links Psychoanalytic theory Stress-related disorders Psychopathological syndromes

Functional neurologic disorder

Functional neurologic disorder or functional neurological disorder (FND) is a condition in which patients experience neurological symptoms such as weakness, movement problems, sensory symptoms, and convulsions. As a functional disorder, there is, by definition, no known disease process affecting the structure of the body, yet the person experiences symptoms relating to their body function. Symptoms of functional neurological disorders are clinically recognisable, but are not categorically associated with a definable organic disease. The intended contrast is with an organic brain syndrome, where a pathology (disease process) which affects the body's physiology can be identified. Subsets of functional neurological disorders include functional neurologic symptom disorder (FNsD) (conversion disorder), functional movement disorder, and functional seizures. The diagnosis is made based on positive signs and symptoms in the history and examination during consultation of a neurologist. Physiotherapy is particularly helpful for patients with motor symptoms (weakness, gait disorders, movement disorders) and tailored cognitive behavioural therapy has the best evidence in patients with non-epileptic seizures. History From the 18th century, there was a move from the idea of FND being caused by the nervous system. This led to an understanding that it could affect both sexes. Jean Martin Charcot argued that, what would be later called FND, was caused by "a hereditary degeneration of the nervous system, namely a neurological disorder". In the 18th century, the illness was confirmed as a neurological disorder but a small number of doctors still believed in the previous definition. However, as early as 1874, doctors, including W.B. Carpenter and J.A. Omerod, began to speak out against this other term due to there being no evidence of its existence. Although the term "conversion disorder" has been used for many years, another term was still being used in the 20th century. However, by this point, it bore little resemblance to the original meaning. It referred instead to symptoms that could not be explained by a recognised organic pathology, and was therefore believed to be the result of stress, anxiety, trauma or depression. The term fell out of favour over time due to the negative connotations. Furthermore, critics pointed out that it can be challenging to find organic pathologies for all symptoms, and so the practice of diagnosing that patients who had such symptoms were imagining them led to the disorder being meaningless, vague and a sham-diagnosis, as it did not refer to any definable disease. Throughout its history, many patients have been misdiagnosed with conversion disorder when they had organic disorders such as tumours or epilepsy or vascular diseases. This has led to patient deaths, a lack of appropriate care and suffering for the patients. Eliot Slater, after studying the condition in the 1950s, was outspoken against the condition, as there has never been any evidence to prove that it exists. He stated that "The diagnosis of 'hysteria' is a disguise for ignorance and a fertile source of clinical error. It is, in fact, not only a delusion but also a snare". In 1980, the DSM III added 'conversion disorder' to its list of conditions. The diagnostic criteria for this condition are nearly identical to those used for hysteria. The diagnostic criteria were: A. The predominant disturbance is a loss of or alteration in physical functioning suggesting a physical disorder. It is involuntary and medically unexplainable B. One of the following must also be present: A temporal relationship between symptom onset and some external event of psychological conflict. The symptom allows the individual to avoid unpleasant activity. The symptom provides opportunity for support which may not have been otherwise available. Today, there is a growing understanding that symptoms are real and distressing, and are caused by an incorrect functioning of the brain rather than being imagined or made up. Signs and symptoms There are a great number of symptoms experienced by those with a functional neurological disorder. While these symptoms are very real, their origin is complex, since it can be associated with severe psychological trauma (conversion disorder), and idiopathic neurological dysfunction. The core symptoms are those of motor or sensory dysfunction or episodes of altered awareness: Limb weakness or paralysis Non-epileptic seizures – these may look like epileptic seizures or faints Movement disorders including tremors, dystonia (spasms), myoclonus (jerky movements) Visual symptoms including loss of vision or double vision Speech symptoms including dysphonia (whispering speech), slurred or stuttering speech Sensory disturbance including hemisensory syndrome (altered sensation down one side of the body) Numbness or inability to sense touch Dizziness and balance problems Pain (including chronic migraines) Extreme slowness and fatigue Causes A systematic review found that stressful life events and childhood neglect were significantly more common in patients with FND than the general population, although some patients report no stressors. Converging evidence from several studies using different techniques and paradigms has now demonstrated distinctive brain activation patterns associated with functional deficits, unlike those seen in actors simulating similar deficits.  The new findings advance current understanding of the mechanisms involved in this disease, and offer the possibility of identifying markers of the condition and patients' prognosis. FND has been reported as a rare occurrence in the period following general anesthesia. Diagnosis A diagnosis of a functional neurological disorder is dependent on positive features from the history and examination. Positive features of functional weakness on examination include Hoover's sign, when there is weakness of hip extension which normalizes with contralateral hip flexion. Signs of functional tremor include entrainment and distractibility. The patient with tremor should be asked to copy rhythmical movements with one hand or foot. If the tremor of the other hand entrains to the same rhythm, stops, or if the patient has trouble copying a simple movement this may indicate a functional tremor. Functional dystonia usually presents with an inverted ankle posture or clenched fist. Positive features of dissociative or non-epileptic seizures include prolonged motionless unresponsiveness, long duration episodes (>2minutes) and symptoms of dissociation prior to the attack. These signs can be usefully discussed with patients when the diagnosis is being made. Patients with functional movement disorders and limb weakness may experience symptom onset triggered by an episode of acute pain, a physical injury or physical trauma. They may also experience symptoms when faced with a psychological stressor, but this isn't the case for most patients. Patients with functional neurological disorders are more likely to have a history of another illness such as irritable bowel syndrome, chronic pelvic pain or fibromyalgia but this cannot be used to make a diagnosis. FND does not show up on blood tests or structural brain imaging such as MRI or CT scanning. However, this is also the case for many other neurological conditions so negative investigations should not be used alone to make the diagnosis. FND can occur alongside other neurological diseases and tests may show non-specific abnormalities which cause confusion for doctors and patients. DSM-5 diagnostic criteria The Diagnostic and Statistical Manual of Mental Illness (DSM-5) lists the following diagnostic criteria for functional neurological symptoms (conversion disorder): One or more symptoms of altered voluntary motor or sensory function. Clinical findings can provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. Another medical or mental disorder does not better explain the symptom or deficit. The symptom or deficit results in clinically significant distress or impairment in social, occupational, or other vital areas of functioning or warrants medical evaluation. The presence of symptoms defines an acute episode of functional neurologic disorder for less than six months, and persistent functional neurologic disorder includes the presence of symptoms for greater than six months. Functional neurologic disorder can also have the specifier of with or without the psychological stressor. Associated conditions Epidemiological studies and meta-analysis have shown higher rates of depression and anxiety in patients with FND compared to the general population, but rates are similar to patients with other neurological disorders such as epilepsy or Parkinson's disease. This is often the case because of years of misdiagnosis and accusations of malingering. Multiple sclerosis has some overlapping symptoms with FND, potentially a source of misdiagnosis. Prevalence Dissociative (non-epileptic) seizures account for about 1 in 7 referrals to neurologists after an initial seizure, and functional weakness has a similar prevalence to multiple sclerosis. Treatment Treatment requires a firm and transparent diagnosis based on positive features which both health professionals and patients can feel confident about. It is essential that the health professional confirms that this is a common problem which is genuine, not imagined and not a diagnosis of exclusion. A multi-disciplinary approach to treating functional neurological disorder is recommended. Treatment options can include: Medication such as sleeping tablets, painkillers, anti-epileptic medications and anti-depressants (for patients with depression co-morbid or for pain relief) Cognitive behavior therapy (CBT) can help a person modify their thought patterns to change emotions, mood, or behavior Physiotherapy and occupational therapy Physiotherapy with someone who understands functional disorders may be the initial treatment of choice for patients with motor symptoms such as weakness, gait (walking) disorder and movement disorders. Nielsen et al. have reviewed the medical literature on physiotherapy for functional motor disorders up to 2012 and concluded that the available studies, although limited, mainly report positive results. For many patients with FND, accessing treatment can be difficult. Availability of expertise is limited and they may feel that they are being dismissed or told 'it's all in your head' especially if psychological input is part of the treatment plan. Some medical professionals are uncomfortable explaining and treating patients with functional symptoms. Changes in the diagnostic criteria, increasing evidence, literature about how to make the diagnosis and how to explain it and changes in medical training is slowly changing this. People with functional or dissociative seizures should try to identify warning signs and learn techniques to avoid harm or injury during and after the seizure. Be aware that relapses and flare-ups often recur, despite treatment. Controversy There was historically much controversy surrounding the FND diagnosis. Many doctors continue to believe that all FND patients have unresolved traumatic events (often of a sexual nature) which are being expressed in a physical way. However, some doctors do not believe this to be the case. Wessely and White have argued that FND may merely be an unexplained somatic symptom disorder. FND remains a stigmatized condition in the healthcare setting. References Further reading Neurological disorders

Mental health literacy

Mental health literacy has been defined as "knowledge and beliefs about mental disorders which aid their recognition, management and prevention. Mental health literacy includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking". The concept of mental health literacy was derived from health literacy, which aims to increase patient knowledge about physical health, illnesses, and treatments. Framework Mental health literacy has three major components: recognition, knowledge, and attitudes. A conceptual framework of mental health literacy illustrates the connections between components, and each is conceptualized as an area to target for measurement or intervention. While some researchers have focused on a single component, others have focused on multiple and/or the connection between components. For example, a researcher may focus solely on improving recognition of disorders through an education program, whereas another researcher may focus on integrating all three components into one program. Recognition Recognition can be broken down into symptom or illness recognition. Symptom recognition is the ability to detect beliefs, behaviors, and other physical manifestations of mental illness, without knowing explicitly which disorder they link to. Specific illness recognition is the ability to identify the presentation of a disorder, such as major depressive disorder. The recognition of difference between knowledge and attitudes is a crucial part of the mental health literacy framework. While some efforts have focused on promoting knowledge, other researchers have argued that changing attitudes by reducing stigma is a more prolific way of creating meaningful change in mental healthcare utilization. Overall, both approaches have benefits for improving outcomes. Knowledge Knowledge is the largest component of mental health literacy, and important topics in Mental Health include: How to get information: the networks and systems individuals use to get information about mental disorders. This may include friends, family, educators, or broader sources, such as entertainment or social media. Risk factors: what factors put individuals at greatest risk for specific mental health disorders. Risk factors can be unemployment, low income, lack of education, discrimination, and violence. Causes of mental disorders Self-treatment or self-help: what are the best individuals can do to help themselves recover without consulting with professionals, including the use of self-help books and media. Although many self- treatments are quite ineffective and even harmful due to lack of knowledge. Professional help: where to get professional help and/or what professional help is available. Attitudes Attitudes are studied in two sub-components: attitudes about mental disorders, or persons with mental disorders, and attitudes about seeking professional help or treatment. Attitudes can vary greatly by individual, and can often be difficult to measure or target with intervention. Nonetheless, a large body of research literature exists on both sub-components, though not always explicitly tied to the mental health literacy. Recent research recognizes the varying attitudes across mental health professionals towards prognosis, long-term outcomes and likelihood of discrimination as more negative than those of the public. The attitudes of mental health professionals also differ towards interventions, but this variability is usually related to professional orientation. Public outlook Surveys of the public have been carried out in a number of countries to investigate mental health literacy. These surveys demonstrate that the recognition of mental disorders is lacking and reveal negative beliefs about some standard psychiatric treatments, particularly medications. On the other hand, psychological, complementary and self-help methods are viewed much more positively. The public tends to prefer self-help and lifestyle interventions, opposed to medical, and psychopharmacological interventions. Implications surrounding public attitudes towards mental disorders include negative Stereotypes, Prejudice, or Stigma. As a result, this can influence help-seeking behavior or failure to seek treatment. In Canada, a national survey found that young adult males tend to manage their problems individually and are less likely to seek formal help. Media influence plays a huge role in perpetuating negative mindsets towards mental illness, such as prescribing menacing qualities. A recent study highlights how the majority of participants note the media as the primary source of their beliefs about mental illness being associated with violence, and how this attitude is more prevalent towards serious mental illnesses. Fear and perceptions of danger related to mental illness have increased over the past few decades, largely due to serious mental illness such as schizophrenia being associated as potentially violent and harmful to others. These beliefs and attitudes are potential barriers to seeking individual professional help, and being supportive of others. Additionally, the negative stigma against mental health may impede the ability of some to get help. When a caregiver avoids seeking mental health treatment due to fear of the stigma surrounding the label of a mental illness, it is seen as affiliate stigma. This phenomenon is exacerbated in scenarios where children who present with signs of mental illness have parents who hold negative beliefs about mental illness. Studies found that individuals that have a negative impression of mental health labels might refuse seeking treatment for themselves or their children in order to avoid mental illness label. A study in 2015 found that affiliate stigma decreases a parent's willingness to pursue mental health treatment for their children, which can lead to decreases in overall well-being for children. This same study found that some parents fear that general practitioners will judge them as bad parents if their children are diagnosed with ADHD. A case study from a supplement to the 2001 US Surgeon General’s report on mental health in America shows an example of low mental health literacy and/or fear of the stigma of mental illness: "An was a 30-year-old bilingual, Vietnamese male who was placed in involuntary psychiatric hold for psychotic disorganization. After neighbors found him screaming and smelling of urine and feces, they called the police, who escorted him to a psychiatric emergency room… His parents had a poor understanding of schizophrenia and were extremely distrustful of mental health providers. They thought that his psychosis was caused by mental weakness and poor tolerance of the recent heat wave…These misconceptions and differences in beliefs caused the parents to avoid the use of mental health services" Affiliate stigma and lack of mental health literacy can cause harm in those suffering from mental illness. Military Along with schizophrenia, PTSD is also a highly stigmatized mental disorder that is often misunderstood, especially among the military community. Studies have found that there are various barriers to treatment that prevent many veterans from seeking treatment for PTSD and other mental disorders such as concerns that others will see them as "crazy", beliefs that treatment is ineffective or is simply not worth it, and beliefs that those with mental health problems cannot be relied upon. These beliefs about mental health and mental health treatment is more prevalent in the military community due to the culture of the military that places a strong emphasis on emotional toughness, self-control and stoicism. Though these values are useful in combat scenarios, they can serve as barriers to seeking treatment and treatment adherence. Measures Researchers have measured aspects of mental health literacy in several ways. Popular methodologies include vignette studies and achievement tests. Vignette studies measure mental health literacy by providing a brief, detailed story of an individual (or individuals) with a mental health problem, and ask participants questions to identify what problem the individual is experiencing, and at times, additional questions about how the individual can help themselves. Achievement tests measure mental health literacy on a continuum, such that higher scores on a test indicate greater overall knowledge or understanding of a concept. Achievement tests can be formatted using multiple-choice, true/false, or other quantitative scales. Various scales have been created to measure the various components of mental health literacy, though not all are validated. Mental health literacy has been measured across several populations, varying in age range, culture, and profession. Most studies have focused on adult and young adult populations, though improving literacy in children has been a focus of prevention efforts. Parental label avoidance can be measured by the Self-Stigma of Seeking Help Scale (SSOSH). Family empowerment is measured by the Family Empowerment Scale (FES). Limitations Low literacy within a population is a relevant concern, since at the most basic level, mental health literacy is linked to general literacy. Without this foundation, the beneficial effects of mental health literacy are challenging for those who face difficulties with reading and writing. Increased measures to increase literacy rates must be employed to empower and encourage the self-help components of mental health literacy. Populations can be diverse, which means barriers, such as cultural and social contexts, must be addressed. Within and across cultures, social, economic and political factors profoundly influence mental health. There are numerous environmental and socioeconomic determinants of mental health and mental illness, just as there are for physical health and physical illness. Social determinants of physical health including poverty, education and social support also serve as influencers. In order to encompass mental health literacy and diverse perspectives, further research in these areas are needed. Recognizing uncommon mental disorders is another hurdle that can disrupt mental health literacy within the public. Recent research shows that most studies are limited to identifying depression, generalized anxiety, and schizophrenia. In a recent Canadian study, most participants demonstrated good mental health literacy in regards to most mental health disorders, but a poor understanding of panic disorder. An increased awareness surrounding underrepresented or more uncommon mental disorders is needed to widen public knowledge. A concluding limitation is the lack of research on child mental health literacy, as the majority of studies focus on adults and adolescents. If caregivers are not educated on recognizing and supporting mental disorders, this could create confusion and result in delayed treatment or wrongful prognosis for dependents. A child mental health literacy (CMHL) initiative could be implemented to target all adults in the general population, as well as parents, teachers, health professionals and/or children themselves. Improvement approaches A number of approaches have been tried and suggested to improve mental health literacy, many of which have evidence of effectiveness. These include: Whole of community campaigns. Examples are beyondblue and the Compass Strategy in Australia, the Defeat Depression Campaign in the United Kingdom, and the Nuremberg Alliance Against Depression in Germany. School-based interventions. These include MindMatters and Mental Illness Education in Australia, and the Mental Health & High School Curriculum Guide in Canada Individual training programs. These include mental health first aid training and training in suicide prevention skills. Initiatives that encourage empowerment and choice would also be beneficial, such as web-based self-directed therapy. Websites and books aimed at the public. There is evidence that both websites and books can improve mental health literacy. However, the quality of information on websites can sometimes be low. Rapport between mental health professionals and clients. By creating a partnership, professionals can promote competence, informed choice, and comprehensible knowledge for all levels of understanding, such as translating research findings into simpler language. Family empowerment Children often must rely on their families in order to access mental health services leading to parents receiving an increasing amount of attention from mental health professionals in order to educate them on mental health. The status of family empowerment (FE) is composed of two dimensions: (a) levels of empowerment (family, knowledge, system and community) and (b) the manor that empowerment is expressed (such as attitudes, knowledge and behaviors). Studies have shown that FE is positively associated with healthy child functioning. FE also deals with an individual's belief in their ability to execute behaviors necessary to produce specific performance attainments, also called self-efficacy, specifically regarding attaining knowledge of mental health. A study conducted in 2022 found that increased parent self-efficacy regarding mental health is positively correlated with child well-being outcomes. Sports Mental health literacy has also found its uses in the realm of sports. Sports social workers are promoting mental health literacy of athletes through various means. Social workers are engaging in research, education, policy development, advocating for individuals, organizing communities, and through direct practice. See also Mental health first aid Psychological literacy References Mental disorders Health education

Euthymia (medicine)

In psychiatry and psychology, euthymia is a normal, tranquil mental state or mood. In those with bipolar disorder, euthymia is a stable mental state or mood that is neither manic nor depressive. Achieving euthymia is the goal of the treatment for bipolar patients. Euthymia is also the “baseline” of other cyclical mood disorders like major depressive disorder (MDD), as well as borderline personality disorder (BPD) and narcissistic personality disorder (NPD). This state is the goal of psychiatric and psychological interventions. Etymology The term euthymia is derived from the Greek words eu and thymos . The word “thymos” also had four additional meanings: life energy; feelings and passions; desires and inclinations; and thought or intelligence. Euthymia is also derived from a verb, “euthymeo”, that means both “I am happy, in good spirits” and “I make others happy, I reassure and encourage”. This is the basis on which the first formal definition of euthymia was built. History Democritus, who coined the philosophical concept of euthymia, said that euthymia is achieved when "one is satisfied with what is present and available, taking little heed of people who are envied and admired and observing the lives of those who suffer and yet endure". This was later amended in the translation given by the Roman philosopher Seneca the Younger in which euthymia means a state of internal calm and contentment. Seneca was also the first to link the state of euthymia to a learning process; in order to achieve it, one must be aware of psychological well-being. Seneca’s definition included a caveat about detachment from current events. Later, the Greek biographer Plutarch removed this caveat with his definition which focused more on learning from adverse events. The traditional clinical concept of euthymia is an absence of disorder. This turns out to be insufficient: patients considered to be in remission are not displaying any symptoms meeting the threshold for diagnosis, but still have impairments in psychological well-being compared to healthy subjects. Expansion of clinical concept In 1958, Marie Jahoda gave a modern clinical definition of mental health in the terms of positive symptoms by outlining the criteria for mental health: "autonomy (regulation of behavior from within), environmental mastery, satisfactory interactions with other people and the milieu, the individual’s style and degree of growth, development or self-actualization, the attitudes of an individual toward his/her own self". In her definition she acknowledged the absence of disease as being necessary, but not enough, to constitute positive mental health, or euthymia. Carol Ryff (1989) was the first to develop a comprehensive scale that could assess euthymia: the six-factor model of psychological well-being. The 84-item scale includes facets of self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth. Garamoni et al (1991) described euthymia as having a balance between the positive and negative in six dimensions of cognition and affects similar to the Ryff factors. Having too much positivity in one factor is not euthymia: for example, a person with too little "purpose in life" would lack a sense of meaning in life, while one with too much would have unrealistic expectations and hopes. The concept of resilience (or, resistance to stress) was added again in the 2000s by authors in the field. Fava and Bech (2016)'s definition can be seen as a modern example: Lack of mood disturbances. As with the older clinical sense, full remission from past mood disorder. If there is any sadness, anxiety, or irritable mood, it should be short-lived and possible to be interrupted. Positive affects. Cheerfulness, relaxation, interest in things, plus restorative sleep. Psychological well-being. Flexibility (balance of psychic forces, similar to Garamoni), consistency (a unifying outlook on life), resillance (resistance to stress), and tolerance to anxiety and frustration. Medical applications of the expanded concept In 1987, Kellner R published the Symptom Questionaire, containging 24 items referring to positive feelings and 68 referring to the negative. With the inclusion of positive feelings such as relaxation and friendliness, the SQ was found to be more sensitive to the effects of psychotrophic medication. A number of other scales, such as the WHO-5, PWB, AAQ-II, CIE, have been developed to also measure the positive side of euthymia. Macro-analysis and micro-analysis are techniques used by clinicians to combine the assessments of psychological well-being and distress. Using both fields may offer more insight into the planning of treatment: for example, well-being therapy (WBT) can be used to help a patient self-observe and increase periods of well-being, while cognitive behavioral therapy (CBT) can be used to target distress. Other therapies that focus on aspects of well-being include mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT) which focus on flexibility, and the less-proven Pedasky and Mooney's strengths-based CBT and forgiveness therapy. A few clinical trials have been done using a sequential model, where patients who have responded to antidepressants are tapered off the drug and then given a combination cognitive-wellbeing therapy. Although the results have been impressive with regard to relapse rates, it is unclear how much is due to this added well-being component. In a different trial setup, anxiety patients who have responded to behavioral theapy and mood disorder patients who have responded to medication are assigned to either CBT or WBT for residual symptoms. While both achieved a significant reduction of symptoms, WBT provided more benefit in terms of observer rating and PWB scores. WBT may also be applicable to cyclothymic disorder. MBCT seem to be an effective add-on to treatment-as-usual in treatment-resistant depression. Related terms Parathymia, on the other hand, is related to pathological laughter (called “Witzelsucht”). See also Cyclothymia Hyperthymia Dysphoria Euphoria Euthymia (philosophy) Hypomania Major depressive disorder Mania Quality of life References Happiness Medical signs

Functional medicine

Functional medicine (FM) is a form of alternative medicine that encompasses a number of unproven and disproven methods and treatments. It has been described as pseudoscience, quackery, and at its essence a rebranding of complementary and alternative medicine. In the United States, FM practices have been ruled ineligible for course credits by the American Academy of Family Physicians because of concerns they may be harmful. Functional medicine was created by Jeffrey Bland, who founded The Institute for Functional Medicine (IFM) in the early 1990s as part of one of his companies, HealthComm. IFM, which promotes functional medicine, became a registered non-profit in 2001. Mark Hyman became an IFM board member and prominent promoter. Description David Gorski has written that FM is not well-defined and performs "expensive and generally unnecessary tests". Gorski says FM's vagueness is a deliberate tactic that makes functional medicine difficult to challenge. Proponents of functional medicine oppose established medical knowledge and reject its models, instead adopting a model of disease based on the notion of "antecedents", "triggers", and "mediators". These are meant to correspond to the underlying causes of health issues, the immediate causes, and the particular characteristics of a person's illness. A functional medicine practitioner devises a "matrix" from these factors to serve as the basis for treatment. Treatments, practices, and concepts are generally not supported by medical evidence. Reception FM practitioners claim to diagnose and treat conditions that have been found by research studies not to exist, such as adrenal fatigue and numerous imbalances in body chemistry. For instance, contrary to scientific evidence, Joe Pizzorno, a major figure in FM, claimed that 25% of people in the United States have heavy metal poisoning and need to undergo detoxification. Many scientists state that such detox supplements are a waste of time and money. Detox has been also called "mass delusion". In 2014, the American Academy of Family Physicians withdrew course credits for functional medicine courses, having identified some of its treatments as "harmful and dangerous". In 2018, it partly lifted the ban, but only to allow overview classes, not to teach its practice. The opening of centers for functional medicine at the Cleveland Clinic and George Washington University was described by David Gorski as an "unfortunate" example of quackery infiltrating academic medical centers. References Further reading Pseudoscience Alternative medicine Health fraud

Dysexecutive syndrome

Dysexecutive syndrome (DES) consists of a group of symptoms, usually resulting from brain damage, that fall into cognitive, behavioural and emotional categories and tend to occur together. The term was introduced by Alan Baddeley to describe a common pattern of dysfunction in executive functions, such as planning, abstract thinking, flexibility and behavioural control. It is thought to be Baddeley's hypothesized working memory system and the central executive that are the hypothetical systems impaired in DES. The syndrome was once known as frontal lobe syndrome; however 'dysexecutive syndrome' is preferred because it emphasizes the functional pattern of deficits (the symptoms) over the location of the syndrome in the frontal lobe, which is often not the only area affected. Symptoms and signs Symptoms of DES fall into three broad categories: cognitive, emotional and behavioural. Many of the symptoms can be seen as a direct result of impairment to the central executive component of working memory, which is responsible for attentional control and inhibition. Although many of the symptoms regularly co-occur, it is common to encounter patients who have several, but not all symptoms. The accumulated effects of the symptoms have a large impact on daily life. Cognitive symptoms Cognitive symptoms refer to a person's ability to process thoughts. Cognition primarily refers to memory, the ability to learn new information, speech, and reading comprehension. Deficits within this area cause many problems with everyday life decisions. One of the main difficulties for an individual with DES is planning and reasoning. Impaired planning and reasoning affect the individual's ability to realistically assess and manage the problems of everyday living. New problems and situations may be especially poorly handled because of the inability to transfer previous knowledge to the new event. An individual that has DES may have a short attention span due to impairment in attentional control. This may alter the individual's ability to focus, and as such have difficulty with reading and following a storyline or conversation. For instance, they can easily lose track of conversations which can make it difficult to hold a meaningful conversation and may result in avoiding social interactions. Individuals with DES will have very poor working memory and short term memory due to executive dysfunction. The dysfunction can range from mild and subtle to severe and obvious. There is a tremendous variability in the manifestations of executive dysfunction with strong influences often apparent from the affected person's personality, life experiences and intellect. Individuals with DES may experience confabulation, which is the spontaneous reporting of events that never happened. This can affect their autobiographical memory. It is thought that patients may not be able to assess the accuracy of memory retrieval and therefore elaborate on implausible memories. Individuals with dementia, delirium or other severe psychiatric illnesses combined with DES often have disturbed sleep patterns. Some will not recognize that it is night-time and may become upset when someone tries to correct them. Emotional symptoms The emotional symptoms that individuals with DES experience may be quite extreme and can cause extensive problems. They may have difficulty inhibiting many types of emotions such as anger, excitement, sadness, or frustration. Due to multiple impairments of cognitive functioning, there can be much more frustration when expressing certain feelings and understanding how to interpret everyday situations. Individuals with DES may have higher levels of aggression or anger because they lack abilities that are related to behavioural control. They can also have difficulty understanding others' points of view, which can lead to anger and frustration. Behavioural symptoms Behavioural symptoms are evident through an individual's actions. People with DES often lose their social skills because their judgments and insights into what others may be thinking are impaired. They may have trouble knowing how to behave in group situations and may not know how to follow social norms. The central executive helps control impulses; therefore when impaired, patients have poor impulse control. This can lead to higher levels of aggression and anger. DES can also cause patients to appear self-centered and stubborn. Utilization behaviour is when a patient automatically uses an object in the appropriate manner, but at an inappropriate time. For example, if a pen and paper are placed in front of an individual with DES they will start to write or if there is a deck of cards they will deal them out. Patients showing this symptom will begin the behaviour in the middle of conversations or during auditory tests. Utilization behaviour is thought to occur because an action is initiated when an object is seen, but patients with DES lack the central executive control to inhibit acting it out at inappropriate times. Perseveration is also often seen in patients with DES. Perseveration is the repetition of thoughts, behaviours, or actions after they have already been completed. For instance, continually blowing out a match, after it is no longer lit is an example of perseveration behaviour. There are three types of perseveration: continuous perseveration, stuck-in-set perseveration, and recurrent perseveration. Stuck-in-set perseveration is most often seen in dysexecutive syndrome. This type of perseveration refers to when a patient cannot get out of a specific frame of mind, such as when asked to name animals they can only name one. If you ask them to then name colours, they may still give you animals. Perseveration may explain why some patients appear to have obsessive-compulsive disorder. Comorbid disorders DES often occurs with other disorders, which is known as comorbidity. Many studies have examined the presence of DES in patients with schizophrenia. Results of schizophrenic patients on the Behavioural Assessment of the Dysexecutive Syndrome (BADS) test (discussed below) are comparable to brain injured patients. Further, results of BADS have been shown to correlate with phases of schizophrenia. Patients in the chronic phase of the disorder have significantly lower scores than those who are acute. This is logical due to the similarities in executive disruptions that make everyday life difficult for those with schizophrenia and symptoms that form DES. Patients with Alzheimer's disease and other forms of dementia have been shown to exhibit impairment in executive functioning as well. The effects of DES symptoms on the executive functions and working memory, such as attentiveness, planning and remembering recently learned things, are some of the earliest indicators of Alzheimer's disease and dementia with Lewy bodies. Studies have also indicated that chronic alcoholism (see Korsakoff's syndrome) can lead to a mild form of DES according to results of BADS. Causes The most frequent cause of the syndrome is brain damage to the frontal lobe. Brain damage leading to the dysexecutive pattern of symptoms can result from physical trauma such as a blow to the head or a stroke or other internal trauma. It is important to note that frontal lobe damage is not the only cause of the syndrome. It has been shown that damage, such as lesions, in other areas of the brain may indirectly affect executive functions and lead to similar symptoms (such as ventral tegmental area, basal ganglia and thalamus). There is not one specific pattern of damage that leads to DES, as multiple affected brain structures and locations have led to the symptoms. This is one reason why the term frontal lobe syndrome is not preferred. Diagnosis Assessment of patients with DES can be difficult because traditional tests generally focus on one specific problem for a short period of time. People with DES can do fairly well on these tests because their problems are related to integrating individual skills into everyday tasks. The lack of everyday application of traditional tests is known as low ecological validity. Behavioural The Behavioural Assessment of the Dysexecutive Syndrome (BADS) was designed to address the problems of traditional tests and evaluate the everyday problems arising from DES. BADS is designed around six subtests and ends with the Dysexecutive Questionnaire (DEX). These tests assess executive functioning in more complex, real-life situations, which improves their ability to predict day-to-day difficulties of DES. The six tests are as follows: Rule Shift Cards - Assesses the subject's ability to ignore a prior rule after being given a new rule to follow. Action Program - This test requires the use of problem solving to accomplish a new, practical task. Key Search - This test reflects the real-life situation of needing to find something that has been lost. It assesses the patient's ability to plan how to accomplish the task and monitor their own progress. Temporal Judgment - Patients are asked to make estimated guesses to a series of questions such as, "how fast do racehorses gallop?". It tests the ability to make sensible guesses. Zoo Map - Tests the ability to plan while following a set of rules. Modified Six Elements - This test assesses the subject's ability to plan, organize and monitor behaviour. The Dysexecutive Questionnaire (DEX) is a 20-item questionnaire designed to sample emotional, motivational, behavioural and cognitive changes in a subject with DES. One version is designed for the subject to complete and another version is designed for someone who is close to the individual, such as a relative or caregiver. Instructions are given to the participant to read 20 statements describing common problems of everyday life and to rate them according to their personal experience. Each item is scored on a 5-point scale according to its frequency from never (0 point) to very often (4 points). Treatment There is no cure for individuals with DES, but there are therapies to help them cope with their symptoms. DES can affect a number of functions in the brain and vary from person to person. Because of this variance, it is suggested that the most successful therapy would include multiple methods. Researchers suggest that a number of factors in the executive functioning need to be improved, including self-awareness, goal setting, planning, self-initiation, self-monitoring, self-inhibition, flexibility, and strategic behaviour. One method for individuals to improve in these areas is to help them plan and carry out actions and intentions through a series of goals and sub-goals. To accomplish this, therapists teach patients a three-step model called the General Planning Approach. The first step is Information and Awareness, in which the patients are taught about their own problems and shown how this affects their lives. The patients are then taught to monitor their executive functions and begin to evaluate them. The second stage, Goal Setting and Planning, consists of patients making specific goals, as well as devising a plan to accomplish them. For example, patients may decide they will have lunch with a friend (their goal). They are taught to write down which friend it may be, where they are going for lunch, what time they are going, how they will get there, etc. (sub-goals). They are also taught to make sure the steps go in the correct order. The final stage, named Initiation, Execution, and Regulation, requires patients to implement their goals in their everyday lives. Initiation can be taught through normal routines. The first step can cue the patient to go to the next step in their plan. Execution and regulation are put into action with reminders of how to proceed if something goes wrong in the behavioural script. This treatment method has resulted in improved daily executive functioning, however no improvements were seen on formal executive functioning tests. Since planning is needed in many activities, different techniques have been used to improve this deficit in patients with DES. Autobiographical memories can be used to help direct future behaviour. You can draw on past experiences to know what to do in the future. For example, when you want to take a bus, you know from past experience that you have to walk to the bus stop, have the exact amount of change, put the change in the slot, and then you can go find a seat. Patients with DES seem to not be able to use this autobiographical memory as well as a normal person. Training for DES patients asks them to think of a specific time when they did an activity previously. They are then instructed to think about how they accomplished this activity. An example includes "how would you plan a holiday". Patients are taught to think of specific times they went on a holiday and then to think how they may have planned these holidays. By drawing on past experiences patients were better able to make good decisions and plans. Cognitive Analytic Therapy (CAT) has also been used to help those with DES. Because individuals with this syndrome have trouble integrating information into their actions it is often suggested that they have programmed reminders delivered to a cell phone or pager. This helps them remember how they should behave and discontinue inappropriate actions. Another method of reminding is to have patients write a letter to themselves. They can then read the letter whenever they need to. To help patients remember how to behave, they may also create a diagram. The diagram helps organize their thoughts and shows the patient how they can change their behaviour in everyday situations. The use of auditory stimuli has been examined in the treatment of DES. The presentation of auditory stimuli causes an interruption in current activity, which appears to aid in preventing "goal neglect" by increasing the patients' ability to monitor time and focus on goals. Given such stimuli, subjects no longer performed below their age group average IQ. Controversy Some researchers have suggested that DES is mislabelled as a syndrome because it is possible for the symptoms to exist on their own. Also, there is not a distinct pattern of damage that leads to the syndrome. Not all patients with frontal lobe damage have DES and some patients with no damage at all to the frontal lobe exhibit the necessary pattern of symptoms. This has led research to investigate the possibility that executive functioning is broken down into multiple processes that are spread throughout the frontal lobe. Further disagreement comes from the syndrome being based on Baddeley and Hitch's model of working memory and the central executive, which is a hypothetical construct. The vagueness of some aspects of the syndrome has led researchers to test for it in a non-clinical sample. The results show that some dysexecutive behaviours are part of everyday life, and the symptoms exist to varying degrees in everyone. For example, absent-mindedness and lapses in attention are common everyday occurrences for most people. However, for the majority of the population such inattentiveness is manageable, whereas patients with DES experience it to such a degree that daily tasks become difficult. See also ADHD Executive dysfunction FASD Schizophrenia References Neurobiological brain disorders Syndromes affecting the nervous system Frontal lobe

Lunatic asylum

The lunatic asylum, insane asylum or mental asylum was an institution where people with mental illness were confined. It was an early precursor of the modern psychiatric hospital. Modern psychiatric hospitals evolved from and eventually replaced the older lunatic asylum. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint. The discovery of anti-psychotic drugs and mood-stabilizing drugs resulted in a shift in focus from containment in lunatic asylums to treatment in psychiatric hospitals. Later, there was further and more thorough critique in the form of the deinstitutionalization movement which focuses on treatment at home or in less isolated institutions. History Medieval era In the Islamic world, the Bimaristans were described by European travellers, who wrote about their wonder at the care and kindness shown to lunatics. In 872, Ahmad ibn Tulun built a hospital in Cairo that provided care to the insane, which included music therapy. Nonetheless, British historian of medicine Roy Porter cautioned against idealising the role of hospitals generally in medieval Islam, stating that "They were a drop in the ocean for the vast population that they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession." In Europe during the medieval era, a small subsection of the population of those considered mad were housed in a variety of institutional settings. Mentally ill people were often held captive in cages or kept up within the city walls, or they were compelled to amuse members of courtly society. Porter gives examples of such locales where some of the insane were cared for, such as in monasteries. A few towns had towers where madmen were kept (called Narrentürme in German, or "fools' towers"). The ancient Parisian hospital Hôtel-Dieu also had a small number of cells set aside for lunatics, whilst the town of Elbing boasted a madhouse, the Tollhaus, attached to the Teutonic Knights' hospital. Dave Sheppard's Development of Mental Health Law and Practice begins in 1285 with a case that linked "the instigation of the devil" with being "frantic and mad". In Spain, other such institutions for the insane were established after the Christian Reconquista; facilities included hospitals in Valencia (1407), Zaragoza (1425), Seville (1436), Barcelona (1481) and Toledo (1483). In London, England, the Priory of Saint Mary of Bethlehem, which later became known more notoriously as Bedlam, was founded in 1247. At the start of the 15th century, it housed six insane men. The former lunatic asylum, Het Dolhuys, established in the 16th century in Haarlem, the Netherlands, has been adapted as a museum of psychiatry, with an overview of treatments from the origins of the building up to the 1990s. Emergence of public lunatic asylums The level of specialist institutional provision for the care and control of the insane remained extremely limited at the turn of the 18th century. Madness was seen principally as a domestic problem, with families and parish authorities in Europe and England central to regimens of care. Various forms of outdoor relief were extended by the parish authorities to families in these circumstances, including financial support, the provision of parish nurses and, where family care was not possible, lunatics might be 'boarded out' to other members of the local community or committed to private madhouses. Exceptionally, if those deemed mad were judged to be particularly disturbing or violent, parish authorities might meet the not inconsiderable costs of their confinement in charitable asylums such as Bethlem, in Houses of Correction or in workhouses. In the late 17th century, this model began to change, and privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded that Bethlem Royal Hospital, London had "below stairs a parlor, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in". Inmates who were deemed dangerous or disturbing were chained, but Bethlem was an otherwise open building. Its inhabitants could roam around its confines and possibly throughout the general neighborhood in which the hospital was situated. In 1676, Bethlem expanded into newly built premises at Moorfields with a capacity for 100 inmates. A second public charitable institution was opened in 1713, the Bethel in Norwich. It was a small facility which generally housed between twenty and thirty inmates. In 1728 at Guy's Hospital, London, wards were established for chronic lunatics. From the mid-eighteenth century the number of public charitably funded asylums expanded moderately with the opening of St Luke's Hospital in 1751 in Upper Moorfields, London; the establishment in 1765 of the Hospital for Lunatics at Newcastle upon Tyne; the Manchester Lunatic Hospital, which opened in 1766; the York Asylum in 1777 (not to be confused with the York Retreat); the Leicester Lunatic Asylum (1794), and the Liverpool Lunatic Asylum (1797). A similar expansion took place in the British American colonies. The Pennsylvania Hospital was founded in Philadelphia in 1751 as a result of work begun in 1709 by the Religious Society of Friends. A portion of this hospital was set apart for the mentally ill, and the first patients were admitted in 1752. Virginia is recognized as the first state to establish an institution for the mentally ill. Eastern State Hospital, located in Williamsburg, Virginia, was incorporated in 1768 under the name of the "Public Hospital for Persons of Insane and Disordered Minds" and its first patients were admitted in 1773. Trade in lunacy There was no centralised state response to “madness” in society in century Britain until the 19th century, however private madhouses proliferated there in 18th on a scale unseen elsewhere. References to such institutions are limited for the 17th century but it is evident that by the start of the 18th century, the so-called 'trade in lunacy' was well established. Daniel Defoe, an ardent critic of private madhouses, estimated in 1724 that there were fifteen then operating in the London area. Defoe may have exaggerated but exact figures for private metropolitan madhouses are available only from 1774, when licensing legislation was introduced: sixteen institutions were recorded. At least two of these, Hoxton House and Wood's Close, Clerkenwell, had been in operation since the 17th century. By 1807, the number had increased to seventeen. This limited growth in the number of London madhouses is believed likely to reflect the fact that vested interests, especially the College of Physicians, exercised considerable control in preventing new entrants to the market. Thus, rather than there being a proliferation of private madhouses in London, existing institutions tended to expand considerably in size. The establishments which increased most during the 18th century, such as Hoxton House, did so by accepting pauper patients rather than private, middle class, fee-paying patients. Significantly, pauper patients, unlike their private counterparts, were not subject to inspection under the 1774 legislation. Fragmentary evidence indicates that some provincial madhouses existed in Britain from at least the 17th century and possibly earlier. A madhouse at Kingsdown, Box, Wiltshire was opened during the 17th century. Further locales of early businesses include one at Guildford in Surrey which was accepting patients by 1700, one at Fonthill Gifford in Wiltshire from 1718, another at Hook Norton in Oxfordshire from about 1725, one at St Albans dating from around 1740, and a madhouse at Fishponds in Bristol from 1766. It is likely that many of these provincial madhouses, as was the case with the exclusive Ticehurst House, may have evolved from householders who were boarding lunatics on behalf of parochial authorities and later formalised this practice into a business venture. The vast majority were small in scale with only seven asylums outside London with in excess of thirty patients by 1800 and somewhere between ten and twenty institutions had fewer patients than this. Humanitarian reform During the Age of Enlightenment, attitudes began to change, in particular among the educated classes in Western Europe. “Mental illness” came to be viewed as a disorder that required some form of compassionate but clinical, “rational” treatment that would aid in the rehabilitation of the patient into a rational being. When the ruling monarch of the United Kingdom, George III, who had a mental disorder, experienced a remission in 1789, mental illness came to be seen as something which could be treated and cured. The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke. In 1792, Pinel became the chief physician at the Bicêtre Hospital in Le Kremlin-Bicêtre, near Paris. Before his arrival, inmates were chained in cramped cell-like rooms where there was poor ventilation, led by a man named Jackson 'Brutis' Taylor. Taylor was then killed by the inmates leading to Pinel's leadership. In 1797, Jean-Baptiste Pussin, the "governor" of mental patients at Bicêtre, first freed patients of their chains and banned physical punishment, although straitjackets could be used instead. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel argued that mental illness was the result of excessive exposure to social and psychological stresses, to heredity and physiological damage. Pussin and Pinel's approach was seen as remarkably successful, and they later brought similar reforms to a mental hospital in Paris for female patients, La Salpetrière. Pinel's student and successor, Jean Esquirol, went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to patients' pleas, menaces, or complaints. William Tuke led the development of a radical new type of institution in Northern England, following the death of a fellow Quaker in a local asylum in 1790. In 1796, with the help of fellow Quakers and others, he founded the York Retreat, where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centred around minimising restraints and cultivating rationality and moral strength. The entire Tuke family became known as founders of moral treatment. They created a family-style ethos, and patients performed chores to give them a sense of contribution. There was a daily routine of both work and leisure time. If patients behaved well, they were rewarded; if they behaved poorly, there was some minimal use of restraints or instilling of fear. The patients were told that treatment depended on their conduct. In this sense, the patient's moral autonomy was recognised. William Tuke's grandson, Samuel Tuke, published an influential work in the early 19th century on the methods of the retreat; Pinel's Treatise on Insanity had by then been published, and Samuel Tuke translated his term as "moral treatment". Tuke's Retreat became a model throughout the world for humane and moral treatment of patients with mental disorders. The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now the Institute of Living). Benjamin Rush of Philadelphia also promoted humane treatment of the insane outside dungeons and without iron restraints, as well as sought their reintegration into society. In 1792, Rush successfully campaigned for a separate ward for the insane at the Pennsylvania Hospital. His talk-based approach could be considered as a rudimentary form of modern occupational therapy, although most of his physical approaches have long been discredited, such as bleeding and purging, hot and cold baths, mercury pills, a "tranquilizing chair" and gyroscope. A similar reform was carried out in Italy by Vincenzo Chiarugi, who discontinued the use of chains on the inmates in the early 19th century. In the town of Interlaken, Johann Jakob Guggenbühl started a retreat for mentally disabled children in 1841. Institutionalisation The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many 'pauper lunatics'. Nine counties first applied, and the first public asylum opened in 1811 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem Hospital – its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions the inmates lived in. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, to focus on lunacy legislation reform. The commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act: the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. A national body for asylum superintendents – the Medico-Psychological Association – was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841. In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies, and, in 1839, he opened the first school for the "severely retarded". His method of treatment was based on the assumption that the "mentally deficient" did not suffer from disease. In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. Looking into the late 19th and early 20th century history of the Homewood Retreat of Guelph, Ontario, and the context of commitments to asylums in North America and Great Britain, Cheryl Krasnick Warsh states that "the kin of asylum patients were, in fact, the major impetus behind commitment, but their motivations were based not so much upon greed as upon the internal dynamics of the family, and upon the economic structure of western society in the 19th and early 20th centuries." Women in psychiatric institutions Based on her study of cases from the Homewood Retreat, Cheryl Krasnick Warsh concludes that "the realities of the household in late Victorian and Edwardian middle class society rendered certain elements—socially redundant women in particular—more susceptible to institutionalization than others." In the 18th to the early 20th century, women were sometimes institutionalised due to their opinions, their unruliness and their inability to be controlled properly by a primarily male-dominated culture. There were financial incentives too; before the passage of the Married Women's Property Act 1882, all of a wife's assets passed automatically to her husband. The men who were in charge of these women, either a husband, father or brother, could send these women to mental institutions, stating that they believed that these women were mentally ill because of their strong opinions. "Between the years of 1850–1900, women were placed in mental institutions for behaving in ways the male society did not agree with." These men had the last say when it came to the mental health of these women, so if they believed that these women were mentally ill, or if they simply wanted to silence the voices and opinions of these women, they could easily send them to mental institutions. This was an easy way to render them vulnerable and submissive. An early fictional example is Mary Wollstonecraft's posthumously published novel Maria: or, The Wrongs of Woman (1798), in which the title character is confined to an insane asylum when she becomes inconvenient to her husband. Real women's stories reached the public through court cases: Louisa Nottidge was abducted by male relatives to prevent her committing her inheritance and her life to live in a revivalist clergyman's intentional community. Wilkie Collins based his 1859 novel The Woman in White on this case, dedicating it to Bryan Procter, the Commissioner for Lunacy. A generation later, Rosina Bulwer Lytton, daughter of the women's rights advocate Anna Wheeler, was locked up by her husband Edward Bulwer-Lytton and subsequently wrote of this in A Blighted Life (1880). In 1887, journalist Nellie Bly had herself committed to the Blackwell's Island Insane Asylum in New York City, in order to investigate conditions there. Her account was published in the New York World newspaper, and in book form as Ten Days in a Mad-House. In 1902, Margarethe von Ende de, wife of the German arms manufacturer Friedrich Alfred Krupp, was consigned to an insane asylum by Kaiser Wilhelm II, a family friend, when she asked him to respond to reports of her husband's gay orgies on Capri. New practices In continental Europe, universities often played a part in the administration of the asylums. In Germany, many practising psychiatrists were educated in universities associated with particular asylums. However, because Germany remained a loosely bound conglomerate of individual states, it lacked a national regulatory framework for asylums. Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread in the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with—a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country. Hill's system was adapted, since Conolly was unable to supervise each attendant as closely as Hill had done. By September 1839, mechanical restraint was no longer required for any patient. William A. F. Browne (1805–1885) introduced activities for patients including writing, art, group activity and drama, pioneered early forms of occupational therapy and art therapy, and initiated one of the earliest collections of artistic work by patients, at Montrose Asylum. Rapid expansion By the end of the 19th century, national systems of regulated asylums for the mentally ill had been established in most industrialized countries. At the turn of the century, Britain and France combined had only a few hundred people in asylums, but by the end of the century this number had risen to the hundreds of thousands. The United States housed 150,000 patients in mental hospitals by 1904. Germany housed more than 400 public and private sector asylums. These asylums were critical to the evolution of psychiatry as they provided places of practice throughout the world. However, the hope that mental illness could be ameliorated through treatment during the mid-19th century was disappointed. Instead, psychiatrists were pressured by an ever-increasing patient population. The average number of patients in asylums in the United States jumped 927%. Numbers were similar in Britain and Germany. Overcrowding was rampant in France, where asylums would commonly take in double their maximum capacity. Increases in asylum populations may have been a result of the transfer of care from families and poorhouses, but the specific reasons as to why the increase occurred are still debated today. No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutions and the reputation of psychiatry in the medical world had hit an extreme low. In the 1800s, middle class facilities became more common, replacing private care for wealthier persons. However, facilities in this period were largely oversubscribed. Individuals were referred to facilities either by the community or by the criminal justice system. Dangerous or violent cases were usually given precedence for admission. A survey taken in 1891 in Cape Town, South Africa shows the distribution between different facilities. Out of 2046 persons surveyed, 1,281 were in private dwellings, 120 in jails and 645 in asylums, with men representing nearly two-thirds of the number surveyed. Defining someone as insane was a necessary prerequisite for being admitted to a facility. A doctor was only called after someone was labelled insane on social terms and had become socially or economically problematic. Until the 1890s, little distinction existed between the lunatic and criminal lunatic. The term was often used to police vagrancy as well as paupers and the insane. In the 1850s, lurid rumours that medical doctors were declaring normal people "insane" in Britain, were spread by the press causing widespread public anxiety. The fear was that people who were a source of embarrassment to their families were conveniently disposed of into asylums with the willing connivance of the psychiatric profession. This sensationalism appeared in widely read novels of the time, including The Woman in White. 20th century Physical therapies A series of radical physical therapies were developed in central and continental Europe in the late 1910s, the 1920s and most particularly, the 1930s. Among these, we may note the Austrian psychiatrist Julius Wagner-Jauregg's malarial therapy for general paresis of the insane (or neurosyphilis) first used in 1917, and for which he won a Nobel Prize in 1927. This treatment heralded the beginning of a radical and experimental era in psychiatric medicine that increasingly broke with an asylum-based culture of therapeutic nihilism in the treatment of chronic psychiatric disorders, most particularly dementia praecox (increasingly known as schizophrenia from the 1910s, although the two terms were used more or less interchangeably until at least the end of the 1930s), which were typically regarded as hereditary degenerative disorders and therefore unamenable to any therapeutic intervention. Malarial therapy was followed in 1920 by barbiturate-induced deep sleep therapy to treat dementia praecox, which was popularised by the Swiss psychiatrist Jakob Klaesi. In 1933 the Vienna-based psychiatrist Manfred Sakel introduced insulin shock therapy, and in August 1934 Ladislas J. Meduna, a Hungarian neuropathologist and psychiatrist working in Budapest, introduced cardiazol shock therapy (cardiazol is the tradename of the chemical compound pentylenetetrazol, known by the tradename metrazol in the United States), which was the first convulsive or seizure therapy for a psychiatric disorder. Again, both of these therapies were initially targeted at curing dementia praecox. Cardiazol shock therapy, founded on the theoretical notion that there existed a biological antagonism between schizophrenia and epilepsy and that therefore inducing epileptiform fits in schizophrenic patients might effect a cure, was superseded by electroconvulsive therapy (ECT), invented by the Italian neurologist Ugo Cerletti in 1938. The use of psychosurgery was narrowed to a very small number of people for specific indications. Egas Moniz performed the first leucotomy, or lobotomy in Portugal in 1935, which targets the brain's frontal lobes. This was shortly thereafter adapted by Walter Freeman and James W. Watts in what is known as Freeman–Watts procedure or the standard prefrontal lobotomy. From 1946, Freeman developed the transorbital lobotomy, using a device akin to an ice-pick. This was an "office" procedure which did not have to be performed in a surgical theatre and took as little as fifteen minutes to complete. Freeman is credited with the popularisation of the technique in the United States. In 1949, 5,074 lobotomies were carried out in the United States and by 1951, 18,608 people had undergone the controversial procedure in that country. One of the most famous people to have a lobotomy was the sister of John F. Kennedy, Rosemary Kennedy, who was rendered profoundly intellectually disabled as a result of the surgery. In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", although the insulin shock therapy was still seen as the only option which produced any noticeable effect on patients. ECT is still used in the West in the 21st century, but it is seen as a last resort for treatment of mood disorders and is administered much more safely than in the past. Elsewhere, particularly in India, use of ECT is reportedly increasing, as a cost-effective alternative to drug treatment. The effect of a shock on an overly excitable patient often allowed these patients to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution to institutionalisation. Lobotomies were performed in the thousands from the 1930s to the 1950s, and were ultimately replaced with modern psychotropic drugs. Eugenics movement The eugenics movement of the early 20th century led to a number of countries enacting laws for the compulsory sterilization of the "feeble minded", which resulted in the forced sterilization of numerous psychiatric inmates. As late as the 1950s, laws in Japan allowed the forcible sterilization of patients with psychiatric illnesses. Under Nazi Germany, the Aktion T4 euthanasia program resulted in the killings of thousands of the mentally ill housed in state institutions. In 1939, the Nazis secretly began to exterminate the mentally ill in a euthanasia campaign. Around 6,000 disabled babies, children and teenagers were murdered by starvation or lethal injection. Psychiatric internment as a political device Psychiatrists around the world have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience. Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials. In Nazi Germany in the 1940s, the 'duty to care' was violated on an enormous scale: A reported 300,000 individuals were sterilised and 100,000 killed in Germany alone, as were many thousands further afield, mainly in Eastern Europe. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia and Yugoslavia. A "mental health genocide" reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era. A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China. Drugs The 20th century saw the development of the first effective psychiatric drugs. The first anti-psychotic drug, chlorpromazine (known under the trade name Largactil in Europe and Thorazine in the United States), was first synthesized in France in 1950. Pierre Deniker, a psychiatrist of the Saint-Anne Psychiatric Center in Paris, is credited with first recognising the specificity of action of the drug in psychosis in 1952. Denier traveled with a colleague to the United States and Canada promoting the drug at medical conferences in 1954. The first publication regarding its use in North America was made in the same year by the Canadian psychiatrist Heinz Lehmann, who was based in Montreal. Also in 1954 another antipsychotic, reserpine, was first used by an American psychiatrist based in New York, Nathan S. Kline. At a Paris-based colloquium on neuroleptics (antipsychotics) in 1955 a series of psychiatric studies were presented by, among others, Hans Hoff (Vienna), Dr. Ihsan Aksel (Istanbul), Felix Labarth (Basle), Linford Rees (London), Sarro (Barcelona), Manfred Bleuler (Zurich), Willi Mayer-Gross (Birmingham), Winford (Washington) and Denber (New York) attesting to the effective and concordant action of the new drugs in the treatment of psychosis. The new antipsychotics had an immense impact on the lives of psychiatrists and patients. For instance, Henri Ey, a French psychiatrist at Bonneval, related that between 1921 and 1937 only 6% of patients with schizophrenia and chronic delirium were discharged from his institution. The comparable figure for the period from 1955 to 1967, after the introduction of chlorpromazine, was 67%. Between 1955 and 1968 the residential psychiatric population in the United States dropped by 30%. Newly developed antidepressants were used to treat cases of depression, and the introduction of muscle relaxants allowed ECT to be used in a modified form for the treatment of severe depression and a few other disorders. The discovery of the mood stabilizing effect of lithium carbonate by John Cade in 1948 would eventually revolutionise the treatment of bipolar disorder, although its use was banned in the United States until the 1970s. United States: reform in the 1940s From 1942 to 1947, conscientious objectors in the US assigned to psychiatric hospitals under Civilian Public Service exposed abuses throughout the psychiatric care system and were instrumental in reforms of the 1940s and 1950s. The CPS reformers were especially active at the Philadelphia State Hospital where four Quakers initiated The Attendant magazine as a way to communicate ideas and promote reform. This periodical later became The Psychiatric Aide, a professional journal for mental health workers. On 6 May 1946, Life magazine printed an exposé of the psychiatric system by Albert Q. Maisel based on the reports of COs. Another effort of CPS, namely the Mental Hygiene Project, became the national Mental Health Foundation. Initially skeptical about the value of Civilian Public Service, Eleanor Roosevelt, impressed by the changes introduced by COs in the mental health system, became a sponsor of the National Mental Health Foundation and actively inspired other prominent citizens including Owen J. Roberts, Pearl Buck and Harry Emerson Fosdick to join her in advancing the organization's objectives of reform and humane treatment of patients. Deinstitutionalisation By the beginning of the 20th century, ever-increasing admissions had resulted in serious overcrowding. Funding was often cut, especially during periods of economic decline, and during wartime in particular many patients starved to death. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, and ill-treatment and abuse of patients. The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalisation came to the fore in various Western countries in the 1950s and 1960s. The prevailing public arguments, time of onset, and pace of reforms varied by country. Class action lawsuits in the United States, and the scrutiny of institutions through disability activism and antipsychiatry, helped expose the poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion and disability, causing people to be institutionalised. There was an argument that community services would be cheaper. It was suggested that new psychiatric medications made it more feasible to release people into the community. There were differing views on deinstitutionalization, however, in groups such as mental health professionals, public officials, families, advocacy groups, public citizens and unions. Today Africa Uganda has one psychiatric hospital. South Africa currently has 27 registered psychiatric hospitals. These hospitals are spread throughout the country. Some of the most well-known institutions are: Weskoppies Psychiatric Hospital, colloquially known as Groendakkies ("Little Green Roofs") and Denmar Psychiatric Hospital in Pretoria, TARA in Johannesburg, and Valkenberg Hospital in Cape Town. Asia In Japan, the number of hospital beds has risen steadily over the last few decades. In Hong Kong, a number of residential care services such as half-way houses, long-stay care homes, and supported hostels are provided for the discharged patients. In addition, a number of community support services such as Community Rehabilitation Day Services, Community Mental Health Link, Community Mental Health Care, etc. have been launched to facilitate the re-integration of patients into the community. Europe Countries where deinstitutionalisation has happened may be experiencing a process of "re-institutionalisation" or relocation to different institutions, as evidenced by increases in the number of supported housing facilities, forensic psychiatric beds and rising numbers in the prison population. New Zealand New Zealand established a reconciliation initiative in 2005 in the context of ongoing compensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. The forum heard of poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate complaints mechanisms; pressures and difficulties for staff, within an authoritarian psychiatric hierarchy based on containment; fear and humiliation in the misuse of seclusion; over-use and abuse of ECT, psychiatric medication and other treatments/punishments, including group therapy, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice and emotional distress and trauma. There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, and advice on their rights, including access to records and legal redress. South America In several South American countries, the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings. United Kingdom At the beginning of the 19th century, there were, perhaps, a few thousand "lunatics" housed in a variety of disparate institutions; but, by the beginning of the 20th century, that figure had grown to about 100,000. This growth coincided with the development of "alienism," now known as psychiatry, as a medical specialty. United States The United States has experienced two waves of deinstitutionalization. Wave one began in the 1950s and targeted people with mental illness. The second wave began roughly fifteen years after and focused on individuals who had been diagnosed with a developmental disability (e.g. intellectual disability). A process of indirect cost-shifting may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant. In summer 2009, author and columnist Heather Mac Donald stated in City Journal, "jails have become society's primary mental institutions, though few have the funding or expertise to carry out that role properly... at Rikers, 28% of the inmates require mental health services, a number that rises each year." See also Deinstitutionalization History of mental disorders Kirkbride Plan Timeline of psychiatry History of psychiatric institutions in China List of asylums commissioned in England and Wales Ann Pratt References Further reading Michel Foucault, Histoire de la folie à l'âge classique, 1961, Gallimard, Tel, 688 p. Claude Quétel, Histoire de la folie : De l'Antiquité à nos jours, 2009, Editions Tallandier, Texto, 618 pages. Total institutions

History of mental disorders

Historically, mental disorders have had three major explanations, namely, the supernatural, biological and psychological models. For much of recorded history, deviant behavior has been considered supernatural and a reflection of the battle between good and evil. When confronted with unexplainable, irrational behavior and by suffering and upheaval, people have perceived evil. In fact, in the Persian Empire from 550 to 330 B.C.E., all physical and mental disorders were considered the work of the devil. Physical causes of mental disorders have been sought in history. Hippocrates was important in this tradition as he identified syphilis as a disease and was, therefore, an early proponent of the idea that psychological disorders are biologically caused. This was a precursor to modern psycho-social treatment approaches to the causation of psychopathology, with the focus on psychological, social and cultural factors. Well known philosophers like Plato, Aristotle, etc., wrote about the importance of fantasies, dreams, and thus anticipated, to some extent, the fields of psychoanalytic thought and cognitive science that were later developed. They were also some of the first to advocate for humane and responsible care for individuals with psychological disturbances. Ancient period There is archaeological evidence for the use of trepanation in around 6500 BC. Mesopotamia Mental illnesses were well known in ancient Mesopotamia, where diseases and mental disorders were believed to be caused by specific deities. Because hands symbolized control over a person, mental illnesses were known as "hands" of certain deities. One psychological illness was known as Qāt Ištar, meaning "Hand of Ishtar". Others were known as "Hand of Shamash", "Hand of the Ghost", and "Hand of the God". Descriptions of these illnesses, however, are so vague that it is usually impossible to determine which illnesses they correspond to in modern terminology. Mesopotamian doctors kept detailed record of their patients' hallucinations and assigned spiritual meanings to them. A patient who hallucinated that he was seeing a dog was predicted to die; whereas, if he saw a gazelle, he would recover. The royal family of Elam was notorious for its members frequently being insane. Erectile dysfunction was recognized as being rooted in psychological problems. Egypt Limited notes in an ancient Egyptian document known as the Ebers papyrus appear to describe the affected states of concentration, attention, and emotional distress in the heart or mind. Some of these were interpreted later, and renamed as hysteria and melancholy. Somatic treatments included applying bodily fluids while reciting magical spells. Hallucinogens may have been used as a part of the healing rituals. Religious temples may have been used as therapeutic retreats, possibly for the induction of receptive states to facilitate sleep and the interpretation of dreams. India Ancient Hindu scriptures-Ramayana and Mahabharata-contain fictional descriptions of depression and anxiety. Mental disorders were generally thought to reflect abstract metaphysical entities, supernatural agents, sorcery and witchcraft. The Charaka Samhita which is a part of the Hindu Ayurveda ("knowledge of life"), saw ill health as resulting from an imbalance among the three body fluids or forces called Tri-Dosha. These also affected the personality types among people. Suggested causes included inappropriate diet, disrespect towards the gods, teachers or others, mental shock due to excessive fear or joy, and faulty bodily activity. Treatments included the use of herbs and ointments, charms and prayers, and moral or emotional persuasion. In the Hindu epic Ramayana, the Dasharatha died from despondency, which Shiv Gautam states illustrates major depressive disorder. China The earliest known record of mental illness in ancient China dates back to 1100 B.C. Mental disorders were treated mainly under Traditional Chinese medicine using herbs, acupuncture or "emotional therapy". The Inner Canon of the Yellow Emperor described symptoms, mechanisms and therapies for mental illness, emphasizing connections between bodily organs and emotions. The ancient Chinese believed that demonic possession played a role in mental illness during this time period. They felt that areas of emotional outbursts, such as funeral homes, could open up the Wei Chi and allow entities to possess an individual. Trauma was also considered to be something that caused high levels of emotion. Thus, trauma is a possible catalyst for mental illness due to its ability to allow the Wei Chi open to possession. This explains why the ancient Chinese believed that a mental illness was, in reality, a demonic possession. According to Chinese thought, five stages or elements comprised the conditions of imbalance between yin and yang. Mental illness, according to the Chinese perspective, is thus considered an imbalance of the yin and yang because optimum health arises from balance with nature. China was one of the earliest developed civilizations in which medicine and attention to mental disorders were introduced (Soong, 2006). As in the West, Chinese views of mental disorders regressed to a belief in supernatural forces as causal agents. From the later part of the second century through the early part of the ninth century, ghosts and devils were implicated in "ghostevil" insanity, which presumably resulted from possession by evil spirits. The "Dark Ages" in China, however, were neither so severe (in terms of the treatment of mental patients) nor as long-lasting as in the West. A return to biological, somatic (bodily) views and an emphasis on psychosocial factors occurred in the centuries that followed. In recent history, China has been experiencing a broadening of ideas in mental health services and has been incorporating many ideas from Western psychiatry (Zhang & Lu, 2006). Greece and Rome In ancient Greece and Rome, madness was associated stereotypically with aimless wandering and violence. However, Socrates considered positive aspects including prophesying (a 'manic art'); mystical initiations and rituals; poetic inspiration; and the madness of lovers. Now often seen as the very epitome of rational thought and as the founder of philosophy, Socrates freely admitted to experiencing what are now called "command hallucinations" (then called his 'daemon'). Pythagoras also heard voices. Hippocrates (470–) classified mental disorders, including paranoia, epilepsy, mania and melancholia. Hippocrates mentions the practice of bloodletting in the fifth century BC. Through long contact with Greek culture, and their eventual conquest of Greece, the Romans absorbed many Greek (and other) ideas on medicine. The humoral theory fell out of favor in some quarters. The Greek physician Asclepiades (–40 BC), who practiced in Rome, discarded it and advocated humane treatments, and had insane persons freed from confinement and treated them with natural therapy, such as diet and massages. Arateus (–90 AD) argued that it is hard to pinpoint from where a mental illness comes. However, Galen (129–), practicing in Greece and Rome, revived humoral theory. Galen, however, adopted a single symptom approach rather than broad diagnostic categories, for example studying separate states of sadness, excitement, confusion and memory loss. Playwrights such as Homer, Sophocles and Euripides described madmen driven insane by the gods, imbalanced humors or circumstances. As well as the triad (of which mania was often used as an overarching term for insanity) there were a variable and overlapping range of terms for such things as delusion, eccentricity, frenzy, and lunacy. Roman encyclopedist Celsus argued that insanity is really present when a continuous dementia begins due to the mind being at the mercy of imaginings. He suggested that people must heal their own souls through philosophy and personal strength. He described common practices of dietetics, bloodletting, drugs, talking therapy, incubation in temples, exorcism, incantations and amulets, as well as restraints and "tortures" to restore rationality, including starvation, being terrified suddenly, agitation of the spirit, and stoning and beating. Most, however, did not receive medical treatment but stayed with family or wandered the streets, vulnerable to assault and derision. Accounts of delusions from the time included people who thought themselves to be famous actors or speakers, animals, inanimate objects, or one of the gods. Some were arrested for political reasons, such as Jesus ben Ananias who was eventually released as a madman after showing no concern for his own fate during torture. Israel and the Hebrew diaspora Passages of the Hebrew Bible/Old Testament have been interpreted as describing mood disorders in figures such as Job, King Saul and in the Psalms of David. In the Book of Daniel, King Nebuchadnezzar is described as temporarily losing his sanity. Mental disorder was not a problem like any other, caused by one of the gods, but rather caused by problems in the relationship between the individual and God. They believed that abnormal behavior was the result of possessions that represented the wrath and punishment from God. This punishment was seen as a withdrawal of God's protection and the abandonment of the individual to evil forces. From the beginning of the twentieth century, the mental health of Jesus is also discussed. Middle Ages Middle East Persian and Arabic scholars were heavily involved in translating, analyzing and synthesizing Greek texts and concepts. As the Muslim world expanded, Greek concepts were integrated with religious thought and over time, new ideas and concepts were developed. Arab texts from this period contain discussions of melancholia, mania, hallucinations, delusions, and other mental disorders. Mental disorder was generally connected to loss of reason, and writings covered links between the brain and disorders, and spiritual/mystical meaning of disorders. wrote about fear and anxiety, anger and aggression, sadness and depression, and obsessions. Authors who wrote on mental disorders and/or proposed treatments during this period include Al-Balkhi, Al-Razi, Al-Farabi, Ibn-Sina, Al-Majusi Abu al-Qasim al-Zahrawi, Averroes, and Najab ud-din Unhammad. Some thought mental disorder could be caused by possession by a djinn (devil), which could be either good or demon-like. There were sometimes beatings to exorcise the djin, or alternatively over-zealous attempts at cures. Islamic views often merged with local traditions. In Morocco the traditional Berber people were animists and the concept of sorcery was integral to the understanding of mental disorder; it was mixed with the Islamic concepts of djin and often treated by religious scholars combining the roles of holy man, sage, seer and sorcerer. The first bimaristan was founded in Baghdad in the 9th century, and several others of increasing complexity were created throughout the Arab world in the following centuries. Some of them contained wards dedicated to the care of mentally ill patients, most of whom had debilitating illnesses or exhibited violence. In the centuries to come, the Muslim world would eventually serve as a critical way station of knowledge for Renaissance Europe, through the Latin translations of many scientific Islamic texts. Ibn-Sina's (Avicenna's) Canon of Medicine became the standard of medical science in Europe for centuries, together with works of Hippocrates and Galen. Europe Conceptions of madness in the Middle Ages in Europe were a mixture of the divine, diabolical, magical and transcendental. Theories of the four humors (black bile, yellow bile, phlegm, and blood) were applied, sometimes separately (a matter of "physic") and sometimes combined with theories of evil spirits (a matter of "faith"). Arnaldus de Villanova (1235–1313) combined "evil spirit" and Galen-oriented "four humours" theories and promoted trephining as a cure to let demons and excess humours escape. Other bodily remedies in general use included purges, bloodletting and whipping. Madness was often seen as a moral issue, either a punishment for sin or a test of faith and character. Christian theology endorsed various therapies, including fasting and prayer for those estranged from God and exorcism of those possessed by the devil. Thus, although mental disorder was often thought to be due to sin, other more mundane causes were also explored, including intemperate diet and alcohol, overwork, and grief. The Franciscan friar Bartholomeus Anglicus ( – 1272) described a condition which resembles depression in his encyclopedia, De Proprietatibis Rerum, and he suggested that music would help. A semi-official tract called the Praerogativa regis distinguished between the "natural born idiot" and the "lunatic". The latter term was applied to those with periods of mental disorder; deriving from either Roman mythology describing people "moonstruck" by the goddess Luna or theories of an influence of the moon. Episodes of mass dancing mania are reported from the Middle Ages, "which gave to the individuals affected all the appearance of insanity". This was one kind of mass delusion or mass hysteria/panic that has occurred around the world through the millennia. The care of lunatics was primarily the responsibility of the family. In England, if the family were unable or unwilling, an assessment was made by crown representatives in consultation with a local jury and all interested parties, including the subject himself or herself. The process was confined to those with real estate or personal estate, but it encompassed poor as well as rich and took into account psychological and social issues. Those considered lunatics at the time probably had more support from their communities and families than those diagnosed with mental disorders today, since the focus now is primarily on providing professional medical support. As in other eras, visions were generally interpreted as meaningful spiritual and visionary insights; some may have been causally related to mental disorders, but since hallucinations were culturally supported they may not have had the same connections as today. Modern period Europe and the Americas 16th to 18th centuries Some mentally ill people may have been victims of the witch-hunts that spread in waves in early modern Europe. However, those judged insane were increasingly admitted to local workhouses, poorhouses and jails (particularly the "pauper insane") or sometimes to the new private madhouses. Restraints and forcible confinement were used for those thought dangerously disturbed or potentially violent to themselves, others or property. The latter likely grew out of lodging arrangements for single individuals (who, in workhouses, were considered disruptive or ungovernable) then there were a few catering each for only a handful of people, then they gradually expanded (e.g. 16 in London in 1774, and 40 by 1819). By the mid-19th century there would be 100 to 500 inmates in each. The development of this network of madhouses has been linked to new capitalist social relations and a service economy, that meant families were no longer able or willing to look after disturbed relatives. Madness was commonly depicted in literary works, such as the plays of Shakespeare. By the end of the 17th century and into the Enlightenment, madness was increasingly seen as an organic physical phenomenon, no longer involving the soul or moral responsibility. The mentally ill were typically viewed as insensitive wild animals. Harsh treatment and restraint in chains was seen as therapeutic, helping suppress the animal passions. There was sometimes a focus on the management of the environment of madhouses, from diet to exercise regimes to number of visitors. Severe somatic treatments were used, similar to those in medieval times. Madhouse owners sometimes boasted of their ability with the whip. Treatment in the few public asylums was also barbaric, often secondary to prisons. The most notorious was Bedlam where at one time spectators could pay a penny to watch the inmates as a form of entertainment. Concepts based in humoral theory gradually gave way to metaphors and terminology from mechanics and other developing physical sciences. Complex new schemes were developed for the classification of mental disorders, influenced by emerging systems for the biological classification of organisms and medical classification of diseases. The term "crazy" (from Middle English meaning cracked) and insane (from Latin insanus meaning unhealthy) came to mean mental disorder in this period. The term "lunacy", long used to refer to periodic disturbance or epilepsy, came to be synonymous with insanity. "Madness", long in use in root form since at least the early centuries AD, and originally meaning crippled, hurt or foolish, came to mean loss of reason or self-restraint. "Psychosis", from Greek "principle of life/animation", had varied usage referring to a condition of the mind/soul. "Nervous", from an Indo-European root meaning to wind or twist, meant muscle or vigor, was adopted by physiologists to refer to the body's electrochemical signaling process (thus called the nervous system), and was then used to refer to nervous disorders and neurosis. "Obsession", from a Latin root meaning to sit on or sit against, originally meant to besiege or be possessed by an evil spirit, came to mean a fixed idea that could decompose the mind. With the rise of madhouses and the professionalization and specialization of medicine, there was a considerable incentive for medical doctors to become involved. In the 18th century, they began to stake a claim to a monopoly over madhouses and treatments. Madhouses could be a lucrative business, and many made a fortune from them. There were some bourgeois ex-patient reformers who opposed the often brutal regimes, blaming both the madhouse owners and the medics, who in turn resisted the reforms. Towards the end of the 18th century, a moral treatment movement developed, that implemented more humane, psychosocial, and personalized approaches. Notable figures included the medic Vincenzo Chiarugi in Italy under Enlightenment leadership; the ex-patient superintendent Pussin and the psychologically inclined medic Philippe Pinel in revolutionary France; the Quakers in England, led by businessman William Tuke; and later, in the United States, campaigner Dorothea Dix. 19th century The 19th century, in the context of industrialization and population growth, saw a massive expansion of the number and size of insane asylums in every Western country, a process called "the great confinement" or the "asylum era". Laws were introduced to compel authorities to deal with those judged insane by family members and hospital superintendents. Although originally based on the concepts and structures of moral treatment, they became large impersonal institutions overburdened with large numbers of people with a complex mix of mental and social-economic problems. The success of moral treatment had cast doubt on the approach of medics, and many had opposed it, but by the mid-19th century many became advocates of it but argued that the mad also often had physical/organic problems so that both approaches were necessary. This argument has been described as an important step in the profession's eventual success in securing a monopoly on the treatment of lunacy. However, it is well documented that very little therapeutic activity occurred in the new asylum system, that medics were little more than administrators who seldom attended to patients, and then mainly for other physical problems. The "oldest forensic secure hospital in Europe" was opened in 1850 after Sir Thomas Freemantle introduced the bill that was to establish a Central Criminal Lunatic Asylum in Ireland on 19 May 1845. Clear descriptions of some syndromes, such as the condition that would later be termed schizophrenia, have been identified as relatively rare prior to the 19th century, although interpretations of the evidence and its implications are inconsistent. Numerous different classification schemes and diagnostic terms were developed by different authorities, taking an increasingly anatomical-clinical descriptive approach. The term "psychiatry" was coined as the medical specialty became more academically established. Asylum superintendents, later to be psychiatrists, were generally called "alienists" because they were thought to deal with people alienated from society; they adopted largely isolated and managerial roles in the asylums while milder "neurotic" conditions were dealt with by neurologists and general physicians, although there was overlap for conditions such as neurasthenia. In the United States it was proposed that black slaves who tried to escape had a mental disorder termed drapetomania. It was then argued in scientific journals that mental disorders were rare under conditions of slavery but became more common following emancipation, and later that mental illness in African Americans was due to evolutionary factors or various negative characteristics, and that they were not suitable for therapeutic intervention. By the 1870s in North America, officials who ran Lunatic Asylums renamed them Insane Asylums. By the late century, the term "asylum" had lost its original meaning as a place of refuge, retreat or safety, and was associated with abuses that had been widely publicized in the media, including by ex-patient organization the Alleged Lunatics' Friend Society and ex-patients like Elizabeth Packard. The relative proportion of the public officially diagnosed with mental disorders was increasing, however. This has been linked to various factors, including possibly humanitarian concern; incentives for professional status/money; a lowered tolerance of communities for unusual behavior due to the existence of asylums to place them in (this affected the poor the most); and the strain placed on families by industrialization. 20th century The turn of the 20th century saw the development of psychoanalysis, which came to the fore later. Kraepelin's classification gained popularity, including the separation of mood disorders from what would later be termed schizophrenia. Asylum superintendents sought to improve the image and medical status of their profession. Asylum "inmates" were increasingly referred to as "patients" and asylums renamed as hospitals. Referring to people as having a "mental illness" dates from this period in the early 20th century. In the United States, a "mental hygiene" movement, originally defined in the 19th century, gained momentum and aimed to "prevent the disease of insanity" through public health methods and clinics. The term mental health became more popular, however. Clinical psychology and social work developed as professions alongside psychiatry. Theories of eugenics led to compulsory sterilization movements in many countries around the world for several decades, often encompassing patients in public mental institutions. World War I saw a massive increase of conditions that came to be termed "shell shock". In Nazi Germany, the institutionalized mentally ill were among the earliest targets of sterilization campaigns and covert "euthanasia" programs. It has been estimated that over 200,000 individuals with mental disorders of all kinds were put to death, although their mass murder has received relatively little historical attention. Despite not being formally ordered to take part, psychiatrists and psychiatric institutions were at the center of justifying, planning and carrying out the atrocities at every stage, and "constituted the connection" to the later annihilation of Jews and other "undesirables" such as homosexuals in The Holocaust. In other areas of the world, funding was often cut for asylums, especially during periods of economic decline, and during wartime in particular many patients starved to death. Soldiers received increased psychiatric attention, and World War II saw the development in the US of a new psychiatric manual for categorizing mental disorders, which along with existing systems for collecting census and hospital statistics led to the first Diagnostic and Statistical Manual of Mental Disorders (DSM). The International Classification of Diseases (ICD) followed suit with a section on mental disorders. Previously restricted to the treatment of severely disturbed people in asylums, psychiatrists cultivated clients with a broader range of problems, and between 1917 and 1970 the number practicing outside institutions swelled from 8 percent to 66 percent. The term stress, having emerged from endocrinology work in the 1930s, was popularized with an increasingly broad biopsychosocial meaning, and was increasingly linked to mental disorders. "Outpatient commitment" laws were gradually expanded or introduced in some countries. Lobotomies, Insulin shock therapy, Electro convulsive therapy, and the "neuroleptic" chlorpromazine came into use mid-century. An antipsychiatry movement came to the fore in the 1960s. Deinstitutionalization gradually occurred in the West, with isolated psychiatric hospitals being closed down in favor of community mental health services. However, inadequate services and continued social exclusion often led to many being homeless or in prison. A consumer/survivor movement gained momentum. Other kinds of psychiatric medication gradually came into use, such as "psychic energizers" and lithium. Benzodiazepines gained widespread use in the 1970s for anxiety and depression, until dependency problems curtailed their popularity. Advances in neuroscience and genetics led to new research agendas. Cognitive behavioral therapy was developed. Through the 1990s, new SSRI antidepressants became some of the most widely prescribed drugs in the world. The DSM and then ICD adopted new criteria-based classification, representing a return to a Kraepelin-like descriptive system. The number of "official" diagnoses saw a large expansion, although homosexuality was gradually downgraded and dropped in the face of human rights protests. Different regions sometimes developed alternatives such as the Chinese Classification of Mental Disorders or Latin American Guide for Psychiatric Diagnosis. In early 20th century, lobotomy was introduced until the mid-1950s. In 1927 insulin coma therapy was introduced and used until 1960. Physicians deliberately put the patient into a low blood sugar coma because they thought that large fluctuations in insulin levels could alter the function of the brain. Risks included prolonged coma. Electroconvulsive Therapy (ECT) was later adopted as a substitution to this treatment. 21st century DSM-IV and previous versions of the Diagnostic and Statistical Manual of Mental Disorders presented extremely high comorbidity, diagnostic heterogeneity of the categories, unclear boundaries, that have been interpreted as intrinsic anomalies of the criterial, neopositivistic approach leading the system to a state of scientific crisis. Accordingly, a radical rethinking of the concept of mental disorder and the need of a radical scientific revolution in psychiatric taxonomy was proposed. In 2013, the American Psychiatric Association published the DSM–5 after more than 10 years of research. See also Notes and references Further reading Mental disorders Medical sociology

Nomothetic and idiographic

Nomothetic and idiographic are terms used by Neo-Kantian philosopher Wilhelm Windelband to describe two distinct approaches to knowledge, each one corresponding to a different intellectual tendency, and each one corresponding to a different branch of academia. To say that Windelband supported that last dichotomy is a consequent misunderstanding of his own thought. For him, any branch of science and any discipline can be handled by both methods as they offer two integrating points of view. Nomothetic is based on what Kant described as a tendency to generalize, and is typical for the natural sciences. It describes the effort to derive laws that explain types or categories of objective phenomena, in general. Idiographic is based on what Kant described as a tendency to specify, and is typical for the humanities. It describes the effort to understand the meaning of contingent, unique, and often cultural or subjective phenomena. Use in the social sciences The problem of whether to use nomothetic or idiographic approaches is most sharply felt in the social sciences, whose subject are unique individuals (idiographic perspective), but who have certain general properties or behave according to general rules (nomothetic perspective). Often, nomothetic approaches are quantitative, and idiographic approaches are qualitative, although the "Personal Questionnaire" developed by Monte B. Shapiro and its further developments (e.g. Discan scale and PSYCHLOPS) are both quantitative and idiographic. Another very influential quantitative but idiographic tool is the Repertory grid when used with elicited constructs and perhaps elicited elements. Personal cognition (D.A. Booth) is idiographic, qualitative and quantitative, using the individual's own narrative of action within situation to scale the ongoing biosocial cognitive processes in units of discrimination from norm (with M.T. Conner 1986, R.P.J. Freeman 1993 and O. Sharpe 2005). Methods of "rigorous idiography" allow probabilistic evaluation of information transfer even with fully idiographic data. In psychology, idiographic describes the study of the individual, who is seen as a unique agent with a unique life history, with properties setting them apart from other individuals (see idiographic image). A common method to study these unique characteristics is an (auto)biography, i.e. a narrative that recounts the unique sequence of events that made the person who they are. Nomothetic describes the study of classes or cohorts of individuals. Here the subject is seen as an exemplar of a population and their corresponding personality traits and behaviours. It is widely held that the terms idiographic and nomothetic were introduced to American psychology by Gordon Allport in 1937, but Hugo Münsterberg used them in his 1898 presidential address at the American Psychological Association meeting. This address was published in Psychological Review in 1899. Theodore Millon stated that when spotting and diagnosing personality disorders, first clinicians start with the nomothetic perspective and look for various general scientific laws; then when they believe they have identified a disorder, they switch their view to the idiographic perspective to focus on the specific individual and his or her unique traits. In sociology, the nomothetic model tries to find independent variables that account for the variations in a given phenomenon (e.g. What is the relationship between timing/frequency of childbirth and education?). Nomothetic explanations are probabilistic and usually incomplete. The idiographic model focuses on a complete, in-depth understanding of a single case (e.g. Why do I not have any pets?). In anthropology, idiographic describes the study of a group, seen as an entity, with specific properties that set it apart from other groups. Nomothetic refers to the use of generalization rather than specific properties in the same context. See also Nomological References Further reading Cone, J. D. (1986). "Idiographic, nomothetic, and related perspectives in behavioral assessment." In: R. O. Nelson & S. C. Hayes (eds.): Conceptual foundations of behavioral assessment (pp. 111–128). New York: Guilford. Thomae, H. (1999). "The nomothetic-idiographic issue: Some roots and recent trends." International Journal of Group Tensions, 28(1), 187–215. Concepts in epistemology

Human services

Human services is an interdisciplinary field of study with the objective of meeting human needs through an applied knowledge base, focusing on prevention as well as remediation of problems, and maintaining a commitment to improving the overall quality of life of service populations The process involves the study of social technologies (practice methods, models, and theories), service technologies (programs, organizations, and systems), and scientific innovations designed to ameliorate problems and enhance the quality of life of individuals, families and communities to improve the delivery of service with better coordination, accessibility and accountability. The mission of human services is to promote a practice that involves simultaneously working at all levels of society (whole-person approach) in the process of promoting the autonomy of individuals or groups, making informal or formal human services systems more efficient and effective, and advocating for positive social change within society. Human services practitioners strive to advance the autonomy of service users through civic engagement, education, health promotion and social change at all levels of society. Practitioners also engage in advocating so human systems remain accessible, integrated, efficient and effective. Human services academic programs can be easily accessible in colleges and universities, which award degrees at the associate, baccalaureate, and graduate levels. Human services programs are in countries all around the world. History United States Human services has its roots in charitable activities of religious and civic organizations that date back to the Colonial period. However, the academic discipline of human services did not start until the 1960s. At that time, a group of college academics started the new human services movement and began to promote the adoption of a new ideology about human service delivery and professionalism among traditional helping disciplines. The movement's major goal was to make service delivery more efficient, effective, and humane. The other goals dealt with the reeducation of traditional helping professionals to have a greater appreciation of the individual as a whole person (humanistic psychology) and to be accountable to the communities they serve (postmodernism). Furthermore, professionals would learn to take responsibility at all levels of government, use systems approaches to consider human problems, and be involved in progressive social change. Traditional academic programs such as education, nursing, social work, law and medicine were resistant to the new human services movement's ideology because it appeared to challenge their professional status. Changing the traditional concept of professionalism involved rethinking consumer control and the distribution of power. The new movement also called on human service professionals to work for social change. It was proposed that reducing monopolistic control on professionals could result in democratization of knowledge, thus leading to said professionals counteracting dominant establishments and advocating on behalf of their clients and communities. The movement also hoped that human service delivery systems would become integrated, comprehensive, and more accessible, which would make them more humane for service users. Ultimately, the resistance from traditional helping professions served as the impetus for a group of educators in higher education to start the new academic discipline of human services. Some maintain that the human services discipline has a concrete identity as a profession that supplements and complements other traditional professions. Yet other professionals and scholars have not agreed upon an authoritative definition for human services. Academic programs United States Development Chenault and Burnford argued that human services programs must inform and train students at the graduate or postgraduate level if human services hoped to be considered a professional discipline. A progressive graduate human services program was established by Audrey Cohen (1931–1996), who was considered an innovative educator for her time. The Audrey Cohen College of Human Services, now called the Metropolitan College of New York, offered one of the first graduate programs in 1974. In the same time period, Springfield College in Massachusetts became a major force in preserving human services as an academic discipline. Currently, Springfield College is one of the oldest and largest human services program in the United States. Manpower studies in the 1960s and 70s had shown that there would be a shortage of helping professionals in an array of service delivery areas. In turn, some educators proposed that the training of nonprofessionals (e.g., mental health technicians) could bridge this looming personnel shortage. One of the earliest educational initiatives to develop undergraduate curricula was undertaken by the Southern Regional Education Board (SREB), which was funded by the National Institute on Health. Professionals of the SREB Undergraduate Social Welfare Manpower Project helped colleges develop new social welfare programs, which later became known as human services. Some believed community college human services programs were the most expedient way to train paraprofessionals for direct service jobs in areas such as mental health. Currently, a large percentage of human services programs are run at the community college level. The development of community college human services programs was supported with government funding that was earmarked for the federal new careers initiatives. In turn, the federally funded New Careers Program was created to produce a nonprofessional career track for economically disadvantaged, underemployed, and unemployed adults as a strategy to eradicate poverty within society and to end a critical shortage of health-care personnel. Graduates from these programs successfully acquired employment as paraprofessionals, but there were limitations to their upward mobility within social service agencies because they lacked a graduate or professional degree. Current programs Currently, there are academic programs in human services at the associate, baccalaureate, and graduate levels. There are approximately 600 human services programs throughout the United States. An online directory of human services programs lists many (but not all) of the programs state y state in conjunction with their accreditation status from the Council for Standards in Human Services Education (CSHSE). The CSHSE offers accreditation for human services programs in higher education. The accreditation process is voluntary and labor-intensive; it is designed to assure the quality, consistency, and relevance of human service education through research-based standards and a peer-review process. According to the CSHSE's webpage there are only 43 accredited human services programs in the United States. Human services curricula are based on an interdisciplinary knowledge foundation that allows students to consider practical solutions from multiple disciplinary perspectives. Across the curriculum human services students are often taught to view human problems from a socioecological perspective (developed by Urie Bronfenbrenner) that involves viewing human strengths and problems as interconnected to a family unit, community, and society. This perspective is considered a "whole-person perspective". Overall, undergraduate programs prepare students to be human services generalists while master's programs prepare students to be human services administrators, and doctoral programs prepare students to be researcher-analysts and college-level educators. Research in this field focuses on an array of topics that deal with direct service issues, case management, organizational change, management of human service organizations, advocacy, community organizing, community development, social welfare policy, service integration, multiculturalism, integration of technology, poverty issues, social justice, development, and social change strategies. Certification and continuing education United States The Center for Credentialing & Education (CCE) conceptualized the Human Services-Board Certified Practitioner (HS-BCP) credential with the assistance of the National Organization for Human Services (NOHS) and the Council for Standards in Human Service Education (CSHSE). The credential was created for human services practitioners seeking to advance their careers by acquiring independent verification of their practical knowledge and educational background. Graduates from human services programs can obtain a Human Services Board Certified Practitioner (HS-BCP) credential offered by the Center for Credentialing & Education (CCE). The HS-BCP certification ensures that human services practitioners offer quality services, are competent service providers, are committed to high standards, and adhere to the NOHS Ethical Standards of Human Service Professionals, as well as to help solidify the professional identity of human services practitioners. HS-BCPE Experience Requirements for the certification: HS-BCP applicants must meet post-graduation experience requirements to be eligible to take the examination. However, graduates of a CSHSE accredited degree program may sit for the HS-BCP exam without verifying their human services work experience. Otherwise experience requirements for candidates not from a CSHSE accredited program are as follows: Associate degree with post degree experience requires three years, including a minimum of 4,500 hours; Bachelor's Degree with post degree experience requires two years, including a minimum of 3,000 hours; Master's or Doctorate with post degree experience requires one year, including a minimum of 1,500 hours. The HS-BCP exam is designed to verify a candidate's human services knowledge. The exam was created as a collaborative effort of human services subject-matter experts and normed on a population of professionals in the field. The HS-BCP exam covers the following areas: Assessment, treatment planning, and outcome evaluation Theoretical orientation/interventions Case management, professional practice, and ethics Administration, program development/evaluation, and supervision Tools and methodology There are numerous different tools and methods utilized in human services. For example, qualitative and quantitative surveys are administered to define community problems that need addressing. These surveys can narrow down what service is needed, who would receive it, for how long, and where the problem is concentrated. Additional necessary skills include strong communication and professional coordination- since networking is crucial for obtaining and transporting resources to areas of need. Lack of these skills could lead to dangerous consequences as a communities needs are not adequately met. Furthermore, research is a key component to the successful conduct of human service. Both theoretical and empirical research is required if one is to pursue a career in human services because being uninformed can leave communities in confusion and disarray- thus perpetuating the problem that was supposed to be resolved. In relation to social work, a professional must be unbiased and patient because they will be closely working with a vast and diverse population who are often in extremely dire situations. Allowing one's personal beliefs to bleed into their human service profession could negatively impact the quality of and or limit the scope of potential outreach. Employment outlook United States Currently, the three major employment roles played by human services graduates include providing direct service, performing administrative work, and working in the community. According to the Occupational Outlook Handbook, published by the US Department of Labor, the employment of human service assistants is anticipated to grow by 34% through 2016, which is faster than average for all occupations. There are several different occupations for individuals with post-secondary degrees. Specialization is crucial when applying for a human service career because many different job occupations and skills fall under the broad scope of human services, especially if said job is related to social work. This is because many different types of people require different types of aid. For example, a child would need special attention compared to an adult- and would visit a professional who has trained directly with younger people. Furthermore, an alcoholic or addict would specifically need a professional rehabilitation counselor. On the other hand, a victim of a natural disaster would need a crisis support worker for immediate assistance. Other examples of human service jobs include but are not limited to; criminology, community service, housing, health, therapy, and sociology. Professional organizations North America There are several different professional human services organizations for professionals, educators, and students to join across North America. United States The National Organization for Human Services (NOHS) is a professional organization open to educators, professionals, and students interested in current issues in the field of human services. NOHS sponsors an annual conference in different parts of the United States. In addition, there are four independent human services regional organizations: (a) Mid-Atlantic Consortium for Human Services, (b) Midwest Organization for Human Services, (c) New England Organization for Human Service, and the (d) Northwest Human Services Association. All the regional organizations are also open to educators, professionals, students and each regional organization has an annual conference in different locations throughout their region such as universities or institutions. Human services special interest groups also exist within the American Society for Public Administration (ASPA) and the American Educational Research Association (AERA). The ASPA subsection is named the Section on Health and Human Services Administration and its purpose is to foster the development of knowledge, understanding and practice in the fields of health and human services administration and to foster professional growth and communication among academics and practitioners in these fields. Fields of health and human services administration share a common and unique focus on improving the quality of life through client-centered policies and service transactions. The AERA special interest group is named the Education, Health and Human Service Linkages. Its purpose is to create a community of researchers and practitioners interested in developing knowledge about comprehensive school health, school linked services, and initiatives that support children and their families. This subgroup also focuses on interpersonal collaboration, integration of services, and interdisciplinary approaches. The group's interests encompass interrelated policy, practice, and research that challenge efforts to create viable linkages among these three distinct areas. The American Public Human Services Association (APHSA) is a nonprofit organization that pursues distinction in health and human services by working with policymakers, supporting state and local agencies, and working with partners to promote innovative, integrative and efficient solutions in health and human services policy and practice. APHSA has individual and student memberships. Canada The Canadian Institute for Human Services is an advocacy, education and action-research organization for the advancement of health equity, progressive education and social innovation. The institute collaborates with researchers, field practitioners, community organizations, socially conscious companies—along with various levels of government and educational institutions—to ensure the Canadian health and human services sector remains accountable to the greater good of Canadian civil society rather than short-term professional, business or economic gains. See also References Further reading Brager, G., & Holloway, S. (1978). Changing human services organizations: Political and practice. New York, NY: The Free Press. Bronfenbrenner, U. (2005). Making human beings human: Biological perspectives on human development. Thousand Oaks, CA: Sage Publications. Cimbala, P.A., & Miller, R.M. (1999). The Freedman's Bureau and Reconstruction. New York, NY: Fordham University Press. Colman, P. (2007). Breaking the chains: The crusade of Dorothea Lynde Dix. New York, NY: ASJA Press. De Tocqueville, A. (2006). Democracy in America (G. Lawrence, Trans.). New York, NY: Harper Perennial Modern Classic (Original work published 1832). Friedman, L. J. (2003). Giving and caring in early America 1601-1861. In L.J. Friedman, & M.D. McGarvie, Charity, philanthropy, and civility in American history (pp. 23–48). Cambridge, UK: Cambridge University Press. Hasenfeld, Y. (1992). The nature of human service organizations. In Y. Hasenfeld, Human Services as Complex Organizations (pp. 3–23). Newbury Park, CA: Sage Publications. Marshall, J. (2011). The life of George Washington. Fresno, CA: Edwards Publishing House. Nellis, E.G., & Decker, A.D. (2001). The eighteenth-century records of the Boston overseers of the poor. Charlottesville, VA: University of Virginia Press. Neukrug, E. (2016). Theory, practice, and trends in human services: An introduction (6th ed.). Belmont, CA: Cengage. Slack, P. (1995). The English Poor Law, 1531-1782. Cambridge, UK: Cambridge University Press. Trattner, W.I. (1999). From Poor Law to welfare state: A History of social welfare in America. New York, NY: The Free Press. Academic disciplines Community building Human sciences

Nursing diagnosis

A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician's orders (e.g., medication administration). Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health or life processes or crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when possible, throughout the process. NANDA International (NANDA-I) is body of professionals that develops, researches and refines an official taxonomy of nursing diagnosis. All nurses must be familiar with the steps of the nursing process in order to gain the most efficiency from their positions. In order to correctly diagnose, the nurse must make quick and accurate inferences from patient data during assessment, based on knowledge of the nursing discipline and concepts of concern to nurses. NANDA International NANDA International, Inc., formerly known as the North American Nursing Diagnosis Association, is the primary organization for defining, researching, revising, distributing and integrating standardized nursing diagnoses worldwide. NANDA-I has worked in this area for more than 45 years to ensure that diagnoses are developed through a peer-reviewed process requiring standardised levels of evidence, definitions, defining characteristics, related factors or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilise standardised languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characteristics) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations, as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide. As research in the field of nursing continues to grow, NANDA-I continually develops and adds new diagnostic labels. Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes. Global The ICNP (International Classification for Nursing Practice) published by the International Council of Nurses has been accepted by the World Health Organization family of classifications. ICNP is a nursing language which can be used by nurses to diagnose. Structure The NANDA-I system of nursing diagnosis provides for four categories and each has 3 parts: diagnostic label or the human response, related factors or the cause of the response, and defining characteristics found in the selected patient are the signs/symptoms present that are supporting the diagnosis. Problem-focused diagnosis A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community. An example of an actual nursing diagnosis is: Sleep deprivation. Risk diagnosis Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability. An example of a risk diagnosis is: Risk for shock. Health promotion diagnosis A clinical judgment about a person's, family's or community's motivation and desire to increase wellbeing and actualise human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state. An example of a health promotion diagnosis is: Readiness for enhanced nutrition. Syndrome diagnosis A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions. An example of a syndrome diagnosis is: Relocation stress syndrome. Process The diagnostic process requires a nurse to use critical thinking. In addition to knowing the nursing diagnoses and their definitions, the nurse becomes aware of defining characteristics and behaviors of the diagnoses, related factors to the diagnoses, and the interventions suited for treating the diagnoses. Assessment The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patient's psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative stage. Diagnosis The diagnosing phase involves a nurse making an educated judgement about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include a description of the problem or illness (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient's readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment. Planning Once a patient and nurse agree of the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritise each assessment and devote attention to severe symptoms and high risk patients. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardised terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning. Implementation The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for a follow-up. Implementation can take place over the course of hours, days, weeks, or even months. Evaluation Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine if the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilised, and patient's condition deteriorated. In the event where the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step. Examples The following are nursing diagnoses arising from the nursing literature with varying degrees of authentication by ICNP or NANDA-I standards. Anxiety Constipation Pain Decreased Activity Tolerance Impaired Gas Exchange Excessive Fluid Volume Caregiver Role Strain Ineffective Coping Readiness for Enhanced Health Maintenance Readiness for enhanced spiritual well-being See also Clinical Care Classification System Clinical formulation Nursing Nursing process Nursing care plan Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) References External links Diagnosis, Nursing

Spoon theory

Spoon theory is a metaphor describing the amount of physical or mental energy that a person has available for daily activities and tasks, and how it can become limited. The term was coined in a 2003 essay by American writer Christine Miserandino. In the essay, Miserandino describes her experience with chronic illness, using a handful of spoons as a metaphor for units of energy available to perform everyday actions. The metaphor has since been used to describe a wide range of disabilities, mental health issues, forms of marginalization, and other factors that might place unseen burdens on individuals. Origin In her 2003 essay "The Spoon Theory", American writer Christine Miserandino tells a story about a time she told a friend about her experience with lupus. As they were at a restaurant, Miserandino grabbed spoons and gave them to her friend. Miserandino used the spoons to demonstrate that people with chronic illness often start their days off with limited quantities of energy. The number of spoons represented how much energy she had to spend throughout the day. As Miserandino's friend stated the different tasks she completed throughout the day, Miserandino took away a spoon for each activity. The exercise demonstrated how people with chronic illness may plan their actions in advance in order to conserve their energy. Chronic illness and spoon theory Those with chronic illness or pain have reported feelings of difference and division between themselves and people without disabilities. This theory and the claiming of the term spoonie is utilized to build communities for those with chronic illness that can support each other. Because of this, many people with chronic illness have to plan around and ration their energy and activities throughout the day. Ordinary activities must often be curtailed or avoided, because they carry an invisible cost in terms of spoons available later for other things. This has been described as being a major concern of people with a (fatigue-related) disability or chronic condition/illness/disease because people without these disabilities are not typically concerned with the energy expended during ordinary tasks such as bathing and getting dressed. The theory explains the difference and facilitates discussion between those with limited energy reserves and those with (seemingly) limitless energy reserves. Other uses Spoon theory has since spread throughout the disability community and even to marginalized groups to describe the exhaustion that may characterize their specific situations. It is most commonly used to refer to the experience of having an invisible disability, because people with no outward symptoms or symbols of their condition are often perceived as lazy, inconsistent or having poor time management skills by those who have no first-hand knowledge of living with a chronic illness or disability. Naomi Chainey has described how the term has also spread to use by some in the wider disability community, and eventually the non-disabled community tried to appropriate it for other uses, to refer to non-chronic forms of fatigue and mental exhaustion – which she attributes to people with invisible disabilities being a sometimes marginalized group even within the disability community. Those with mental health issues such as anxiety or depression may similarly find it challenging to go about seemingly simple tasks throughout the day, or to deal with a crisis. Spoon theory could even be used to show the exhaustion of having a newborn baby, as this situation often leads to a chronic lack of sleep on the part of the baby's caregiver(s). See also References Bibliography Further reading 2003 neologisms disability psychological theories

Factitious disorder imposed on self

Factitious disorder imposed on self, also known as Munchausen syndrome, is a factitious disorder in which those affected feign or induce disease, illness, injury, abuse, or psychological trauma to draw attention, sympathy, or reassurance to themselves. Munchausen syndrome fits within the subclass of factitious disorder with predominantly physical signs and symptoms, but patients also have a history of recurrent hospitalization, travelling, and dramatic, extremely improbable tales of their past experiences. The term Munchausen syndrome derives its name from the fictional character Baron Munchausen. Factitious disorder imposed on self is related to factitious disorder imposed on another, which refers to the abuse of another person, most often of a child and occasionally of another adult such as of a partner, in order to seek attention or sympathy for the abuser. This is considered "Munchausen by proxy", and the drive to create symptoms for the victim can result in unnecessary and costly diagnostic or corrective procedures. Signs and symptoms In factitious disorder imposed on self, the affected person exaggerates or creates symptoms of illnesses in themselves to gain examination, treatment, attention, sympathy or comfort from medical personnel. It often involves elements of victim playing and attention seeking. In some extreme cases, people with Munchausen syndrome are highly knowledgeable about the practice of medicine and are able to produce symptoms that result in lengthy and costly medical analysis, prolonged hospital stays, and unnecessary operations. The role of patient is a familiar and comforting one, and it fills a psychological need in people with this syndrome. This disorder is distinct from hypochondriasis and other somatoform disorders in that those with the latter do not intentionally produce their somatic symptoms. Factitious disorder is distinct from malingering in that people with factitious disorder imposed on self do not fabricate symptoms for material gain such as financial compensation, absence from work, or access to drugs. The exact cause of factitious disorder is not known, but researchers believe both biological and psychological factors play a role in the development of this disorder. Risk factors for developing factitious disorder may include childhood traumas, growing up with parents/caretakers who were emotionally unavailable due to illness or emotional problems, a serious illness as a child, failed aspirations to work in the medical field, personality disorders, and low self-esteem. While there are no reliable statistics regarding the number of people in the United States who have factitious disorder, FD is believed to be most common in mothers having the above risk factors. Those with a history of working in healthcare are also at greater risk of developing it. Arrhythmogenic Munchausen syndrome describes individuals who simulate or stimulate cardiac arrhythmias to gain medical attention. A related behavior called factitious disorder imposed on another has been documented in the parent or guardian of a child or the owner of a pet animal. The adult ensures that their child will experience some medical condition, therefore compelling the child to suffer through treatments and spend a significant portion during youth in hospitals. Furthermore, a disease may actually be initiated in the child by the parent or guardian. This condition is considered distinct from Munchausen syndrome. There is growing consensus in the pediatric community that this disorder should be renamed "medical abuse" to highlight the harm caused by the deception and to make it less likely that the sufferer can use a psychiatric defense when harm is done. Diagnosis Due to the behaviors involved, diagnosing factitious disorder is very difficult. If the healthcare provider finds no physical reason for the symptoms, they may refer the person to a psychiatrist or psychologist (mental health professionals who are specially trained to diagnose and treat mental illnesses). Psychiatrists and psychologists use thorough history, physical examinations, laboratory tests, imagery, and psychological testing to evaluate a person for physical and mental conditions. Once the person's history has been thoroughly evaluated, diagnosing factitious disorder imposed on self requires a clinical assessment. Clinicians should be aware that those presenting with symptoms (or persons reporting for that person) may exaggerate, and caution should be taken to ensure there is evidence for a diagnosis. Lab tests may be required, including complete blood count (CBC), urine toxicology, drug levels from blood, cultures, coagulation tests, assays for thyroid function, or DNA typing. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may also be employed. A summary of more common and reported cases of factitious disorder (Munchausen syndrome), and the laboratory tests used to differentiate these from physical disease is provided below: There are several criteria that together may point to factitious disorder, including frequent hospitalizations, knowledge of several illnesses, frequently requesting medication such as pain killers, openness to extensive surgery, few or no visitors during hospitalizations, and exaggerated or fabricated stories about several medical problems. People may fake their symptoms in multiple ways. Other than making up past medical histories and faking illnesses, people might inflict harm on themselves by consuming laxatives or other substances, self-inflicting injury to induce bleeding, and altering laboratory samples. Many of these conditions do not have clearly observable or diagnostic symptoms and sometimes the syndrome will go undetected because patients will fabricate identities when visiting the hospital several times. Factitious disorder has several complications, as these people will go to great lengths to fake their illness. Severe health problems, serious injuries, loss of limbs or organs, and even death are possible complications. Treatment Because there is uncertainty in treating suspected factitious disorder imposed on self, some advocate that health care providers first explicitly rule out the possibility that the person has another early-stage disease. Then they may take a careful history and seek medical records to look for early deprivation, childhood abuse, or mental illness. If a person is at risk to themself, psychiatric hospitalization may be initiated. Healthcare providers may consider working with mental health specialists to help treat the underlying mood or other disorder as well as to avoid countertransference. Therapeutic and medical treatment may center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient's prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication or cognitive behavioral therapy, whereas borderline personality disorder, like all personality disorders, is presumed to be pervasive and more stable over time, and thus offers a worse prognosis. History The name "Munchausen syndrome" derives from Baron Munchausen, a literary character loosely based on the German nobleman Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720–1797). The historical baron became a well-known storyteller in the late 18th century for entertaining dinner guests with tales about his adventures during the Russo-Turkish War. In 1785, German-born writer and con artist Rudolf Erich Raspe anonymously published a book in which a heavily fictionalized version of "Baron Munchausen" tells many fantastic and impossible stories about himself. Raspe's Munchausen became a sensation, establishing a literary exemplar of a bombastic liar or exaggerator. In 1951, Richard Asher was the first to describe a pattern of self-harm, wherein individuals fabricated histories, signs, and symptoms of illness. Remembering Baron Munchausen, Asher named this condition Munchausen's Syndrome in his article in The Lancet in February 1951, quoted in his obituary in the British Medical Journal: Asher's nomenclature sparked some controversy, with medical authorities debating the appropriateness of the name for about fifty years. While Asher was praised for bringing cases of factitious disorder to light, participants in the debate objected variously that a literary allusion was inappropriate given the seriousness of the disease; that its use of the anglicized spelling "Munchausen" showed poor form; that the name linked the disease with the real-life Münchhausen, who did not have it; and that the name's connection to works of humor and fantasy, and to the essentially ridiculous character of the fictional Baron Munchausen, was disrespectful to patients with the disorder. Originally, this term was used for all factitious disorders. Now, however, in the DSM-5, "Munchausen syndrome" and "Munchausen by proxy" have been replaced with "factitious disorder imposed on self" and "factitious disorder imposed on another" respectively. Munchausen by Internet Munchausen by Internet is a term describing the pattern of behavior in factitious disorder imposed on self, wherein those affected feign illnesses in online venues. It has been described in medical literature as a manifestation of factitious disorder imposed on self. Reports of users who deceive Internet forum participants by portraying themselves as gravely ill or as victims of violence first appeared in the 1990s due to the relative newness of Internet communications. The specific internet pattern was named "Münchausen by Internet" in 1998 by psychiatrist Marc Feldman. New Zealand PC World Magazine called Munchausen by Internet "cybermunch", and those who posed online "cybermunchers". A person may attempt to gain sympathy from a group whose sole reason for existence is to support others. Some have speculated that health care professionals, with their limited time, greater medical knowledge, and tendency to be more skeptical in their diagnoses, may be less likely to provide that support. In an article published in The Guardian, Steve Jones speculated that the anonymity of the Internet impedes people's abilities to realize when someone is lying. Online interaction has only been possible since the 1980s, steadily growing over the years. When discovered, forum members are frequently banned from some online forums. Because no money is exchanged and laws are rarely broken, there is little legal recourse to take upon discovery of someone faking illness. Such dramatic situations can polarize online communities. Members may feel ashamed for believing elaborate lies, while others remain staunch supporters. Feldman admits that an element of sadism may be evident in some of the more egregious abuses of trust. Other perpetrators react by issuing general accusations of dishonesty to everyone, following the exposure of such fabrications. The support groups themselves often bar discussion about the fraudulent perpetrator, in order to avoid further argument and negativity. Many forums do not recover, often splintering or shutting down. In 2004, members of the blog hosting service LiveJournal established a forum dedicated to investigating cases of members of online communities dying—sometimes while online. In 2007 The LiveJournal forum reported that, of the deaths reported to them, about 10% were real. See also List of Munchausen by proxy cases Hypochondriasis Psychosomatic illness References Bibliography External links Article in Discover magazine, July 1993, by Abigail Zuger Forensic psychology Factitious disorders Psychopathological syndromes Baron Munchausen

Clinical research

Clinical research is a branch of medical research that involves people and aims to determine the effectiveness (efficacy) and safety of medications, devices, diagnostic products, and treatment regimens intended for improving human health. These research procedures are designed for the prevention, treatment, diagnosis or understanding of disease symptoms. Clinical research is different from clinical practice: in clinical practice, established treatments are used to improve the condition of a person, while in clinical research, evidence is collected under rigorous study conditions on groups of people to determine the efficacy and safety of a treatment. Description The term "clinical research" refers to the entire process of studying and writing about a drug, a medical device or a form of treatment, which includes conducting interventional studies (clinical trials) or observational studies on human participants. Clinical research can cover any medical method or product from its inception in the lab to its introduction to the consumer market and beyond. Once the promising candidate or the molecule is identified in the lab, it is subjected to pre-clinical studies or animal studies where different aspects of the test article (including its safety toxicity if applicable and efficacy, if possible at this early stage) are studied. The clinical research ecosystem involves a complex network of sites, pharmaceutical companies and academic research institutions. Clinical research is often conducted at academic medical centers and affiliated research study sites. These centers and sites provide the prestige of the academic institution as well as access to larger metropolitan areas, providing a larger pool of medical participants. These academic medical centers often have their internal Institutional Review Boards that oversee the ethical conduct of medical research. Patient and public involvement Besides being participants in a clinical trial, members of the public can actively collaborate with researchers in designing and conducting clinical research. This is known as patient and public involvement (PPI). Public involvement involves a working partnership between patients, caregivers, people with lived experience, and researchers to shape and influence what is researcher and how. PPI can improve the quality of research and make it more relevant and accessible. People with current or past experience of illness can provide a different perspective than professionals and compliment their knowledge. Through their personal knowledge they can identify research topics that are relevant and important to those living with an illness or using a service. They can also help to make the research more grounded in the needs of the specific communities they are part of. Public contributors can also ensure that the research is presented in plain language that is clear to the wider society and the specific groups it is most relevant for. Phases Following preclinical research, clinical trials involving new drugs are commonly classified into four phases. Each phase of the drug approval process is treated as a separate clinical trial. If the drug successfully passes through Phases I, II, and III, it will be approved by the national regulatory authority for use in the general population. Phase IV is post-approval studies. Phase I includes 20 to 100 healthy volunteers or individuals with the disease or condition. This study typically lasts several months and its purpose is to prove safety and an effective dosage. Phase II includes a larger number of individual participants in the range of 100–300, and Phase III includes some 1000-3000 participants to assess efficacy and safety of the drug at different doses. Only 25-30% of drugs advance to the end of Phase III. Clinical research by country United States In the United States, when a test article is unapproved or not yet cleared by the Food and Drug Administration (FDA), or when an approved or cleared test article is used in a way that may significantly increase the risks (or decreases the acceptability of the risks), the data obtained from the preclinical studies or other supporting evidence, or case studies of off label use are submitted to the FDA in support of an Investigational New Drug application. Where devices are concerned the submission to the FDA would be for an Investigational Device Exemption application if the device is a significant risk device or is not in some way exempt from prior submission to the FDA. In addition, clinical research may require Institutional Review Board or Research Ethics Board and possibly other institutional committee reviews, Privacy Board, Conflict of Interest Committee, Radiation Safety Committee or Radioactive Drug Research Committee. European Union In the European Union, the European Medicines Agency acts in a similar fashion for studies conducted in their region. These human studies are conducted in four phases in research subjects that give consent to participate in the clinical trials. See also Clinical research associate Clinical research ethics Clinical trial management system Randomized controlled trial Evidence-based medicine Unethical human experimentation References Health research

SCAN

Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a set of tools created by WHO aimed at diagnosing and measuring mental illness that may occur in adult life. It is not constructed explicitly for use with either ICD-10 or DSM-IV but can be used for both systems. The SCAN system was originally called PSE, or Present State Examination, but since version 10 (PSE-10), the commonly accepted name has been SCAN. The current version of SCAN is 2.1. Interview items The entire SCAN interview consists of 1,872 items, spread out over 28 sections. Most patients, however, will only need parts of the interview, and it is assessed in the beginning of each section if the section is actually relevant. The sections are as follows: Section 0 - Face sheet and sociodemographic items The first section in the SCAN interview is concerned with sociodemographic items such as age, gender, education, etc. Section 1 - Beginning the Interview In section 1 (the second section), the interviewer starts to ask the respondent or patient about what kinds of symptoms has been experienced. This section is not used in diagnosis, but it is intended as a help for the interviewer to determine which items in the interview to emphasize on. As such, it is a screening tool for part 1 of the interview (sections 2 to 13). Section 2 - Somatoform and dissociative symptoms Section 2 is primarily centered on somatoform and dissociative symptoms and is rated both by using direct questions and by observing the patient. Section 3 - Worrying, tension, etc. Section 3 explores the degree of worrying and tension in the patient, by direct questions about feelings of worrying, nervous tension, muscular tension, fatiguability, noise sensitivity, etc. Section 4 - Panic, Anxiety and phobias Section 4 measures the degree and physiological reactions associated with potential anxiety attacks and phobias, including behaviour in which situations are avoided due to phobias. Fear of dying and generalized anxiety disorder are also measured. Section 5 - Obsessional symptoms Section 5 explores, by direct questions, whether the respondent experiences behaviour characteristic of OCD. Section 6 - Depressed mood and ideation Section 6 measures, by direct questions, whether the respondent is depressed, by items relating to feeling low, uncontrolled crying, anhedonia, loss of feeling, suicidal tendencies, social withdrawal, insomnia or hypersomnia, dysthymia, etc. Section 7 - Thinking, concentration, energy, interest Section 7 measures cognitive functioning through direct questions about concentration, loss of interests or drive, and being overwhelmed by everyday tasks. Section 8 - Bodily functions Section 8 asks direct questions about weight and weight gain or loss, appetite, sleep patterns, and libido. Section 9 - Eating disorders Section 9 aims to diagnose eating disorders such as bulimia and anorexia nervosa. Section 10 - Expansive mood and ideation Section 10 measures whether the respondent experiences euphoria or abnormally elevated mood (mania), which can be used in diagnosing, for instance, bipolar disorders. Section 11 - Use of alcohol Section 11 measures, through direct questions, amounts of alcoholic beverages consumed and social, legal, physical, and other problems related to alcohol use. Section 12 - Use of psychoactive substances other than alcohol Section 12 measures, again through direct questions, the same as section 11, only relating to prescription drugs, illicit drugs, and nicotine. Section 13 - Interference and attributions for part one This section is rated by the interviewer based on the clinical picture of the interview and the patient in general, and is thus not completed by using direct questions. Section 14 - Screen for items in part two Just like section 1, section 14 is used for screening the existence of symptoms, in this case for part 2 of the SCAN interview which focuses on psychotic symptoms. Section 15 - Language problems at examination In this section, the interviewer rates the existence of any language problems that makes conducting the interview impossible. Many of the other sections provide options for rating that assessment of individual items is impossible because of the presence of language problems recorded in section 15. Section 16 - Perceptual disorders other than hallucinations Section 16 measures, through direct questions, whether non-hallucinatory perceptual disorders are present. These may present themselves by the respondents stating to have experiences of their surroundings being distorted, or unreal (derealization), or that they themselves are not real, but more like characters in a play (depersonalization). Experiences such as believing that one's reflection is unrecognizable, or that one's appearance has been changed, are also rated here. Section 17 - Hallucinations In this section, the respondent is asked about the experience of hallucinations, be they visual, auditory (verbal or non-verbal), olfactory, tactile, or sexual. Section 18 - Experiences of thought interference and replacement of will Section 18 measures the existence and type of thought interference. These include the respondents' thoughts being read, loud (i.e. having voice-like sound), echoing, being broadcast, or even stolen. Experiences of thought being inserted into the respondents' minds are also rated here, as is the experience of thought stopping, involuntarily, as suddenly as a TV becoming unplugged. Alternate lines of thought, that don't belong to the respondent but that comment on the respondents thoughts, are rated as well. So is the experience of external forces (e.g. other people) controlling the respondents' will, voice, handwriting, actions, or affect. Section 19 - Delusions Delusions of being spied upon, and other paranoid delusions, are rated by direct questions in this section. Other types of delusions covered in this section include others not being who they claim to be, that people close to the respondent have been replaced with lookalikes, and delusions of conspiracy. Furthermore, hypochondrial delusions, and grandiose delusions, etc., are rated by the interviewer. Section 20 - Further information for classification of Part 2 symptoms This section is fully rated by the interviewer after the interview, and deals with aspects of duration and course of schizophrenia and psychosis and other symptoms rated in part 2 of the SCAN interview. Section 21 - Cognitive impairment and decline This section consists of a series of tests to be conducted by the respondent to establish the presence of cognitive impairment such as dementia. The majority of the section consists of a Mini-Mental State Examination (MMSE). This includes testing the respondents' ability to know where they are, what the date and year is, to remember words, to follow instructions, attention, and concentration. Section 22 - Motor and behavioral items This section is rated by the interviewer based on observing the respondents, or consulting their medical charts. A variety of items are assessed, including underactivity, stupor, distractibility, agitation, ambitendence, echopraxia, embarrassing or bizarre behavior, histrionic behavior, self injury, hoarding of objects, and a variety of negative symptoms. See also Diagnostic classification and rating scales used in psychiatry References Wing, J. "SCAN and the PSE tradition." Soc.Psychiatry Psychiatr.Epidemiol. 31.2 (1996): 50–54. Wing, J. K., et al. "SCAN. Schedules for Clinical Assessment in Neuropsychiatry." Arch.Gen.Psychiatry 47.6 (1990): 589–93. Mental disorders screening and assessment tools

Mindfulness

Mindfulness is the cognitive skill, usually developed through meditation, of sustaining meta-attentive awareness towards the contents of one's own mind in the present moment. Mindfulness derives from sati, a significant element of Hindu and Buddhist traditions, and is based on Zen, Vipassanā, and Tibetan meditation techniques. Though definitions and techniques of mindfulness are wide-ranging, Buddhist traditions describe what constitutes mindfulness, such as how perceptions of the past, present and future arise and cease as momentary sense-impressions and mental phenomena. Individuals who have contributed to the popularity of mindfulness in the modern Western context include Thích Nhất Hạnh, Joseph Goldstein, Herbert Benson, Jon Kabat-Zinn, and Richard J. Davidson. Clinical psychology and psychiatry since the 1970s have developed a number of therapeutic applications based on mindfulness for helping people experiencing a variety of psychological conditions. Mindfulness practice has been employed to reduce depression, stress, anxiety, and in the treatment of drug addiction. Programs based on mindfulness models have been adopted within schools, prisons, hospitals, veterans' centers, and other environments, and mindfulness programs have been applied for additional outcomes such as for healthy aging, weight management, athletic performance, helping children with special needs, and as an intervention during early pregnancy. Clinical studies have documented both physical- and mental-health benefits of mindfulness in different patient categories as well as in healthy adults and children. Studies have shown a positive relationship between trait mindfulness (which can be cultivated through the practice of mindfulness-based interventions) and psychological health. The practice of mindfulness appears to provide therapeutic benefits to people with psychiatric disorders, including moderate benefits to those with psychosis. Studies also indicate that rumination and worry contribute to a variety of mental disorders, and that mindfulness-based interventions can enhance trait mindfulness and reduce both rumination and worry. Further, the practice of mindfulness may be a preventive strategy to halt the development of mental-health problems. Mindfulness practices have been said to enable individuals to respond more effectively to stressful situations by helping them strike the balance between over-identification and suppression of their emotional experiences by finding the middle point which is recognition and acceptance. Evidence suggests that engaging in mindfulness meditation may influence physical health. For example, the psychological habit of repeatedly dwelling on stressful thoughts appears to intensify the physiological effects of the stressor (as a result of the continual activation of the sympathetic nervous system and the hypothalamus-pituitary-adrenal axis) with the potential to lead to physical-health-related clinical manifestations. Studies indicate that mindfulness meditation, which brings about reductions in rumination, may alter these biological clinical pathways. Further, research indicates that mindfulness may favorably influence the immune system as well as inflammation, which can consequently impact physical health, especially considering that inflammation has been linked to the development of several chronic health conditions. Other studies support these findings. Critics have questioned both the commercialization and the over-marketing of mindfulness for health benefits—as well as emphasizing the need for more randomized controlled studies, for more methodological details in reported studies and for the use of larger sample-sizes. While mindfulness-based interventions may be effective for youth, research has not determined methods in which mindfulness could be introduced and delivered in schools. Practice Mindfulness practice involves the process of developing the skill of bringing one's attention to whatever is happening in the present moment. Watching the breath, body-scan and other techniques There are several exercises designed to develop mindfulness meditation, which may be aided by guided meditations "to get the hang of it". As forms of self-observation and interoception, these methods increase awareness of the body, so they are usually beneficial to people with low self-awareness or low awareness of their bodies or emotional state. However, it may provoke anxiety, panic attacks, depression, and dissociation, in people who are very focused on themselves, their bodies, and their emotions. One method is to sit in a straight-backed chair or sit cross-legged on the floor or a cushion, close one's eyes and bring attention to either the sensations of breathing in the proximity of one's nostrils or to the movements of the abdomen when breathing in and out. In this meditation practice, one does not try to control one's breathing, but attempts to simply be aware of one's natural breathing process/rhythm. When engaged in this practice, the mind will often run off to other thoughts and associations, and if this happens, one passively notices that the mind has wandered, and in an accepting, non-judgmental way, returns to focusing on breathing. In body-scan meditation the attention is directed at various areas of the body and noting body sensations that happen in the present moment. One could also focus on sounds, sensations, thoughts, feelings and actions that happen in the present. In this regard, a famous exercise, introduced by Kabat-Zinn in his MBSR program, is the mindful tasting of a raisin, in which a raisin is being tasted and eaten mindfully. By enabling reconnection with internal hunger and satiety cues, mindful eating has been suggested to be a means of maintaining healthy and conscious eating patterns. Other approaches include practicing yoga asanas while attending to movements and body sensations, and walking meditation. Timings Meditators are recommended to start with short periods of 10 minutes or so of meditation practice per day. As one practices regularly, it becomes easier to keep the attention focused on breathing. An old Zen saying suggests, "You should sit in meditation for 20 minutes every day — unless you're too busy. Then you should sit for an hour." In Buddhist context; moral precepts In a Buddhist context the keeping of moral precepts is an essential preparatory stage for mindfulness or meditation. Vipassana also includes contemplation and reflection on phenomena as dukkha, anatta and anicca, and reflections on causation and other Buddhist teachings. Translations Mindfulness meditation is part of Buddhist psychological traditions and the developing scholarship within empirical psychology. Sati and smṛti The Buddhist term translated into English as "mindfulness" originates in the Pali term sati and in its Sanskrit counterpart smṛti. It is often translated as "bare attention", but in the Buddhist tradition it has a broader meaning and application, and the meaning of these terms has been the topic of extensive debate and discussion. According to Bryan Levman, "the word sati incorporates the meaning of 'memory' and 'remembrance' in much of its usage in both the suttas and the [traditional Buddhist] commentary, and ... without the memory component, the notion of mindfulness cannot be properly understood or applied, as mindfulness requires memory for its effectiveness". According to Robert Sharf, smṛti originally meant "to remember", "to recollect", "to bear in mind", as in the Vedic tradition of remembering the sacred texts. The term sati also means "to remember". In the Satipaṭṭhāna-sutta the term sati means to remember the dharmas, whereby the true nature of phenomena can be seen. Sharf refers to the Milindapañha, which said that the arising of sati calls to mind the wholesome dhammas such as the four foundations of mindfulness, the five faculties, the five powers, the seven awakening-factors, the noble eightfold path, and the attainment of insight. According to Rupert Gethin, Sharf further notes that this has little to do with "bare attention", the popular contemporary interpretation of sati, "since it entails, among other things, the proper discrimination of the moral valence of phenomena as they arise." Georges Dreyfus has also expressed unease with the definition of mindfulness as "bare attention" or "nonelaborative, nonjudgmental, present-centered awareness", stressing that mindfulness in a Buddhist context also means "remembering", which indicates that the function of mindfulness also includes the retention of information. Robert H. Sharf notes that Buddhist practice is aimed at the attainment of "correct view", not just "bare attention". Jay L. Garfield, quoting Shantideva and other sources, stresses that mindfulness is constituted by the union of two functions, calling to mind and vigilantly retaining in mind. He demonstrates that there is a direct connection between the practice of mindfulness and the cultivation of moralityat least in the context of Buddhism, from which modern interpretations of mindfulness are stemming. Translation The Pali-language scholar Thomas William Rhys Davids (1843–1922) first translated sati in 1881 as English mindfulness in sammā-sati "Right Mindfulness; the active, watchful mind". Noting that Daniel John Gogerly (1845) initially rendered sammā-sati as "correct meditation", Davids said: Alternative translations John D. Dunne says that the translation of sati and smṛti as mindfulness is confusing. A number of Buddhist scholars have started trying to establish "retention" as the preferred alternative. Bhikkhu Bodhi also describes the meaning of sati as "memory". The terms sati/smṛti have been translated as: Attention (Jack Kornfield) Awareness Concentrated attention (Mahasi Sayadaw) Inspection (Herbert V. Günther) Mindful attention Mindfulness Recollecting mindfulness (Alexander Berzin) Recollection (Erik Pema Kunsang, Buddhadasa) Reflective awareness (Buddhadasa) Remindfulness (James H. Austin) Retention Self-recollection (Jack Kornfield) Definitions Psychology A.M. Hayes and G. Feldman have highlighted that mindfulness can be seen as a strategy that stands in contrast to a strategy of avoidance of emotion on the one hand and to the strategy of emotional over-engagement on the other hand. Mindfulness can also be viewed as a means to develop self-knowledge and wisdom. Trait, state and practice According to Brown, Ryan, and Creswell, definitions of mindfulness are typically selectively interpreted based on who is studying it and how it is applied. Some have viewed mindfulness as a mental state, while others have viewed it as a set of skills and techniques. A distinction can also be made between the state of mindfulness and the trait of mindfulness. According to David S. Black, whereas "mindfulness" originally was associated with esoteric beliefs and religion, and "a capacity attainable only by certain people", scientific researchers have translated the term into measurable terms, providing a valid operational definition of mindfulness. Black mentions three possible domains: A trait, a dispositional characteristic (a relatively long lasting trait), a person's tendency to more frequently enter into and more easily abide in mindful states; A state, an outcome (a state of awareness resulting from mindfulness training), being in a state of present-moment awareness; A practice (mindfulness meditation practice itself). Trait-like constructs According to Brown, mindfulness is: Several mindfulness measures have been developed which are based on self-reporting of trait-like constructs: Mindful Attention Awareness Scale (MAAS) Freiburg Mindfulness Inventory (FMI) Kentucky Inventory of Mindfulness Skills (KIMS) Cognitive and Affective Mindfulness Scale (CAMS) Mindfulness Questionnaire (MQ) Revised Cognitive and Affective Mindfulness Scale (CAMS-R) Philadelphia Mindfulness Scale (PHLMS) State-like phenomenon According to Bishop, et alia, mindfulness is, "A kind of nonelaborative, nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is." The Toronto Mindfulness Scale (TMS) measures mindfulness as a state-like phenomenon, that is evoked and maintained by regular practice. The State Mindfulness Scale (SMS) is a 21-item survey with an overall state mindfulness scale, and 2 sub-scales (state mindfulness of mind, and state mindfulness of body). Mindfulness-practice Mindfulness as a practice is described as: "Mindfulness is a way of paying attention that originated in Eastern meditation practices" "Paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally" "Bringing one's complete attention to the present experience on a moment-to-moment basis" According to Steven F. Hick, mindfulness practice involves both formal and informal meditation practices, and nonmeditation-based exercises. Formal mindfulness, or meditation, is the practice of sustaining attention on body, breath or sensations, or whatever arises in each moment. Informal mindfulness is the application of mindful attention in everyday life. Nonmeditation-based exercises are specifically used in dialectical behavior therapy and in acceptance and commitment therapy. Definitions arising in modern teaching of meditation Since the 1970s, most books on meditation use definitions of mindfulness similar to Jon Kabat-Zinn's definition as "present moment awareness". However, recently a number of teachers of meditation have proposed quite different definitions of mindfulness. Shinzen Young says a person is mindful when they have mindful awareness, and defines that to be when "concentration power, sensory clarity, and equanimity [are] working together." John Yates (Culadasa) defines mindfulness to be "the optimal interaction between attention and peripheral awareness", where he distinguishes attention and peripheral awareness as two distinct modes in which one may be conscious of things. Buddhism According to American Buddhist monk Ven Bhante Vimalaramsi's book A Guide to Tranquil Wisdom Insight Meditation, the term mindfulness is often interpreted differently than what was originally formulated by the Buddha. In the context of Buddhism, he offers the following definition: In Buddhism, mindfulness is closely intertwined with the concept of interbeing, a philosophical concept used by Thich Nhat Hanh to highlight the interconnectedness of all things. This philosophy, rooted in Buddhist teachings such as Vipassana and Zen meditation, emphasizes awareness of the present moment and ethical living, reflecting the interconnected nature of existence. Other uses The English term mindfulness already existed before it came to be used in a (western) Buddhist context. It was first recorded as myndfulness in 1530 (John Palsgrave translates French pensée), as mindfulnesse in 1561, and mindfulness in 1817. Morphologically earlier terms include mindful (first recorded in 1340), mindfully (1382), and the obsolete mindiness (c. 1200). According to the Merriam-Webster Dictionary, mindfulness may also refer to "a state of being aware". Synonyms for this "state of being aware" are wakefulness, attention, alertness, prudence, conscientiousness, awareness, consciousness, and observation. Models and frameworks for mindfulness practices Two-component model A two-component model of mindfulness based upon a consensus among clinical psychologists has been proposed as an operational and testable definition, : In this two-component model, self-regulated attention (the first component) "involves bringing awareness to current experience—observing and attending to the changing fields of "objects" (thoughts, feelings, sensations), from moment to moment – by regulating the focus of attention". Orientation to experience (the second component) involves maintaining an attitude of curiosity about objects experienced at each moment, and about where and how the mind wanders when it drifts from the selected focus of attention. Clients are asked to avoid trying to produce a particular state (e.g. relaxation), but rather to just notice each object that arises in the stream of consciousness. The five-aggregate model An ancient model of the mind, generally known as the five-aggregate model enables one to understand the moment-to-moment manifestation of subjective conscious experience, and therefore can be a potentially useful theoretical resource to guide mindfulness interventions. This model is based upon the traditional buddhist description of the Skandhas. The five aggregates are described as follows: Material form: includes both the physical body and external matter where material elements are continuously moving to and from the material body. Feelings: can be pleasant, unpleasant or neutral. Perceptions: represent being aware of attributes of an object (e.g. color, shape, etc.) Volition: represents bodily, verbal, or psychological behavior. Sensory consciousness: refers to input from the five senses (seeing, hearing, smelling, tasting or touch sensations) or a thought that happens to arise in the mind. This model describes how sensory consciousness results in the generation of feelings, perception or volition, and how individuals' previously conditioned attitudes and past associations influence this generation. The five aggregates are described as constantly arising and ceasing in the present moment. Cultivating self-knowledge and wisdom The practice of mindfulness can be utilized to gradually develop self-knowledge and wisdom. In this regard, Buddhist teachings provide detailed instructions on how one can carry out an inquiry into the nature of the mind, and this guidance can help one to make sense of one's subjective experience. This could include understanding what the "present moment" is, how various thoughts, etc., arise following input from the senses, the conditioned nature of thoughts, and other realizations. In Buddhist teachings, ultimate wisdom refers to gaining deep insight into all phenomena or "seeing things as they are." Historical development Buddhism Mindfulness as a modern, Western practice is founded on Zen and modern Vipassanā, and involves the training of sati, which means "moment to moment awareness of present events", but also "remembering to be aware of something". Early Buddhism Sati is one of the seven factors of enlightenment. "Correct" or "right" mindfulness (Pali: sammā-sati, Sanskrit samyak-smṛti) is the seventh element of the Noble Eightfold Path. Mindfulness is an antidote to delusion and is considered as a 'power' (Pali: bala) which contributes to the attainment of Nibbana. This faculty becomes a power in particular when it is coupled with clear comprehension of whatever is taking place. Nirvana is a state of being in which greed, hatred and delusion (Pali: moha) have been overcome and abandoned, and are absent from the mind. According to Paul Williams, referring to Erich Frauwallner, mindfulness provided the way in Early Buddhism to liberation, "constantly watching sensory experience in order to prevent the arising of cravings which would power future experience into rebirths." According to Vetter, Jhanas may have been the original core practice of the Buddha, which aided the maintenance of mindfulness. According to Thomas William Rhys Davids, the doctrine of mindfulness is "perhaps the most important" after the Four Noble Truths and the Noble Eightfold Path. T.W. Rhys Davids viewed the teachings of Gotama Buddha as a rational technique for self-actualization and rejected a few parts of it, mainly the doctrine of rebirth, as residual superstitions. Zazen The aim of zazen is just sitting, that is, suspending all judgmental thinking and letting words, ideas, images and thoughts pass by without getting involved in them. Contemporary Vipassana-meditation In modern vipassana-meditation, as propagated by the Vipassana movement, sati aids vipassana, insight into the true nature of reality, namely the three marks of existence, the impermanence of and the suffering of every conditioned thing that exists, and non-self. With this insight, the practitioner becomes a so-called Sotāpanna, a "stream-enterer", the first stage on the path to liberation. Vipassana is practiced in tandem with Samatha, and also plays a central role in other Buddhist traditions. According to the contemporary Theravada orthodoxy, Samatha is used as a preparation for Vipassanā, pacifying the mind and strengthening the concentration in order to allow the work of insight, which leads to liberation. Vipassanā-meditation has gained popularity in the west through the modern Buddhist vipassana movement, modeled after Theravāda Buddhism meditation practices, which employs vipassanā and ānāpāna meditation as its primary techniques and places emphasis on the teachings of the Sutta. Anapanasati, satipaṭṭhāna, and vipassana Anapanasati is mindfulness of breathing. "Sati" means mindfulness; "ānāpāna" refers to inhalation and exhalation. Anapanasati means to feel the sensations caused by the movements of the breath in the body. The Anapanasati Sutta gives an exposition on this practice. Satipaṭṭhāna is the establishment of mindfulness in one's day-to-day life, maintaining as much as possible a calm awareness of one's body, feelings, mind, and dhammas. The practice of mindfulness supports analysis resulting in the arising of wisdom (Pali: paññā, Sanskrit: prajñā). Samprajaña, apramāda and atappa In contemporary Theravada practice, "mindfulness" also includes samprajaña, meaning "clear comprehension" and apramāda meaning "vigilance". All three terms are sometimes (confusingly) translated as "mindfulness", but they all have specific shades of meaning. In a publicly available correspondence between Bhikkhu Bodhi and B. Alan Wallace, Bodhi has described Ven. Nyanaponika Thera's views on "right mindfulness" and sampajañña as follows: Monitoring mental processes According to Buddhadasa, the aim of mindfulness is to stop the arising of disturbing thoughts and emotions, which arise from sense-contact. According to Grzegorz Polak, the four upassanā (foundations of mindfulness) have been misunderstood by the developing Buddhist tradition, including Theravada, to refer to four different foundations. According to Polak, the four upassanā do not refer to four different foundations, but to the awareness of four different aspects of raising mindfulness: the six sense-bases which one needs to be aware of (kāyānupassanā); contemplation on vedanās, which arise with the contact between the senses and their objects (vedanānupassanā); the altered states of mind to which this practice leads (cittānupassanā); the development from the five hindrances to the seven factors of enlightenment (dhammānupassanā). Stoicism The Greek philosophical school of Stoicism founded by Zeno of Citium included practices resembling those of mindfulness, such as visualization exercises. In his Discourses, Stoic philosopher Epictetus addresses in particular the concept of attention (prosoche), an idea also found in Seneca and Marcus Aurelius. By cultivating it over time, this skill would prevent the practitioner from becoming unattentive and moved by instinct rather than according to reason. Christianity Mindfulness traditions are also found in some Christian spiritual traditions. In his Rules for Eating, St. Ignatius of Loyola teaches, "let him guard against all his soul being intent on what he is eating, and in eating let him not go hurriedly, through appetite, but be master of himself, as well in the manner of eating as in the quantity which he eats." He might have been inspired by Epictetus' Enchiridion. Transcendentalism Mindfulness practitioner Jon Kabat-Zinn refers to Thoreau as a predecessor of the interest in mindfulness, together with other eminent Transcendentalists such as Emerson and Whitman: The forms of Asian religion and spirituality which were introduced in the west were themselves influenced by Transcendentalism and other 19th-century manifestations of Western esotericism. Transcendentalism was closely connected to the Unitarian Church, which in India collaborated with Ram Mohan Roy (1772–1833) and his Brahmo Samaj. He found that Unitarianism came closest to true Christianity, and had a strong sympathy for the Unitarians. This influence worked through on Vivekananda, whose modern but idiosyncratic interpretation of Hinduism became widely popular in the west. Vipassana meditation, presented as a centuries-old meditation system, was a 19th-century reinvention, which gained popularity in south-east due to the accessibility of the Buddhist sutras through English translations from the Pali Text Society. It was brought to western attention in the 19th century by the Theosophical Society. Zen Buddhism first gained popularity in the west through the writings of D.T. Suzuki, who attempted to present a modern interpretation of Zen, adjusted to western tastes. Jon Kabat-Zinn and MBSR In 1979, Jon Kabat-Zinn founded the Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts to treat the chronically ill. This program sparked the application of mindfulness ideas and practices in Medicine for the treatment of a variety of conditions in both healthy and unhealthy people. MBSR and similar programs are now widely applied in schools, prisons, hospitals, veterans centers, and other environments. Mindfulness practices were inspired mainly by teachings from the Eastern World, particularly from Buddhist traditions. Kabat-Zinn was first introduced to meditation by Philip Kapleau, a Zen missionary who came to speak at MIT where Kabat-Zinn was a student. Kabat-Zinn went on to study meditation with other Zen-Buddhist teachers such as Thích Nhất Hạnh and Seungsahn. He also studied at the Insight Meditation Society and eventually taught there. One of MBSR's techniques—the "body scan"—was derived from a meditation practice ("sweeping") of the Burmese U Ba Khin tradition, as taught by S. N. Goenka in his Vipassana retreats, which he began in 1976. The body scan method has since been widely adapted to secular settings, independent of religious or cultural contexts. Kabat-Zinn was also influenced by the book The Varieties of Religious Experience by William James which suggests that religions point toward the same experience, and which 1960s counterculture figures interpreted as meaning that the same universal, experiential truth could be reached in different ways, including via non-religious activities. Popularization, "mindfulness movement" Mindfulness is gaining a growing popularity as a practice in daily life, apart from Buddhist insight meditation and its application in clinical psychology. In this context mindfulness is defined as moment-by-moment awareness of thoughts, feelings, bodily sensations, and surrounding environment, characterized mainly by "acceptance"—attention to thoughts and feelings without judging whether they are right or wrong. Mindfulness focuses the human brain on what is being sensed at each moment, instead of on its normal rumination on the past or the future. Mindfulness may be seen as a mode of being, and can be practiced outside a formal setting. The terminology used by scholars of religion, scientists, journalists, and popular media writers to describe this movement of mindfulness "popularization," and the many new contexts of mindfulness practice which have cropped up, has regularly evolved over the past 20 years, with some criticisms arising. The latest changes when people moved from real-life meditation sessions to the applications on their smart devices has been even more accelerated by the global pandemic. Modern applications like are adapting to the needs of their users by using AI technology, involving professional psychologists and offering many different mindfulness approaches to serve a wider audience. Applications According to Jon Kabat-Zinn the practice of mindfulness may be beneficial to many people in Western society who might be unwilling to adopt Buddhist traditions or vocabulary. Western researchers and clinicians who have introduced mindfulness practice into mental health treatment programs usually teach these skills independently of the religious and cultural traditions of their origins. Programs based on MBSR and similar models have been widely adopted in schools, prisons, hospitals, veterans centers, and other environments. Therapy programs Mindfulness-based stress reduction Mindfulness-based stress reduction (MBSR) is a mindfulness-based program developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center, which uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful. While MBSR has its roots in spiritual teachings, the program itself is secular. Mindfulness-based cognitive therapy Mindfulness-based cognitive therapy (MBCT) is a psychological therapy designed to aid in preventing the relapse of depression, specifically in individuals with Major depressive disorder (MDD). It uses traditional cognitive behavioral therapy (CBT) methods and adds in newer psychological strategies such as mindfulness and mindfulness meditation. Cognitive methods can include educating the participant about depression. Mindfulness and mindfulness meditation focus on becoming aware of all incoming thoughts and feelings and accepting them, but not attaching or reacting to them. Like CBT, MBCT functions on the theory that when individuals who have historically had depression become distressed, they return to automatic cognitive processes that can trigger a depressive episode. The goal of MBCT is to interrupt these automatic processes and teach the participants to focus less on reacting to incoming stimuli, and instead accepting and observing them without judgment. This mindfulness practice allows the participant to notice when automatic processes are occurring and to alter their reaction to be more of a reflection. Research supports the effects of MBCT in people who have been depressed three or more times and demonstrates reduced relapse rates by 50%. Mindfulness-based pain management Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness. Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework. It was developed by Vidyamala Burch and is delivered through the programs of Breathworks. It has been subject to a range of clinical studies demonstrating its effectiveness. Acceptance and commitment therapy Acceptance and commitment therapy or (ACT) (typically pronounced as the word "act") is a form of clinical behavior analysis (CBA) used in psychotherapy. It is a psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. It was developed in the late 1980s by Steven C. Hayes, Kelly G. Wilson, and Kirk Strosahl. Dialectical behavior therapy Mindfulness is a "core" exercise used in dialectical behavior therapy (DBT), a psychosocial treatment Marsha M. Linehan developed for treating people with borderline personality disorder. DBT is dialectic, says Linehan, in the sense of "the reconciliation of opposites in a continual process of synthesis." As a practitioner of Buddhist meditation techniques, Linehan says: Mode deactivation therapy Mode deactivation therapy (MDT) is a treatment methodology that is derived from the principles of cognitive-behavioral therapy and incorporates elements of Acceptance and commitment therapy, Dialectical behavior therapy, and mindfulness techniques. Mindfulness techniques such as simple breathing exercises are applied to assist the client in awareness and non-judgmental acceptance of unpleasant and distressing thoughts and feelings as they occur in the present moment. Mode Deactivation Therapy was developed and is established as an effective treatment for adolescents with problem behaviors and complex trauma-related psychological problems, according to recent publications by Jack A. Apsche and Joan Swart. Other programs Morita therapy The Japanese psychiatrist Shoma Morita, who trained in Zen meditation, developed Morita therapy upon principles of mindfulness and non-attachment. IFS Internal Family Systems Model (IFS), developed by Richard C. Schwartz, emphasizes the importance of both therapist and client engaging in therapy from the Self, which is the IFS term for one's "spiritual center". The Self is curious about whatever arises in one's present experience and open and accepting toward all manifestations. Mindfulness relaxation Mindfulness relaxation uses breathing methods, guided imagery, and other practices to relax the body and mind and help reduce stress. Schools In 2012 Congressman Tim Ryan of Ohio published A Mindful Nation, and received a $1 million federal grant to teach mindfulness in schools in his home district. Mindful Kids Miami is a tax-exempt, 501 (c)(3), non-profit corporation established in 2011 dedicated to making age-appropriate mindfulness training available to school children in Miami-Dade County public and private schools. This is primarily accomplished by training educators and other childcare providers to incorporate mindfulness practices in the children's daily activities. In 2000, The Inner Kids Program, a mindfulness-based program developed for children, was introduced into public and private school curricula in the greater Los Angeles area. MindUP, a classroom-based program spearheaded by Goldie Hawn's Hawn Foundation, teaches students to self-regulate behavior and mindfully engage in focused concentration required for academic success. For the last decade, MindUP has trained teachers in over 1,000 schools in cities from Arizona to Washington. The Holistic Life Foundation, a non-profit organization that created an in-school mindfulness program called Mindful Moment, is currently serving almost 350 students daily at Robert W. Coleman Elementary School and approximately 1300 students at Patterson Park High School in Baltimore, Maryland. At Patterson High School, the Mindful Moment program engages the school's faculty along with the students during a 15-minute mindfulness practice at the beginning and end of each school day. Mindful Life Project, a non-profit 501(c)3 based out of Richmond, California, teaches mindfulness to elementary school students in underserved schools in the South Richmond school district. Utilizing curriculum, "Rise-Up" is a regular school day intervention program serving 430 students weekly, while "Mindful Community" is currently implemented at six South Richmond partner schools. These in-school mindfulness programs have been endorsed by Richmond Mayor Gayle McLaughlin, who has recommended additional funding to expand the program in order to serve all Richmond youth. Education Mindfulness practices are becoming more common within educational institutions including Elementary and Secondary schools. This has been referred to as part of a 'contemplative turn' in education that has emerged since the turn of the millennium. The applications of mindfulness in schools are aimed at calming and relaxation of students as well as for students and educators to build compassion and empathy for others. An additional benefit to Mindfulness in education is for the practice to reduce anxiety and stress in students. Based on a broad meta-analytical review, scholars said that the application of mindfulness practice enhances the goals of education in the 21st century, which include adapting to a rapidly changing world and being a caring and committed citizen. Within educational systems, the application of mindfulness practices shows an improvement of students' attention and focus, emotional regulation, creativity, and problem solving skills. As discussed by Ergas and Todd, the development of this field since the turn of the millennium has brought diverse possibilities as well as complexities, given the origins of mindfulness within Buddhism and the processes of its secularization and measurement based on science. Renshaw and Cook state, "As scientific interest in the utility of Mindfulness-Based Intervention (MBI) in schools grew steadily, popular interest in mindfulness in schools seemed to grow exponentially". Despite research on mindfulness being comparatively unexamined, especially with young students, the practice has seen a spike in use within the educational arena. "A relatively recent addition to discourse around preventing school expulsion and failure, mindfulness is gaining popularity for its potential to improve students' social, emotional, behavioral, and learning-related cognitive control, thereby improving academic outcomes". Researchers and educators are interested in how mindfulness can provide optimal conditions for a students' personal development and academic success. Current research on mindfulness in education is limited but can provide insight into the potential benefits for students, and areas of improvement for future studies. Mindfulness in the classroom is being touted as a promising new intervention tool for young students. According to Choudhury and Moses, "Although still marginal and in some cases controversial, secular programs of mindfulness have been implemented with ambitious goals of improving attentional focus of pupils, social-emotional learning in "at-risk" children and youth, not least, to intervene in problems of poverty and incarceration". Emerging research is concerned with studying teachers and programs using mindfulness practices with students and is discovering tension arising from the moral reframing of eastern practices in western school settings. As cited by Renshaw and Cook, "Unlike most other approaches to contemporary school-based intervention, which are squarely grounded in behavioral, cognitive-behavioral, and ecological systems theories, MBIs have their origins in Eastern religious traditions". Some school administrators are concerned about implementing such practices, and parents have been reported to take their children out of mindfulness programs because of their personal religious beliefs. Yet, MBIs continue to be accepted by the mainstream in both primary and secondary schools because, "Mindfulness practices, particularly in relation to children who might otherwise be considered broken or unredeemable, fill a critical niche – one that allows its advocates to imagine a world where people can change, become more compassionate, resilient, reflective, and aware; a world with a viable future". As mindfulness in education continues to develop, ethical consequences will remain a controversial issue because the generic description for the "benefits" and "results" of MBIs are largely concerned with individual and inward-focused achievement, rather than the original Buddhist ideal of global human connection. Available research reveals a relationship between mindfulness and attention. Semple, Lee, Rosa, & Miller say, "Anxiety can impair attention and promote emotionally reactive behaviors that interfere with the development of good study skills, so it seems reasonable that increased mindfulness would be associated with less anxiety". They conducted a randomized trial of Mindfulness-Based Cognitive Therapy for Children (MBCT-C) that found promise in managing anxiety for elementary school-aged children, and suggests that those who completed the program displayed fewer attention problems. In addition, Flook shows how an eight-week mindfulness awareness program was evaluated in a random and controlled school setting and measured the effects of awareness practices on executive functions in elementary school children. Their findings concluded, "Participation in the mindfulness awareness program was associated with improvements in behavioral regulation, metacognition, and overall executive functions". In the study by Flook, parents and teachers completed questionnaires which propose that participation in mindfulness programs is associated with improvements in child behavioral regulation. These perspectives are a valuable source of data given that caregivers and educators interact with the children daily and across a variety of settings. According to Eklund, Omalley, and Meyer, "School-based practitioners should find promise in the evidence supporting mindfulness-based practices with children, parents, and educators". Lastly, a third study by Zenner, Herrnleben-Kurz, and Walach concluded, "Analysis suggest that mindfulness-based interventions for children and youths are able to increase cognitive capacity of attending and learning by nearly one standard deviation and yield". Application of Mindfulness-Based Interventions continue to increase in popularity and practice. Mindfulness-Based Interventions are rising across western culture, but its effectiveness in school programs is still being determined. Research contends, "Mindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness among young people". Although much of the available studies find a high number of mindfulness acceptability among students and teachers, more research needs to be conducted on its effects on well-being and mental health for students. In a firmly controlled experiment, Johnson, Burke, Brinkman, and Wade evaluated "the impact of an existing and widely available school-based mindfulness program". According to their research, "no improvements were demonstrated on any outcome measured either immediately post-intervention or at three-month follow-up". Many questions remain on which practices best implement effective and reliable mindfulness programs at schools, and further research is needed to identify the optimal methods and measurement tools for mindfulness in education. Business Mindfulness training appears to be getting popular in the business world, and many large corporations have been incorporating mindfulness practices into their culture. For example, companies such as Google, Apple, Procter & Gamble, General Mills, Mayo Clinic, and the U.S. Army offer mindfulness coaching, meditation breaks and other resources to their employees to improve workplace functioning. The introduction of mindfulness in corporate settings still remains in early stages and its potential long-term impact requires further assessment. Mindfulness has been found to result in better employee well-being, lower levels of frustration, lower absenteeism and burnout as well as an improved overall work environment. Law Legal and law enforcement organizations are also showing interest in mindfulness: Harvard Law School's Program on Negotiation hosted a workshop on "Mindfulness in the Law & Alternative Dispute Resolution." Many law firms offer mindfulness classes. Prison-programs Mindfulness has been taught in prisons, reducing hostility and mood disturbance among inmates, and improving their self-esteem. Additional studies indicate that mindfulness interventions can result in significant reductions in anger, reductions in substance use, increased relaxation capacity, self-regulation and optimism. Government Many government organizations offer mindfulness training. Coping Strategies is an example of a program utilized by United States Armed Forces personnel. The British Parliament organized a mindfulness-session for its members in 2014, led by Ruby Wax. Scientific research Effects and efficacy of mindfulness practice Mindfulness has gained increasing empirical attention since 1970 and has been studied often as an intervention for stress reduction. Meta analyses indicate its beneficial effects for healthy adults, for adolescents and children, as well as for different health-related outcomes including weight management, psychiatric conditions, heart disease, sleep disorders, cancer care, adult autism treatment, multiple sclerosis, and other health-related conditions. An often-cited meta-analysis on meditation research published in JAMA in 2014, found insufficient evidence of any effect of meditation programs on positive mood, attention, substance use, eating habits, sleep, and weight, but found that there is moderate evidence that meditation reduces anxiety, depression, and pain. However, this study included a highly heterogeneous group of meditation styles (i.e., it did not focus exclusively on mindfulness meditation), which is a significant limitation of this study. Additionally, while mindfulness is well known to have positive psychological effect among individuals diagnosed with various types of cancers, the evidence is unclear regarding its effectiveness in men with prostate cancer. Thousands of studies on meditation have been conducted, though the methodological quality of some of the studies is poor. Recent reviews have described many of these issues. Nonetheless, mindfulness meditation is a popular subject for research, and many present potential benefits for a wide array of conditions and outcomes. For example, the practice of mindfulness has also been used to improve athletic performance, as a beneficial intervention for children with special needs and their caregivers, as a viable treatment option for people with insomnia an effective intervention for healthy aging, as a strategy for managing dermatological conditions and as a useful intervention during early pregnancy. Recent studies have also demonstrated that mindfulness meditation significantly attenuates physical pain through multiple, unique mechanisms. Meditation also may allow one to modulate pain. When exposed to pain from heating, the brain scans of the mindfulness meditation participants (by use of functional magnetic resonance imaging) showed their brains notice the pain equally, however it does not get converted to a perceived pain signal. As such they experienced up to 40–50% less pain. Research has also investigated mindful movements and mindful exercises for different patient populations. Neurological studies Research studies have also focused on the effects of mindfulness on the brain using neuroimaging techniques, physiological measures and behavioral tests. Research on the neural perspective of how mindfulness meditation works suggests that it exerts its effects in components of attention regulation, body awareness and emotional regulation. When considering aspects such as sense of responsibility, authenticity, compassion, self-acceptance and character, studies have shown that mindfulness meditation contributes to a more coherent and healthy sense of self and identity. Neuroimaging techniques suggest that mindfulness practices such as mindfulness meditation are associated with "changes in the anterior cingulate cortex, insula, temporo-parietal junction, fronto-limbic network and default mode network structures." Further, mindfulness meditation may prevent or delay the onset of mild cognitive impairment and Alzheimer's disease. Additionally, mindfulness-induced emotional and behavioral changes have been found to be related to functional and structural changes in the brain. It has also been suggested that the default mode network of the brain can be used as a potential biomarker for monitoring the therapeutic benefits of meditation. Recent research also suggest that the practice of mindfulness could influence genetic expression leading to a reduced risk of inflammation-related diseases and favourable changes in biomarkers. Grey matter concentrations in brain regions that regulate emotion, self-referential processing, learning and memory processes have shown changes in density following MBSR. Additionally, MBSR practice has been associated with improvement of the immune system which could explain the correlation between stress reduction and increased quality of life. Part of these changes are a result of the thickening of the prefrontal cortex (executive functioning) and hippocampus (learning and memorisation ability), the shrinking of the amygdala (emotion and stress response) and the strengthening of the connections between brain cells. Long-term meditators have larger amounts of gyrification ("folding" of the cortex, which may allow the brain to process information faster) than people who do not meditate. Further, a direct correlation was found between the amount of gyrification and the number of meditation years, possibly providing further proof of the brain's neuroplasticity, or ability to adapt to environmental changes. Associations of mindfulness with other variables Mindfulness (as a trait, distinguished from mindfulness practice) has been linked to many outcomes. In an overview, Keng, Smoski, and Robins summarize: "Trait mindfulness has been associated with higher levels of life satisfaction, agreeableness, conscientiousness, vitality, self esteem, empathy, sense of autonomy, competence, optimism, and pleasant affect. A 2020 study found links between dispositional mindfulness and prosocial behavior. Studies have also demonstrated significant negative correlations between mindfulness and depression, neuroticism, absentmindedness, dissociation, rumination, cognitive reactivity, social anxiety, difficulties in emotion regulation, experiential avoidance, alexithymia, intensity of delusional experience in the context of psychosis, and general psychological symptoms." (References to underlying studies omitted from quotation.) Effects on mindfulness The mechanisms that make people less or more mindful have been researched less than the effects of mindfulness programmes, so little is known about which components of mindfulness practice are relevant for promoting mindfulness. For example, meta-analyses have shown that mindfulness practice does increase mindfulness when compared to active control groups. This may be because we do not know how to measure mindfulness. It could also be that mindfulness is dose-dependent and increases with more experience. To counter that, Bergomi et al. found that "results provide evidence for the associations between self-reported mindfulness and meditation practice and suggest that mindfulness is particularly associated with continued practice in the present, rather than with accumulated practice over years." Some research into other mechanisms has been done. One study conceptualized such mechanisms in terms of competition for attention. In a test of that framework, mindfulness was found to be associated (as predicted) with having an activated intention to be mindful, with feeling good, and with not being hurried or very busy. Regarding the relationship between feeling good and being mindful, a different study found that causality probably works both ways: feeling good increases mindfulness, and mindfulness increases feeling good. One theory suggests an additional mechanism termed as reperceiving. Reperceiving is the beneficial effect that comes after the process of being mindful after all the intention, attention, and attitude has been experienced. Through reperceiving there is a shift in perspective. Reperceiving permits disassociation from thoughts, emotions, and physical sensations, and allows one to exist with them instead of being defined by them. Adverse effects Meditation (of which mindfulness is just a version) has also been correlated with unpleasant experiences. In some cases, it has also been linked to psychosis and suicide. Both the soundness of its scientific foundations and the desirability of its societal effects have been questioned. In one study, published in 2019, of 1,232 regular meditators with at least two months of meditation experience, about a quarter reported having had particularly unpleasant meditation-related experiences (such as anxiety, fear, distorted emotions or thoughts, altered sense of self or the world), which they thought may have been caused by their meditation practice. Meditators with high levels of repetitive negative thinking and those who only engage in deconstructive meditation were more likely to report unpleasant side effects. Adverse effects were less frequently reported in women and religious meditators. Another study from 2021 on the effects of mindfulness-based programs (MBPs) found negative side-effects in 37% of the sample while lasting bad effects in 6–14% of the sample. Most of the side effects were related to signs of dysregulated arousal (i.e., hyperarousal and dissociation). The majority of these adverse events occurred as a result of regular practice at home or during class, something that challenges the notion that it is only intense practice that can give rise to negative experiences; as it turns out intense all-day retreats or working with difficulty practice accounts for only 6% of adverse effects. The symptoms most readily recognized as negative were those of hyperarousal (e.g., anxiety and insomnia). On the other hand, There is also mounting evidence that meditation can disturb various prosocial behaviors. By blunting emotions, in particular the social emotions of guilt and shame, it may produce deficits in the feelings of empathy and remorse thus creating calm but callous practitioners. In one study with 1400 participants researchers found that focused-breathing meditation can dampen the relationship between transgressions and the desire to engage in reparative prosocial behaviors. Another study found that meditation can increase the trait of selfishness. The study, consisting of two interrelated parts and totaling 691 participants, found that a mindfulness induction, compared to a control condition, led to decreased prosocial behavior. This effect was moderated by self-construals such that people with relatively independent self-construals became less prosocial while people with relatively interdependent self-construals became more so. In the western world where independent self-construals generally predominate meditation may thus have potentially detrimental effects. These new findings about meditations socially problematic effects imply that it can be contraindicated to use meditation as a tool to handle acute personal conflicts or relational difficulties; in the words of Andrew Hafenbrack, one of the authors of the study, “If we 'artificially' reduce our guilt by meditating it away, we may end up with worse relationships, or even fewer relationships”. Difficult experiences encountered in meditation are mentioned in traditional sources; and some may be considered to be an expected part of the process, e.g., seven stages of purification mentioned in Theravāda Buddhism. Possible "unwholesome or frightening visions" are mentioned in a practical manual on vipassanā meditation. Classical sources have various terms for "meditation sickness" and related difficulties, such as zouhuorumo, chanbing and mojing. An article from the Journal of Buddhist Ethics states, Concerns and criticism Scholarly research Many of the above cited review studies also indicate the necessity for more high-quality research in this field such as conducting intervention studies using larger sample sizes, the use of more randomized controlled studies and the need for providing more methodological details in reported studies. The majority of studies also either measure mindfulness as a trait, and in research that use mindfulness interventions in clinical practice, the lack of true randomisation poses a problem for understanding the true effectiveness of mindfulness. Experimental methods using randomised samples, though, suggest that mindfulness as a state or temporary practice can influence felt emotions such as disgust and promote abstract decision-making. There are also a few review studies that have found little difference between mindfulness interventions and control groups, though they did also indicate that their intervention group was treated too briefly for the research to be conclusive. In some domains, such as sport, a lack of internal validity across studies prevents any strong claims being made about the effects of mindfulness. These studies also list the need for more robust research investigations. Several issues pertaining to the assessment of mindfulness have also been identified including the current use of self-report questionnaires. Potential for bias also exists to the extent that researchers in the field are also practitioners and possibly subject to pressures to publish positive or significant results. Various scholars have criticized how mindfulness has been defined or represented in recent Western psychology publications. These modern understandings depart significantly from the accounts of mindfulness in early Buddhist texts and authoritative commentaries in the Theravada and Indian Mahayana traditions. Adam Valerio has introduced the idea that conflict between academic disciplines over how mindfulness is defined, understood, and popularly presented may be indicative of a personal, institutional, or paradigmatic battle for ownership over mindfulness, one where academics, researchers, and other writers are invested as individuals in much the same way as religious communities. Shortcomings The popularization of mindfulness as a "commodity" has been criticized, being termed "McMindfulness" by some critics. According to John Safran, the popularity of mindfulness is the result of a marketing strategy: "McMindfulness is the marketing of a constructed dream; an idealized lifestyle; an identity makeover." The psychologist Thomas Joiner says that modern mindfulness meditation has been "corrupted" for commercial gain by self-help celebrities, and suggests that it encourages unhealthy narcissistic and self-obsessed mindsets. According to Purser and Loy, mindfulness is not being used as a means to awaken to insight in the "unwholesome roots of greed, ill will and delusion," but reshaped into a "banal, therapeutic, self-help technique" that has the opposite effect of reinforcing those passions. While mindfulness is marketed as a means to reduce stress, in a Buddhist context it is part of an all-embracing ethical program to foster "wise action, social harmony, and compassion." The privatization of mindfulness neglects the societal and organizational causes of stress and discomfort, instead propagating adaptation to these circumstances. According to Bhikkhu Bodhi, "[A]bsent a sharp social critique, Buddhist practices could easily be used to justify and stabilize the status quo, becoming a reinforcement of consumer capitalism." The popularity of this new brand of mindfulness has resulted in the commercialization of meditation through self-help books, guided meditation classes, and mindfulness retreats. Buddhist commentators have criticized the movement as being presented as equivalent to Buddhist practice, while in reality it is very possibly denatured with undesirable consequences, such as being ungrounded in the traditional reflective morality and therefore, astray from traditional Buddhist ethics. Criticisms suggest it to be either de-moralized or re-moralized into clinically based ethics. The conflict is often presented with concern to the teacher's credentials and qualifications, rather than the student's actual practice. Reformed Buddhist-influenced practices are being standardized and manualized in a distinct separation from Buddhism - which is seen as a religion based in monastic temples - and expressed as “mindfulness” in a new psychology ethic, practiced in modern meditation centers. See also Alexander Technique Affect labeling Buddhism and psychology Buddhist meditation Choiceless awareness Coping (psychology) Coping Planning Eternal Now (New Age) Four stages of competence Full Catastrophe Living John Garrie Richard Geller S.N. Goenka Henepola Gunaratana Dennis Lewis Mahasati Meditation Metacognition Mindfulness (journal) Mindfulness and technology Mindfulness Day Mindful yoga Nonviolent communication Nepsis Ovsiankina effect Phronesis Sacca Satya Satyagraha Sampajanna Samu (Zen) Satipatthana Self-compassion Taqwa and dhikr, related Islamic concepts Transcendental Meditation Watchfulness (Christian) Hasidic Meditation Notes References Bibliography Printed sources (The use of mindfulness in psychology, and the history of mindfulness) Siegel, Ronald D. (2010). The Mindfulness Solution: Everyday Practices for Everyday Problems. The Guilford Press. Web sources Further reading Origins Buddhism Psychology Other Critical Open access 01 01 Buddhist meditation Meditation Mind–body interventions Plum Village Tradition sv:Medveten närvaro (buddhism)

Conversion disorder

Conversion disorder (CD), or functional neurologic symptom disorder (FNsD), is a functional disorder that causes abnormal sensory experiences and movement problems during periods of high psychological stress. Individuals with CD present with highly distressing neurological symptoms such as numbness, blindness, paralysis, or convulsions, which are not consistent with a well-established organic cause and can be traced back to a psychological trigger. It is thought that these symptoms arise in response to stressful situations affecting a patient's mental health or an ongoing mental health condition such as depression. Individuals diagnosed with conversion disorder have a greater chance of experiencing certain psychiatric disorders such as anxiety, depression, and personality disorders compared to those diagnosed with neurological disorders. Conversion disorder was retained in the DSM-5-TR, but was renamed to functional neurologic symptom disorder (FNsD), a subset of functional neurologic disorder (FND). FND covers the same range of symptoms as FNsD, but does not include the requirements for a psychological stressor to be present. The new criteria no longer requires feigning to be disproven before diagnosing FND nor FNsD. The ICD-11 classifies conversion disorder as a dissociative disorder with unspecified neurological symptoms. Signs and symptoms Conversion disorder presents symptoms following exposure to a certain stressor, typically associated with trauma or psychological distress. Usually, the physical symptoms of the syndrome affect the senses or movement. Common symptoms include blindness, partial or total paralysis, inability to speak, deafness, numbness, difficulty swallowing, incontinence, balance problems, non-epileptic seizures, tremors, and difficulty walking. The symptom of feeling unable to breathe, but where the lips are not turning blue, can indicate conversion disorder or sleep paralysis. Sleep paralysis and narcolepsy can be ruled out with sleep tests. These symptoms are attributed to conversion disorder when a medical explanation for the conditions cannot be found. Symptoms of conversion disorder usually occur suddenly. Conversion disorder is typically seen in people aged 10 to 35, and affects between 0.011% and 0.5% of the general population. Conversion disorder can present with motor or sensory symptoms including any of the following: Motor symptoms or deficits: Impaired coordination or balance Weakness/paralysis of a limb or the entire body (hysterical paralysis or motor conversion disorders) Impairment or loss of speech (hysterical aphonia) Difficulty swallowing (dysphagia) or a sensation of a lump in the throat Urinary retention Psychogenic non-epileptic seizures or convulsions Persistent dystonia Tremor, myoclonus or other movement disorders Gait problems (astasia-abasia) Loss of consciousness (fainting) Sensory symptoms or deficits: Impaired vision, double vision Impaired hearing Loss or disturbance of touch or pain sensation Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms. It has sometimes been stated that the presenting symptoms tend to reflect the patient's own understanding of anatomy and that the less medical knowledge a person has, the more implausible are the presenting symptoms. However, no systematic studies have yet been performed to substantiate this statement. Inconsistent symptoms such as negative lab and imaging results and/or a significant psychiatric disorder are suggestive indicators of functional neurologic disorder. Although the clinician should still exclude any other organic disorders through thorough examination. Sexual dysfunction and pain are also symptoms of conversion disorder, but if a patient only has these symptoms, they should be diagnosed with sexual pain disorder or pain disorder. Diagnosis Definition Conversion disorder is now contained under the umbrella term functional neurologic symptom disorder (FNsD). In cases of conversion disorder, there is a psychological stressor. The diagnostic criteria for functional neurologic symptom disorder, as set out in DSM-5, are: Specify type of symptom or deficit as: With weakness or paralysis With abnormal movement (e.g. tremor, dystonic movement, myoclonus, gait disorder) With swallowing symptoms With speech symptoms (e.g. dysphonia, slurred speech) With attacks or seizures With amnesia or memory loss With special sensory loss symptoms (e.g. visual blindness, olfactory loss, or hearing disturbance) With mixed symptoms. Specify if: Acute episode: symptoms present for less than six months Persistent: symptoms present for six months or more. Specify if: Psychological stressor (conversion disorder) No psychological stressor (functional neurologic symptom disorder) Exclusion of neurological disease Conversion disorder presents with symptoms that typically resemble a neurological disorder such as stroke, multiple sclerosis, epilepsy, hypokalemic periodic paralysis, or narcolepsy. The neurologist must carefully exclude neurological disease, through examination and appropriate investigations. However, it is not uncommon for patients with neurological disease to also have conversion disorder. In excluding neurological disease, the neurologist has traditionally relied partly on the presence of positive signs of conversion disorder, i.e. certain aspects of the presentation that were thought to be rare in neurological disease but common in conversion. The validity of many of these signs has been questioned by a study showing that they also occur in neurological disease. One such symptom, for example, is la belle indifférence, described in DSM-IV as "a relative lack of concern about the nature or implications of the symptoms". In a 2006 study, no evidence was found that patients with functional symptoms are any more likely to exhibit this than patients with a confirmed organic disease. In DSM-V, la belle indifférence was removed as a diagnostic criterion. Another feature thought to be important was that symptoms tended to be more severe on the non-dominant, usually left side of the body. There have been a number of theories about this, such as the relative involvement of cerebral hemispheres in emotional processing, or more simply, that it was "easier" to live with a functional deficit on the non-dominant side. However, a literature review of 121 studies established that this was not true, with publication bias the most likely explanation for this commonly held view. Although agitation is often assumed to be a positive sign of conversion disorder, release of epinephrine is a well-demonstrated cause of paralysis from hypokalemic periodic paralysis. Misdiagnosis does sometimes occur. In a highly influential study from the 1960s, Eliot Slater demonstrated that misdiagnoses had occurred in one third of his 112 patients with conversion disorder. Later authors have argued that the paper was flawed. A 2005 meta-analysis has shown that misdiagnosis rates since that paper was published are around four percent, the same as for other neurological diseases. Psychological mechanism The psychological mechanism of conversion can be the most difficult aspect of a conversion diagnosis. Even if there is a clear antecedent trauma or other possible psychological trigger, it is still not clear exactly how this gives rise to the symptoms observed. Patients with medically unexplained neurological symptoms may not have any psychological stressor, hence the use of the term "functional neurologic symptom disorder" in DSM-5 as opposed to "conversion disorder", and DSM-5's removal of the need for a psychological trigger. Treatment While conversion symptoms are not a normal responses to stress, taking measures to better manage psychological stress can help relieve symptoms. Treatments for conversion syndrome include hypnosis, psychotherapy, physical therapy, stress management, and transcranial magnetic stimulation. Treatment plans will consider duration and presentation of symptoms and may include one or multiple of the above treatments. This may include the following: Occupational therapy to maintain autonomy in activities of daily living. Treatment of comorbid depression or anxiety if present.. Educating patients on the causes of their symptoms might help them learn to manage both the psychiatric and physical aspects of their condition. Psychological counseling is often warranted given the known relationship between conversion disorder and emotional trauma. This approach ideally takes place alongside other types of treatment. Medications such as serotonin–norepinephrine reuptake inhibitors (SNRIs), a class of antidepressants, and sedatives such as benzodiazepines may help reduce stress and also relieve or prevent symptoms from occurring. There is little evidence-based treatment of conversion disorder. Other treatments such as cognitive behavioral therapy, hypnosis, EMDR, and psychodynamic psychotherapy, EEG brain biofeedback need further trials. Psychoanalytic treatment may possibly be helpful. Most studies assessing the efficacy of these treatments are of poor quality and larger, better controlled studies are urgently needed. Cognitive behavioral therapy (CBT) is the most common treatment, with a 13% improvement rate. Prognosis Empirical studies have found that the prognosis for conversion disorder varies widely, with some cases resolving in weeks, and others enduring for years or decades. There is also evidence that there is no cure for conversion disorder, and that although patients may go into remission they can relapse at any point. Many patients can get rid of their symptoms with time, treatments and reassurance. Epidemiology Frequency Information on the frequency of conversion disorder in the West is limited, in part due to the complexities of the diagnostic process. In neurology clinics, the reported prevalence of unexplained symptoms among new patients is very high, between 30 and 60%. However, diagnosis of conversion disorder typically requires an additional psychiatric evaluation, and since few patients will see a psychiatrist, it is unclear what proportion of the unexplained symptoms are actually due to the disorder. In 1976, large scale psychiatric registers in the U.S. and Iceland found incidence rates of 22 and 11 newly diagnosed cases per 100,000 person-years, respectively. In 2002, some estimates claim that in the general population, between 0.011% and 0.5% of the population have conversion disorder. Culture Although it is often thought that the frequency of conversion may be higher outside of the West, perhaps in relation to cultural and medical attitudes, evidence of this is limited. A 2007 community survey of urban Turkey found a prevalence of 5.6%. Many authors have found occurrence of conversion to be more frequent in rural, lower socio-economic groups, where technological investigation of patients is limited and people may know less about medical and psychological concepts. Gender In recent surveys of conversion disorder, females predominate, with between two and six female patients for every male. Some research suggests however that this gender disparity may be confounded by higher rates of violence against women. Age Conversion disorder may present at any age, but is rare in children younger than ten or in the elderly. Studies suggest a peak onset in the mid-to-late 30s. History The first evidence of conversion disorder dates back to 1900 B.C., when the symptoms were blamed on the uterus moving within the female body. The treatment varied "depending on the position of the uterus, which must be forced to return to its natural position. If the uterus had moved upwards, this could be done by placing malodorous and acrid substances near the woman's mouth and nostrils, while scented ones were placed near her vagina; on the contrary, if the uterus had lowered, the document recommends placing the acrid substances near her vagina and the perfumed ones near her mouth and nostrils." In Greek mythology, hysteria, a similarly described condition, was thought to be caused by a lack of orgasms, uterine melancholy, and not procreating. Plato, Aristotle, and Hippocrates believed that a lack of sex causes complications in the uterus. Many Greeks believed it could be prevented and cured with wine and orgies. Hippocrates argued that a lack of regular sexual intercourse led to the uterus producing toxic fumes, causing it to move in the body. Therefore, he argued, all women should be married and enjoy a satisfactory sexual life. Donald Capps argues that the diseases Jesus allegedly healed, such as paralysis and blindness, were actually forms of conversion disorder. He describes Jesus as a "village psychiatrist", who believed that his words had power. From the 13th century, women with hysteria were exorcised, as it was believed that they were possessed by the devil. It was believed that if doctors could not find the cause of a disease or illness, it must be caused by the devil. At the beginning of the 16th century, women were sexually stimulated by midwives in order to relieve their symptoms. Gerolamo Cardano and Giambattista della Porta believed polluted water and fumes caused the symptoms of hysteria. Towards the end of the century, the role of the uterus was no longer thought central to the disorder, with Thomas Willis discovering that the brain and central nervous system were the cause of the symptoms. Thomas Sydenham argued that the symptoms of hysteria may have an organic cause. He also proved the uterus is not the cause of symptoms. In 1692, in the U.S. town of Salem, Massachusetts, there was a reported outbreak of hysteria. This led to the Salem witch trials, where women who were accused of being witches had symptoms such as sudden movements, staring eyes, and uncontrollable jumping. During the 18th century, there was a move from the idea of hysteria being caused by the uterus to it being caused by the brain. This led to an understanding that it could affect both sexes. Jean-Martin Charcot argued that hysteria was caused by "a hereditary degeneration of the nervous system, namely a neurological disorder". In the 19th century, hysteria moved from being considered a neurological disorder to being considered a psychological disorder, when Pierre Janet argued that "dissociation appears autonomously for neurotic reasons, and in such a way as to adversely disturb the individual's everyday life". As early as 1874, doctors including W. B. Carpenter and J. A. Omerod began to speak out against the hysteria phenomenon as there was no evidence to prove its existence. Sigmund Freud referred to the condition as both hysteria and conversion disorder throughout his career. He believed those with the condition could not live in a mature relationship, and that those with the condition were unwell in order to achieve a "secondary gain", in that they are able to manipulate their situation to fit their needs or desires. He also found that both men and women could have the disorder. Freud's model suggested the emotional charge deriving from painful experiences would be consciously repressed as a way of managing the pain, but that the emotional charge would be somehow "converted" into neurological symptoms. Freud later argued that the repressed experiences were of a sexual nature. As Peter Halligan comments, conversion has "the doubtful distinction among psychiatric diagnoses of still invoking Freudian mechanisms". Pierre Janet, a highly noted psychologist during the early 20th century, argued that symptoms arose through the power of suggestion, acting on a personality vulnerable to dissociation. In this hypothetical process, the subject's experience of their leg, for example, is split off from the rest of their consciousness, resulting in paralysis or numbness in that leg. Some support for the Freudian model comes from findings of high rates of childhood sexual abuse in conversion patients. Support for the dissociation model comes from studies showing heightened suggestibility in patients with conversion disorder. Critics argue that it can be challenging to find organic pathologies for all symptoms, and so the practice of diagnosing patients with such symptoms as having hysteria led to the disorder being meaningless, vague and a sham diagnosis, as it does not refer to any definable disease. Throughout its history, many patients have been misdiagnosed with hysteria or conversion disorder when they had organic disorders such as tumors, epilepsy, or vascular diseases. This has led to patient deaths, a lack of appropriate care, and suffering for the patients. Eliot Slater, after studying the condition in the 1950s, stated: "The diagnosis of 'hysteria' is all too often a way of avoiding a confrontation with our own ignorance. This is especially dangerous when there is an underlying organic pathology, not yet recognised. In this penumbra we find patients who know themselves to be ill but, coming up against the blank faces of doctors who refuse to believe in the reality of their illness, proceed by way of emotional lability, overstatement and demands for attention... Here is an area where catastrophic errors can be made. In fact it is often possible to recognise the presence though not the nature of the unrecognisable, to know that a man must be ill or in pain when all the tests are negative. But it is only possible to those who come to their task in a spirit of humility. In the main the diagnosis of 'hysteria' applies to a disorder of the doctor–patient relationship. It is evidence of non-communication, of a mutual misunderstanding... We are, often, unwilling to tell the full truth or to admit to ignorance... Evasions, even untruths, on the doctor's side are among the most powerful and frequently used methods he has for bringing about an efflorescence of 'hysteria'". The onset of conversion disorder often correlates to a traumatic or stressful event. There are certain populations that are considered at risk for conversion disorder, including people with a medical illness or condition, people with personality disorders or dissociative disorders. No biomarkers have yet been found to support the idea that conversion disorder is caused by a psychiatric condition. There has been much recent interest in using functional neuroimaging to study conversion. As researchers identify the mechanisms which underlie conversion symptoms, it is hoped they will enable the development of a neuropsychological model. A number of such studies have been performed, including some which suggest the blood-flow in patients' brains may be abnormal while they are unwell. The studies have all been too small to be confident of the generalisability of their findings, so no neuropsychological model has been clearly established. An evolutionary psychology explanation for conversion disorder is that the symptoms may have been evolutionarily advantageous during warfare. A non-combatant with these symptoms signals non-verbally, possibly to someone speaking a different language, that she or he is not dangerous as a combatant and also may be carrying some form of dangerous infectious disease. This can explain that conversion disorder may develop following a threatening situation, that there may be a group effect with many people simultaneously developing similar symptoms, as in mass psychogenic illness, and the gender difference in prevalence. See also Body-centred countertransference Functional neurologic disorder (FND) Post-traumatic stress disorder (PTSD) and Complex post-traumatic stress disorder (C-PTSD) Somatic symptom disorder Functional disorder References External links Disorders causing seizures Mass psychogenic illness Somatic symptom disorders

Liaison psychiatry

Liaison psychiatry, also known as consultative psychiatry or consultation-liaison psychiatry, is the branch of psychiatry that specialises in the interface between general medicine/pediatrics and psychiatry, usually taking place in a hospital or medical setting. The role of the consultation-liaison psychiatrist is to see patients with comorbid medical conditions at the request of the treating medical or surgical consultant or team. Consultation-liaison psychiatry has areas of overlap with other disciplines including psychosomatic medicine, health psychology and neuropsychiatry. Scope Liaison psychiatry usually provides a service to patients in a general medical hospital, either inpatients, outpatients or attenders at the emergency department. Referrals are made when the treating medical team has questions about a patient's mental health, or how that patient's mental health is affecting his or her care and treatment. Typical issues include: Patients with medical conditions that cause/exacerbate psychiatric or behavioral problems, such as delirium. Supporting the management of patients with mental disorders who have been admitted for the treatment of medical problems. Assisting with assessment of the capacity of a patient to consent to treatment. Patients who may report physical symptoms as a result of a mental disorder, or patients with medically unexplained physical symptoms. Patients who may not have a psychiatric disorder but are experiencing distress related to their medical problems. Patients who have attempted suicide or self-harm. Assisting with the diagnosis, treatment and functional assessment of people with dementia, including advice on discharge planning or the need for long-term care. The psychiatric team liaises with many other services, including the treating medical team, other mental health services, social services, and community services. There is increasing interest on extending liaison psychiatry to primary care, for the management of long-term medical conditions such as diabetes mellitus. Effectiveness of liaison psychiatry Consultation-liaison psychiatry helps improve patients' coping mechanisms, treatment adherence, school/work re-integration and quality of life. An evaluation of the Rapid Assessment, Interface and Discharge (RAID) model of liaison psychiatry—employed at City Hospital, Birmingham—estimated that the service saved between 43 and 64 beds per day through reduced lengths of stay and prevention of readmission. In 2011 the Centre for Mental Health published an economic evaluation of the service, estimating savings of around £3.5 million. This was followed in 2012 by the publication of a report recommending that every NHS hospital should have a liaison psychiatry service as standard. History The history of liaison psychiatry is partly a history of psychiatry and medicine. Galen was highly influential for over 1500 years in medicine particularly advocating the use of experimentation to advance knowledge. The polymath physician Avicenna produced many insights into medicine but only became influential in Western medicine when William Harvey's elucidation of the circulatory system forced a re-evaluation of Galen's work. The French philosopher René Descartes began the dualistic debate on the division between mind and body. Johann Christian August Heinroth is credited with the origination of the term psychosomatic illness. At the beginning of the 19th century Johann Christian Reil created the term psychiatry whilst the polymath Benjamin Rush wrote Diseases of the Mind. The philosopher Spinoza's concept of conatus, Mesmer's development of hypnosis together with Charcot's refinement of this technique influenced Sigmund Freud whose development of psychoanalytic theory was to have a profound impact on the development of liaison psychiatry. Under the guidance of Alan Gregg, psychoanalysis impacted on hospital medicine through figures such as Franz Alexander, Stanley Cobb and Felix Deutsch. Edward Billings first coined the term liaison psychiatry. The publishing of two texts A Handbook of Elementary Psychobiology and Psychiatry, by Billings, and Psychosomatic Medicine, by Edward Weiss and O. Spurgeon English, outlined the theoretical foundations for the developing field. George L. Engel was involved in the development of liaison psychiatry and coined the term biopsychosocial model which overcame divisions created by Cartesian mind-body dualism and was to have wider repercussions on psychiatric practice. United Kingdom The Faculty of Liaison Psychiatry was established within the Royal College of Psychiatrists in 1997. The European Association for Consultation Liaison Psychiatry and Psychosomatics also produced a set of guidelines for training in Liaison Psychiatry. The American Psychiatric Association formally recognized C-L psychiatry as a subspecialty in 2004, with its own sub-specialty board exam. The profession debated about the best term for this specialty, finally settling on "Psychosomatic Medicine". A survey for NHS England in 2015 found 133 out of 179 A&E departments could not deliver the minimum core standard for 24/7 liaison psychiatry. 11 hospitals had no liaison psychiatry service, and only 35 delivered at or above the minimum standards. Collectively there was a shortage of 1,270 trained nurses and 230 trained consultants. References External links Academy of Consultation-Liaison Psychiatry American Psychosomatic Society European Association of Psychosomatic Medicine The Royal College of Psychiatrists - Faculty of Liaison Psychiatry Centre for Mental Health research into liaison psychiatry services in the UK Psychiatric specialities

Cognitive restructuring

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies. Overview Cognitive restructuring involves four steps: Identification of problematic cognitions known as "automatic thoughts" (ATs) which are dysfunctional or negative views of the self, world, or future based upon already existing beliefs about oneself, the world, or the future Identification of the cognitive distortions in the ATs Rational disputation of ATs with the Socratic method Development of a rational rebuttal to the ATs There are six types of automatic thoughts: Self-evaluated thoughts Thoughts about the evaluations of others Evaluative thoughts about the other person with whom they are interacting Thoughts about coping strategies and behavioral plans Thoughts of avoidance Any other thoughts that were not categorized Clinical applications Cognitive restructuring has been used to help individuals experiencing a variety of psychiatric conditions, including depression, substance abuse disorders, anxiety disorders collectively, bulimia, social phobia, borderline personality disorder, attention deficit hyperactivity disorder (ADHD), and problem gambling. When utilizing cognitive restructuring in rational emotive therapy (RET), the emphasis is on two central notions: (1) thoughts affect human emotion as well as behavior and (2) irrational beliefs are mainly responsible for a wide range of disorders. RET also classifies four types of irrational beliefs: dire necessity, feeling awful, cannot stand something, and self-condemnation. It is described as cognitive-emotional retraining. The rationale used in cognitive restructuring attempts to strengthen the client's belief that (1) "self-talk" can influence performance, and (2) in particular self-defeating thoughts or negative self-statements can cause emotional distress and interfere with performance, a process that then repeats again in a cycle. Mood repair strategies are implemented in cognitive restructuring in hopes of contributing to a cessation of the negative cycle. When utilizing cognitive restructuring in cognitive behavioral therapy (CBT), it is combined with psychoeducation, monitoring, in vivo experience, imaginal exposure, behavioral activation, and homework assignments to achieve remission. The cognitive behavioral approach is said to consist of three core techniques: cognitive restructuring, training in coping skills, and problem solving. Applications within therapy There are many methods used in cognitive restructuring, which usually involve identifying and labelling distorted thoughts, such as "all or none thinking, disqualifying the positive, mental filtering, jumping to conclusions, catastrophizing, emotional reasoning, should statements, and personalization." The following lists methods commonly used in cognitive restructuring: Socratic questioning Thought recording Identifying cognitive errors Examining the evidence (pro-con analysis or cost-benefits analysis) Understanding idiosyncratic meaning/semantic techniques Labeling distortions Decatastrophizing Reattribution Cognitive rehearsal Guided imagery Listing rational alternatives Rational emotive behavior therapy (REBT) includes awfulizing, when a person causes themselves disturbance by labelling an upcoming situation as 'awful', rather than envisaging how the situation may actually unfold, and Must-ing, when a person places a false demand on themselves that something 'must' happen (e.g. 'I must get an A in this exam'.) Criticism Critics of cognitive restructuring claim that the process of challenging dysfunctional thoughts will "teach clients to become better suppressors and avoiders of their unwanted thoughts" and that cognitive restructuring shows less immediate improvement because real-world practice is often required. Other criticisms include that the approach is mechanistic and impersonal and that the relationship between therapist and client is irrelevant. Neil Jacobson's component analysis of cognitive behavioural therapy (CBT), claims that the cognitive restructuring component is unnecessary, at least with depression. He argues that it is the behavioural activation components of CBT that are effective in giving therapy, not cognitive restructuring, as delivered by cognitive behavioural therapy. Others also argue that it's not necessary to challenge thoughts with cognitive restructuring. See also Cognitive appraisal Cognitive reframing Cognitive science Cognitive psychology References External links A free Thinking Matters Facilitator Manual National Institute of Corrections An Overview of Cognitive-behavioral Group Therapy for Social Phobia Cognitive Restructuring - ACCI's list of erroneous beliefs of the criminal mind. Cognitive Restructuring Techniques - as pioneered by Albert Ellis, Aaron Beck, and others. Cognitive restructuring worksheets - Tools that therapists use to help guide cognitive restructuring Cognitive therapy

Impostor syndrome

Impostor syndrome, also known as impostor phenomenon or impostorism, is a psychological experience of intellectual and professional fraudulence. One source defines it as "the subjective experience of perceived self-doubt in one's abilities and accomplishments compared with others, despite evidence to suggest the contrary". Those who have it may doubt their skills, talents, or accomplishments. They may have a persistent internalized fear of being exposed as frauds. Despite external evidence of their competence, those experiencing this phenomenon do not believe they deserve their success or luck. They may think that they are deceiving others because they feel as if they are not as intelligent as they outwardly portray themselves to be. Impostor syndrome is not a recognized psychiatric disorder and is not featured in the American Psychiatric Association's Diagnostic and Statistical Manual nor is it listed as a diagnosis in the International Classification of Diseases, Tenth Revision (ICD-10). Thus, clinicians lack information on the prevalence, comorbidities, and best practices for assessing and treating impostor syndrome. However, outside the academic literature, impostor syndrome has become widely discussed, especially in the context of achievement in the workplace. Signs and symptoms Impostor phenomenon is studied as a reaction to particular stimuli and events. It is an experience that a person has, not a mental disorder. Impostor phenomenon is not recognized in the DSM or ICD, although both of these classification systems recognize low self-esteem and sense of failure as associated symptoms of depression. Although impostor phenomenon is not a pathological condition, it is a distorted system of belief about oneself that can have a powerful negative impact on a person's valuation of their own worth. Comorbidity People with impostor syndrome have a higher chance to suffer from depression and anxiety. They are also more likely to experience low self esteem, somatic symptoms and social dysfunctions. Associated factors Impostor syndrome is associated with several factors. Some of them are considered to be risk factors, while others are considered to be consequences. However, since the associations are documented in correlational studies, it is not possible to identify cause and effect. Risk factors Impostor phenomenon is linked to neuroticism, low self-esteem and perfectionism. It is negatively correlated with the personality traits of extraversion, agreeableness, and conscientiousness. Impostor syndrome can stem from and result in strained personal relationships and can hinder people from achieving their full potential in their fields of interest. The term "impostorization" shifts the source of the phenomenon away from the supposed impostor to institutions whose policies, practices, or workplace cultures "either make or intend to make individuals question their intelligence, competence, and sense of belonging." Implications People with impostor syndrome tend to be less satisfied at work and have lower job performance. They also show higher rates of burnout. Diagnosis The first scale designated to measure characteristics of impostor phenomenon was designed by Harvey in 1981 and included 14 items. In 1985, the Clance Impostor Phenomenon Scale (CIPS) was developed. This 20-item measure, in contrast to the Harvey Impostor Scale, recognizes the anxiety associated with being judged and the sense of inferiority towards peers. The scale is the most frequently used. However, research has not yet conclusively shown its superiority over other scales. Other measures include the Perceived Fraudulence Scale (by Kolligian and Sternberg) and the Leary Impostor Scale, a 7-item test that assesses a single facet of the impostor phenomenon: a perception of being an impostor or fraud. In 2023 the Impostor Phenomenon Assessment was developed based on three factors: Doubts about achievement - fear of failure/success and overpreparation. For example: "I often feel that I have to work harder than others to achieve all that I do" Perceived discrepancy - discounting achievements and attributing success to external factors such as luck. For example: "I feel that I have attained my present academic or professional position through 'pulling strings' or 'having connections'. Self-handicapping behaviours - avoidance and perfectionism. For example - I find myself often leaving tasks to the last minute. Management Psychology professors dealing with impostor syndrome have suggested several recommendations for people in similar situations. These include: Try not to let emotions of worthlessness or uncertainty control your actions; instead, embrace your fears and move forward. Consider your accomplishments in the past as proof against impostor syndrome, and utilize them as a fallback when you start to doubt your abilities. Build a rapport with a counselor who can assist you in identifying false ideas that perpetuate impostor syndrome. As a reminder of your belonging, create areas where your identities are honored and expressed. Help others reject impostor beliefs by reflecting back to them their values, abilities, and talents; assisting others may also work as a beneficial reminder for you. Psychosocial interventions In 2019, when a systematic review was conducted, none of the 62 studies on impostor syndrome empirically assessed the efficacy of treatment. In their 1978 paper, Clance and Imes proposed a therapeutic approach they used for their participants or clients with impostor phenomenon. This technique includes a group setting where people meet others who are also living with this experience. The researchers explained that group meetings made a significant impact on their participants. They proposed that this impact was a result of the realization that they were not the only ones who experienced these feelings. The participants were required to complete various homework assignments as well. In one assignment, participants recalled all of the people they believed they had fooled or tricked in the past. In another take-home task, people wrote down the positive feedback they had received. Later, they would have to recall why they received this feedback and what about it made them perceive it in a negative light. In the group sessions, the researchers also had the participants re-frame common thoughts and ideas about performance. An example would be to change: "I might fail this exam" to "I will do well on this exam". The researchers concluded that simply extracting the self-doubt before an event occurs helps eliminate feelings of impostorism. It was recommended that people struggling with this experience seek support from friends and family. Epidemiology Impostor syndrome prevalence rates range considerably from 9 to 82%, depending on the screening method and threshold used. Rates are especially high among ethnic minority groups. The syndrome is common among men and women and in people of all ages (from teenagers to late-stage professionals). Impostor phenomenon is not uncommon for students who enter a new academic environment. Feelings of insecurity can come as a result of an unknown, new environment. This can lead to lower self-confidence and belief in their own abilities. Gender differences When impostor syndrome was first conceptualised, it was viewed as a phenomenon that was common among high-achieving women. Further research has shown that it affects both men and women; the proportion affected are more or less equally distributed among the genders. People with impostor syndrome often have corresponding mental health issues, which may be treated with psychological interventions, though the phenomenon is not a formal mental disorder. Clance and Imes stated in their 1978 article that, based on their clinical experience, impostor phenomenon was less prevalent in men. However, more recent research has mostly found that impostor phenomenon is spread equally among men and women. Settings Impostor phenomenon can occur in other various settings. Some examples include a new environment, academic settings, and in the workplace. 22 to 60% of physicians suffer from impostor phenomenon. The worry and emotions the students held, had a direct impact of their performance in the program. Common facets of impostor phenomenon experienced by students include not feeling prepared academically (especially when comparing themselves to classmates). Cokley et al. investigated the impact impostor phenomenon has on students, specifically ethnic minority students. They found that the feelings the students had of being fraudulent resulted in psychological distress. Ethnic minority students often questioned the grounds on which they were accepted into the program. They held the false assumption that they only received their acceptance due to affirmative action—rather than an extraordinary application and qualities they had to offer. Tigranyan et al. (2021) examined the way impostor phenomenon relates to psychology doctoral students. The purpose of the study was to investigate the Impostor Phenomenon's relationship to perfectionistic cognitions, depression, anxiety, achievement motives, self-efficacy, self-compassion, and self-esteem in clinical and counseling psychology doctoral students. Furthermore, this study sought to investigate how Impostor Phenomenon interferes with academic, practicum, and internship performance of these students and how Impostor Phenomenon manifests throughout a psychology doctoral program. Included were 84 clinical and counseling psychology doctoral students and they were instructed to respond to an online survey. The data was analyzed using a Pearson's product-moment correlation and a multiple linear regression. Eighty-eight percent of the students in the study reported at least moderate feelings of Impostor Phenomenon characteristics. This study also found significant positive correlations between the Impostor Phenomenon and perfectionistic cognitions, depression, anxiety, and self-compassion. This study indicates that clinical faculty and supervisors should take a supportive approach to assist students to help decrease feelings of Impostor Phenomenon, in hopes of increasing feelings of competence and confidence. History The term impostor phenomenon was introduced in an article published in 1978, titled "The Impostor Phenomenon in High Achieving Women: Dynamics and Therapeutic Intervention" by Pauline R. Clance and Suzanne A. Imes. Clance and Imes defined impostor phenomenon as "an internal experience of intellectual phoniness". In 1985, Clance published a book on the topic, and the phenomenon became widely known. Initially, Clance identified the syndrome with high-achieving professional women, but later studies found that it is widespread in both men and women and in many professional settings. Society and culture Several famous people have reported suffering from impostor syndrome. These include Michelle Obama and Sheryl Sandberg. See also Dunning–Kruger effect a cognitive bias wherein people of non-average ability (both high and low) inaccurately estimate their own abilities Explanatory style how people typically explain events to themselves Illusory superiority a cognitive bias whereby people overestimate their own qualities and abilities Inner critic a manifestation of the inner voice which demeans and criticises the person it belongs to "Fakin' It" (Simon & Garfunkel song) 1960s-era pop/rock song on the subject Inferiority complex Jonah complex the fear of success which prevents the realisation of one's potential Poseur Self-handicapping Setting oneself up to fail a psychological phenomenon where someone intentionally attempts to prevent their own success at a given task Tall poppy syndrome aspects of a culture where people of high status are resented for having been viewed as superior to their peers References External links 1978 introductions Popular psychology 1970s neologisms Cognitive biases

Erikson's stages of psychosocial development

Erikson's stages of psychosocial development, as articulated in the second half of the 20th century by Erik Erikson in collaboration with Joan Erikson, is a comprehensive psychoanalytic theory that identifies a series of eight stages that a healthy developing individual should pass through from infancy to late adulthood. According to Erikson's theory the results from each stage, whether positive or negative, influence the results of succeeding stages. Erikson published a book called Childhood and Society in 1950 that highlighted his research on the eight stages of psychosocial development. Erikson was originally influenced by Sigmund Freud's psychosexual stages of development. He began by working with Freud's theories specifically, but as he began to dive deeper into biopsychosocial development and how other environmental factors affect human development, he soon progressed past Freud's theories and developed his own ideas. Erikson developed different substantial ways to create a theory about lifespan he theorized about the nature of personality development as it unfolds from birth through old age or death. He argued that the social experience was valuable throughout our life to each stage that can be recognizable by a conflict specifically as we encounter between the psychological needs and the surroundings of the social environment. Erikson's stage theory characterizes an individual advancing through the eight life stages as a function of negotiating their biological and sociocultural forces. The two conflicting forces each have a psychosocial crisis which characterizes the eight stages. If an individual does indeed successfully reconcile these forces (favoring the first mentioned attribute in the crisis), they emerge from the stage with the corresponding virtue. For example, if an infant enters into the toddler stage (autonomy vs. shame and doubt) with more trust than mistrust, they carry the virtue of hope into the remaining life stages. The stage challenges that are not successfully overcome may be expected to return as problems in the future. However, mastery of a stage is not required to advance to the next stage. In one study, subjects showed significant development as a result of organized activities. Stages Psychological periodization of stages of human development Hope: trust vs. mistrust (oral-sensory, infancy, under 1 year) Existential Question: Can I Trust the World? The first stage of Erik Erikson's theory centers around the infant's basic needs being met by the parents or caregiver and how this interaction leads to trust or mistrust. Trust as defined by Erikson is "an essential trustfulness of others as well as a fundamental sense of one's own trustworthiness." The infant depends on the parents, especially the mother, for sustenance and comfort. Infants will often use methods such as pointing to indicate their interests or desires to their parents or caregivers. The child's relative understanding of the world and society comes from the parents and their interaction with the child. Children first learn to trust their parents or a caregiver. If the parents expose their child to warmth, security, and dependable affection, the infant's view of the world will be one of trust. As the child learns to trust the world around them, they also acquire the virtue of hope. Should parents fail to provide a secure environment and to meet the child's basic needs; a sense of mistrust will result. Development of mistrust can later lead to feelings of frustration, suspicion, withdrawal, and a lack of confidence. According to Erik Erikson, the major developmental task in infancy is to learn whether or not other people, especially primary caregivers, regularly satisfy basic needs. If caregivers are consistent sources of food, comfort, and affection, an infant learns trust — that others are dependable and reliable. If they are neglectful, or perhaps even abusive, the infant instead learns mistrust — that the world is an undependable, unpredictable, and possibly a dangerous place. Having some experience with mistrust allows the infant to gain an understanding of what constitutes dangerous situations later in life. However, infants and toddlers should not be subjected to prolonged situations of mistrust. This causes children to be ill adjusted later in life and see life with a cautious and careful outlook, which can be detrimental later in their life. In this stage, the child's most important needs are to feel safe, comforted, and well cared for. This stage is where a child learns an attachment style to their caregiver. The attachment style the child develops can affect their relationships through the rest of their life. For example, if the infant is hungry, will it be fed? If their diaper got soiled, would anybody change it? If they're sad, will they be comforted? The infant's mind would tell if the world is a trustworthy place with trustworthy people. Infants need protection and support from the familiar adult; otherwise, they will most likely not survive. This concept was studied more by Bowlby and Ainsworth in their attachment theory which is consistent with Erikson's research. Will: autonomy vs. shame/doubt (muscular-anal, toddlerhood, 1–2 years) Existential Question: Is It Okay to Be Me? As the child gains control over eliminative functions and motor abilities, they begin to explore their surroundings. Parents still provide a strong base of security from which the child can venture out to assert their will. The parents' patience and encouragement help to foster autonomy in the child. During early childhood, the child will start to have learning tasks and skills that instill personal responsibility, which allows the children to make choices that could help them develop a sense of autonomy and confidence. Children at this age like to explore the world around them and they are constantly learning about their environment. Caution must be taken at this age while children may explore things that are dangerous to their health and safety. At this age, children develop their first interests. For example, a child who enjoys music may like to play with the radio. Children who enjoy the outdoors may be interested in animals and plants. Highly restrictive parents are more likely to instill in the child a sense of doubt, and reluctance to try new and challenging opportunities. As the child gains increased muscular coordination and mobility, toddlers become capable of satisfying some of their own needs. They begin to feed themselves, wash and dress themselves, and use the bathroom. If caregivers encourage self-sufficient behavior, toddlers will develop a sense of autonomy—a sense of being able to handle many problems on their own. On the contrary, there is the possibility that the caregiver can demand too much too soon. This will likely lead the child to develop shame and doubt in their ability to handle problems. This shame and doubt could also come as a result of a caregiver ridiculing a child's early performance attempts. There is definitely a delicate balance to be had with autonomy. If the child receives too much autonomy, they have the potential to grow up with little concern for rules or regulations. It is worth noting that this could also increase the likelihood of injury. Conversely, if the parents exert too much control over them, the child can grow up to be more rebellious and impulsive. The abilities of the child are limited. Purpose: initiative vs. guilt (locomotor-genital, early childhood, 3–6 years) Existential Question: Is it Okay for Me to Do, Move, and Act? Initiative adds to autonomy the quality of planning, undertaking, and attacking a task for the sake of just being active and on the move. The child is learning to master the world around them, learning basic skills and principles of physics. Things fall down, not up, round things roll. They learn how to zip and tie, count and speak with ease. At this stage, the child wants to begin and complete their own actions for a purpose. Guilt is a confusing new emotion. They may feel guilty over things that logically should not cause guilt. They may feel guilt when this initiative does not produce desired results. The development of courage and independence are what set preschoolers, ages three to six years of age, apart from other age groups. Young children in this category face the psychological crisis of initiative versus guilt. This includes learning how to face complexities of planning and developing a sense of judgment. During this stage, the child learns to take initiative and prepares for leadership roles, and to achieve goals. Activities sought out by a child in this stage may include risk-taking behaviors, such as crossing a street alone or riding a bike without a helmet; both these examples involve self-limits. The child may also develop negative behaviors as they learn to take initiative. These negative behaviors, such as throwing objects, hitting, or yelling, can be a result of the child feeling frustrated after not being able to achieve a goal as planned. Preschoolers are increasingly able to accomplish tasks on their own and can explore new areas. With this growing independence comes many choices about activities to be pursued. Sometimes children take on projects they can readily accomplish, but at other times they undertake projects that are beyond their capabilities or that interfere with other people's plans and activities. If parents and preschool teachers encourage and support children's efforts, while also helping them make realistic and appropriate choices, children develop initiative—independence in planning and undertaking activities. But if instead, adults discourage the pursuit of independent activities or dismiss them as silly and bothersome, children develop guilt about their needs and desires. Competence: industry vs. inferiority (latency, late childhood, 7–10 years) Existential Question: Can I Make it in the World of People and Things? The aim of this stage is to bring a productive situation to completion which gradually supersedes the whims and wishes of play. The fundamentals of technology are developed. The failure to master trust, autonomy, and industrious skills may cause the child to doubt their future, leading to shame, guilt, and the experience of defeat and inferiority. The child must deal with demands to learn new skills or risk a sense of inferiority, failure, and incompetence. In doing so, children are able to start contributing to society and making a difference in the world. They become more aware of themselves and how competent, or not, they are. "Children at this age are becoming more aware of themselves as individuals." They work hard at "being responsible, being good and doing it right." They are now more reasonable to share and cooperate. Allen and Marotz (2003) also list some perceptual cognitive developmental traits specific for this age group. Children grasp the concepts of space and time in more logical, practical ways. They gain a better understanding of cause and effect, and of calendar time. At this stage, children are eager to learn and accomplish more complex skills: reading, writing, telling time. They also get to form moral values, recognize cultural and individual differences and are able to manage most of their personal needs and grooming with minimal assistance. At this stage, children might express their independence by talking back and being disobedient and rebellious. Erikson viewed the elementary school years as critical for the development of self-confidence. Ideally, elementary school provides many opportunities to achieve the recognition of teachers, parents and peers by producing things—drawing pictures, solving addition problems, writing sentences, and so on. If children are encouraged to make and do things and are then praised for their accomplishments, they begin to demonstrate industry by being diligent, persevering at tasks until completed, and putting work before pleasure. If children are instead ridiculed or punished for their efforts or if they find they are incapable of meeting their teachers' and parents' expectations, they develop feelings of inferiority about their capabilities. Children also begin to make relationships with others around them. Being social is especially important for this stage. It helps school aged children become either more or less confident about themselves and their abilities. Also, during this age, children also begin to migrate into their own social groups. Depending on the child's "group", the child will have more or less self confidence. At this age, children start recognizing their special talents and continue to discover interests as their education improves. They may begin to choose to do more activities to pursue that interest, such as joining a sport if they know they have athletic ability, or joining the band if they are good at music. If not allowed to discover their own talents in their own time, they will develop a sense of lack of motivation, low self-esteem, and lethargy. They may become "couch potatoes" if they are not allowed to develop interests. Fidelity: identity vs. role confusion (adolescence, 11–19 years) Existential Question: Who Am I and What Can I Be? The adolescent is newly concerned with how they appear to others. Superego identity is the accrued confidence that the outer sameness and continuity prepared in the future are matched by the sameness and continuity of one's meaning for oneself, as evidenced in the promise of a career. The ability to settle on a school or occupational identity is pleasant. In later stages of adolescence, the child develops a sense of sexual identity. Adolescents become curious about the roles they will play in the adult world as they transition from childhood to adulthood. Initially, they are apt to experience some role confusion—mixed ideas and feelings about the specific ways in which they will fit into society—and may experiment with a variety of behaviors and activities (e.g. tinkering with cars, baby-sitting for neighbors, affiliating with certain political or religious groups). Eventually, Erikson proposed, most adolescents achieve a sense of identity regarding who they are and where their lives are headed. The teenager must achieve identity in occupation, gender roles, politics, and, in some cultures, religion. This is not always easy, however. The teenager must seek to find their place in this world and to find out how they can contribute to the world. Erikson is credited with coining the term "identity crisis". He describes identity crisis as a critical part of development in which an adolescent or youth develops a sense of self. Identity crisis involves the integration of the physical self, personality, potential roles and occupations. It is influenced by culture and historical trends. This stage is necessary for the successful development of future stages. Each stage that came before and that follows has its own 'crisis', but even more so now, for this marks the transition from childhood to adulthood. This passage is necessary because "Throughout infancy and childhood, a person forms many identifications. But the need for identity in youth is not met by these." This turning point in human development seems to be the reconciliation between 'the person one has come to be' and 'the person society expects one to become'. This emerging sense of self will be established by 'forging' past experiences with anticipations of the future. In relation to the eight life stages as a whole, the fifth stage corresponds to the crossroads: What is unique about the stage of Identity, is that it is a special sort of synthesis of earlier stages and a special sort of anticipation of later ones. Youth has a certain unique quality in a person's life; it is a bridge between childhood and adulthood. Youth is a time of radical change—the great body changes accompanying puberty, the ability of the mind to search one's own intentions and the intentions of others, the suddenly sharpened awareness of the roles society has offered for later life. Adolescents "are confronted by the need to re-establish boundaries for themselves and to do this in the face of an often potentially hostile world". This is often challenging since commitments are being asked for before particular identity roles have formed. At this point, one is in a state of 'identity confusion', but society normally makes allowances for youth to "find themselves", and this state is called 'the moratorium': The problem of adolescence is one of role confusion—a reluctance to commit which may haunt a person into his mature years. Given the right conditions—and Erikson believes these are essentially having enough space and time, a psychosocial moratorium, when a person can freely experiment and explore—what may emerge is a firm sense of identity, an emotional and deep awareness of who they are. As in other stages, bio-psycho-social forces are at work. No matter how one has been raised, one's personal ideologies are now chosen for oneself. Often, this leads to conflict with adults over religious and political orientations. Another area where teenagers are deciding for themselves is their career choice, and often parents want to have a decisive say in that role. If society is too insistent, the teenager will acquiesce to external wishes, effectively forcing him or her to ‘foreclose' on experimentation and, therefore, true self-discovery. Once someone settles on a worldview and vocation, will they be able to integrate this aspect of self-definition into a diverse society? According to Erikson, when an adolescent has balanced both perspectives of "What have I got?" and "What am I going to do with it?" they have established their identity: Dependent on this stage is the ego quality of fidelity—the ability to sustain loyalties freely pledged in spite of the inevitable contradictions and confusions of value systems. (Italics in original) Leaving past childhood and facing the unknown of adulthood is a component of adolescence. Another characteristic of this stage is moratorium which tends to end as adulthood begins. Given that the next stage (Intimacy) is often characterized by marriage, many are tempted to cap off the fifth stage at 20 years of age. However, these age ranges are actually quite fluid, especially for the achievement of identity, since it may take many years to become grounded, to identify the object of one's fidelity, to feel that one has "come of age". In the biographies Young Man Luther and Gandhi's Truth, Erikson determined that their crises ended at ages 25 and 30, respectively: Erikson does note that the time of Identity crisis for persons of genius is frequently prolonged. He further notes that in our industrial society, identity formation tends to be long, because it takes us so long to gain the skills needed for adulthood's tasks in our technological world. So… there is not exact time span in which to find oneself. It does not happen automatically at eighteen or at twenty-one. A very approximate rule of thumb for our society would put the end somewhere in one's twenties. Love: intimacy vs. isolation (early adulthood, 20–45 years) Existential Question: Can I Love? The Intimacy versus Isolation conflict occurs following adolescence. At the start of this stage, identity versus role confusion is coming to an end, although it still lingers at the foundation of the stage. The stage doesn't always involve a romantic relationship but includes the strong bonds with others being formed. Young adults are still eager to blend their identities with those of their friends because they want to fit in. Erikson believes that people are sometimes isolated due to intimacy. People are afraid of rejections such as being turned down or their partners breaking up with them. Human beings are familiar with pain, and to some people, rejection is so painful that their egos cannot bear it. Erikson also argues that distantiation occurs with intimacy. Distantiation is the desire to isolate or destroy things that may be dangerous to one's own ideals or life. This can occur if a person has their intimate relationship invaded by outsiders. Once people have established their identities, they are ready to make long-term commitments to others. They become capable of forming intimate, reciprocal relationships (e.g. through close friendships or marriage) and willingly make the sacrifices and compromises that such relationships require. Those in more advanced stages of identity development are often associated with greater success pertaining to intimacy formation. If people cannot form these intimate relationships—perhaps because of their own needs—then a sense of isolation may result, thereby arousing feelings of darkness and angst. Erickson’s documentation of his theory spends time considering intimacy between 2 people. The main conflict is whether an individual is willing to give themselves up to someone else. As suggested in the previous paragraphs, it seems that it could be very valuable for someone at this stage to let go of some of their fears in order to gain a solid relationship with another person. Erickson discusses the differences of his theory as compared to Freud’s theory of psychosexual development. Freud tended to focus more on sexual gratification without deep personal relationships being involved. Erikson’s proposal suggests that there is more to intimacy than sexual gratification. There is value in the deep bonds that can be shared between two people socially. It is worth noting that Erikson, in his writing, does still discuss and see the value of sexual relations within a socially intimate relationship. Care: generativity vs. stagnation (middle adulthood, 45–64 years) Existential Question: Can I Make My Life Count? Generativity is the concern of guiding the next generation. Socially-valued work and disciplines are expressions of generativity. The adult stage of generativity has broad application to family, relationships, work, and society. "Generativity, then is primarily the concern in establishing and guiding the next generation... the concept is meant to include... productivity and creativity." During middle age, the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity—a sense of productivity and accomplishment—results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation—a dissatisfaction with the relative lack of productivity. People in this stage consider what they are leaving behind for their posterity and community, as they are coming closer to the end of their life. The virtue that is related with this stage is care. In contrary, the maladaptive virtue is rejectivity. As shared in the quote above, productivity and creativity are announced as being related to generativity. Despite this relation, Erikson hopes that those two words don’t take away from the main message. That message being that generativity is focusing on helping other people. Our society can sometimes hyperfixate on the idea that children need parents. Erikson shares and reinforces another view. Adults need children. The effort that is given to the children can help the adult become more mature. On top of that, as an adult is generative to youth, it can influence the children to return the favor when they grow up. Central tasks of middle adulthood Express love through more than sexual contacts. Maintain healthy life patterns. Develop a sense of unity with mate. Help growing and grown children to be responsible adults. Relinquish central role in lives of grown children. Accept children's mates and friends. Create a comfortable home. Be proud of accomplishments of self and mate/spouse. Reverse roles with aging parents. Achieve mature, civic and social responsibility. Adjust to physical changes of middle age. Use leisure time creatively. Wisdom: ego integrity vs. despair (late adulthood, 65 years and above) Existential Question: Is it Okay to Have Been Me? As people grow older and become senior citizens, they tend to slow down their productivity and explore life as a retired person. Factors such as leisure activities and family involvement play a significant role in the life of a retiree and their adjustment to living without having to perform specific duties each day pertaining to their career. Even during this stage of adulthood, however, they are still developing. The association between aging and retirement can bring about a reappearance of bipolar tensions of earlier stages in Erikson's model, meaning that aspects of previous life stages can reactivate because of the onset of aging and retirement. Development at this stage also includes periods of reevaluation regarding life satisfaction, sustainment of active involvement, and developing a sense of health maintenance. Developmental conflicts may arise in this stage, but psychological growth in earlier stages can help significantly in resolving these conflicts. It is during this time that they contemplate their accomplishments and evaluate the person that they have become. They are able to develop integrity if they see themselves as leading a successful life. Those that have developed integrity perceive that their lives have meaning. They tend to feel generally satisfied and accept themselves and others. As they near the end of their lives, they are more likely to be at peace about death. If they see their life as unproductive or feel that they did not accomplish their life goals, they become dissatisfied with life and develop despair. This can often lead to feelings of depression and hopelessness. They may also feel that life is unfair and be fearful of dying. During this time there may be a renewal in interest in many things. This is believed to occur because the individuals in this time of life strive to be autonomous. As their bodies and minds start to deteriorate, they want to find a sense of balance. They will cling to their autonomy so that they will not need to be reliant on others for everything. Erikson explains that it is also important for adults in this stage to maintain relationships with others of different ages in order to develop integrity. The final developmental task is retrospection: people look back on their lives and accomplishments. Practices such as narrative therapy can help individuals reinterpret their minds pertaining to their past and allow them to focus on the brighter aspects of their lives. They develop feelings of contentment and integrity if they believe that they have led a happy and productive life. If they look back on a life of disappointments and unachieved goals, they may instead develop a sense of despair. This stage can occur out of the sequence when an individual feels they are near the end of their life (such as when receiving a terminal disease diagnosis). When looking back on life, a person should hope to find both meaning and order. There are ways to alter or buoy one’s perspective during this stage. Altering or buoying one’s view could bring them closer to ego integrity. With that being said, it is better that a person has already carried out a life with meaning and order prior to beginning this stage. Erikson ties this stage of development back into the first stage, trust vs mistrust. As shared by Erikson, the Webster dictionary once claimed that trust is “the assured reliance on another’s integrity”. One’s integrity could influence someone else’s trust. If a person at the end of their life fears death, then it could influence children to possibly fear life. If an adult is able to overcome any fears of death, then it can reinforce children to not be afraid of the life ahead of them. Ninth stage Psychosocial Crises: All first eight stages in reverse quotient order Joan Erikson, who married and collaborated with Erik Erikson, added a ninth stage in The Life Cycle Completed: Extended Version. Living in the ninth stage, she wrote, "old age in one's eighties and nineties brings with it new demands, reevaluations, and daily difficulties". Addressing these new challenges requires "designating a new ninth stage". Erikson was ninety-three years old when she wrote about the ninth stage. Joan Erikson showed that all the eight stages "are relevant and recurring in the ninth stage". In the ninth stage, the psychosocial crises of the eight stages are faced again, but with the quotient order reversed. For example, in the first stage (infancy), the psychosocial crisis was "Trust vs. Mistrust" with Trust being the "syntonic quotient" and Mistrust being the "dystonic". Joan Erikson applies the earlier psychosocial crises to the ninth stage as follows: "Basic Mistrust vs. Trust: Hope" In the ninth stage, "elders are forced to mistrust their own capabilities" because one's "body inevitably weakens". Yet, Joan Erikson asserts that "while there is light, there is hope" for a "bright light and revelation". "Shame and Doubt vs. Autonomy: Will" Ninth stage elders face the "shame of lost control" and doubt "their autonomy over their own bodies". So it is that "shame and doubt challenge cherished autonomy". "Inferiority vs. Industry: Competence" Industry as a "driving force" that elders once had is gone in the ninth stage. Being incompetent "because of aging is belittling" and makes elders "like unhappy small children of great age". "Identity confusion vs. Identity: Fidelity" Elders experience confusion about their "existential identity" in the ninth stage and "a real uncertainty about status and role". "Isolation vs. Intimacy: Love" In the ninth stage, the "years of intimacy and love" are often replaced by "isolation and deprivation". Relationships become "overshadowed by new incapacities and dependencies". "Stagnation vs. Generativity: Care" The generativity in the seventh stage of "work and family relationships", if it goes satisfactorily, is "a wonderful time to be alive". In one's eighties and nineties, there is less energy for generativity or caretaking. Thus, "a sense of stagnation may well take over". "Despair and Disgust vs. Integrity: Wisdom" Integrity imposes "a serious demand on the senses of elders". Wisdom requires capacities that ninth stage elders "do not usually have". The eighth stage includes retrospection that can evoke a "degree of disgust and despair". In the ninth stage, introspection is replaced by the attention demanded to one's "loss of capacities and disintegration". Living in the ninth stage, Joan Erikson expressed confidence that the psychosocial crisis of the ninth stage can be met as in the first stage with the "basic trust" with which "we are blessed". Development of post-Freudian theory Erikson was a student of Anna Freud, the daughter of Sigmund Freud, whose psychoanalytic theory and psychosexual stages contributed to the basic outline of the eight stages, at least those concerned with childhood. Namely, the first four of Erikson's life stages correspond to Freud's oral, anal, phallic, and latency phases, respectively. Also, the fifth stage of adolescence is said to parallel the genital stage in psychosexual development: Although the first three phases are linked to those of the Freudian theory, it can be seen that they are conceived along very different lines. Emphasis is not so much on sexual modes and their consequences, but on the ego qualities which emerge from each of the stages. There is an attempt also to link the sequence of individual development to the broader context of society. Erikson saw a dynamic at work throughout life, one that did not stop at adolescence. He also viewed the life stages as a cycle: the end of one generation was the beginning of the next. Seen in its social context, the life stages were linear for an individual but circular for societal development: In Freud's view, development is largely complete by adolescence. In contrast, one of Freud's students, Erik Erikson (1902–1994) believed that development continues throughout life. Erikson took the foundation laid by Freud and extended it through adulthood and into late life. Criticism One major criticism of Erikson's theory of psychosocial development is that it primarily describes the development of European or American males. Erikson's theory may be questioned as to whether his stages must be regarded as sequential, and only occurring within the age ranges he suggests. There is debate as to whether people only search for identity during the adolescent years or if one stage needs to happen before other stages can be completed. However, Erikson states that each of these processes occur throughout the lifetime in one form or another, and he emphasizes these "phases" only because it is at these times that the conflicts become most prominent. Most empirical research into Erikson has related to his views on adolescence and attempts to establish identity. His theoretical approach was studied and supported, particularly regarding adolescence, by James E. Marcia. Marcia's work has distinguished different forms of identity, and there is some empirical evidence that those people who form the most coherent self-concept in adolescence are those who are most able to make intimate attachments in early adulthood. This supports the part of Eriksonian theory, that suggests that those best equipped to resolve the crisis of early adulthood are those who have most successfully resolved the crisis of adolescence. Erikson attributed the development of the stages to the presence of specific tensions which may be present at any moment of a person's life. This causes another criticism of Erikson's theory of psychosocial development: that Erikson does not go into detail about what causes these stages of development or how they are resolved. There is little information stated about the experiences that result in how a person develops at each stage. Just as there are vague details about the causes of each theory that does not outline the necessary steps to resolve conflict in order to enter the next stage. See also Child development Developmental psychology Ethnic identity development Kohlberg's stages of moral development Neo-Freudianism Positive disintegration References Works cited Further reading Erikson, E. (1950). Childhood and Society (1st ed.). New York: Norton . Erikson, Erik H. (1959). Identity and the Life Cycle. New York: International Universities Press. Erikson, Erik H. (1968). Identity, Youth and Crisis. New York: Norton. Sheehy, Gail (1976). Passages: Predictable Crises of Adult Life. New York: E. P. Dutton. Stevens, Richard (1983). Erik Erikson: An Introduction. New York: St. Martin's. Developmental stage theories Psychoanalysis

Somatization

Somatization is a tendency to experience and communicate psychological distress as bodily and organic symptoms and to seek medical help for them. More commonly expressed, it is the generation of physical symptoms of a psychiatric condition such as anxiety. The term somatization was introduced by Wilhelm Stekel in 1924. Somatization is a worldwide phenomenon. A somatization spectrum can be identified, with chronic cases being classified as somatization disorder. Related psychological conditions Somatization can be, but is not always, related to a psychological condition such as: Affective disorders (anxiety and depression) Somatoform disorders The American Psychiatric Association (APA) has classified somatoform disorders in the DSM-IV and the World Health Organization (WHO) have classified these in the ICD-10. Both classification systems use similar criteria. Most current practitioners will use one over the other, though in cases of borderline diagnoses, both systems may be referred to. In spite of extensive research over the last 20 years, researchers are still perplexed by somatoform disorders. Ego defense In psychodynamic theory, somatization is conceptualized as an ego defense, the unconscious rechannelling of repressed emotions into somatic symptoms as a form of symbolic communication (organ language). Sigmund Freud's famous case study of Anna O. featured a woman who suffered from numerous physical symptoms, which Freud believed were the result of repressed grief over her father's illness, although treatment did not resolve her symptoms and later research is skeptical of Freud's diagnosis. Children While it is normal for stresses and strains in a child's life to be expressed in bodily pains/upsets, there is evidence that children in families where bodily complaints receive special attention are significantly more likely to use somatization as a defence in later life. Treatment Treatment for somatic symptom disorders combine different strategies for managing the patient's symptoms, including regularly scheduled outpatient visits, psychosocial interventions (such as joint meetings with family members), psychoeducation, and treatment of prominent comorbid symptoms of anxiety or depression. Based on multiple systematic reviews, the initial suggested treatment for somatic disorder is regular, scheduled outpatient visits (every 4–8 weeks) that are not based on active symptoms. These visits should focus on establishing a therapeutic alliance, legitimizing the somatic symptoms, and limiting diagnostic tests and referral to specialists. Cultural examples Author Virginia Woolf's mental and emotional difficulties were often expressed directly in physical symptoms: "Such 'sensations' spread over my spine & head...the horror – physically like a painful wave about the heart". See also Psychosomatic medicine Identified patient Amplification (psychology) Hypochondriasis Medically unexplained physical symptoms The Nocebo effect: A similar effect of symptoms being caused by psychological effects. Somatic marker hypothesis References External links Pain and Somatization Somatic symptom disorders Defence mechanisms 1920s neologisms

Medical model of disability

The medical model of disability, or medical model, is based in a biomedical perception of disability. This model links a disability diagnosis to an individual's physical body. The model supposes that a disability may reduce the individual's quality of life and aims to correct or diminish the disability with medical intervention. It is often contrasted with the social model of disability. The medical model focuses on curing or managing illness or disability. By extension, the medical model supposes a compassionate or just society invests resources in health care and related services in an attempt to cure or manage disabilities medically. This is in an aim to expand or improve functioning, and to allow disabled people to lead a more "normal" life. The medical profession's responsibility and potential in this area is seen as central. History Before the introduction of the biomedical model, patients relaying their narratives to the doctors was paramount. Through these narratives and developing an intimate relationship with the patients, the doctors would develop treatment plans in a time when diagnostic and treatment options were limited. This could particularly be illustrated with aristocratic doctors treating the elite during the 17th and 18th century. In 1980, the World Health Organization (WHO) introduced a framework for working with disability, publishing the "International Classification of Impairments, Disabilities and Handicaps". The framework proposed to approach disability by using the terms Impairment, Handicap and Disability. Impairment = a loss or abnormality of physical bodily structure or function, of logic-psychic origin, or physiological or anatomical origin Disability = any limitation or function loss deriving from impairment that prevents the performance of an activity in the time lapse considered normal for a human being Handicap = the disadvantaged condition deriving from impairment or disability limiting a person performing a role considered normal in respect of age, sex and social and cultural factors Components and usage While personal narrative is present in interpersonal interactions, and particularly dominant in Western Culture, personal narrative during interactions with medical personnel is reduced to relaying information about specific symptoms of the disability to medical professionals. The medical professionals then interpret the information provided about the disability by the patient to determine a diagnosis, which likely will be linked to biological causes. Medical professionals now define what is "normal" and what is "abnormal" in terms of biology and disability. In some countries, the medical model of disability has influenced legislation and policy pertaining to persons with disabilities on a national level. The International Classification of Functioning, Disability and Health (ICF), published in 2001, defines disability as an umbrella term for impairments, activity limitations and participation restrictions. Disability is the interaction between individuals with a health condition (such as cerebral palsy, Down syndrome and depression) and personal and environmental factors (such as negative attitudes, inaccessible transportation and public buildings, and limited social supports). The altered language and words used show a marked change in emphasis from talking in terms of disease or impairment to talking in terms of levels of health and functioning. It takes into account the social aspects of disability and does not see disability only as a 'medical' or 'biological' dysfunction. That change is consistent with widespread acceptance of the social model of disability. Criticism The medical model focuses on individual intervention and treatment as the proper approach to disability. Emphasis is placed on the biological expression of disability rather than on the systems and structures that can inhibit the lives of people with disabilities. Under the medical model, disabled bodies are defined as something to be corrected, changed, or cured. Terminology used can perpetuate negative labels such as deviant, pathological, and defective, thus, best understood in medical terms. The history and future of disability are severely constricted, focusing solely on medical implications and can overlook social constructions contributing to the experience of disability. Alternatively, the social model presents disability less as an objective fact of the body and mind, and positions it in terms of social relations and barriers that an individual may face in social settings. The medical model of disability can influence the factors within the creation of medical or disability aides, such as creating aides reminiscent of hospital settings and institutions which can be traumatic to some who have spent and extended period of time there, or which solely reflect the function of hospital aides but not necessarily the function of an aide outside of these contexts. Among advocates of disability rights, who tend to subscribe to the social model instead, the medical model of disability is often cited as the basis of an unintended social degradation of disabled people (otherwise known as ableism). Resources are seen as excessively misdirected towards an almost-exclusively medical focus when those same resources could potentially be used towards things like universal design and societal inclusionary practices. This includes the monetary and societal costs and benefits of various interventions, be they medical, surgical, social or occupational, from prosthetics, drug-based and other "cures", and medical tests such as genetic screening or preimplantation genetic diagnosis. According to disability rights advocates, the medical model of disability is used to justify large investment in these procedures, technologies and research, when adaptation of the disabled person's environment could potentially be more beneficial to the society at large, as well as financially cheaper and physically more attainable. Also, some disability rights groups see the medical model of disability as a civil rights issue and criticize charitable organizations or medical initiatives that use it in their portrayal of disabled people, because it promotes a pitiable, essentially negative, largely disempowered image of people with disabilities rather than casting disability as a political, social and environmental problem (see also the political slogan "Piss On Pity"). See also Cure Medical model of autism Medicalization Models of deafness Neurodiversity References External links The Open University: Making your teaching inclusive: The Medical Model Disability Medical sociology Medical models Sociological theories Social theories

Medicalization

Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment. Medicalization can be driven by new evidence or hypotheses about conditions; by changing social attitudes or economic considerations; or by the development of new medications or treatments. Medicalization is studied from a sociologic perspective in terms of the role and power of professionals, patients, and corporations, and also for its implications for ordinary people whose self-identity and life decisions may depend on the prevailing concepts of health and illness. Once a condition is classified as medical, a medical model of disability tends to be used in place of a social model. Medicalization may also be termed pathologization or (pejoratively) "disease mongering". Since medicalization is the social process through which a condition becomes a medical disease in need of treatment, medicalization may be viewed as a benefit to human society. According to this view, the identification of a condition as a disease will lead to the treatment of certain symptoms and conditions, which will improve overall quality of life. History The concept of medicalization was devised by sociologists to explain how medical knowledge is applied to behaviors which are not self-evidently medical or biological. The term medicalization entered the sociology literature in the 1970s in the works of Irving Zola, Peter Conrad and Thomas Szasz, among others. According to Eric Cassell's book, The Nature of Suffering and the Goals of Medicine (2004), the expansion of medical social control is being justified as a means of explaining deviance. These sociologists viewed medicalization as a form of social control in which medical authority expanded into domains of everyday existence, and they rejected medicalization in the name of liberation. This critique was embodied in works such as Conrad's article "The discovery of hyperkinesis: notes on medicalization of deviance", published in 1973 (hyperkinesis was the term then used to describe what we might now call ADHD). Nevertheless, opium was used to pacify children in ancient Egypt before 2000 BC. These sociologists did not believe medicalization to be a new phenomenon, arguing that medical authorities had always been concerned with social behavior and traditionally functioned as agents of social control (Foucault, 1965; Szasz,1970; Rosen). However, these authors took the view that increasingly sophisticated technology had extended the potential reach of medicalization as a form of social control, especially in terms of "psychotechnology" (Chorover,1973). In the 1975 book Limits to medicine: Medical nemesis (1975), Ivan Illich put forth one of the earliest uses of the term "medicalization". Illich, a philosopher, argued that the medical profession harms people through iatrogenesis, a process in which illness and social problems increase due to medical intervention. Illich saw iatrogenesis occurring on three levels: the clinical, involving serious side effects worse than the original condition; the social, whereby the general public is made docile and reliant on the medical profession to cope with life in their society; and the structural, whereby the idea of aging and dying as medical illnesses effectively "medicalized" human life and left individuals and societies less able to deal with these "natural" processes. The concept of medicalization dovetailed with some aspects of the 1970s feminist movement. Critics such as Ehrenreich and English (1978) argued that women's bodies were being medicalized by the predominantly male medical profession. Menstruation and pregnancy had come to be seen as medical problems requiring interventions such as hysterectomies. Marxists such as Vicente Navarro (1980) linked medicalization to an oppressive capitalist society. They argued that medicine disguised the underlying causes of disease, such as social inequality and poverty, and instead presented health as an individual issue. Others examined the power and prestige of the medical profession, including the use of terminology to mystify and of professional rules to exclude or subordinate others. Tiago Correia (2017) offers an alternative perspective on medicalization. He argues that medicalization needs to be detached from biomedicine to overcome much of the criticism it has faced, and to protect its value in contemporary sociological debates. Building on Gadamer's hermeneutical view of medicine, he focuses on medicine's common traits, regardless of empirical differences in both time and space. Medicalization and social control are viewed as distinct analytical dimensions that in practice may or may not overlap. Correia contends that the idea of "making things medical" needs to include all forms of medical knowledge in a global society, not simply those forms linked to the established (bio)medical professions. Looking at "knowledge", beyond the confines of professional boundaries, may help us understand the multiplicity of ways in which medicalization can exist in different times and societies, and allow contemporary societies to avoid such pitfalls as "demedicalization" (through a turn towards complementary and alternative medicine) on the one hand, or the over-rapid and unregulated adoption of biomedical medicine in non-western societies on the other. The challenge is to determine what medical knowledge is present, and how it is being used to medicalize behaviors and symptoms. Areas Sexuality Many aspects of human sexuality have been medicalized and pathologised by psychiatry, psychology and the pharmaceutical industry. This includes masturbation, homosexuality, erectile dysfunction and female sexual dysfunction. Medicalization has also been used to justify sexualisation of transgender people, intersex people and those diagnosed with HIV/AIDS. The medicalization of sexuality has resulted in increased social control, disease mongering, surveillance, and increased funding in some research areas of sexology and human physiology. The practice of medicalizing sexuality has been widely criticized, with one of the most common criticisms being that the biological reductionism and other tenets of medicalisation, individualism and naturalism, generally fail to take into account sociocultural factors contributing to human sexuality. The HIV/AIDS pandemic allegedly caused from the 1980s a "profound re-medicalization of sexuality". The diagnosis of premenstrual dysphoric disorder (PMDD) has caused some controversy when fluoxetine (also known as Prozac) was being repackaged as a PMDD therapy under the trade named Sarafem. The psychologist Peggy Kleinplatz has criticized the diagnosis as the medicalization of normal human behavior. Other medicalized aspects of women's health include infertility, breastfeeding, the childbirth process, and postpartum depression. Although it has received less attention, it is claimed that masculinity has also faced medicalization, being deemed damaging to health and requiring regulation or enhancement through drugs, technologies or therapy. Specifically, erectile dysfunction was once considered a natural part of the aging process in men, but has since been medicalized as a problem, late-onset hypogonadism. According to Mike Fitzpatrick, resistance to medicalization was a common theme of the gay liberation, anti-psychiatry, and feminist movements of the 1970s, but now there is "virtually no resistance to the advance of government intrusion in lifestyle if it is deemed to be justified in terms of public health." Moreover, the pressure for medicalization now comes from society itself as well as from the government and medical professionals. Psychiatry For many years, marginalized psychiatrists (such as Peter Breggin, Paula Caplan, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality". More recently these concerns have come from insiders who have worked for and promoted the American Psychiatric Association (e.g., Robert Spitzer, Allen Frances). Benjamin Rush, the father of American psychiatry, claimed that Black people had black skin because they were ill with hereditary leprosy. Consequently, he considered vitiligo as a "spontaneous cure". According to Franco Basaglia and his followers, whose approach pointed out the role of psychiatric institutions in the control and medicalization of deviant behaviors and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups. As scholars have long argued, governmental and medical institutions code menaces to authority as mental diseases during political disturbances. According to Kittrie, a number of phenomena considered "deviant", such as alcoholism, drug addiction, prostitution, pedophilia, and masturbation ("self-abuse"), were originally considered as moral, then legal, and now medical problems. Innumerable other conditions such as obesity, smoking cigarettes, draft malingering, bachelorhood, divorce, unwanted pregnancy, kleptomania, and grief, have been declared diseases by medical and psychiatric authorities. Due to these perceptions, peculiar deviants were subjected to moral, then legal, and now medical modes of social control. Similarly, Conrad and Schneider concluded their review of the medicalization of deviance by identifying three major paradigms that have reigned over deviance designations in different historical periods: deviance as sin; deviance as crime; and deviance as sickness. According to Thomas Szasz, "the therapeutic state swallows up everything human on the seemingly rational ground that nothing falls outside the province of health and medicine, just as the theological state had swallowed up everything human on the perfectly rational ground that nothing falls outside the province of God and religion". Labeling theory A 2002 editorial in the British Medical Journal warned of inappropriate medicalization leading to disease mongering, where the boundaries of the definition of illnesses are expanded to include personal problems as medical problems or risks of diseases are emphasized to broaden the market for medications. The authors noted: Healthism Public health campaigns have been criticized as a form of "healthism", which is moralistic in nature rather than primarily focused on health. Medical doctors Petr Shkrabanek and James McCormick wrote a series of publications on this topic in the late 1980s and early 1990s criticizing the UK's Health of The Nation campaign. These publications exposed abuse of epidemiology and statistics by public health authorities and organizations to support lifestyle interventions and screening programs. Inculcating a fear of ill-health and a strong notion of individual responsibility has been derided as "health fascism" by some scholars as it objectifies the individual without considering emotional or social factors. Professionals, patients, corporations and society Several decades on the definition of medicalization is complicated, if for no other reason than because the term is so widely used. Many contemporary critics position pharmaceutical companies in the space once held by doctors as the supposed catalysts of medicalization. Titles such as "The making of a disease" or "Sex, drugs, and marketing" critique the pharmaceutical industry for shunting everyday problems into the domain of professional biomedicine. At the same time, others reject as implausible any suggestion that society rejects drugs or drug companies and highlight that the same drugs that are allegedly used to treat deviances from societal norms also help many people live their lives. Even scholars who critique the societal implications of brand-name drugs generally remain open to these drugs' curative effects – a far cry from earlier calls for a revolution against the biomedical establishment. The emphasis in many quarters has come to be on "overmedicalization" rather than "medicalization" in itself. Others, however, argue that in practice the process of medicalization tends to strip subjects of their social context, so they come to be understood in terms of the prevailing biomedical ideology, resulting in a disregard for overarching social causes such as unequal distribution of power and resources. A series of publications by Mens Sana Monographs have focused on medicine as a corporate capitalist enterprise. Scholars argue that in the late 20th century transformation within the health sector in the US altered the relationship between people in the healthcare sector. This has been attributed to the commodification of healthcare and the role of parties other than doctors such as insurance companies, the pharmaceutical industry, and the government, referred to collectively as countervailing powers. The doctor remains an authority figure who prescribes pharmaceuticals to patients. However, in some countries, such as the US, ubiquitous direct-to-consumer advertising encourages patients to ask for particular drugs by name, thereby creating a conversation between consumer and drug company that threatens to cut the doctor out of the loop. Additionally, there is a widespread concern regarding the extent of the pharmaceutical marketing direct to doctors and other healthcare professionals. Examples of this direct marketing are visits by salespeople, funding of journals, training courses or conferences, incentives for prescribing, and the routine provision of "information" written by the pharmaceutical company. The role of patients in this economy has also changed. Once regarded as passive victims of medicalization, patients can now occupy active positions as advocates, consumers, or even agents of change. In response to theory based on medicalisation being insufficient to explain social processes, some scholars have developed a concept of biomedicalization which argues that technical and scientific interventions are transforming medicine. One aspect is pharmaceuticalization, the influence of the use of pharmaceutical drugs rather than other interventions. Other components are computerization of parts of healthcare such as public health, the creation of a "biopolitical economy" of private research outside of state, the perception of health as a moral obligation. Medicalization has brought health issues to the fore, so people think more and more about things in terms of health and act to promote health. When it comes to health issues, medicine is not the only provider of answers, but there have always been alternatives and competitors. At the same time as medicalization, "paramedicalization" has strengthened: also many treatments for which there is no medical basis, at least for now, are popular and commercially successful. See also Interventionism (medicine) Gothenburg Study of Children with DAMP Medical model Sociology of health and illness Social stigma References Further reading Horwitz, Allan, and Wakefield, Jerome (2007).The Loss of Sadness: How Psychiatry Has Transformed Normal Sadness into Depressive Disorder. Oxford University Press. Lane, Christopher (2007). Shyness: How Normal Behavior Became a Sickness. Yale University Press. Robert A. Nye (2003). "The evolution of the concept of medicalization in the late twentieth century". J Hist Behav Sci, 39(2), 115–129. doi:10.1002/jhbs.10108 Medical sociology Medical controversies Social constructionism Social problems in medicine

Political abuse of psychiatry

Political abuse of psychiatry, also known as punitive psychiatry, refers to the misuse of psychiatric diagnosis, detention, and treatment to suppress individual or group human rights in society. This abuse involves the deliberate psychiatric diagnosis of individuals who require neither psychiatric restraint nor treatment, often for political purposes. Psychiatrists have been implicated in human rights abuses worldwide, particularly in states where diagnostic criteria for mental illness are expanded to include political disobedience. Scholars have long observed that government and medical institutions tend to label threats to authority as mentally ill during periods of political unrest. In many countries, political prisoners are confined and abused in psychiatric hospitals. Psychiatry is uniquely vulnerable to being used for abusive purposes compared to other specialties of medicine. The power to diagnose mental illness allows the state to detain individuals against their will and administer unnecessary treatments under the guise of serving both individual and societal interests. This can be exploited to circumvent standard legal procedures for determining guilt or innocence, effectively incarcerating political dissidents while avoiding public scrutiny. The use of psychiatric hospitals instead of prisons also prevents the victims from receiving legal aid, makes indefinite incarceration possible, and discredits the individual and their ideas. This allows authorities to avoid open trials when deemed undesirable. The political abuse of medical power, particularly in psychiatry, has a long history, including notable examples during the Nazi era and Soviet rule, where religious and political dissenters were labeled "mentally ill" and subjected to inhumane "treatments". From the 1960s to 1986, systematic psychiatric abuse for political and ideological purposes was reported in the Soviet Union, with occasional occurrences in other Eastern European countries like Romania, Hungary, Czechoslovakia, and Yugoslavia. The practice of incarcerating religious and political dissidents in psychiatric hospitals in the Eastern Bloc and the former USSR severely damaged the credibility of psychiatric practice in these states and drew strong condemnation from the international community. Similar abuses have been reported in the People's Republic of China. Psychiatric diagnoses, such as "sluggish schizophrenia" in the USSR, were specifically developed and used for political purposes. In the United States, psychiatry was used to control African-American slaves, a practice that some argue continues to this day. By country Canada The Duplessis Orphans were several thousand orphaned children that were falsely certified as mentally ill by the government of the province of Quebec, Canada, and confined to psychiatric institutions. Donald Ewen Cameron's operation was running from what is today known as the Allen Memorial Institute (AMI), part of the Royal Victoria Hospital, and not to be confused with the non-governmental organization based in Montreal, AMI-Québec Agir contre la maladie mentale. China In 2002, Human Rights Watch published the book Dangerous Minds: Political Psychiatry in China Today and its Origins in the Mao Era written by Robin Munro and based on the documents obtained by him. The British researcher Robin Munro, a sinologist who was writing his dissertation in London after a long sojourn in China, had traveled to China several times to survey libraries in provincial towns and while he was there, he had gathered a large amount of literature which bore the stamp 'secret' but at the same time, it was openly available. This literature even included historical analyses which were published during the Cultural Revolution and it concerned articles and reports on the number of people who were taken to mental hospitals because they complained about a series of issues. It was found, according to Munro, that the involuntary confinement of religious groups, political dissidents, and whistleblowers had a long history in China. The abuses began in the 1950s and 1960s, and they became extremely widespread throughout the Cultural Revolution. During the period of the Cultural Revolution, from 1966 to 1976, the political abuse of psychiatry reached its apogee in China, which was then under the rule of Mao Zedong and the Gang of Four, who established a very repressive and harsh regime. No deviance or opposition was tolerated, either in thought or in practice. The documents described the massive abuses of psychiatry that were committed for political purposes during the rule of Mao Zedong, when millions of people were declared mentally sick. In the 1980s, according to official documents, fifteen percent of all forensic psychiatric cases had political connotations. In the early 1990s, the number of such cases had dropped to five percent, but with the beginning of the campaign against Falun Gong, the percentage of such cases increased quite rapidly. Official Chinese psychiatric literature distinctly testifies that the Communist Party's notion of 'political dangerousness' was institutionally engrafted as the main concept in the diagnostic armory of China's psychiatry for a long time and its most important tool for suppressing opposition was the concept of psychiatric dangerousness. Despite international criticism, China seems to be continuing its political abuse of psychiatry. Political abuse of psychiatry in China is high on the agenda and it has produced recurring disputes in the international psychiatric community. The abuses there appear to be even more widespread than they were in the Soviet Union in the 1970s and 1980s and they involve the incarceration of 'petitioners', human rights workers, trade union activists, members of the Falun Gong movement, and people who complain about injustices that have been committed against them by local authorities. It also seems that, China had no known high security forensic institutions until 1989. However, since then, the Chinese authorities have constructed an entire network of special forensic mental hospitals which are called Ankang which means 'Peace and Health' in Chinese. By that time, China had 20 Ankang institutions and their staff was employed by the Ministry of State Security (MSS). The psychiatrists who worked there wore uniforms under their white coats. The political abuse of psychiatry in China only seems to take place in the institutions which are under the authority of the police and the MSS but it does not take place in those institutions which belong to other governmental sectors. Psychiatric care in China falls into four sectors which are hardly connected with each other. These are the Ankang institutions of the MSS; those which belong to the police; those which fall under the authority of the Ministry of Social Affairs; those which belong to the Ministry of Health. The sectors which belong to the police and the MSS are all closed to the public, and, consequently, information about them hardly ever leaks out. In the hospitals which belong to the Ministry of Health, psychiatrists do not have any contact with the Ankang institutions, and they have no idea of what occurred there, which means they can sincerely state that they were not informed about the political abuse of psychiatry in China. In China, the structure of forensic psychiatry was to a great extent identical to that which existed in the Soviet Union. On its own, it is not so strange, since psychiatrists from the Moscow Serbsky Institute visited Beijing in 1957 in order to help their Chinese 'brethren', the same psychiatrists who promoted the system of political abuse of psychiatry in the Soviet Union. As a consequence, diagnostics in China were not much different than those which were made in the Soviet Union. The only difference was that the Soviet Union preferred "sluggish schizophrenia" as a diagnosis, and that China generally cleaved to the diagnosis of "paranoia" or "paranoid schizophrenia". However, the results were the same: long hospitalizations in mental hospitals, involuntary treatments with neuroleptics, torture, abuse, all of which were aimed at breaking the victim's will. In accordance with Chinese law which contains the concept of "political harm to society" and the similar phrase dangerous mentally ill behavior, police take "political maniacs into mental hospitals, those who are defined as persons who write reactionary letters, make anti-government speeches, or "express opinions on important domestic and international affairs". Psychiatrists are frequently caught involved in such cases, unable and unwilling to challenge the police, according to psychiatry professor at the Peking University Yu Xin. As Liu's database suggests, today's most frequent victims of psychiatric abuse are political dissidents, petitioners, and Falun Gong members. In the beginning of the 2000s, Human Rights Watch accused China of locking up Falun Gong members and dissidents in a number of Chinese mental hospitals managed by the Public Security Bureau. Access to the hospitals was requested by the World Psychiatric Association (WPA), but denied by China, and the controversy subsided. The WPA attempted to confine the problem by presenting it as Falung Gong issue and, at the same time, make the impression that the members of the movement were likely not mentally sound, that it was a sect which likely brainwashed its members, etc. There was even a diagnosis of 'qigong syndrome' which was used reflecting on the exercises practiced by Falung Gong. It was the unfair game aiming to avoid the political abuse of psychiatry from dominating the WPA agenda. In August 2002, the General Assembly was to take place during the next WPA World Congress in Yokohama. The issue of Chinese political abuse of psychiatry had been placed as one of the final items on the agenda of the General Assembly. When the issue was broached during the General Assembly, the exact nature of compromise came to light. In order to investigate the political abuse of psychiatry, the WPA would send an investigative mission to China. The visit was projected for the spring of 2003 in order to assure that one could present a report during the annual meeting of the British Royal College of Psychiatrists in June/July of that year and the Annual Meeting of the American Psychiatric Association in May of the same year. After the 2002 World Congress, the WPA Executive Committee's half-hearted attitude in Yokohama came to light: it was an omen of a longstanding policy of diversion and postponement. The 2003 investigative mission never took place, and when finally a visit to China did take place, this visit was more of scientific exchange. In the meantime, the political abuse of psychiatry persisted unabatedly, nevertheless the WPA did not seem to care. In August 2022, Safeguard Defenders issued an 85-page report on forced hospitalization in psychiatric hospitals between 2015 and 2021. Based on information from 144 cases, the report identifies 109 hospitals from 21 provinces in China, and documents repeated hospitalization of up to more than five times for victims. Some have spent around ten or more years inside. According to the report, victims are mostly petitioners and activists. Cuba Although Cuba has been politically connected to the Soviet Union since the United States broke off relations with Cuba shortly after Fidel Castro came to power in 1959, few considerable allegations regarding the political abuse of psychiatry in this country emerged before the late 1980s. Americas Watch and Amnesty International published reports alluding to cases of possible unwarranted hospitalization and ill-treatment of political prisoners. These reports concerned the Gustavo Machin hospital in Santiago de Cuba in the southeast of the country and the major mental hospital in Havana. In 1977, a report on alleged abuse of psychiatry in Cuba presenting cases of ill-treatment in mental hospitals going back to the 1970s came out in the United States. It presents grave allegations that prisoners end up in the forensic ward of mental hospitals in Santiago de Cuba and Havana where they undergo ill-treatment including electroconvulsive therapy without muscle relaxants or anaesthesia. The reported application of ECT in the forensic wards seems, at least in many of the cited cases, not to be an adequate clinical treatment for the diagnosed state of the prisoner—in some cases the prisoners seem not to have been diagnosed at all. Conditions in the forensic wards have been described in repulsive terms and apparently are in striking contrast to the other parts of the mental hospitals that are said to be well-kept and modern. In August 1981, the Marxist historian Ariel Hidalgo was apprehended and accused of 'incitement against the social order, international solidarity and the Socialist State' and sentenced to eight years' imprisonment. In September 1981, he was transported from State Security Headquarters to the Carbó-Serviá (forensic) ward of Havana Psychiatric Hospital where he stayed for several weeks. Germany By 1936, killing of the "physically and socially unfit" became accepted practice in Nazi Germany. In the 1940s, the abuse of psychiatry involved the abuse of the "duty to care" on an enormous scale: 300,000 individuals were involuntarily sterilized and 77,000 murdered in Germany alone and many thousands further afield, mainly in eastern Europe. Psychiatrists were instrumental in establishing a system of identifying, notifying, transporting, and killing hundreds of thousands of "racially and cognitively compromised" persons and the mentally ill in settings that ranged from centralized mental-hospitals to jails and death camps. Psychiatrists played a central and prominent role in sterilization and 'euthanasia', constituting two categories of the crimes against humanity. The taking of thousands of brains from 'euthanasia' victims demonstrated the way medical research was connected to the psychiatric killings. Germany operated six psychiatric extermination centers: Bernburg, Brandenburg, Grafeneck, Hadamar, Hartheim, and Sonnenstein. They played a crucial role in developments leading to the Holocaust. India It was reported in June, 2012, that the Indian Government has approached NIMHANS, a well known mental health establishment in South India, to assist in suppressing anti-nuclear protests regards to building of the Kudankulam Nuclear Power Plant. The government was in talks with NIMHANS representatives to chalk up a plan to dispatch psychiatrists to Kudankulam, for counselling protesters opposed to the building of the plant. To fulfill this, NIMHANS developed a team of six members, all of them, from the Department of Social Psychiatry. The psychiatrists were sent to get a "peek into the protesters' minds" and help them learn the importance of the plant according to one news source. In July, 2013, the same institution, NIMHANS, was involved in a controversy where it was alleged that it provided assistance to the Central Bureau of Investigation relating to some interrogation techniques. Japan Japanese psychiatric hospitals during the country's imperial era reported an abnormally large number of patient deaths, peaking in 1945 after the surrender of Japan to Allied forces. The patients of these institutions were mistreated mainly because they were considered a hindrance to society. Under the Imperial Japanese government, citizens were expected to contribute in one way or another to the war effort, and the mentally ill were unable to do so, and as such were looked down upon and abused. The main cause of death for these patients was starvation, as caretakers did not supply the patients with adequate food, likely as a form of torture and a method of sedation. Because mentally ill patients were kept secluded from the outside world, the large number of deaths went unnoticed by the general public. After the end of Allied occupation, the National Diet of Japan passed the in 1950, which improved the status of the mentally ill and prohibited the domestic containment of mental patients in medical institutions. However, the Mental Hygiene Act had unforeseen consequences. Along with many other reforms, the law prevented the mentally ill from being charged with any sort of crime in Japanese courts. Anyone who was found to be mentally unstable by a qualified psychiatrist was required to be hospitalized rather than incarcerated, regardless of the severity of any crime that person may have committed. The Ministry of Justice tried several times to amend the law, but was met with opposition from those who believed the legal system should not interfere with medical science. After almost four decades, the was finally passed in 1987. The new law corrected the flaws of the Mental Hygiene Act by allowing the Ministry of Health and Welfare to set regulations on the treatment of mental patients in both medical and legal settings. With the new law, the mentally ill have the right to voluntary hospitalization, the ability to be charged with a crime, and right to use the insanity defense in court, and the right to pursue legal action in the event of abuse or negligence on the part of medical professionals. Norway There have been a few accusations about abuse of psychiatry in Norway. See Arnold Juklerød and Knut Hamsun. Romania In Romania, there have been allegations of some particular cases of psychiatric abuse during over a decade. In addition to particular cases, there is evidence that mental hospitals were utilized as short-term detainment centers. For instance, before the 1982 International University Sports 'Olympiad', over 600 dissidents were detained and kept out of public view in mental hospitals. Like in the Soviet Union, on the eve of Communist holidays, potential "troublemakers" were sent to mental hospitals by busloads and discharged when the holidays had passed. The People's Republic of Romania held to a doctrine of state atheism. Many Christians, including those from the Baptist Church and Lord's Army wing of the Orthodox Church, were forced into psychiatric hospitals where they died. Russia Reports on particular cases continue to come from Russia where the worsening political climate appears to create an atmosphere in which local authorities feel able, once again to use psychiatry as a means of intimidation. Soviet Union In 1971 detailed reports about the inmates of Soviet psychiatric hospitals who had been detained for political reasons began to reach the West. These showed that the periodic use of incarceration in psychiatric institutions during the 1960s (see the biography of Vladimir Bukovsky) had started to become a systematic way of dealing with dissent, political or religious. In accordance with the doctrine of state atheism, the USSR hospitalized individuals who were devout in their faith, such as many Baptist Christians. In March 1971 Vladimir Bukovsky sent detailed diagnoses of six individuals (Natalya Gorbanevskaya and Pyotr Grigorenko among them) to psychiatrists in the West. They responded and over the next 13 years activists inside the USSR and support groups in Britain, Europe and North America conducted a sustained campaign to expose psychiatric abuses. In 1977 the World Psychiatric Association (WPA) condemned the USSR for this practice. Six years later, the Soviet All-Union Society of Neuropathologists and Psychiatrists seceded from the WPA rather than face almost certain expulsion. During this period reports of continuous repression multiplied, but Soviet psychiatric officials refused to allow international bodies to see the hospitals and patients in question. They denied the charges of abuse. In February 1989, however, at the height of perestroika and over the opposition of the psychiatric establishment, the Soviet government permitted a delegation of psychiatrists from the United States, representing the U.S. government, to carry out extensive interviews of suspected victims of abuse. The delegation was able systematically to interview and assess present and past involuntarily admitted mental patients chosen by the visiting team, as well as to talk over procedures and methods of treatment with some of the patients, their friends, relatives and, sometimes, their treating psychiatrists. The delegation originally sought interviews with 48 persons, but saw only 15 hospitalized and 12 discharged patients. About half of the hospitalized patients were released in the two months between the submission of the initial list of names to the Soviet authorities and the departure from the Soviet Union of the US delegation. The delegation concluded that nine of the 15 hospitalized patients had disorders which would be classified in the United States as serious psychoses, diagnoses corresponding broadly with those used by the Soviet psychiatrists. One of the hospitalized patients had been diagnosed as having schizophrenia although the US team saw no evidence of mental disorder. Among the 12 discharged patients examined, the US delegation found that nine had no evidence of any current or past mental disorder; the remaining three had comparatively slight symptoms which would not usually warrant involuntary commitment in Western countries. According to medical records, all these patients had diagnoses of psychopathology or schizophrenia. The authorities had justified compulsory psychiatric treatment by slow and weak forms of schizophrenia – a so-called "latent schizophrenia" according to a concept of Eugen Bleuler. Such forms would allegedly make the sufferer prone to criminal acts. Returning home after a visit of more than two weeks, the delegation members wrote a report which was highly damaging to the Soviet authorities. The delegation established that there had been systematic political abuse of psychiatry in the past and that it had not yet come to an end. Victims continued to be held in mental hospitals, while the Soviet authorities and the Soviet Society of Psychiatrists and Neuropathologists in particular still denied that psychiatry had been employed as a method of repression. The American report and other pressures, domestic and external, led the Politburo to pass a resolution (15 November 1989) "On improvements in Soviet law concerning procedures for the treatment of psychiatric patients". Suriname Louis Doedel (1905–1980) was a trade unionist. He was involuntary committed in psychiatric hospital on 28 May 1937 by Governor Kielstra. Doedel was forgotten and presumed dead. It was not until 1980, 43 years later, that he was released. Thailand Following the 2014 Thai coup d'état, there were a few cases where the National Council for Peace and Order (NCPO, the Thai military junta) alleged its opponents, including a protesting schoolchild, Nattanan Warintawaret, were mentally disturbed. In addition, the military junta introduced a systematic process of 'attitude adjustment', whereby hundreds of dissidents were subjected to forcible detention and propaganda until they reformed their views of the junta; the majority did not and were subsequently charged with crimes. While psychiatrists were not employed, a team of psychologists was involved, implying psychological warfare rather than political psychiatry.:453 On 9 July 2020 Tiwagorn Withiton, a Facebook user who went viral after posting a picture of himself wearing a t-shirt printed with the message "I lost faith in the monarchy" was forcibly detained by police officers and admitted to Rajanagarindra Psychiatric Hospital in Khon Kaen. Tiwagorn has stated that he does not wish the Thai monarchy to be abolished but 'loss of faith' may imply lèse-majesté, a serious crime in Thailand. Tiwagorn is quoted as saying, "I well understand that it is political to have to make people think I'm insane. I won't hold it against the officials if there is a diagnosis that I'm insane, because I take it that they have to follow orders." Subsequent to protests by civil rights groups and media stories, Tiwagorn was released by Rajanagarindra Psychiatric Hospital, on July 22, 2020. United States "Drapetomania" was a supposed mental illness described by American physician Samuel A. Cartwright in 1851 that caused black slaves to flee captivity. In addition to inventing drapetomania, Cartwright prescribed a remedy. His feeling was that with "proper medical advice, strictly followed, this troublesome practice that many Negroes have of running away can be almost entirely prevented." In the case of slaves "sulky and dissatisfied without cause"—a warning sign of imminent flight—Cartwright prescribed "whipping the devil out of them" as a "preventative measure". As a remedy for this disease, doctors also made running a physical impossibility by prescribing the removal of both big toes. Cartwright also proposed "dysaesthesia aethiopica" as a mental illness that caused laziness among slaves. In the United States, political dissenters have been involuntarily committed. For example, in 1927 a demonstrator named Aurora D'Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of Sacco and Vanzetti. When Clennon W. King, Jr., an African-American pastor and activist of the Civil Rights Movement, attempted to enroll at the all-white University of Mississippi for summer graduate courses in 1958, the Mississippi police arrested him on the grounds that "any [Black person] who tried to enter Ole Miss must be crazy." Keeping King's whereabouts secret for 48 hours, the Mississippi authorities kept him confined to a mental hospital for twelve days before a panel of doctors established the activist's sanity. In the 1964 election, Fact magazine polled American Psychiatric Association members on whether Barry Goldwater was fit to be president and published "The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater." This led to the adoption of an ethical rule against diagnosis of public figures by a clinician who has not performed an examination or been authorized to release information by the patient. This became the Goldwater rule. In the 1970s, Martha Beall Mitchell, wife of U.S. Attorney General John Mitchell, was diagnosed with a paranoid mental disorder for claiming that the administration of President Richard M. Nixon was engaged in illegal activities. Many of her claims were later proved correct, and the term "Martha Mitchell effect" was coined to describe mental health misdiagnoses when accurate claims are dismissed as delusional. In 2010, the book The Protest Psychosis: How Schizophrenia Became a Black Disease by psychiatrist Jonathan Metzl (who also has a Ph.D. in American studies) was published. The book covers the history of the 1960s Ionia State Hospital located in Ionia, Michigan, and now converted to a prison and focuses on exposing the trend of this hospital to diagnose African Americans with schizophrenia because of their civil rights ideas. The book suggests that in part the sudden influx of such diagnoses could be traced to a change in wording in the DSM-II, which compared to the previous edition added "hostility" and "aggression" as signs of the disorder. Clinical psychologist Bruce E. Levine, argues that Oppositional Defiant Disorder, which can be easily used to pathologize anti-authoritarianism, is an abuse of psychiatry. In 2014, The Mercury News published a series of articles detailing questionable use of psychotropic drugs within California's foster care system where bad behavior is attributed to various mental conditions, and little care is provided besides drugs. Likewise, many experts questioned the long-term effects of high dosages on developing brains, and some former patients reported permanent side effects even after stopping the meds. California "5150 (involuntary psychiatric hold)" – There are many instances of usage of California law section 5150, which allows for involuntary psychiatric hold based on the opinion of a law enforcement official, psychological professional (or many other individuals who hold no qualification for making psychological assessment), which have been challenged as being unrelated to safety, and misused as an extension of political power. New York Whistleblowers who part ranks with their organizations have had their mental stability questioned, such as, for example, NYPD veteran Adrian Schoolcraft who was coerced to falsify crime statistics in his department and then became a whistleblower. In 2010 he was forcibly committed to a psychiatric hospital. See also Wrongful involuntary commitment Involuntary commitment Anti-psychiatry Institutionalisation Global Initiative on Psychiatry Medical torture Pharmacological torture Patient abuse Medically indigent adult The Protest Psychosis: How Schizophrenia Became a Black Disease Unethical human experimentation References External links Imprisonment and detention Institutional abuse Medical sociology Political repression Social problems in medicine Ethics in psychiatry Psychiatry controversies

Occupational therapist

Occupational therapists (OTs) are health care professionals specializing in occupational therapy and occupational science. OTs and occupational therapy assistants (OTAs) use scientific bases and a holistic perspective to promote a person's ability to fulfill their daily routines and roles. OTs have training in the physical, psychological, and social aspects of human functioning deriving from an education grounded in anatomical and physiological concepts, and psychological perspectives. They enable individuals across the lifespan by optimizing their abilities to perform activities that are meaningful to them ("occupations"). Human occupations include activities of daily living, work/vocation, play, education, leisure, rest and sleep, and social participation. OTs work in a variety of fields, including pediatrics, orthopedics, neurology, low vision therapy, physical rehabilitation, mental health, assistive technology, oncological rehabilitation, and geriatrics. OTs are employed in healthcare settings such as hospitals, nursing homes, residential care facilities, home health agencies, outpatient rehabilitation centers, etc. OTs are also employed by school systems, and as consultants by businesses to address employee work-related safety and productivity. Many OTs are also self-employed and own independent practices. In the United States, OTs are also employed as commissioned officers in the Army, Navy and Air force branches of the military. In the US Army, OTs are part of the Army Medical Specialist Corps. OTs are also a part of the United States Public Health Service Commissioned Corps, one of eight uniformed services of the United States. Occupational therapy interventions are aimed to restore/ improve functional abilities, and/or alleviate/ eliminate limitations or disabilities through compensatory/adaptive methods/and or drug use. OTs, thus, evaluate and address both the individual's capacities and his/ her environment (physical and psycho-social) in order to help the individual optimize their function and fulfill their occupational roles. They often recommend adaptive equipment/ assistive technology products and provide training in its use to help mitigate limitations and enhance safety. Preparation and qualifications To practice as an occupational therapist, the individual trained in the United States: Has graduated from an occupational therapy program (currently at the master's or doctoral levels) accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) or predecessor organizations; Has successfully completed a period of supervised fieldwork experience required by the recognized educational institution where the applicant met the academic requirements of an educational program for occupational therapists that is accredited by ACOTE or predecessor organizations; Has passed a nationally recognized registration examination for occupational therapists (OTR, for "Occupational Therapist, Registered, Licensed") administered by the National Board for Certification in Occupational Therapy (NBCOT); and Fulfills state requirements for licensure, certification, or registration. Places of work Employment may include hospitals, clinics, day and community-based rehabilitation centers, home care programs, special schools, industry, and private enterprise. Many occupational therapists work in private practice and as educators and consultants. Occupational therapist practitioners (OTPs) also work in community outreach, after school programs, community centers, and anywhere meaningful life activities occur. Occupational therapists meet clients in natural settings where real life activities and routines occur. Role Occupational therapists are skilled healthcare professionals who promote participation, health, and well-being through meaningful engagement in everyday activities. One of their main goals is to help their patients function effectively in their roles and routines in everyday life. Occupational therapy practitioners work with clients of all ages in diverse practice areas, some of which include rehabilitation after illness/injury, pediatrics, mental health, geriatrics, assistive technology, health and wellness, pain management, work/industry, and community accessibility. Occupational therapists may promote client participation and independence in life by strengthening client factors and performance skills such as physical, cognitive, and perceptual abilities. OTs may also help clients achieve their desired outcomes by facilitating their use of adaptive strategies, adaptive equipment, and/or environmental modifications. Occupational therapists focus on providing a client-centered, holistic approach to each patient, using therapeutic interventions geared toward the person, occupation, and environment. Occupational therapists bring attention to a person's unique identity, abilities, strengths, interests, and environment to provide strategies and techniques that will allow clients to live life to the fullest. Occupational therapists foster promotion of self-esteem, self-efficacy, and a sense of achievement through doing, being, and belonging in a client's choice of activities, roles, routines, contexts, and environments. Occupational therapists can also provide prevention and education regarding physical, mental, and social-emotional aspects of health and wellness within the realm of prevention, promotion, and intervention. Occupational therapists are often involved in multidisciplinary teams that may include health care practitioners such as physicians, nurses, physiotherapists, speech and language therapists, rehabilitation psychologists, and social workers. Building effective partnerships with other professionals in the interest of quality service provision to clients are essential to valuable practice. Collaboration with members of the client's team enriches interdisciplinary communication and ensures the best outcomes for clients. The client and their family and caregivers remain the central focus and driving force of the team. Work-related therapy Some occupational therapists treat individuals whose ability to function in a work environment has been impaired. These practitioners arrange employment, evaluate the work environment, plan work activities, and assess the client's progress. Therapists also may collaborate with the client and the employer to modify the work environment so that the work can be successfully completed. Pediatric practice Pediatric occupational therapists support their communities by providing services to infants, toddlers, children, youth, and their families across a variety of settings that might include schools, clinics, and homes. They do this by implementing intervention that is driven by science and backed by evidence. A child's life is made up of "occupations". These "occupations", or daily activities, include play, learning, and socializing. The role of the pediatric occupational therapist is to support the child in any environment in which the child is not able to carry out the desired occupations. The most common areas of practice for a pediatric occupational therapist include: neonatal intensive care units (NICU), early intervention, schools, and outpatient services. Areas of emerging practice include primary care and community-based. Neonatal intensive care units (NICU) From the beginning of life, occupational therapists might work with infants who are medically fragile in NICU of medical centers. An occupational therapist might address areas such as feeding/nutrition, positioning, development, sensory processing and integration, and sleep. Early intervention An occupational therapist may work with children in early intervention, from birth to three years old. The role of the occupational therapist is to support the child's needs by collaborating with the caregivers/parents. The goal of the occupational therapist in early intervention is to support the achievement of developmental milestones. They do this by providing intervention and education in the context of play and daily living. Therapeutic intervention may include feeding/nutrition, physical development, play skill development, social/emotional development. In early intervention, a strong emphasis is placed on parent/caregiver education. The reason Occupational Therapists are vital to the NICU, is due to the vulnerability of premature infants. NICU-based therapists teach the skills the infant needs to live optimally. However, they do this while simultaneously understanding the medical interventions occurring, and how these medical needs need to be worked around during a therapy session. Infants who received more therapy displayed better neurological behaviors. Occupational Therapists mainly focus on positioning the child, including equipment and how to promote optimal development. Schools Once a child is over the age of three and meets eligibility for special education services, the child may receive occupational therapy services through an Individualized Education Program (IEP). In the school setting, the goal of occupational therapy is to support the implementation of the IEP. The occupational therapist might do this by providing direct or indirect services. Direct services might include individual or group services. Indirect services might include consultation with their school team, creating modifications and/or accommodations for the classroom, and/or providing training to the school team. Outpatient services Occupational therapists might also work with children in an outpatient clinic. When serving children in an outpatient clinic, services typically have to meet the criteria for medical necessity. Occupational therapists continue to focus on "occupations"; however, the "occupations" typically are related to medically necessary occupations such as safety and health. Primary care Primary care for occupational therapists is an emerging area of practice. Traditionally a primary care office included physician, physician assistant, nurse, or nurse practitioner. In this model, the physician is limited to diagnosing and medical management. The field of occupational therapy is advocating for occupational therapists to become a part of primary care teams. In regard to children, an occupational therapist could contribute by providing early parent training, developmental screenings, tips for wellness and prevention. Community-based Another emerging area of practice for occupational therapy is promoting health and wellness through community-based programming. Occupational therapist can do this by coaching and consulting in the community. It is implemented through not just the OTs but through the community stakeholders and those with disabilities themselves. OTs work in community-based rehabilitation projects as trainers and educators to help teach community members while facilitating them and developing programs. Some examples include backpack awareness, promoting physical activity in families, creating inclusive community environments such as churches and health facilities, advocacy at government levels, conducting rallies, etc. Human displacement This refers to forced movement of communities by environmental or social factors which causes loss of occupational activities. This is caused by a number of factors including natural disaster, famine, armed conflict or developmental and economic changes. Occupational therapists work with these displaced persons in order to help rebuild roles, routines, self-efficacy, so that occupational imbalance, injustice, or deprivation does not occur. Occupational therapists work through community-based programs that are client-centered and culturally sensitive. With older people Occupational therapy is very beneficial to the older population. Therapists help older people lead more productive, active, and independent lives through a variety of methods, including the use of adaptive equipment. Occupational therapists work with older people in many varied environments, such as in their homes in the community, in hospital, and in residential care facilities to name a few. In the home environment, occupational therapists may work with the individuals to assess for hazards and to identify environmental factors that contribute to falls. Occupational therapists are often instrumental in assessing for appropriate wheelchairs for older people who may need them. In addition, therapists with specialized training in driver rehabilitation assess an individual's ability to drive using both clinical and on-the-road tests. The evaluations allow the therapist to make recommendations for adaptive equipment, training to prolong driving independence, and alternative transport options. Mental health During World War II, occupational therapy began to play a far bigger role in the treatment of soldiers in psychiatric hospitals run by or for the British military. Therapists found that engagement in occupation (usually crafts such as woodwork, sign writing, carpentry, etc.) was an effective intervention for increasing self-regulation and mental well-being in people with physical disabilities such as loss of limb and mental illness. In the decades since, occupational therapy has continued to advance and services in mental health now aim to promote positive mental health, prevent mental health problems, and help manage mental health challenges by providing client-centered care. According to the World Federation of Occupational Therapists (2019, p. 2), occupational therapists recognize that good mental health enables people to realize their potential, cope with life's normal stresses, work productively, and contribute to their communities". Occupational therapists acknowledge the unique identities of each individual and their lived experiences and values choice and autonomy with one's recovery journey to promote participation in meaningful occupations of everyday life. Occupational therapists address the needs of clients in all phases of mental health recovery and in all settings, ranging from acute inpatient mental health settings to community mental health settings. Occupational therapists also work with clients on a large continuum of mental health challenges, including clients with substance-use disorders, mental illness, eating disorders, stress-related challenges, trauma, and adverse experiences. Skilled interventions with clients may include: Self-regulation and coping strategies (e.g. mindfulness, grounding) Emotional awareness training and emotional regulation strategies, including advocacy Social emotional skills and training Social cognitive skills Training in executive functioning strategies Quality of life measures and awareness Implementation of healthy habits and routines Motivational interviewing Strategies to reduce stress Sensory modulation-related interventions to self-regulate Behavioral interventions, such as cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT) Trauma-informed care Skills training with accommodations or compensatory strategies Mental health literacy Lifestyle redesign, a preventative occupational therapy intervention to promote wellness With terminally-ill patients Occupational therapy (OT) practitioners help patients with terminal illnesses and conditions by assisting them with their needs related to end-of-life support. All of the areas of a patient's life including work, play and leisure are widely affected. An occupational therapist provides various treatment modalities to help such individuals to restore or maintain their deteriorating performance components by using their remaining capabilities to give them a sense of self-importance and a measure of self-confidence. The World Federation of Occupational Therapy (WFOT) recognizes the important role OT practitioners have in end-of-life care. In working with patients who have severe health conditions, disabilities and terminal illnesses, the OT clinician will help these individuals engage in meaningful, everyday occupations, as well as exercise the right to well-being and the best quality of life despite the unavoidable conclusion to their lifecycle. An OT practitioner understands the transactional relationship that exists between the individual, environment, and occupation; so that life enhancing, ongoing performance in quality of life activities are promoted. The WFOT recognizes an optimistic presence for OT in end-of-life care with an ongoing need for advocacy and support. With people experiencing chronic pain Occupational therapists often work within interdisciplinary or multidisciplinary teams (professionals such as physical therapists, nurses and physicians) to help individuals with chronic pain develop active self-management strategies. An area of specific concern to occupational therapists is the usage of a patient's time but it is also common for occupational therapists to help people return to work, and to return to leisure and family activities. Occupational therapists may use a variety of interventions including biofeedback, relaxation, goal setting, problem solving, planning, and can use those tools within both group and individual settings. Therapists may work within a clinic setting, or in the community including the workplace, school, home and health care centers. Occupational therapists may assess occupational performance before and after intervention, as a measure of effectiveness and reduction in disability. Models Occupational therapists can work from a variety of models, both broad and discrete. Top-down approaches are considered more broad and focus on the occupation itself while taking into consideration the many contextual factors (environmental, social, cultural, etc.), in comparison to bottom-up approaches which are more narrow or discrete. These models include the Person-Environment-Occupation (PEO), Person-Environment-Occupation-Performance (PEOP), Canadian Model of Occupational Performance and Engagement (CMOP-E), Model of Human Occupation (MOHO), and Ecology of Human Performance (EHP). Assessment In order for an individual or group to receive occupational therapy services they must first be referred by themselves, another health care provider, or through their support system (family, friends) to receive an occupational therapy evaluation. As part of the service delivery process, the evaluation consists of the initial occupational profile followed by an analysis of occupational performance. Occupational therapy evaluations and occupational therapy assessments are important in determining an individual's skill set or deficiency. Through the occupational profile, which is a structured interview of the client, an occupational therapist can identify the client's self-perceived strengths and limitations in participating in daily occupations and help create an individualized treatment plan that addresses the occupations that are meaningful and necessary to the client. As part of the occupational profile, an occupational therapist also seeks to identify physical and social supports and barriers to participation. Occupational therapists often gather additional information by communicating with the client's support system, which may include a child's parents/guardians, a student's teacher, an adult's spouse/siblings/friends, or a senior's caretaker. The analysis of occupational performance may be gathered through standardized assessments, clinical observations of the client performing a set of tasks and activities, and analysis of the physical or social environment and context in which the client performs the occupations. Occupational therapist utilize skilled observation simultaneously with evaluation of motor and process skills and the effect on the ability of an individual to perform complex or instrumental and personal activities of daily living (ADLs). Occupational therapists are trained in the administration of standardized assessments across the lifespan from infancy to old age, although some standardized assessments require an occupational therapist to gain additional certifications to administer. Examples of the types of assessments or skill areas occupational therapy practitioners assess include: Sensory processing skills Visual perception and visual motor skills gross motor and fine motor skills Handwriting Upper Limb Hand dexterity Cognition and intelligence School-based evaluations Developmental milestones Daily living tasks include dressing and eating Pain Executive functioning Environmental assessments Employment-based assessments Ergonomic assessments Through the initial evaluation process, occupational therapists work with the client to establish an individualized treatment plan. Data is collected and recorded throughout the treatment process to be utilized to assess progress and guide ongoing client-centered intervention. This data is also frequently utilized for reimbursement of services. At the conclusion of therapy services, an occupational therapist will complete an outcome assessment which may include a re-evaluation. Assessment may also be more broad such as assessing the accessibility of public spaces for all individuals. Occupational therapists can provide recommendations for building design to allow for access for all. Occupational therapists are also skilled at completing home safety assessments and altering the environment or providing accommodations for ways to complete occupations in the home and for increased safety of clients and caregivers. Occupational therapists can also complete driving assessments to determine the required accommodations in the car or the ability of an individual to safely drive. Furthermore, occupational therapists can work with whole organizations to assess their workspaces to ensure that the work demands and physical set up are conducive to safe working habits to prevent workplace injuries. Hand therapy Occupational therapy also plays a major role in the rehabilitation and recovery of patients who have hand injuries, as well as upper and lower extremity injuries. Occupational therapists play a significant role in collaborating with Hand/Orthopedic Surgeons, a patient's employers and/or case managers in providing the best client-centered rehabilitation program. Occupational therapists treat conditions ranging from soft tissue injuries such as tennis elbow to neuropathies such as carpal tunnel syndrome. An Array of Upper Limb assessments are utilized to provide a treatment care plan that is effective and appropriate for each person and their injury. Treatment modalities such as orthosis/splints, soft braces and education are examples of the common treatment tools that an occupational therapist will use during treatment. Hand therapy is a specialized field of occupational therapy and therapists that work in this area are highly skilled and knowledgeable in upper limb anatomy. See also Allied health professional Child life specialist Doctor of Medicine Doctor of Osteopathic Medicine Mental health counselor Nonviolent communication Occupational science Occupational therapy in the United Kingdom Psychiatrist Rehabilitation psychology Psychotherapist Recreational therapist Social worker Speech–language pathology References Further reading AOTA Inc. (1994). Policy 5.3.1: Definition of occupational therapy practice for state regulation. The American Journal of Occupational Therapy, 48(11), 1072–1073. Occupational Therapists. Bureau of Labor Statistics, US Department of Labor,Occupational Outlook Handbook, 2004-05 Edition, Bulletin 2570. Superintendent of Documents, US Government Printing Office, Washington, D.C., 2004. External links Occupational Therapists Rehabilitation team bn:কর্মসংক্রান্ত চিকিৎসা ca:Teràpia ocupacional cs:Ergoterapie de:Ergotherapie fr:Ergothérapie hr:Radna terapija it:Terapia occupazionale he:ריפוי בעיסוק lt:Ergoterapija sr:Окупациона терапија th:กิจกรรมบำบัด

Pastoral care

Pastoral care, or cure of souls, refers to emotional, social and spiritual support. The term is considered inclusive of distinctly religious and non-religious forms of support, including atheist and religious communities. It is also an important form of support found in many spiritual and religious traditions. Definition Modern context Pastoral care as a contemporary term is distinguished from traditional pastoral ministry, which is primarily Christian and tied to Christian beliefs. Institutional pastoral care departments in Europe are increasingly multi-faith and inclusive of non-religious, humanist approaches to providing support and comfort. Just as the theory and philosophy behind modern pastoral care are not dependent on any one set of beliefs or traditions, pastoral care itself is guided by a broad framework. This involves personal support and outreach and is rooted in a practice of relating with the inner world of individuals from all walks of life. Pastoral care is usually provided in the form of the practitioner and client sitting with each other and the client shares personal details while the practitioner keeps it private and offers guidance and counsel. In many private schools in Australia, usually Catholic schools, homeroom is referred to as "PCG" (pastoral care group), "pastoral period", or simply "pastoral", where the teacher is called a "PCA" (pastoral care advisor). As in Romania, a 'PCA' also performs the role of a counsellor. In Christianity Definition Pastoral Care is a Christian approach to improve mental distress and has been practiced since the formation of the Christian Church. By offering guidance and counsel, it is an easy and often preferred contact point for religious people seeking help with psychological problems or personal issues. The model for pastoral care is based on the stories about how Jesus was healing people. In the early church the term 'Poimenic' was used to describe this task of soul-care. In the New Testament, the interactions that are described with the term "pastoral care" are also described with Paraklesis (Greek: παράκλησις paráklēsis) which broadly means "accompaniment", "encouragement", "admonition" and "consolation" (e.g. Rom 12:8; Phil 2:1; 1 Tim 4:13; 1 Thess 5:14). Pastoral care occurs in various contexts, including congregations, hospital chaplaincy, crisis intervention, prison chaplaincy, psychiatry, telephone helplines, counseling centers, senior care facilities, disability work, hospices, end-of-life care, grief support, and more. The term pastoral ministry relates to shepherds and their role caring for sheep. Christians were the first to adopt the term for metaphorical usage, although many religions and non-religious traditions place an emphasis on care and social responsibility. In the West, pastoral ministry has since expanded into pastoral care embracing many different religions and non-religious beliefs. The Bible does not explicitly define the role of a pastor but associates it with teaching. Pastoral ministry involves shepherding the flock. …Shepherding involves protection, tending to needs, strengthening the weak, encouragement, feeding the flock, making provision, shielding, refreshing, restoring, leading by example to move people on in their pursuit of holiness, comforting, guiding (Ps 78:52; 23). History In the ancient church, pastoral care primarily revolved around the Christian's struggle against sin, which jeopardized their ultimate salvation. The theologians Clement of Alexandria, Origen and Eusebius of Caesarea mainly understood this as the concern of individuals for their own souls. Increasingly, the role of pastoral caregivers was seen as assisting individual Christians in this endeavor. The first pastoral movement emerged among the Desert Fathers, who were often visited by Christians seeking advice; however, this was not yet referred to as pastoral care. Similarly, the early monastic-like communities served as such pastoral care centers. The letters of Basil of Ancyra, Gregory of Nazianzus, and John Chrysostom contain numerous examples of pastoral counsel; the term "pastoral care" shifted towards a concern for the souls of others At the transition to the Middle Ages, Gregory the Great composed the "Liber Regulae Pastoris", directed towards the Pope, one of the most influential books on pastoral care (cura) ever written. During the Middle Ages, pastoral care was closely tied to the practice of the sacrament of penance, which included confession of sins, making amends, and absolution by the priest. Against the often mechanized routine, particularly from the monastic tradition, efforts were made to address this, such as by Bernard of Clairvaux. The Latin term "cura animarum" (care of souls) emerged as the proper responsibility of the bishop as the pastor responsible for individual Christians, which he usually delegated to a priest, typically the parish priest. In this sense, "cura animarum" is also used in today's canon law of the Roman Catholic Church. Among the Reformers, the emphasis shifted from the focus on sin to the emphasis on God's forgiveness and comfort, particularly evident in the works of Martin Luther and Heinrich Bullinger. In many cases, however, church discipline soon replaced pastoral care. In the 19th century, the Protestant theologian Friedrich Schleiermacher established Practical Theology. He emphasized that pastoral care should strengthen the freedom and autonomy of individual members within a congregation. As early as 1777, the field of Pastoral Theology was introduced into the curriculum of the University of Vienna (Austria) under Franz Stephan Rautenstrauch, and was taught in the national language rather than Latin. In Germany, it was further developed and disseminated primarily by Johann Michael Sailer, and is considered a precursor to modern pastoral care. In the United States, Anton Theophilus Boisen, one of the key figures in the American pastoral care movement, developed the concept of "Clinical Pastoral Training" in the 1920s. This concept integrated pastoral care, psychology, and education. In the mid-1960s, the pastoral care movement spread to Germany through the Netherlands, leading to the development of Pastoral Psychology. In the theology of the regional churches (Landeskirchen), pastoral care with a focus on pastoral psychology remains a standard practice to this day. Modern context The field of pastoral care is nowadays very specialized. Browning (1993) divided Christian care giving practices into three different categories which are pastoral care, pastoral counseling, and pastoral psychotherapy. This distinction can still be found nowadays, especially in written English papers. According to this definition, pastoral care describes the general work of the clergy of taking care of the people in their community. This comprises funerals, hospital visits, birthday visits or dialogues that do not focus only on a specific problem. Nowadays, there exist many approaches to pastoral care which vary according to their religious denomination. Many protestant christian approaches to pastoral care include contemporary psychological knowledge, which is reflected in the training of pastoral care practitioners. For example, in Germany, the distinctions and the curricula of the different pastoral care training approaches, are provided by the German Society for Pastoral Psychology (Deutsche Gesellschaft für Pastoralpsychologie – DGfP). The five approaches are clinical pastoral care (Klinische Seelsorge Ausbildung - KSA), the group-organisation-system approach (Gruppe-Organisation, System), the Gestalt and psychodrama approach (Gestalt und Psychodrama), the person-centric approach (Personenzentriert) and the depth psychology approach (Tiefenpsychologie). Humanist and non-religious Humanist groups, which act on behalf of non-religious people, have developed pastoral care offerings in response to growing demand for the provision of like-minded support from populations undergoing rapid secularisation, such as the UK. Humanists UK, for example, manages the Non-Religious Pastoral Support Network, a network of trained and accredited volunteers and professionals who operate throughout prisons, hospitals, and universities in the UK. The terms pastoral care and pastoral support are preferred because these sound less religious than terms such as chaplaincy. Surveys have shown that more than two thirds of patients support non-religious pastoral care being available in British institutions. Similar offerings are available from humanist groups around Europe and North America. Pastoral care vs pastoral ministry Pastoral ministry Catholicism In Catholic theology, pastoral ministry for the sick and infirm is one of the most significant ways that members of the Body of Christ continue the ministry and mission of Jesus. Pastoral ministry is considered to be the responsibility of all the baptized. Understood in the broad sense of "helping others", pastoral ministry is the responsibility of all Christians. Sacramental pastoral ministry is the administration of the sacraments (Baptism, Confirmation, Eucharist, Penance, Extreme Unction, Holy Orders, Matrimony) that is reserved to consecrated priests except for Baptism (in an emergency, anyone can baptize) and marriage, where the spouses are the ministers and the priest is the witness. Pastoral ministry was understood differently at different times in history. A significant development occurred after the Fourth Lateran Council in 1215 (more on this in the link to Father Boyle's lecture below). The Second Vatican Council (Vatican II) applied the word "pastoral" to a variety of situations involving care of souls; on this point, go to the link to Monsignor Gherardini's lecture). Many Catholic parishes employ lay ecclesial ministers as "pastoral associates" or "pastoral assistants", lay people who serve in ministerial or administrative roles, assisting the priest in his work, but who are not ordained clerics. They are responsible, among other things, for the spiritual care of frail and housebound as well as for running a multitude of tasks associated with the sacramental life of the Church. If priests have the necessary qualifications in counseling or in psychotherapy, they may offer professional psychological services when they give pastoral counseling as part of their pastoral ministry of souls. However, the church hierarchy under John Paul II and Benedict XVI has emphasized that the Sacrament of Penance, or Reconciliation, is for the forgiveness of sins and not counseling and as such should not be confused with or incorporated into the therapy given to a person by a priest, even if the therapist priest is also their confessor. The two processes, both of which are privileged and confidential under civil and canon law, are separate by nature. Youth workers and youth ministers are also finding a place within parishes, and this involves their spirituality. It is common for Youth workers/ministers to be involved in pastoral ministry and are required to have a qualification in counseling before entering into this arm of ministry. Orthodoxy The priesthood obligations of Orthodox clergymen are outlined by John Chrysostom (347–407) in his treatise On the Priesthood. It is perhaps the first pastoral work written, although he was only a deacon when he penned it. It stresses the dignity of the priesthood. The priest, it says, is greater than kings, angels, or parents, but priests are for that reason most tempted to pride and ambition. They, more than anyone else, need clear and unshakable wisdom, patience that disarms pride, and exceptional prudence in dealing with souls. Protestantism There are many assumptions about what a pastor's ministry is. The core practices of a pastor's ministry in mainline Protestant churches include leading worship, preaching, pastoral care, outreach, and supporting the work of the congregation. Theological Seminaries provide a curriculum that supports these key facets of ministry. Pastors are often expected to also be involved in local ministries, such as hospital chaplaincy, visitation, funerals, weddings and organizing religious activities. "Pastoral ministry" includes outreach, encouragement, support, counseling and other care for members and friends of the congregation. In many churches, there are groups like deacons that provide outreach and support, often led and supported by the pastor. For example, the Evangelical Wesleyan Church instructs clergy with the following words: "We should endeavor to assist those under our ministry, and to aid in the salvation of souls by instructing them in their homes. ... Family religion is waning in many branches. And what avails public preaching alone, though we could preach like angels? We must, yea, every traveling preacher must instruct the people from house to house." The Presbyterian Church (USA) is structured so that there is parity between lay leaders and pastors. Deacons and elders are ordained, with specific duties. See also Clearness committee Clinical pastoral education Faith healing Holistic health References Bibliography Arnold, Bruce Makoto, "Shepherding a Flock of a Different Fleece: A Historical and Social Analysis of the Unique Attributes of the African American Pastoral Caregiver". The Journal of Pastoral Care and Counseling, Vol. 66, No. 2. (June 2012 Multi-faith Centre, University of Canberra, 2013 Henri Nouwen, Spiritual Direction (San Francisco, HarperOne, 2006). Emmanuel Yartekwei Lartey, Pastoral Theology in an Intercultural World (Cleveland, (OH), Pilgrim Press, 2006). Neil Pembroke, Renewing Pastoral Practice: Trinitarian Perspectives on Pastoral Care and Counselling (Ashgate, Aldershot, 2006) (Explorations in Practical, Pastoral and Empirical Theology). Beth Allison Barr, The Pastoral Care of Women in Late Medieval England (Rochester, NY: Boydell Press, 2008) (Gender in the Middle Ages, 3). George R. Ross, Evaluating Models of Christian Counseling (Eugene (OR), Wipf and Stock, 2011). Hamer, Dean (2004). The God Gene: How Faith is Hardwired into Our Genes. New York: Doubleday. . External links St. Thomas Aquinas and the Third Millennium, by Leonard Boyle. The Pastoral Nature of Vatican II: An Evaluation, by Brunero Gherardini. Translation of: Sull'indole pastorale del Vaticano II: una valutazione in Concilio Vaticano II, un concilio pastorale (Frigento, Italy: Casa Mariana Editrice, 2011). Christian religious occupations Christian terminology Religion and health

High-functioning autism

High-functioning autism (HFA) was historically an autism classification to describe a person who exhibited no intellectual disability but otherwise showed autistic traits, such as difficulty in social interaction and communication, as well as repetitive, restricted patterns of behavior. However, many in medical and autistic communities have called to stop using the term, finding it simplistic and unindicative of the difficulties some autistic people face. HFA has never been included in either the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) or the World Health Organization's International Classification of Diseases (ICD), the two major classification and diagnostic guidelines for psychiatric conditions. The DSM-5-TR subtypes autism into three levels based on support needs. Autism Level 1 has the least support needs and corresponds most closely with the "high-functioning" identifier. Characterization The term high-functioning autism was used in a manner similar to Asperger syndrome, another outdated classification. The defining characteristic recognized by psychologists was a significant delay in the development of early speech and language skills, before the age of three years. The term Asperger syndrome typically excluded a general language delay. Other differences noted in features of high-functioning autism and Asperger syndrome included the following: Lower verbal reasoning ability Better visual/spatial skills (Being uniquely artistically talented) Less deviating locomotion (e.g. clumsiness) Problems functioning independently Curiosity and interest for many different things Not as good at empathizing with other people Male to female ratio (4:1) much smaller Comorbidities See main article: Conditions comorbid to autism Individuals with autism spectrum disorders risk developing symptoms of anxiety. While anxiety is one of the most commonly occurring mental health symptoms, children and adolescents with high functioning autism are at an even greater risk of developing symptoms. There are other comorbidities, the presence of one or more disorders in addition to the primary disorder, associated with high-functioning autism. Some of these include bipolar disorder and obsessive–compulsive disorder (OCD). In particular the link between HFA and OCD, has been studied; both have abnormalities associated with serotonin. Observable comorbidities associated with HFA include ADHD and Tourette syndrome. HFA does not cause, nor include, intellectual disabilities. This characteristic distinguishes HFA from low-functioning autism; between 40 and 55% of individuals with autism also have an intellectual disability. Behavior An association between HFA and criminal behavior is not completely characterized. Several studies have shown that the features associated with HFA may increase the probability of engaging in criminal behavior. While there is still a great deal of research that needs to be done in this area, recent studies on the correlation between HFA and criminal actions suggest that there is a need to understand the attributes of HFA that may lead to violent behavior. There have been several case studies that link the lack of empathy and social naïveté associated with HFA to criminal actions. There is still a need for more research on the link between HFA and crimes, because many other studies point out that most people with ASD are more likely to be victims and less likely to commit crimes than the general population. But there are also small-subgroups of people with autism that commit crimes because they lack understanding of the laws they have broken. Misunderstandings are especially common regarding autism and sex offenses, since many people with autism do not receive sex education. Cause Although little is known about the biological basis of autism, studies have revealed structural abnormalities in specific brain regions. Regions identified in the "social" brain include the amygdala, superior temporal sulcus, fusiform gyrus area and orbitofrontal cortex. Further abnormalities have been observed in the caudate nucleus, believed to be involved in restrictive behaviors, as well as in a significant increase in the amount of cortical grey matter and atypical connectivity between brain regions. Diagnosis and IQ HFA is not a recognised diagnosis by the American Psychiatric Association or the World Health Organization. HFA was, however, previously used in clinical settings to describe cases of autism spectrum disorder where indicators suggested an intelligence quotient (IQ) of 70 or greater. Treatment While there exists no single treatment or medicine for people with autism, there exists several strategies to help lessen the symptoms and effects of the condition. There is however no one size fits all solution, so that the best treatment course is different for each individual. Furthermore, research shows that earlier diagnosis and interventions are more likely to have significant beneficial effects later in life. Augmentative and alternative communication Augmentative and alternative communication (AAC) is used for autistic people who cannot communicate orally. People who have problems speaking may be taught to use other forms of communication, such as body language, computers, interactive devices, and pictures. The Picture Exchange Communication System (PECS) is a commonly used form of augmentative and alternative communication with children and adults who cannot communicate well orally. People are taught how to link pictures and symbols to their feelings, desires and observation, and may be able to link sentences together with the vocabulary that they form. Speech–language pathologists Speech–language pathologists (SLPs) can help those with autism who need to develop or improve communication skills. People with autism may have issues with communication, or speaking spoken words. According to the ASHA, SLPs can help diagnosing autism as they often are among the earliest practitioners that children with autism see, and help with finding means of communication that better suit the child. They can also counsel caretakers, and accompany people with autism when they transition into adulthood and a work environment, such as help in writing an adequate CV. SLPs may teach someone how to communicate more effectively with others or work on starting to develop speech patterns. SLPs use a variety of therapies depending on the child's needs and practitioner's preferences, usually a mix composed in majority of promising therapies and a few unestablished therapies according to evidence-based guidelines. Occupational therapy Occupational therapy helps autistic children and adults learn everyday skills that help them with daily tasks, such as personal hygiene and movement. These skills are then integrated into their home, school, and work environments. Therapists will oftentimes help people learn to adapt their environment to their skill level. This type of therapy could help autistic people become more engaged in their environment. An occupational therapist will create a plan based on a person's needs and desires and work with them to achieve their set goals. Applied behavioral analysis (ABA) Applied behavior analysis (ABA) is considered the most effective therapy for autism spectrum disorders by the American Academy of Pediatrics. ABA focuses on teaching adaptive behaviors like social skills, play skills, or communication skills and diminishing problematic behaviors such as self-injury by creating a specialized plan that uses behavioral therapy techniques, such as positive or negative reinforcement, to encourage or discourage certain behaviors over-time. However, ABA has been strongly criticised by the autistic community, who view it as abusive and detrimental to autistic children's growth. Sensory integration therapy Sensory integration therapy helps people with autism adapt to different kinds of sensory stimuli. Many with autism can be oversensitive to certain stimuli, such as lights or sounds, causing them to overreact. Others may not react to certain stimuli, such as someone speaking to them. Many types of therapy activities involve a form of play, such as using swings, toys and trampolines to help engage people with sensory stimuli. Therapists will create a plan that focuses on the type of stimulation the person needs integration with. Medication There are no medications specifically designed to treat autism. Medication is usually used for symptoms associated with autism, such as depression, anxiety, or behavioral problems. Medicines are usually used after other alternative forms of treatment have failed. See also Asperger syndrome Low-functioning autism References Further reading Autism spectrum disorders Learning disabilities

Childhood disintegrative disorder

Childhood disintegrative disorder (CDD), also known as Heller's syndrome and disintegrative psychosis, is a rare condition characterized by late onset of developmental delays—or severe and sudden reversals—in language (receptive and expressive), social engagement, bowel and bladder, play and motor skills. Researchers have not been successful in finding a cause for the disorder. CDD has some similarities to autism and is sometimes considered a low-functioning form of it. In May 2013, CDD, along with other sub-types of PDD (Asperger's syndrome, Classic autism, and PDD-NOS), was fused into a single diagnostic term called "autism spectrum disorder" under the new DSM-5 manual. CDD was originally described by Austrian educator Theodor Heller (1869–1938) in 1908, 35 years before Leo Kanner and Hans Asperger described autism. Heller had previously used the name dementia infantilis for the syndrome. An apparent period of fairly normal development is often noted before a regression in skills or a series of regressions in skills. The age at which this regression can occur varies; after three years of normal development is typical. The regression, known as a prodrome, can be so dramatic that the child may be aware of it, and may in its beginning even ask, vocally, what is happening to them. Some children describe or appear to be reacting to hallucinations, but the most obvious symptom is that skills apparently attained are lost. Many children are already somewhat delayed when the disorder becomes apparent, but these delays are not always obvious in young children. This has been described by many writers as a devastating condition, affecting both the family and the individual's future. As is the case with all pervasive developmental disorder categories, there is considerable controversy about the right treatment for CDD. Signs and symptoms CDD is a rare condition, with only 1.7 cases per 100,000. A child affected with childhood disintegrative disorder shows normal development. Up until this point, the child has developed normally in the areas of language skills, social skills, comprehension skills, and has maintained those skills for about two years. However, between the ages of two and 10, skills acquired are lost almost completely in at least two of the following six functional areas: Expressive language skills (being able to produce speech and communicate a message) Receptive language skills (comprehension of language – listening and understanding what is communicated) Social skills and self care skills Control over bowel and bladder Play skills Motor skills Lack of normal function or impairment also occurs in at least two of the following three areas: Social interaction Communication Repetitive behavior and interest patterns In her book Thinking in Pictures, Temple Grandin argues that compared to "Kanner's classic autism" and to Asperger syndrome, CDD is characterized with more severe sensory processing disorder but less severe cognitive problems, despite the fact that most children with CDD regress to severe intellectual disability. She also argues that compared to most autistic individuals, persons with CDD have more severe speech pathology and they usually do not respond well to stimulants. Causes All of the causes of childhood disintegrative disorder are still unknown. Sometimes CDD surfaces abruptly within days or weeks, while in other cases it develops over a longer period of time. A Mayo Clinic report indicates: "Comprehensive medical and neurological examinations in children diagnosed with childhood disintegrative disorder seldom uncover an underlying medical or neurological cause. Although the occurrence of epilepsy is higher in children with childhood disintegrative disorder, experts don't know whether epilepsy plays a role in causing the disorder." CDD, especially in cases of later age of onset, has also been associated with certain other conditions, particularly the following: Lipid storage diseases: In this condition, a toxic buildup of excess fats (lipids) takes place in the brain and nervous system. Subacute sclerosing panencephalitis: Chronic infection of the brain by a form of the measles virus causes subacute sclerosing panencephalitis. This condition leads to brain inflammation and the death of nerve cells. Tuberous sclerosis (TSC): TSC is a genetic disorder. In this disorder, tumors may grow in the brain and other vital organs like kidneys, heart, eyes, lungs, and skin. In this condition, noncancerous (benign) tumors, hamartomas, grow in the brain. Leukodystrophy: In this condition, the myelin sheath does not develop in a normal way, causing white matter in the brain to eventually fail and disintegrate. Encephalitis: Encephalitis is inflammation of the brain sometimes caused by viral or bacterial infection, highlighting the importance of childhood vaccinations, especially in people with compromised immune systems. Treatment Loss of language and skills related to social interaction and self-care are serious. The affected children face ongoing disabilities in certain areas and require long-term care. Treatment of CDD involves both behavior therapy, environmental therapy and medications. Behavior therapy: Applied behavior analysis (ABA) is considered to be the most effective form of treatment for autism spectrum disorders by the American Academy of Pediatrics. The primary goal of ABA is to improve quality of life, and independence by teaching adaptive behaviors to children with autism, and to diminish problematic behaviors like running away from home, or self-injury by using positive or negative reinforcement to encourage or discourage behaviors over time. Environmental therapy: Sensory enrichment therapy uses enrichment of the sensory experience to improve symptoms in autism, many of which are common to CDD. Medications: There are no medications available to directly treat CDD. Antipsychotic medications are used to treat severe behavior problems like aggressive stance and repetitive behavior patterns. Anticonvulsant medications are used to control seizures. References Further reading External links NIH/Medline Pervasive developmental disorders Neurological disorders in children Learning disabilities Autism spectrum disorders

Catatonia

Catatonia is a complex neuropsychiatric behavioral syndrome that is characterized by abnormal movements, immobility, abnormal behaviors, and withdrawal. The onset of catatonia can be acute or subtle and symptoms can wax, wane, or change during episodes. It has historically been related to schizophrenia (catatonic schizophrenia), but catatonia is most often seen in mood disorders. It is now known that catatonic symptoms are nonspecific and may be observed in other mental, neurological, and medical conditions. Catatonia is now a stand-alone diagnosis (although some experts disagree), and the term is used to describe a feature of the underlying disorder. There are several subtypes of catatonia: akinetic catatonia, excited catatonia, malignant catatonia, and delirious mania. Failure to recognize and treat catatonia may lead to poor outcomes and can be potentially fatal. Treatment with benzodiazepines or ECT can lead to remission of catatonia. There is growing evidence of the effectiveness of the NMDA receptor antagonists amantadine and memantine for benzodiazepine-resistant catatonia. Antipsychotics are sometimes employed, but they can worsen symptoms and have serious adverse effects. Signs and symptoms The presenting signs of catatonia vary greatly and may be subtle or more markedly pronounced, and symptoms may develop over hours or days to weeks. Because most patients with catatonia have an underlying psychiatric illness, the majority will present with worsening depression, mania, or psychosis followed by catatonia symptoms. Catatonia presents as a motor disturbance in which patients will display marked reduction in movement, marked agitation, or a mixture of both despite having the physical capacity to move normally. These patients may be unable to start an action or stop one. Movements and mannerisms may be repetitive, or purposeless. The most common signs of catatonia are immobility, mutism, withdrawal and refusal to eat, staring, negativism, posturing (rigidity), rigidity, waxy flexibility/catalepsy, stereotypy (purposeless, repetitive movements), echolalia or echopraxia, verbigeration (repeat meaningless phrases). It should not be assumed that patients presenting with catatonia are unaware of their surroundings as some patients can recall in detail their catatonic state and their actions. There are several subtypes of catatonia and they are characterized by the specific movement disturbance and associated features. Although catatonia can be divided into various subtypes, the natural history of catatonia is often fluctuant and different states can exist within the same individual. Subtypes Withdrawn Catatonia: This form of catatonia is characterized by decreased response to external stimuli, immobility or inhibited movement, mutism, staring, posturing, and negativism. Patients may sit or stand in the same position for hours, may hold odd positions, and may resist movement of their extremities. Excited Catatonia: Excited catatonia is characterized by odd mannerisms/gestures, performing purposeless or inappropriate actions, excessive motor activity, restlessness, stereotypy, impulsivity, agitation, and combativeness. Speech and actions may be repetitive or mimic another person's. People in this state are extremely hyperactive and may have delusions and hallucinations. Malignant Catatonia: Malignant catatonia is a life-threatening condition that may progress rapidly within a few days. It is characterized by fever, abnormalities in blood pressure, heart rate, respiratory rate, diaphoresis (sweating), and delirium. Certain lab findings are common with this presentation; however, they are nonspecific, which means that they are also present in other conditions and do not diagnose catatonia. These lab findings include: leukocytosis, elevated creatine kinase, low serum iron. The signs and symptoms of malignant catatonia overlap significantly with neuroleptic malignant syndrome (NMS) and so a careful history, review of medications, and physical exam are critical to properly differentiate these conditions. For example, if the patient has waxy flexibility and holds a position against gravity when passively moved into that position, then it is likely catatonia. If the patient has a "lead-pipe rigidity" then NMS should be the prime suspect. Other forms: Periodic catatonia is an inconsistently defined entity. In the Wernicke-Kleist-Leonhard school, it is a distinct form of "non-system schizophrenia" characterized by recurrent acute phases with hyperkinetic and akinetic features and often psychotic symptoms, and the build-up of a residual state in between these acute phases, which is characterized by low-level catatonic features and aboulia of varying severity. The condition has a strong hereditary component. According to modern classifications, this may be diagnosed as a form of bipolar disorder, schizoaffective disorder or schizophrenia. Independently, the term periodic catatonia is sometimes used in modern literature to describe a syndrome of recurrent phases of acute catatonia (excited or inhibited type) with full remission between episodes, which resembles the description of "motility psychosis" in the Wernicke-Kleist-Leonhard school. System catatonias or systematic catatonias are only defined in the Wernicke-Kleist-Leonhard school. These are chronic-progressive conditions characterized by specific disturbances of volition and psychomotricity, leading to a dramatic decline of executive and adaptive functioning and ability to communicate. They are considered forms of schizophrenia but distinct from other schizophrenic conditions. Affective flattening and apparent loss of interests are common but may be related to reduced emotional expression rather than lack of emotion. Heredity is low. Of the 21 different forms (6 "simple" and 15 "combined" forms) that have been described, most overlap only partially - if at all - with current definitions of either catatonia or schizophrenia, and thus are difficult to classify according to modern diagnostic manuals. Early childhood catatonias are also a diagnosis exclusive to the Wernicke-Kleist-Leonhard school, and refers to system catatonias that manifest in young children. Clinically, these conditions resemble severe regressive forms of autism. Chronic catatonia-like breakdown or autistic catatonia refers to a functional decline seen in some patients with pre-existing autism spectrum disorder and/or intellectual disability which usually runs a chronic-progressive course and encompasses attenuated catatonic symptoms as well as mood and anxiety symptoms that increasingly interfere with adaptive functioning. Onset is typically insidious and often mistaken for background autistic symptoms. Slowing of voluntary movement, reduced speech, aboulia, increased prompt dependency and obsessive-compulsive symptoms are frequently seen; negativism, (auto-)aggressive behaviors and ill-defined hallucinations have also been reported. Both the causes of this disorder as well as its prognosis appear to be heterogenous, with most patients showing partial recovery upon treatment. It seems to be related to chronic stress as a result of life transitions, loss of external time structuring, sensory sensitivities and/or traumatic experiences, co-morbid mental disorders, or other unknown causes. Since clinical catatonia can not always be diagnosed, this condition has also been renamed to the more general term "late regression". Complications Patients may experience several complications from being in a catatonic state. The nature of these complications will depend on the type of catatonia being experienced by the patient. For example, patients presenting with withdrawn catatonia may have refusal to eat which will in turn lead to malnutrition and dehydration. Furthermore, if immobility is a symptom the patient is presenting with, then they may develop pressure ulcers, muscle contractions, and are at risk of developing deep vein thrombosis (DVT) and pulmonary embolus (PE). Patients with excited catatonia may be aggressive and violent, and physical trauma may result from this. Catatonia may progress to the malignant type which will present with autonomic instability and may be life-threatening. Other complications also include the development of pneumonia and neuroleptic malignant syndrome. Causes Catatonia is almost always secondary to another underlying illness, often a psychiatric disorder. Mood disorders such as a bipolar disorder and depression are the most common etiologies to progress to catatonia. Other psychiatric associations include schizophrenia and other primary psychotic disorders. It also is related to autism spectrum disorders and ADHD. Psychodynamic theorists have interpreted catatonia as a defense against the potentially destructive consequences of responsibility, and the passivity of the disorder provides relief. Catatonia is also seen in many medical disorders, including infections (such as encephalitis), autoimmune disorders, meningitis, focal neurological lesions (including strokes), alcohol withdrawal, abrupt or overly rapid benzodiazepine withdrawal, cerebrovascular disease, neoplasms, head injury, and some metabolic conditions (homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, and hypercalcaemia). Pathogenesis The pathophysiology that leads to catatonia is still poorly understood and a definite mechanism remains unknown. Neurologic studies have implicated several pathways; however, it remains unclear whether these findings are the cause or the consequence of the disorder. Abnormalities in GABA, glutamate signaling, serotonin, and dopamine transmission are believed to be implicated in catatonia. Furthermore, it has also been hypothesized that pathways that connect the basal ganglia with the cortex and thalamus is involved in the development of catatonia. Diagnosis There is not yet a definitive consensus regarding diagnostic criteria of catatonia. In the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013) and the World Health Organization's eleventh edition of the International Classification of Diseases (ICD-11, 2022), the classification is more homogeneous than in earlier editions. Prominent researchers in the field have other suggestions for diagnostic criteria. DSM-5 classification The DSM-5 does not classify catatonia as an independent disorder, but rather it classifies it as catatonia associated with another mental disorder, due to another medical condition, or as unspecified catatonia. Catatonia is diagnosed by the presence of three or more of the following 12 psychomotor symptoms in association with a mental disorder, medical condition, or unspecified: stupor: no psycho-motor activity; not actively relating to the environment catalepsy: passive induction of a posture held against gravity waxy flexibility: allowing positioning by an examiner and maintaining that position mutism: no, or very little, verbal response (exclude if known aphasia) negativism: opposition or no response to instructions or external stimuli posturing: spontaneous and active maintenance of a posture against gravity mannerisms that are odd, circumstantial caricatures of normal actions stereotypy: repetitive, abnormally frequent, non-goal-directed movements agitation, not influenced by external stimuli grimacing: keeping a fixed facial expression echolalia: mimicking another's speech echopraxia: mimicking another's movements. Other disorders (additional code 293.89 [F06.1] to indicate the presence of the co-morbid catatonia): Catatonia associated with autism spectrum disorder Catatonia associated with schizophrenia spectrum and other psychotic disorders Catatonia associated with brief psychotic disorder Catatonia associated with schizophreniform disorder Catatonia associated with schizoaffective disorder Catatonia associated with a substance-induced psychotic disorder Catatonia associated with bipolar and related disorders Catatonia associated with major depressive disorder Catatonic disorder due to another medical condition If catatonic symptoms are present but do not form the catatonic syndrome, a medication- or substance-induced aetiology should first be considered. ICD-11 classification In ICD-11 catatonia is defined as a syndrome of primarily psychomotor disturbances that is characterized by the simultaneous occurrence of several symptoms such as stupor; catalepsy; waxy flexibility; mutism; negativism; posturing; mannerisms; stereotypies; psychomotor agitation; grimacing; echolalia and echopraxia. Catatonia may occur in the context of specific mental disorders, including mood disorders, schizophrenia or other primary psychotic disorders, and Neurodevelopmental disorders, and may be induced by psychoactive substances, including medications. Catatonia may also be caused by a medical condition not classified under mental, behavioral, or neurodevelopmental disorders. Assessment/Physical Catatonia is often overlooked and under-diagnosed. Patients with catatonia most commonly have an underlying psychiatric disorder, for this reason, physicians may overlook signs of catatonia due to the severity of the psychosis the patient is presenting with. Furthermore, the patient may not be presenting with the common signs of catatonia such as mutism and posturing. Additionally, the motor abnormalities seen in catatonia are also present in psychiatric disorders. For example, a patient with mania will show increased motor activity that may progress to exciting catatonia. One way in which physicians can differentiate between the two is to observe the motor abnormality. Patients with mania present with increased goal-directed activity. On the other hand, the increased activity in catatonia is not goal-directed and often repetitive. Catatonia is a clinical diagnosis and there is no specific laboratory test to diagnose it. However, certain testing can help determine what is causing the catatonia. An EEG will likely show diffuse slowing. If seizure activity is driving the syndrome, then an EEG would also be helpful in detecting this. CT or MRI will not show catatonia; however, they might reveal abnormalities that might be leading to the syndrome. Metabolic screens, inflammatory markers, or autoantibodies may reveal reversible medical causes of catatonia. Vital signs should be frequently monitored as catatonia can progress to malignant catatonia which is life-threatening. Malignant catatonia is characterized by fever, hypertension, tachycardia, and tachypnea. Rating scale Various rating scales for catatonia have been developed, however, their utility for clinical care has not been well established. The most commonly used scale is the Bush-Francis Catatonia Rating Scale (BFCRS) (external link is provided below). The scale is composed of 23 items with the first 14 items being used as the screening tool. If 2 of the 14 are positive, this prompts for further evaluation and completion of the remaining 9 items. A diagnosis can be supported by the lorazepam challenge or the zolpidem challenge. While proven useful in the past, barbiturates are no longer commonly used in psychiatry; thus the option of either benzodiazepines or ECT. Differential diagnosis The differential diagnosis of catatonia is extensive as signs and symptoms of catatonia may overlap significantly with those of other conditions. Therefore, a careful and detailed history, medication review, and physical exam are key to diagnosing catatonia and differentiating it from other conditions. Furthermore, some of these conditions can themselves lead to catatonia. The differential diagnosis is as follows: Neuroleptic malignant syndrome (NMS) and catatonia are both life-threatening conditions that share many of the same characteristics including fever, autonomic instability, rigidity, and delirium. Lab values of low serum iron, elevated creatine kinase, and white blood cell count are also shared by the two disorders further complicating the diagnosis. There are features of malignant catatonia (posturing, impulsivity, etc.) that are absent from NMS and the lab results are not as consistent in malignant catatonia as they are in NMS. Some experts consider NMS to be a drug-induced condition associated with antipsychotics, particularly, first generation antipsychotics, but it has not been established as a subtype. Therefore, discontinuing antipsychotics and starting benzodiazepines is a treatment for this condition, and similarly it is helpful in catatonia as well. Anti-NMDA receptor encephalitis is an autoimmune disorder characterized by neuropsychiatric features and the presence of IgG antibodies. The presentation of anti-NMDAR encephalitis has been categorized into 5 phases: prodromal phase, psychotic phase, unresponsive phase, hyperkinetic phase, and recovery phase. The psychotic phase progresses into the unresponsive phase characterized by mutism, decreased motor activity, and catatonia. Both serotonin syndrome and malignant catatonia may present with signs and symptoms of delirium, autonomic instability, hyperthermia, and rigidity. Again, similar to the presentation in NMS. However, patients with Serotonin syndrome have a history of ingestion of serotonergic drugs (Ex: SSRI). These patients will also present with hyperreflexia, myoclonus, nausea, vomiting, and diarrhea. Malignant hyperthermia and malignant catatonia share features of autonomic instability, hyperthermia, and rigidity. However, malignant hyperthermia is a hereditary disorder of skeletal muscle that makes these patients susceptible to exposure to halogenated anesthetics and/or depolarizing muscle relaxants like succinylcholine. Malignant hyperthermia most commonly occurs in the intraoperative or postoperative periods. Other signs and symptoms of malignant hyperthermia include metabolic and respiratory acidosis, hyperkalemia, and cardiac arrhythmias. Akinetic mutism is a neurological disorder characterized by a decrease in goal-directed behavior and motivation; however, the patient has an intact level of consciousness. Patients may present with apathy, and may seem indifferent to pain, hunger, or thirst. Akinetic mutism has been associated with structural damage in a variety of brain areas. Akinetic mutism and catatonia may both manifest with immobility, mutism, and waxy flexibility. Differentiating both disorders is the fact that akinetic mutism does not present with echolalia, echopraxia, or posturing. Furthermore, it is not responsive to benzodiazepines as is the case for catatonia. Elective mutism has an anxious etiology but has also been associated with personality disorders. Patients with this disorder fail to speak with some individuals but will speak with others. Likewise, they may refuse to speak in certain situations; for example, a child who refuses to speak at school but is conversational at home. This disorder is distinguished from catatonia by the absence of any other signs/symptoms. Nonconvulsive status epilepticus is seizure activity with no accompanying tonic-clonic movements. It can present with stupor, similar to catatonia, and they both respond to benzodiazepines. Nonconvulsive status epilepticus is diagnosed by the presence of seizure activity seen on electroencephalogram (EEG). Catatonia on the other hand, is associated with normal EEG or diffuse slowing. Delirium is characterized by fluctuating disturbed perception and consciousness in the ill individual. It has hypoactive and hyperactive or mixed forms. People with hyperactive delirium present similarly to those with excited catatonia and have symptoms of restlessness, agitation, and aggression. Those with hypoactive delirium present with similarly to retarded catatonia, withdrawn and quiet. However, catatonia also includes other distinguishing features including posturing and rigidity as well as a positive response to benzodiazepines. Patients with locked-in syndrome present with immobility and mutism; however, unlike patients with catatonia who are unmotivated to communicate, patients with locked-in syndrome try to communicate with eye movements and blinking. Furthermore, locked-in syndrome is caused by damage to the brainstem. Stiff-person syndrome and catatonia are similar in that they may both present with rigidity, autonomic instability and a positive response to benzodiazepines. However, stiff-person syndrome may be associated with anti-glutamic acid decarboxylase (anti-GAD) antibodies and other catatonic signs such as mutism and posturing are not part of the syndrome. Untreated late-stage Parkinson's disease may present similarly to retarded catatonia with symptoms of immobility, rigidity, and difficulty speaking. Further complicating the diagnosis is the fact that many patients with Parkinson's disease will have major depressive disorder, which may be the underlying cause of catatonia. Parkinson's disease can be distinguished from catatonia by a positive response to levodopa. Catatonia on the other hand will show a positive response to benzodiazepines. Extrapyramidal side effects of antipsychotic medication, especially dystonia and akathisia, can be difficult to distinguish from catatonic symptoms, or may confound them in the psychiatric setting. Extrapyramidal motor disorders usually do not involve social symptoms like negativism, while individuals with catatonic excitement typically do not have the physically painful compulsion to move that is seen in akathisia. Certain stimming behaviors and stress responses in individuals with autism spectrum disorders can present similarly to catatonia. In autism spectrum disorders, chronic catatonia is distinguished by a lasting deterioration of adaptive skills from the background of pre-existing autistic symptomatology that cannot be easily explained. Acute catatonia is usually clearly distinguishable from autistic symptoms. The diagnostic entities of obsessional slowness and psychogenic parkinsonism show overlapping features with catatonia, such as motor slowness, gegenhalten (oppositional paratonia), mannerisms, and reduced or absent speech. However, psychogenic parkinsonism involves tremor which is unusual in catatonia. Obsessional slowness is a controversial diagnosis, with presentations ranging from severe but common manifestations of obsessive compulsive disorder to catatonia. Down Syndrome Disintegrative Disorder (or Down Syndrome Regression Disorder, DSDD / DSRD) is a chronic condition characterized by loss of previously acquired adaptive, cognitive and social functioning occurring in persons with Down Syndrome, usually during adolescence or early adulthood. The clinical picture is variable, but often includes catatonic signs, which is why it was called "catatonic psychosis" in initial reports in 1946. DSDD seems to phenotypically overlap with obsessional slowness (see above) and catatonia-like regression occurring in ASD. Treatment The initial treatment of catatonia is to stop medication that could be potentially leading to the syndrome. These may include steroids, stimulants, anticonvulsants, neuroleptics or dopamine blockers. A "lorazepam challenge", in which patients are given 2 mg of IV lorazepam (or another benzodiazepine) may aid in the diagnosis. Most patients with catatonia will respond significantly to this within the first 15–30 minutes. If no change is observed during the first dose, then a second dose is given and the patient is re-examined. If the patient responds to the lorazepam challenge, then lorazepam can be scheduled at interval doses until the catatonia resolves. The lorazepam must be tapered slowly, otherwise, the catatonia symptoms may return. The underlying cause of the catatonia should also be treated during this time. ECT may also be used to resolve catatonia. The success rate of ECT and lorazepam in the treatment of catatonia is estimated to be 60-100%, with earlier treatment being associated with a greater likelihood of treatment success. ECT is usually administered as multiple sessions over one-two weeks and is usually successful in those in which lorazepam fails. ECT in combination with benzodiazepines is used to treat malignant catatonia. In France, zolpidem has also been used in diagnosis, and response may occur within the same time period. Ultimately the underlying cause needs to be treated. Supportive care is required in those with catatonia. This includes monitoring vital signs and fluid status, and in those with chronic symptoms; maintaining nutrition and hydration, medications to prevent a blood clot, and measures to prevent the development of pressure ulcers. Electroconvulsive therapy (ECT) is an effective treatment for catatonia that is well acknowledged. ECT has also shown favorable outcomes in patients with chronic catatonia. However, it has been pointed out that further high quality randomized controlled trials are needed to evaluate the efficacy, tolerance, and protocols of ECT in catatonia. Antipsychotics are sometimes used in those with a co-existing psychosis, however they should be used with care as they may worsen catatonia and have a risk of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires immediate discontinuation of the antipsychotic. There is evidence that clozapine works better than other antipsychotics to treat catatonia. Excessive glutamate activity is believed to be involved in catatonia; when first-line treatment options fail, NMDA antagonists such as amantadine or memantine may be used. Amantadine may have an increased incidence of tolerance with prolonged use and can cause psychosis, due to its additional effects on the dopamine system. Memantine has a more targeted pharmacological profile for the glutamate system, reduced incidence of psychosis and may therefore be preferred for individuals who cannot tolerate amantadine. Topiramate is another treatment option for resistant catatonia; it produces its therapeutic effects by producing glutamate antagonism via modulation of AMPA receptors. Prognosis Twenty-five percent of psychiatric patients with catatonia will have more than one episode throughout their lives. Treatment response for patients with catatonia is 50–70%, with treatment failure being associated with a poor prognosis. Many of these patients will require long-term and continuous mental health care. For patients with catatonia with underlying schizophrenia, the prognosis is much poorer. Epidemiology Catatonia has been historically studied in psychiatric patients. Catatonia is underrecognized and the features may be mistaken for other disorders (such as negative symptoms of schizophrenia), leading to an underestimate of the prevalence. The prevalence has been reported to be as high as 10% in those with acute psychiatric illnesses, and 9-30% in the setting of inpatient psychiatric care. One large population estimate has suggested that the incidence of catatonia is 10.6 episodes per 100 000 person-years. It occurs in males and females in approximately equal numbers. 21-46% of all catatonia cases can be attributed to a general medical condition. History Reports of stupor-like and catatonia-like states abound in the history of psychiatry. After the middle of the 19th century there was an increase of interest in the motor disorders accompanying madness, culminating in the publication by Karl Ludwig Kahlbaum in 1874 of ("Catatonia or Tension Insanity"). See also Acquiescence Akinetic mutism Autistic catatonia Awakenings (1990 biopic about catatonic patients, based on Oliver Sacks's book of the same name) Blank expression Botulism Clouding of consciousness Disorganized schizophrenia Homecoming (features catatonia as a main plot point) Karolina Olsson Oneiroid syndrome Paranoid schizophrenia Persistent vegetative state Resignation syndrome Sensory overload Tonic immobility Sleep paralysis References External links Catatonia in DSM-5 Encyclopedia of Mental Disorders – Catatonic Disorders "Schizophrenia: Catatonic Type" video by Heinz Edgar Lehmann, 1952 Bush-Francis Catatonia Rating Scale Mood disorders Symptoms of schizophrenia Psychopathological syndromes

Psychological intervention

In applied psychology, interventions are actions performed to bring about change in people. A wide range of intervention strategies exist and they are directed towards various types of issues. Most generally, it means any activities used to modify behavior, emotional state, or feelings. Psychological interventions have many different applications and the most common use is for the treatment of mental disorders, most commonly using psychotherapy. The ultimate goal behind these interventions is not only to alleviate symptoms but also to target the root cause of mental disorders. To treat mental disorders psychological interventions can be coupled with psychoactive medication. Psychiatrists commonly prescribe drugs to manage symptoms of mental disorders. Psychosocial interventions have a greater or more direct focus on a person's social environment in interaction with their psychological functioning. Psychological interventions can also be used to promote good mental health in order to prevent mental disorders. These interventions are not tailored towards treating a condition but are designed to foster healthy emotions, attitudes and habits. Such interventions can improve quality of life even when mental illness is not present. Interventions can be diverse and can be tailored specifically to the individual or group receiving treatment depending on their needs. This versatility adds to their effectiveness in addressing any kind of situation. Psychotherapy Psychotherapy, also known as talk therapy, promotes a relationship between a trained psychotherapist and a person suffering from a psychological disorder. Positive activity interventions (PAIs) are a part of positive psychology. PAIs can be used in psychotherapy as well as outside of it. Examples include helping clients to focus on good things, the future self, gratitude, affirmation of the self and kindness towards others. Psychotherapy is a method that addresses both psychological and emotional issues/challenges by using verbal communication between a certified therapist and an individual, family, or couple, etc. The treatment aims to elevate the patients well-being, lower their stress levels, and promote personalized growth. It can be seen being used to treat mental health issues such as depression, anxiety, and relationship problems. Psychotherapy can be dated back to the late 19th century, where Freud created the early system of psychotherapy, which is psychoanalysis. From the 19th century til today, psychotherapy has evolved into a widely used practice, contributing to the care for mental health worldwide. This form of therapy stands out for its holistic and long-term approach to addressing psychological challenges that people face. The effects of Psychotherapy don't diminish as medications effects would, the self-help strategies developed in Psychotherapy are viewed as sustainable. Pharmaceutical therapy Pharmaceutical drugs are a frequently used intervention in the field of psychiatry, with targeted drugs available for a wide variety of conditions e.g Major Depressive Disorder, Bipolar Disorder, or Generalized Anxiety Disorder, among others. A typical course of treatment with psychotropic medication will involve an initial psychiatric screening, followed by periodic monitoring over the course of treatment to adjust specific dosages or prescriptions, as efficacy and potential side effects vary widely across differing medications The first available psychiatric drugs on the market were neuroleptics, now commonly known as antipsychotics, such as Thorazine, which are used to treat disorders with psychotic symptoms such as Schizophrenia or Bipolar Disorder, though are sometimes prescribed off-label to treat others such as depression with or without psychotic symptoms. These drugs typically work as dopamine antagonists, in line with the dopamine hypothesis of psychotic manifestation. Although showing significant efficacy in reducing acute symptoms of psychosis and its rate of occurrence, antipsychotics have a comparatively higher side effect profile to other psychotropic drugs, such as weight gain, movement disorders (dyskinesia), or, in rare cases, neuroleptic malignant syndrome, a severe and potentially fatal reaction to antipsychotic drugs. Selective Serotonin Reuptake Inhibitors (SSRIs) are the most widely prescribed psychotropic drugs prescribed in the United States, due to their comparatively mild side effects and versatile efficacy profile compared to other psychotropic drug classes, and are primarily used for treating major depressive disorder or anxiety disorders. Effectiveness varies substantially between individual drugs, with negative or unsatisfactorily mild effects being experienced by some patients. In patients experiencing treatment resistant depression or anxiety disorders, psychiatrists may prescribe SSRIs in combination with other drugs such as antipsychotics or benzodiazepines Cognitive Intervention Cognitive intervention is a therapeutic approach that focuses on addressing and modifying cognitive processes, thoughts, and beliefs to bring about positive changes in an individual's emotional and behavioral well-being. This form of intervention is commonly used in the field of psychology and mental health to help individuals overcome various challenges, such as anxiety, depression, addiction, and post-traumatic stress disorder (PTSD) Key elements of cognitive intervention include: Cognitive Restructuring: This technique involves identifying and challenging irrational or negative thought patterns and replacing them with more realistic and positive ones. By changing thought processes, individuals can often change their emotional responses and behaviors. Cognitive Behavioral Therapy (CBT): CBT is a widely used form of cognitive intervention that combines cognitive restructuring with behavioral techniques. It helps individuals recognize and modify unhelpful thought patterns and behaviors that contribute to their psychological distress. Mindfulness and Meditation: Mindfulness-based interventions teach individuals to observe their thoughts without judgment and cultivate a greater awareness of the present moment. These practices can help reduce stress and improve overall mental well-being. Cognitive Rehabilitation: In cases of cognitive deficits due to conditions like traumatic brain injury or neurodegenerative diseases, cognitive intervention may involve specific rehabilitation exercises and strategies to improve cognitive functioning. Problem-Solving Skills: Cognitive intervention often includes teaching individuals effective problem-solving skills to manage life's challenges more adaptively. Overall, cognitive intervention aims to empower individuals to gain better control over their thoughts and emotions, leading to improved mental health and enhanced coping skills to navigate life's difficulties. It is a widely respected and evidence-based approach in the field of psychology and psychotherapy. See also Shakubuku Wake-up call References Further reading Psychotherapy

Special needs

In clinical diagnostic and functional development, special needs (or additional needs) refers to individuals who require assistance for disabilities that may be medical, mental, or psychological. Guidelines for clinical diagnosis are given in both the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases 9th edition. Special needs can range from people with autism, cerebral palsy, Down syndrome, dyslexia, dyscalculia, dyspraxia, dysgraphia, blindness, deafness, ADHD, and cystic fibrosis. They can also include cleft lips and missing limbs. The types of special needs vary in severity, and a student with a special need is classified as being a severe case when the student's IQ is between 20 and 35. These students typically need assistance in school, and have different services provided for them to succeed in a different setting. In the United Kingdom, special needs usually refers to special needs within an educational context. This is also referred to as special educational needs (SEN) or special educational needs and disabilities (SEND). In the United States, 19.4 percent of all children under the age of 18 (14,233,174 children) had special health care needs as of 2018. The term is seen as a dysphemism by many disability rights advocates and is deprecated by a number of style guides (e.g. APA style). U.S. special needs and adoption statistics In the United States "special needs" is a legal term applying in foster care, derived from the language in the Adoption and Safe Families Act of 1997. It is a diagnosis used to classify children as needing more services than those children without special needs who are in the foster care system. It is a diagnosis based on behavior, childhood and family history, and is usually made by a health care professional. More than 150,000 children with special needs in the US have been waiting for permanent homes. Traditionally, children with special needs have been considered harder to place for adoption than other children, but experience has shown that many children with special needs can be placed successfully with families who want them. The Adoption and Safe Families Act of 1997 (P.L. 105–89) has focused more attention on finding homes for children with special needs and making sure they receive the post-adoption services they need. Pre-adoption services are also of critical importance to ensure that adoptive parents are well prepared and equipped with the necessary resources for a successful adoption. The United States Congress enacted the law to ensure that children in foster care who cannot be reunited with their birth parents are freed for adoption and placed with permanent families as quickly as possible. The disruption rate for special needs adoption is found to be somewhere between ten and sixteen percent. A 1989 study performed by Richard Barth and Marianne Berry found that of the adoptive parents that disrupted, 86% said they would likely or definitely adopt again. 50% said that they would adopt the same child, given a greater awareness of what the adoption of special needs children requires. Also, within disrupted special needs adoption cases, parents often said that they were not aware of the child's history or the severity of the child's issues before the adoption. There is also more care that goes into it when a child of special needs is in the process of getting adopted. Because of the Adoption Assistance and Child Welfare Act of 1980 P.L. 96-272, the child's needs have to be met within the home before allowing adoption, including being able to financially support the child. Education The term special needs is a short form of special education needs and is a way to refer to students with disabilities, in which their learning may be altered or delayed compared to other students. The term special needs in the education setting comes into play whenever a child's education program is officially altered from what would normally be provided to students through an Individual Education Plan, which is sometimes referred to as an Individual Program plan. Special education aids the student's learning environment to create a uniform system for all children. In the past, individuals with disabilities were often shunned or kept in isolation in mental hospitals or institutions. In many countries, disabled people were seen as an embarrassment to society, often facing punishments of torture and even execution. In the US, after the creation of the Individuals with Disabilities Education Act and many other regulations, students with disabilities could not be excluded or discriminated against in the education system. Integrated learning environments In many cases, the integration of special needs students into general-learning classrooms has had many benefits. A study done by Douglas Marston tested the effects of an integrated learning environment on the academic success of students with special needs. He first gathered students in from three different categories: those in isolated learning environments, those in integrated learning environments, and those in a combination of both isolated and integrated learning environments. He calculated the average number of words read by each group in the fall and again in the spring, and compared the outcome. The findings showed that those in integrated learning environments or a combination of isolated and integrated environments experienced greater improvements in their reading skills than those in strictly isolated environments. Integrated classrooms can also have many social benefits on students with special needs. By surrounding special needs students with their fully functioning peers, they are exposed to diversity. Their close contact with other students will allow them to develop friendships and improve interpersonal skills. Special needs and education worldwide The integration of children with special needs into school systems is an issue that is being addressed worldwide. In Europe, the number of students with special needs in regular classrooms is rising, while the number of those in segregated exclusive special needs classrooms is declining. However, in other countries such as China, educational opportunities for those with disabilities have been a longstanding issue. Certain cultural beliefs and ideologies have prevented the integration of all students regardless of ability, yet in recent years, China has progressed significantly by allocating more funding to programs to support disabled people and striving to create more inclusive communities within schools. See also ASDAN Attention deficit hyperactivity disorder Auditory processing disorder Autistic spectrum Communication disorder Developmental disability Developmental coordination disorder Dyscalculia Dyslexia Home education in the United Kingdom Intellectual disability Learning disability Learning theory (education) Orthographies and dyslexia Reading for special needs Scotopic sensitivity syndrome Sensory processing disorder Special education Specific language impairment (SLI) Speech disorders Speech perception Visual perception Working memory References External links Special education in the United States Special education Pejorative terms for people with disabilities

Word salad

A word salad is a "confused or unintelligible mixture of seemingly random words and phrases", most often used to describe a symptom of a neurological or mental disorder. The name schizophasia is used in particular to describe the confused language that may be evident in schizophrenia. The words may or may not be grammatically correct, but they are semantically confused to the point that the listener cannot extract any meaning from them. The term is often used in psychiatry as well as in theoretical linguistics to describe a type of grammatical acceptability judgement by native speakers. Psychiatry Word salad may describe a symptom of neurological or psychiatric conditions in which a person attempts to communicate an idea, but words and phrases that may appear to be random and unrelated come out in an incoherent sequence instead. Often, the person is unaware that they did not make sense. It appears in people with dementia and schizophrenia, as well as after anoxic brain injury. In schizophrenia, it is called schizophasia. Clang associations are especially characteristic of mania, as seen in bipolar disorder, as a somewhat more severe variation of flight of ideas. In extreme mania, the patient's speech may become incoherent, with associations markedly loosened, thus presenting as a veritable word salad. It may be present as: Clanging, a speech pattern that follows rhyming and other sound associations rather than meaning Graphorrhea, a written version of word salad that is more rarely seen than logorrhea in people with schizophrenia Logorrhea, a mental condition characterized by excessive talking (incoherent and compulsive) Receptive aphasia, fluent in speech but without making sense, often a result of a stroke or other brain injury See also Gibberish Paragrammatism, inability to produce or create grammatically correct sentences Pressure of speech Thought disorder References External links Medical signs Random text generation

Equine-assisted therapy

Equine-assisted therapy (EAT) encompasses a range of treatments that involve activities with horses and other equines to promote human physical and mental health. Modern use of horses for mental health treatment dates to the 1990s. Systematic review of studies of EAT as applied to physical health date only to about 2007, and a lack of common terminology and standardization has caused problems with meta-analysis. Due to a lack of high-quality studies assessing the efficacy of equine-assisted therapies for mental health treatment, concerns have been raised that these therapies should not replace or divert resources from other evidence-based mental health therapies. The existing body of evidence does not justify the promotion and use of equine-related treatments for mental disorders. Terminology An overall term that encompasses all forms of equine therapy is equine-assisted activities and therapy (EAAT). Various therapies that involve interactions with horses and other equines are used for individuals with and without disabilities including those with physical, cognitive and emotional issues. Terminology within the field is not standardized, and the lack of clear definitions and common terminology presents problems in reviewing medical literature. Within that framework, the more common therapies and terminology used to describe them are: Therapeutic horseback riding uses a therapeutic team, usually including a certified therapeutic riding instructor, two or more volunteers, and a horse, to help an individual ride a horse and work with it on the ground. Hippotherapy involves an occupational therapist, a physiotherapist, or a speech and language therapist working with a client and a horse. Different movements of the horse present challenges to the client to promote different postural responses of the client by the horse influencing the client rather than the client controlling the horse. The word hippotherapy is also used in some contexts to refer to a broader realm of equine therapies. Equine-assisted learning (EAL) is described as an "experiential learning approach that promotes the development of life skills ... through equine-assisted activities." Equine-assisted psychotherapy (EAP) does not necessarily involve riding, but may include grooming, feeding and ground exercises. Mental health professionals work with one or more clients and one or more horses in an experiential manner to help the clients learn about themselves and others, while processing or discussing the client's feelings, behaviours, and patterns. The goal is to help the client in social, emotional, cognitive, or behavioral ways. Other terms for equine psychotherapy include equine-facilitated psychotherapy (EFP), equine-assisted therapy (EAT), equine-facilitated wellness (EFW), equine-facilitated counselling (EFC) and equine facilitated mental health (EFMH). Interactive vaulting involves vaulting activities in a therapeutic milieu. Therapeutic driving involves controlling a horse while driving from a carriage seat or from a wheelchair in a carriage modified to accommodate the wheelchair. Equine-assisted activities (EAA) incorporates all of the above activities plus horse grooming, and stable management, shows, parades, demonstrations, and the like. Types Most research has focused on physical benefit of therapeutic work with horses, though the most rigorous studies have only been subject to systematic review since about 2007. EAAT have been used to treat individuals with neurological diseases or disorders such as cerebral palsy, movement disorders, or balance problems. It is believed the rhythmical gait of a horse acts to move the rider's pelvis in the same rotation and side-to-side movement that occurs when walking; the horse's adjustable gait promotes riders to constantly adjust to encourage pelvic motion while promoting strength, balance, coordination, flexibility, posture, and mobility. EAAT have also been used to treat other disabilities, such as autism, behavioral disorders and psychiatric disorders. Due to a lack of rigorous scientific evidence, there is insufficient evidence to demonstrate if equine therapy for mental health treatment provides any benefit. Therapeutic horseback riding Therapeutic riding is used by disabled individuals who ride horses to relax, and to develop muscle tone, coordination, confidence, and well-being. Therapeutic horseback riding is considered recreational therapy where an individual is taught by a non-therapist riding instructor how to actively control a horse while riding. It is used as exercise to improve sensory and motor skills for coordination, balance, and posture. Most research has focused on the physical benefit of therapeutic work with horses, with the most rigorous studies being subject to systematic review since about 2007. Claims made as to the efficacy of equine therapies for mental health purposes have been criticized as lacking proper medical evidence due in large part to poor study design and lack of quantitative data. Ethical questions relating to its expense and its continued promotion have been raised in light of this lack of evidence. While such therapies do not appear to cause harm, it has been recommended they not be used as a mental treatment at this time unless future evidence shows a benefit for treating specific disorders. Hippotherapy Hippotherapy is an intervention used by a physical therapist, recreational therapist, occupational therapist, or speech and language pathologist. The movement of the horse affects a rider's posture, balance, coordination, strength and sensorimotor systems. It is thought that the warmth and shape of the horse and its rhythmic, three-dimensional movement along with the rider's interactions with the horse and responses to the movement of the horse can improve the flexibility, posture, balance and mobility of the rider. Learning to use verbal cues for the horse, and to speak with the therapist is key to practicing use of speech. It differs from therapeutic horseback riding because it is one treatment strategy used by a licensed physical therapist, occupational therapist, or speech and language pathologists. They guide the rider's posture and actions while the horse is controlled by a horse handler at the direction of the therapist. The therapist guides both the rider and horse to encourage specific motor and sensory inputs. Therapists develop plans to address specific limitations and disabilities such as neuromuscular disorders, walking ability, or general motor function. Equine-assisted psychotherapy Equine-assisted psychotherapy (EAP) or equine-facilitated psychotherapy (EFP) is the use of equines to treat human psychological problems in and around an equestrian facility. It is not the same as therapeutic riding or hippotherapy. Though different organizations may prefer one term over the other for various reasons, in practice, the two terms are used interchangeably. Other terms commonly used, especially in Canada, include equine-facilitated wellness (EFW), equine-facilitated counselling (EFC) and equine-facilitated mental health (EFMH). While some mental health therapies may incorporate vaulting and riding, some utilize groundwork with horses. Some programs only use ground-based work. There are also differences between programs over whether the horse is viewed as a co-facilitator, or simply as a tool. The field of equine-assisted psychotherapy did not publicly become a part of the equine-assisted therapy world until the 1990s, although individuals had been experimenting with the concept prior to that time. The first national group in the United States, the Equine-Facilitated Mental Health Association (EFMHA), now a part of PATH International, formed in 1996. The mental health area of equine-assisted therapy became subject to a major rift when a second group, the Equine Growth and Learning Association (EAGALA) formed in 1999, splitting from EFMHA (now PATH) over differences of opinion about safety protocols. Since that time, additional differences have arisen between the two groups over safety orientation, the therapeutic models used, training programs for practitioners, and the role of riding. EAGALA itself had a further split between its founders in 2006 due to legal issues, with yet another new organization formed. As a result, although PATH and EAGALA remain the two main certification organizations in the United States, there has been a significant amount of misunderstanding amongst practitioners, client, and within the scientific literature. To resolve these differences, an independent organization, the Certification Board for Equine Interaction Professionals (CBEIP) formed, beginning in 2007, to promote professional credibility in the field. However, the world of equine-assisted psychotherapy remains disorganized and has not standardized its requirements for education or credentialing. History Horses have been utilized as a therapeutic aid since the ancient Greeks used them for those people who had incurable illnesses. Its earliest recorded mention is in the writings of Hippocrates who discussed the therapeutic value of riding. The claimed benefits of therapeutic riding have been dated back to 17th century literature where it is documented that it was prescribed for gout, neurological disorder and low morale. In 1946 Equine Therapy was introduced in Scandinavia after an outbreak of poliomyelitis. Hippotherapy, as currently practiced was developed in the 1960s, when it began to be used in Germany, Austria, and Switzerland as an adjunct to traditional physical therapy. The treatment was conducted by a physiotherapist, a specially trained horse, and a horse handler. The physiotherapist gave directives to the horse handler as to the gait, tempo, cadence, and direction for the horse to perform. The first standardized hippotherapy curriculum would be formulated in the late 1980s by a group of Canadian and American therapists who travelled to Germany to learn about hippotherapy and would bring the new discipline back to North America upon their return. The discipline was formalized in the United States in 1992 with the formation of the American Hippotherapy Association (AHA). Since its inception, the AHA has established official standards of practice and formalized therapist educational curriculum processes for occupational, physical and speech therapists in the United States. At about 1952, in Germany, therapeutic riding was used to address orthopaedic dysfunctions such as scoliosis. The first riding centers in North America began in the 1960s and the North American Riding for the Handicapped Association (NARHA) was launched in 1969. Therapeutic riding was introduced to the United States and Canada in 1960 with the formation of the Community Association of Riding of the Disabled (CARD). In the United States riding for disabled people developed as a form of recreation and as a means of motivation for education, as well as its therapeutic benefits. In 1969 the Cheff Therapeutic Riding Center for the Handicapped was established in Michigan, and remains the oldest center specifically for people with disabilities in the United States. The North American Riding for Handicapped Association (NARHA) was founded in 1969 to serve as an advisory body to the various riding for disabled groups across the United States and its neighboring countries. In 2011, NARHA changed its name to the Professional Association of Therapeutic Horsemanship (PATH) International. Horses used In most cases, horses are trained and selected specifically for therapy before being integrated into a program. Therapy programs choose horses of any breed that they find to be calm, even-tempered, gentle, serviceably sound, and well-trained both under saddle and on the ground. As most equine-assisted therapy is done at slow speeds, an older horse that is not in its athletic prime is sometimes used. Equine-assisted therapy programs try to identify horses that are calm but not lazy and physically suited with proper balance, structure, muscling and gaits. Muscling is not generally considered to be as important as the balance and structural correctness, but proper conditioning for the work it is to do is required. Suitable horses move freely and have good quality gaits, especially the walk. Unsound horses that show any signs of lameness are generally avoided. The welfare of the horse is taken into consideration. Each individual animal has natural biological traits but also has a unique personality with its own likes, dislikes and habits. Paying attention to what the animal is trying to communicate is helpful both in sessions of EAAT, but also to prevent burnout for the horse. Some programs refer to the therapy horse as an "equine partner". Other programs view the horse as a "metaphor" with no defined role other than to "be themselves." Equine-facilitated wellness programs, particularly those following the EFW-Canada certification route view the horse as 'sentient being': "The equine is a sentient being, partner and co-facilitator in the equine facilitated relationship and process". Effectiveness There is currently insufficient medical evidence to support the effectiveness of equine-related treatments for mental health. Multiple reviews have noted problems with the quality of research such as the lack of independent observers, rigorous randomized clinical trials, longitudinal studies, and comparisons to currently accepted and effective treatments. A 2014 review found these treatments did no physical harm, but found that all studies examined had methodological flaws, which led to questioning the clinical significance of those studies; the review also raised ethical concerns both about the marketing and promotion of the practice and the opportunity cost if patients in need of mental health services were diverted from evidence-based care. The review recommended that both individuals and organizations avoid this therapy unless future research establishes verifiable treatment benefits. There is some evidence that hippotherapy can help improve the posture control of children with cerebral palsy, although the use of mechanical hippotherapy simulators produced no clear evidence of benefit. A systematic review of studies on the outcomes of horseback riding therapy on gross motor function in children with cerebral palsy was concluded in 2012 with a recommendation for a "large randomized controlled trial using specified protocols" because the studies were too limited to be considered conclusive. Overall, reviews of equine-assisted therapy scientific literature indicate "there is no unified, widely accepted, or empirically supported, theoretical framework for how and why these interventions may be therapeutic". The journal Neurology published a 2014 study finding inadequate data to know whether hippotherapy or therapeutic horseback riding can help the gait, balance, or mood of people with multiple sclerosis. Newer studies have found hippotherapy paired with traditional treatment can increase balance and quality of life in individuals with multiple sclerosis. There is no evidence that therapeutic horseback riding is effective in treating children with autism. Accreditation and certification In Canada, centers and instructors for Therapeutic Riding are regulated by CanTRA, also known as The Canadian Therapeutic Riding Association. The field of equine-facilitated wellness is regulated by Equine Facilitated Wellness – Canada (EFW-Can) which provides a national certification program and certifies trainers and mentors to provide independent training at approved programs across Canada. In the UK there are a growing number of training providers offering externally accredited equine-assisted and facilitated qualifications. There is currently no overarching regulating body in the UK. Some organisations are specifically offering therapeutic or coaching based approaches; others offer skills-based approaches which building on existing professional skills and practices.   In the US, the Professional Association of Therapeutic Horsemanship (PATH) accredits centers and instructors that provide equine-assisted therapy. The Equine Assisted Growth and Learning Association (EAGALA) focuses only on mental health aspects of human-equine interaction, and provides certification for mental-health and equine professionals. The American Hippotherapy Association offers certification for working as a hippotherapist. See also Occupational therapy Physiotherapy Riding for the Disabled Association (UK) Professional Association of Therapeutic Horsemanship (PATH) (US) Horseback riding simulators Wagon-bed riding Notable examples Smoke the Donkey References Psychotherapy by type Equine therapies Mind–body interventions Animal-assisted therapy Physical therapy Occupational therapy

Functional training

Functional training is a classification of exercise which involves training the body for the activities performed in daily life. Functional Strength Training Functional Strength Training is a fitness approach designed to enhance the body's ability to perform everyday movements with ease and efficiency. Unlike traditional strength training that isolates specific muscle groups, functional training focuses on exercises that mimic real-life activities, such as lifting, squatting, and climbing. By engaging multiple muscles and joints simultaneously, functional strength training aims to improve overall body coordination, stability, and strength. Core exercises like squats, lunges, push-ups, and planks are commonly used, as well as tools like kettlebells, resistance bands, and medicine balls. Functional strength training is highly beneficial for improving daily life performance, reducing the risk of injury, and increasing flexibility and balance. It also provides a time-efficient workout by targeting multiple muscle groups at once, making it ideal for individuals seeking practical fitness solutions. This form of training is accessible to all fitness levels, from beginners to athletes, and can be adapted with bodyweight or added resistance, offering a comprehensive way to enhance functional fitness and overall health. Origins Functional training has its origins in rehabilitation. Physical and occupational therapists and chiropractors often use this approach to retrain patients with movement disorders. Interventions are designed to incorporate task and context specific practice in areas meaningful to each patient, with an overall goal of functional independence. For example, exercises that mimic what patients did at home or work may be included in treatment in order to help them return to their lives or jobs after an injury or surgery. Thus if a patient's job required repeatedly heavy lifting, rehabilitation would be targeted towards heavy lifting, if the patient were a parent of young children, it would be targeted towards moderate lifting and endurance, and if the patient were a marathon runner, training would be targeted towards re-building endurance. However, treatments are designed after careful consideration of the patient's condition, what he or she would like to achieve, and ensuring goals of treatment are realistic and achievable. Functional training attempts to adapt or develop exercises which allow individuals to perform the activities of daily life more easily and without injuries. While completing a functional training activity, the body consumes more oxygen, 1 liter for about every 5 calories of energy burned when more muscles are used. In the context of body building, functional training involves mainly weight bearing activities targeted at core muscles of the abdomen and lower back. Fabio Martella wrote that most fitness facilities have a variety of weight training machines which target and isolate specific muscles. As a result, the movements do not necessarily bear any relationship to the movements people make in their regular activities or sports. In rehabilitation, training does not necessarily have to involve weight bearing activities, but can target any task or a combination of tasks that a patient is having difficulty with. Balance training, for example, is often incorporated into a patient's treatment plan if it has been impaired after injury or disease. Evidence Rehabilitation after stroke has evolved over the past 15 years from conventional treatment techniques to task specific training techniques which involve training of basic functions, skills and endurance (muscular and cardiovascular). Functional training has been well supported in evidence-based research for rehabilitation of this population. It has been shown that task specific training yields long-lasting cortical reorganization which is specific to the areas of the brain being used with each task. Studies have also shown that patients make larger gains in functional tasks used in their rehabilitation and since they are more likely to continue practicing these tasks in everyday living, better results during follow-up are obtained. Equipment Some options include: Clubbells Macebells Cable machines Barbells Dumbbells Medicine balls Kettlebells Bodyweight training Physioballs (also called Swiss balls or exercise balls) Resistance bands Rocker and wobble boards Whole Body Vibration equipment (also called WBV or Acceleration Training) Balance disks Sandbags Suspension system Slideboard Redcord Ropes In rehabilitation however, equipment is mainly chosen by its relevance to the patient. In many cases equipment needs are minimal and include things that are familiar and useful to the patient. Cable machines When creating a piece of Universal Gym Equipment in the 1950s, Harold Zinkin improved Jack LaLanne’s invention of the cable machine.Cable machines, also known as pulley machines, are large upright machines, either with a single pulley, or else a pulley attached to both sides. They allow an athlete to recruit all major muscle groups while moving in multiple planes. Cable machines also provide a smooth, continuous action which reduces the need for momentum to start repetitions, provide a constant tension on the muscle, peak-contraction is possible at the top of each rep, a safe means of performing negative repetitions, and a variety of attachments that allow great flexibility in the exercises performed and body parts targeted. Components of a functional exercise program To be effective, a functional exercise program should include a number of different elements which can be adapted to an individual's needs or goals: Based on functional tasks directed toward everyday life activities. Individualized – a training program should be tailored to each individual. Any program must be specific to the goals of an individual, focusing on meaningful tasks. It must also be specific to the individual state of health, including presence or history of injury. An assessment should be performed to help guide exercise selection and training load. Integrated – It should include a variety of exercises that work on flexibility, core, balance, strength and power, focusing on multiple movement planes. Progressive – Progressive training steadily increases the difficulty of the task. Periodized – mainly by training with distributed practice and varying the tasks. Repeated frequently. Use of real life object manipulation. Performed in context-specific environments. Feedback should be incorporated following performance (self-feedback of success is used as well as trainer/therapist feedback). See also Direct visual feedback References Physical exercise Weight training Aerobic exercise

Rehabilitation psychology

Rehabilitation psychology is a specialty area of psychology aimed at maximizing the independence, functional status, health, and social participation of individuals with disabilities and chronic health conditions. Assessment and treatment may include the following areas: psychosocial, cognitive, behavioral, and functional status, self-esteem, coping skills, and quality of life. As the conditions experienced by patients vary widely, rehabilitation psychologists offer individualized treatment approaches. The discipline takes a holistic approach, considering individuals within their broader social context and assessing environmental and demographic factors that may facilitate or impede functioning. This approach, integrating both personal (e.g., deficits, impairments, strengths, assets) and environmental factors, is consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF). In addition to clinical practice, rehabilitation psychologists engage in consultation, program development, teaching, training, public policy, and advocacy. Rehabilitation psychology shares some technical competencies with the specialties of clinical neuropsychology, counseling psychology, and health psychology; however, Rehabilitation Psychology is distinctive in its focus on working with individuals with all types of disability and chronic health conditions to maintain/gain and advance in vocation; in the context of interdisciplinary health care teams; and as social change agents to improve societal attitudes toward individuals living with disabilities and chronic health conditions. Rehabilitation psychologists work as advocates with persons with disabilities to eliminate attitudinal, policy, and physical barriers, and to emphasize employment, environmental access, and social role and community integration.   Rehabilitation psychologists provide clinical services in varied healthcare settings, including acute care hospitals, inpatient and outpatient rehabilitation centers, assisted living centers, long-term care facilities, specialty clinics, and community agencies. They typically work in interdisciplinary teams, often including a physiatrist, physical therapist, occupational therapist, and speech therapist. A nurse, social worker, prosthetist, chaplain, and case manager also may be included depending on individual needs. Members of the team work together to create a treatment plan, set goals, educate both the patient and their support network, and facilitate discharge planning. In the United States, the specialty of Rehabilitation Psychology is coordinated by the Rehabilitation Psychology Specialty Council (RPSC), which comprises five professional organizations that represent the major constituencies in Rehabilitation Psychology: Division 22 of the American Psychological Association (APA), the American Board of Rehabilitation Psychology (ABRP), the Foundation for Rehabilitation Psychology (FRP), the Council of Rehabilitation Psychology Postdoctoral Training Programs (CRPPTP), and the Academy of Rehabilitation Psychology (ARP). RPSC represents the specialty to the Council of Specialties in Professional Psychology(CoS). Rehabilitation Psychology is its official journal. Rehabilitation Psychology is certified as one of 14 specialty competencies by the American Board of Professional Psychology (ABPP). History The specialty of rehabilitation psychology was established well before psychologists were regularly involved in healthcare settings. In the 1940s and 1950s, psychologists became increasingly involved in caring for persons with disabilities, often the result of combat injuries. Advances in medical care had led to an increased number of people surviving injuries and illnesses that would have been fatal in previous generations. Individuals living with disabilities and chronic health conditions needed help to adjust, and rehabilitation psychology emerged to meet these needs using psychological knowledge to help maximize independence, health, and welfare. In 1954, the Vocational Rehabilitation Act was passed, providing grant funding for research and program development. As a result of this act, many universities opened vocational rehabilitation counseling programs within their graduate schools. In 1958, Rehabilitation Psychology was established as Division 22 of the American Psychological Association, as an organization of psychologists concerned with the psychological and social consequences of disability, and with the development of ways to prevent and resolve problems associated with disability. By the 1960s, rehabilitation psychology was considered a mature specialty and was prominent throughout the United States. However, it was not until 1997 that the American Board of Professional Psychology approved the establishment of the American Board of Rehabilitation Psychology. Key principles and models Theoretical models are important in rehabilitation psychology for understanding and explaining impairments, aiding treatment planning, and facilitating the prediction of outcomes. Models help organize, understand, explain, and predict phenomena. The models used integrate information from a number of disciplines, such as biology, psychology, and sociology. A wide array of models is needed because of the diverse problems and concerns faced by individuals with disabilities and chronic health conditions. Often, more than one model must be applied to properly understand an individual's condition. Biopsychosocial model: The biopsychosocial model examines the interaction of medical conditions, psychological stressors, the environment, and personal factors to understand an individual's adaptation to disability. This interdisciplinary model is an acknowledgement that disability only can be understood within a larger context, and reflects the longstanding belief of rehabilitation psychologists that cultural attitudes and environmental barriers influence an individual's adaptation and accentuate disability. Notably, the tenets of this model are reflected in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). The framework is holistic and to apply it providers must learn about the disabled person's home life and broader social context. Psychoanalytic model: In the context of rehabilitation psychology, Freud's concept of castration anxiety can be applied to severe losses, such as the loss of a limb. This concept is reflected in Jerome Siller's stage theory of adjustment, designed to increase understanding of acceptance and adjustment following sudden disability. Social psychology: The pioneers in rehabilitation psychology were a diverse group, but many came from the field of social psychology. Kurt Lewin is one example. As a Jew living in Germany during the early years of the Nazi regime, Lewin's experiences shaped his psychological work. This is reflected in his conceptualization of the insider-outsider distinction, as well as his understanding of stigma. Lewin is known for his conceptualization B = f(p,e), where behavior (B) is a function of both the person (p) and their environment (e). Tamara Dembo and Beatrice Wright, two of Lewin's students, are recognized as pioneering figures in the history of rehabilitation psychology. Wright authored two of the field's seminal texts, Physical Disability: A Psychological Approach and the extensively revised second edition, Physical Disability: A Psychosocial Approach. She also proposed the somatopsychological model, which advocates for interpreting disability within its social context. The somatopsychological model is derived from Lewin's field theory and holds that the environment can either aid or hinder an individual's adjustment. Wright's insights and her articulation of the beliefs and principles underlying rehabilitation psychology practice have come to be known as the "foundational principles of rehabilitation psychology" and her work continues to inform contemporary rehabilitation psychology research, theory, and practice. Cognitive-Behavior Theory: Cognitive behavioral therapy (CBT) approaches such as problem-solving treatment have shown promise in promoting adjustment, well-being, and overall health among individuals with disabilities and chronic health conditions. This model holds that thoughts and coping strategies directly impact feelings and behaviors. By emphasizing, identifying, and changing maladaptive thoughts, CBT works to change an individual's subjective experience and their resulting behavior. A variety of empirical studies have demonstrated CBT's effectiveness in cases of traumatic brain injury, spinal cord injury, and a variety of other conditions common to individuals living with disability and chronic health conditions. Clinical specialty areas In clinical settings, rehabilitation psychologists apply psychological expertise and skills to improve outcomes for individuals living with disabilities or chronic health conditions. Common populations treated include individuals with: AIDS Acquired brain injury Cancer Chronic pain Concussion Limb loss Multiple sclerosis Neuromuscular disorders Spinal cord injury Stroke Traumatic brain injury When addressing these chronic health conditions and disabilities, rehabilitation psychologists offer a variety of services with the goal of increasing an individual's functioning and quality of life. Specific services may include: Assessment To enhance the rehabilitation process, one must not only identify barriers to recovery, but also personal strengths and resiliency factors that foster continued recovery and social reintegration. Rehabilitation psychology's focus on personal strengths and resiliency has been influential in the field of positive psychology. Rehabilitation psychologists take into consideration the medical diagnosis, referral question, background history, pre-morbid functioning (independence with basic and instrumental activities of daily living), current functioning (physical, cognitive, psychological), personality characteristics, and goals (career, academic, personal). Depending upon the referral question and individual patient goals, a structured and focused assessment may include any combination of the following components: cognitive function (decisional capacity, mental status, neurocognitive function); physical function (fatigue, health behavior, pain, sleep); psychological function (emotional adjustment, interpersonal/social functioning, personality, mental health conditions). Aspects of the individual's environment also are assessed, including cultural, community, home, rehabilitation, school, vocational, and social environments. In addition to clinical assessment and interview, standardized measures can be helpful for understanding each of these component areas in greater detail. Specifically, rehabilitation psychologist use data from standardized cognitive assessments to assess both cognitive limitations and positive cognitive abilities such as problem-solving skills. Cognitive rehabilitation Cognitive rehabilitation, also known as cognitive remediation therapy, or neuropsychological rehabilitation, refers to the broad range of evidence-based interventions designed to improve cognitive functioning impaired as a result of changes in the brain due to injury or illness.  Because of their specialized training in the nuances of impaired cognitive abilities, within the context of personality and emotional factors, rehabilitation psychologists are uniquely qualified to provide interventions for cognitive, behavioral, and psychosocial difficulties following brain injury. Cognitive rehabilitation interventions have been used with people who have sustained brain injury, stroke, brain tumor, Parkinson's disease, multiple sclerosis, mild cognitive impairment, ADHD, and a variety of other medical conditions that affect cognitive functioning. Cognitive functions targeted may include processing speed, attention, memory, language, visual-perceptual skills, and executive functioning skills such as problem solving and emotional self-regulation. Cognitive rehabilitation can include computer-based tasks, with the caveat that such tasks are most effective when administered under the guidance of a trained clinician in an individualized setting. Consistent with the foundational principles of rehabilitation psychology, contemporary rehabilitation psychology approaches to cognitive rehabilitation incorporate the subjective experience of the patient while targeting meta-cognition or self regulation. The ultimate goal of all cognitive rehabilitation interventions is to improve the everyday functioning of people in the setting in which they live or work, consistent with their own values and priorities. Ethical and legal considerations Rehabilitation psychologists adhere to the same general principles and ethical codes of conduct as all psychologists, under guidelines set forth by the American Psychological Association (http://www.apa.org/ethics/code/). Rehabilitation psychologists also must follow federal laws relevant to individuals with disability. Rehabilitation psychologists often are faced with ethical and legal considerations when assisting patients with concerns such as end-of-life decision making, ability to return to driving (e.g., following acquired brain injury, stroke, or other medical conditions that may impair driving ability), and the role of faith/religion in the individual's health-care decision making. Relevant federal legislation includes: Rehabilitation Act of 1973: This Act prohibits discrimination of persons based on disability status in programs conducted by Federal agencies, those receiving Federal financial assistance, in Federal employment, and in the employment practices of Federal contractors. Americans with Disabilities Act (ADA): This Act was an extension of the Rehabilitation Act of 1973. The ADA's five titles prohibit discrimination on the basis of disability in employment, government, public and commercial facilities, transportation, and telecommunications. Health Insurance Portability and Accountability Act (HIPAA): This Act was initiated in 1996 in an effort to protect the privacy of patient information. It affects rehabilitation psychologists in a variety of important ways and occasionally contradicts aspects of the APA Ethical Code. For example, under the Act, tests designed to measure psychological and neurocognitive function may not be released to the general public. Instead of releasing the tests themselves, rehabilitation psychologists typically provide summaries of the data, interpretation, and treatment recommendations. Education and training In the United States, rehabilitation psychologists complete doctoral degrees (e.g., PhD or PsyD) in fields such as clinical psychology, counseling psychology, neuropsychology, or school psychology, plus pre-doctoral and post-doctoral clinical training in healthcare settings. Rehabilitation psychologists must be licensed in order to provide services in their state of practice and to receive reimbursement from health insurance payers. In most states, obtaining a license requires a doctoral degree from an approved program, a minimum number of hours of supervised clinical experience, and a passing score on the Examination for Professional Practice in Psychology (EPPP), a standardized knowledge-based examination. Most states also require a prescribed number of continuing education credits per year to renew a license. By the 1960s, the need for standardized guidelines for postdoctoral training in rehabilitation psychology was recognized during the speciality's national conferences. The APA Division of Rehabilitation Psychology (Division 22) and the American Congress of Rehabilitation Medicine spent four years developing guidelines leading up to the 1992 Ann Arbor Conference in Postdoctoral Training in Professional Psychology. Patterson and Hanson outlined the entrance requirements, training length, curriculum requirements, supervision, and evaluations: Trainees are accepted only from doctoral programs approved by the American Psychological Association. Minimum length of training is one year There are a minimum of two supervisors during training Curriculum includes supervised practice, seminars, and coursework Patient populations and didactics are related to disabilities and chronic health conditions There is a minimum of two hours of supervision per week All trainees are funded There are written objectives for the training program Formal trainee evaluations occur at least twice a year Program evaluations occur annually In 1997, the American Board of Professional Psychology approved the establishment of the American Board of Rehabilitation Psychology. Subsequently, the board elaborated on the guidelines from 1995 by requiring a board certification that assesses an individual on the expected competencies. Expected competencies were the capability to assess and treat disability adjustment, cognitive functioning, personality functioning, family functioning, social environment, social functioning, educational functioning, vocational functioning, recreational functioning, sexual functioning, substance abuse, and pain. In addition to displaying these competencies, rehabilitation psychologists are expected to collaborate and consult with other rehabilitation professionals within the interdisciplinary team throughout the treatment process. The ABRP Board Certification process recognizes, certifies, and promotes competence in the specialty. The American Board of Professional Psychology specifies that in order to meet the standards of the speciality, an individual must complete a recognized internship program, have three years of experience within the field, and have supervised experience within the specialty. Notable rehabilitation psychologists Roger Barker Tamara Dembo Beatrice Wright Stephen T. Wegener See also Neurorehabilitation Rehabilitation Psychology (journal) References External links American Board of Rehabilitation Psychology Foundation for Rehabilitation Psychology Council of Rehabilitation Psychology Postdoctoral Training Programs Council of Specialities in Professional Psychology Applied psychology Behavioural sciences Health care occupations

Acceptance and commitment therapy

Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of psychotherapy, as well as a branch of clinical behavior analysis. It is an empirically based psychological intervention that uses acceptance and mindfulness strategies along with commitment and behavior-change strategies to increase psychological flexibility. This approach was first called comprehensive distancing. Steven C. Hayes developed it around 1982 to integrate features of cognitive therapy and behavior analysis, especially behavior analytic data on the often negative effects of verbal rules and how they might be ameliorated. ACT protocols vary with the target behavior and the setting. For example, in behavioral health, a brief version of ACT is focused acceptance and commitment therapy (FACT). The goal of ACT is not elimination of difficult feelings, but to be present with what life brings and to "move toward valued behavior". Acceptance and commitment therapy invites people to open up to unpleasant feelings, not to overreact to them, and not to avoid situations that cause them. Its therapeutic effect aims to be a positive spiral, in which more understanding of one's emotions leads to a better understanding of the truth. In ACT, "truth" is measured through the concept of "workability", or what works to take another step toward what matters (e.g., values, meaning). Technique Basics ACT is developed within a pragmatic philosophy, functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is derived from behavior analysis. Both ACT and RFT are based on B. F. Skinner's philosophy of radical behaviorism. ACT differs from some kinds of cognitive behavioral therapy (CBT) in that, rather than try to teach people to control their thoughts, feelings, sensations, memories, and other private events, ACT teaches them to "just notice", accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a transcendent sense of self, "self-as-context"—the one who is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. ACT tries to help the individual clarify values and then use them as the basis for action, bringing more vitality and meaning to life in the process, while increasing psychological flexibility. While Western psychology has typically operated under the "healthy normality" assumption, which states that humans naturally are psychologically healthy, ACT assumes that the psychological processes of a normal human mind are often destructive. The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioral steps in accord with core values. As a simple way to summarize the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR: Fusion with your thoughts Evaluation of experience Avoidance of your experience Reason-giving for your behavior And the healthy alternative is to ACT: Accept your thoughts and emotions Choose a valued direction Take action Core principles ACT commonly employs six core principles to help clients develop psychological flexibility: Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories. Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) to come and go without struggling with them. Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness. (e.g., mindfulness) The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging. Values: Discovering what is most important to oneself. Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life. Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 meta-analysis showed that the six ACT principles, on average, account for 16–29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods. A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components. Research The website of the Association for Contextual Behavioral Science states that there were over 1,100 randomized controlled trials (RCTs) of ACT, over 500 meta-analyses/systematic reviews, and 84 mediational studies of the ACT literature as of June 2024. Organizations that have stated that acceptance and commitment therapy is empirically supported in certain areas or as a whole according to their standards include (as of March 2022): Society of Clinical Psychology (American Psychological Association/APA Division 12) World Health Organization UK National Institute for Health and Care Excellence Australian Psychological Society Netherlands Institute of Psychologists: Sections of Neuropsychology and Rehabilitation Netherlands National Institute for Public Health and the Environment (RIVM) Sweden Association of Physiotherapists SAMHSA's National Registry of Evidence-based Programs and Practices California Evidence-Based Clearinghouse for Child Welfare U.S. Department of Veterans Affairs/Department of Defense US Department of Justice - Office of Justice Programs Washington State Institute for Public Policy American Headache Society History In 2006, only about 30 randomized clinical trials and controlled time series evaluating ACT were known, in 2011 the number had doubled to more than 60 ACT randomized controlled trials, and in 2023 there were more than 1,000 randomized controlled trials of ACT worldwide. A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment. A 2009 meta-analysis found that ACT was more effective than placebo and "treatment as usual" for most problems. A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety. A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction. Its effectiveness was similar to traditional treatments like cognitive behavioral therapy (CBT). The authors also noted that research methodologies had improved since the studies described in the 2008 meta-analysis. In 2020, a review of meta-analyses examined 20 meta-analyses that included 133 studies and 12,477 participants. The authors concluded ACT is efficacious for all conditions examined, including anxiety, depression, substance use, pain, and transdiagnostic groups. Results also showed that ACT was generally superior to inactive controls, treatment as usual, and most active intervention conditions. In 2020–2021, after three RCTs of ACT by the World Health Organization (WHO), WHO released an ACT-based self-help course Self-Help Plus (SH+) for "groups of up to 30 people who have lived through or are living through adversity". As of July 2023, there are six RCTs of Self-Help Plus. In 2022, a systematic review of meta-analyses about interventions for depressive symptoms in people living with chronic pain concluded "Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice". Professional organizations The Association for Contextual Behavioral Science is committed to research and development in the area of ACT, RFT, and contextual behavioral science more generally. As of 2023 it had over 8,000 members worldwide, about half outside of the United States. It holds annual "world conference" meetings each summer, with the location alternating between North America, Europe, and South America. The Association for Behavior Analysis International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I. ABAI has larger special interest groups for autism and behavioral medicine. ABAI serves as the core intellectual home for behavior analysts. ABAI sponsors three conferences/year—one multi-track in the U.S., one specific to autism and one international. The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. ACT work is commonly presented at ABCT and other mainstream CBT organizations. The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members. Doctoral-level behavior analysts who are psychologists belong to the American Psychological Association's (APA) Division 25—Behavior analysis. ACT has been called a "commonly used treatment with empirical support" within the APA-recognized specialty of behavioral and cognitive psychology. Similarities ACT, dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches have been grouped by Steven Hayes under the name "the third wave of cognitive behavior therapy". However, this classification has been criticized and not everyone agrees with it. For example, David Dozois and Aaron T. Beck argued that there is no "new wave" and that there are a variety of extensions of cognitive therapy; for example, Jeffrey Young's schema therapy came after Beck's cognitive therapy but Young did not name his innovations "the third wave" or "the third generation" of cognitive behavior therapy. According to Hayes' classification, the first wave, behaviour therapy, commenced in the 1920s based on Pavlov's classical (respondent) conditioning and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions. In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes' ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs. People's rigid ideas about themselves, their lack of focus on what is important in their life, and their struggle to change sensations, feelings or thoughts that are troublesome only serve to create greater distress. Steven C. Hayes described the third wave in his ABCT President Address as follows: ACT has also been adapted to create a non-therapy version of the same processes called acceptance and commitment training. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results. The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psychotherapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioral science program, including approaches such as Gestalt therapy, Morita therapy, and others. Hayes and colleagues themselves stated in their book that introduced ACT that "many or even most of the techniques in ACT have been borrowed from elsewhere—from the human potential movement, Eastern traditions, behavior therapy, mystical traditions, and the like". Wilson, Hayes & Byrd explored at length the compatibilities between ACT and the 12-step treatment of addictions and argued that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients' values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self (higher power) within an unconventional, individualized spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking. Criticism The textbook Systems of Psychotherapy: A Transtheoretical Analysis includes various criticisms of third-wave behaviour therapy, including ACT, from the perspectives of other systems of psychotherapy, including the complaint that third-wave therapies "display an annoying tendency to gather effective methods from other traditions and label them as their own". Evidence-based practice In a 2012 blog post, psychologist James C. Coyne criticized the process and studies initially used by the APA to favorably evaluate ACT for the treatment of psychosis in its labeling system for evidence-based medicine. In particular, it relied on only one full randomized trials, supplemented by a pilot study and a feasibility study, despite the criteria for "strong evidence" requiring a treatment to be supported by many such trials. The main study used (Bach, P., & Hayes, S.C., 2002) was alleged not to have clearly specified its hypothesis, that ACT reduces rehospitalization, in advance (a practice that can allow researchers to retrospectively cherry-pick the metric showing the largest positive change after treatment). In 2016, this and other critiques were cited by William O'Donohue and coauthors in a paper on "weak and pseudo-tests" of ACT and added that while "no doubt there are studies of ACT that are quite good", they had examined three trials of ACT that were "weakened and thus made easier to pass", and they listed over 30 ways in which such trials were "weak or pseudo-tests". Drawing on concepts from Karl Popper's philosophy of science and Popper's critique of psychoanalysis as impossible to falsify, O'Donohue and colleagues advocated Popperian severe testing instead. Excessive promotion over other therapies In 2013, psychologist Jonathan W. Kanter said that Hayes and colleagues "argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioral science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT) and demotion of earlier cognitive and behavior change techniques in the absence of clear logic and empirical support." Nevertheless, Kanter concluded that "the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice". Authors of a 2013 paper comparing ACT to cognitive therapy (CT) concluded that "although preliminary research on ACT is promising, we suggest that its proponents need to be appropriately humble in their claims. In particular, like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects." The authors of the paper suggested that many of the assumptions of ACT and CT "are pre-analytical, and cannot be directly pitted against one another in experimental tests." In 2012, ACT appeared to be about as effective as standard CBT, with some meta-analyses showing small differences in favor of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compared to CBT for depression and quality of life. The author did find separation between ACT and CBT on the "primary outcome" – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT. A 2012 clinical trial by Forman et al. found that Beckian CBT obtained better results than ACT. Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One theoretical concern was that the primary authors of ACT and of the corresponding theories of human behavior, relational frame theory (RFT) and functional contextualism (FC), recommended their approach as the proverbial holy grail of psychological therapies. In 2012, in the preface to the second edition of Acceptance and Commitment Therapy, the primary authors of ACT clarified that "ACT has not been created to undercut the traditions from which it came, nor does it claim to be a panacea." See also Behavioral psychotherapy Contextualism Defence mechanism Humanistic psychology Positive psychology Solution-focused brief therapy References External links Contextualpsychology.org – Home for the Association for Contextual Behavioral Science, a professional organization dedicated to ACT, RFT, and functional contextualism. Also helpful for training opportunities for professionals interested in ACT and RFT. Most ACT workshops worldwide are listed here. Behaviorism Cognitive behavioral therapy Mindfulness (psychology) Treatment of obsessive–compulsive disorder

Acute behavioural disturbance

Acute behavioral disturbance (ABD) is an umbrella term referring to various conditions of medical emergency where a person behaves in a manner that may put themselves or others at risk. It is not a formal diagnosis. Another controversial term, the widely rejected idea of excited delirium, is sometimes used interchangeably with ABD (although according to definitions adopted by the Faculty of Forensic and Legal Medicine of the Royal College of Physicians in England, "only about one-third of cases of ABD present as excited delirium"). According to the Faculty of Forensic and Legal Medicine, ABD can be caused by a number of conditions including psychosis (potentially due to bipolar disorder or schizophrenia), substance abuse, hypoglycemia, akathisia, hypoxia, head injury as well as other conditions. Treatment generally consists of verbal deescalation, voluntary sedation with antipsychotics or benzodiazepine, or involuntary treatment with antipsychotics, benzodiazepines or ketamine through intramuscular injection as a means of chemical restraint through rapid tranquilization possibly combined with physical restraint. Treatment in a medical setting The initial treatment is through verbal descalation through encouraging patient to go to an area to avoid arousal, avoidance of confrontational body language or tone of voice. If this is not effective, chemical and physical restraint are used. Internationally, there is some difference in the guidelines for chemical restraint; some guidelines suggest that sedatives should be used alone initially, while others suggest that antipsychotics alone should be used initially. The UK's National Health Service has produced guidelines for handling violence and the risk of violence in psychiatric and emergency departments. When using physical restraint, National Institute for Health and Care Excellence suggest supine rather than prone restraint and that physical restraint should ideally not last longer than 10 minutes. In Australia, so-called behavioural assessment rooms are provided in emergency rooms where an aggressive patient can be moved to. These rooms are alarmed, allow for a patient to be observed from outside, are hidden from the rest of the emergency ward, and are acoustically conditioned to prevent others in the ward from hearing what is going on in the room. They are fitted with restraints that are kept out of sight. They are designed to prevent the individual from self-inflicted suffocation. Treatment in police custody In the UK, police guidelines permit Health Care Professionals (in the custody environment this will usually be a doctor, nurse or paramedic) to administer rapid tranquillisation to individuals in police custody suspected to have an Acute Behavioural Disturbance. The guidance emphasises that ABD is a time-critical medical condition and that the patient should be transported to a hospital Emergency Department as soon as possible, specifically by an emergency ambulance crew. References Abnormal psychology

Enabling

In psychotherapy and mental health, enabling is the encouragement of some behaviour, especially if said behaviour is either particularly positive or dysfunctional. Positive As a positive term, "enabling" describes patterns of interaction which allow individuals to develop and grow in a healthy direction. These patterns may be on any scale, for example within the family. Negative In a negative sense, "enabling" can describe dysfunctional behavior approaches that are intended to help resolve a specific problem but, in fact, may perpetuate or exacerbate the problem. A common theme of enabling in this latter sense is that third parties take responsibility or blame, or make accommodations for a person's ineffective or harmful conduct (often with the best of intentions, or from fear or insecurity which inhibits action). The practical effect is that the person themselves does not have to do so, and is shielded from awareness of the harm it may do, and the need or pressure to change. Codependency Codependency is a theory that attempts to explain imbalanced relationships in which one person enables another person's self-destructive behavior such as addiction, poor mental health, immaturity, irresponsibility, or under-achievement. Enabling may be observed in the relationship between a person with a substance use disorder and their partner, spouse or a parent. Enabling behaviors may include making excuses that prevent others from holding the person accountable, or cleaning up messes that occur in the wake of their impaired judgment. Enabling may prevent psychological growth in the person being enabled, and may contribute to negative symptoms in the enabler. Enabling may be driven by concern for retaliation, or fear of consequence to the person with the substance use disorder, such as job loss, injury or suicide. A parent may allow an addicted adult child to live at home without contributing to the household such as by helping with chores, and be manipulated by the child's excuses, emotional attacks, and threats of self-harm. Abuse In the context of abuse, enablers are distinct from flying monkeys (proxy abusers). Enablers allow or cover for the abuser's own bad behavior while flying monkeys actually perpetrate bad behavior to a third party on their behalf. Padilla et al. (2007), in analyzing destructive leadership, distinguished between conformers and colluders, in which the latter are those who actively participate in the destructive behavior. Emotional abuse is a brainwashing method that over time can turn someone into an enabler. While the abuser often plays the victim, it is quite common for the true victim to believe that he or she is responsible for the abuse and thus must adapt and adjust to it. Examples of enabling in an abusive context are as follows: Making excuses for another's violent rages. Cleaning up someone else's mess. Hiding an abuser's dysfunctional actions from public view. Absorbing the negative consequences of someone else's bad choices. Paying off another person's debts. Refusing to confront or protect oneself when exposed to physical, emotional or verbal assault. Regurgitating the abuser's 'facts' / version of reality to a third party without seeking evidence. Revictimising the abuser's other victims with behaviour such as gaslighting, denial, or scapegoating. Triangulation (playing the part in an abuse triangle as either victim or protector, but never seeing themselves as perpetrator). Keeping secrets for the abuser such as affairs, extramarital children, alcoholism, gambling, incest. Projecting / passing on their own shame (the shame projected on to them by the abuser) to third parties. Giving up/over knowledge of their finances to be taken care of by the abuser (oftentimes resulting in considerable debt). See also Personal boundaries Sycophancy References Motivation Counseling Behavior modification Behavioural syndromes associated with physiological disturbances and physical factors Interpersonal relationships Narcissism Abuse Anti-social behaviour

Positive mental attitude

Positive mental attitude (PMA) is a concept first introduced in 1937 by Napoleon Hill in the book Think and Grow Rich. The book never actually uses the term, but discusses the importance of positive thinking as a contributing factor of success. Napoleon, who along with W. Clement Stone, founder of Combined Insurance, later wrote Success Through a Positive Mental Attitude, defines positive mental attitude as comprising the 'plus' characteristics represented by words as faith, integrity, hope, optimism, courage, initiative, generosity, tolerance, tact, kindliness and good common sense. Positive mental attitude is that philosophy which asserts that having an optimistic disposition in every situation in one's life attracts positive changes and increases achievement. Adherents employ a state of mind that continues to seek, find and execute ways to win, or find a desirable outcome, regardless of the circumstances. This concept is the opposite of negativity, defeatism and hopelessness. Optimism and hope are vital to the development of PMA. Positive mental attitude (PMA) is the philosophy of finding greater joy in small joys, to live without hesitation or holding back our most cherished, held in high esteem, and highest personal virtues and values. Empirical research suggests that individuals who engage in positive self-talk and maintain a mindful approach to their internal dialogues tend to exhibit greater self-control and resilience which is crucial for personal and professional growth, highlighting the significance of self-regulation and mindfulness in fostering a positive mental attitude. Furthermore, research on leadership strategies suggest that a positive mental attitude, characterized by a proactive approach to personal and organizational challenges, significantly improves leadership effectiveness and success in leadership roles. Psychology PMA is under the umbrella of positive psychology. In positive psychology, high self-efficacy can help in gaining learned optimism which ultimately leads to PMA. PMA is considered an internal focus of control that influences external factors. Research has shown that through emotional intelligence training and positive psychology therapy, a person's attitudes and perceptions can be modified to improve one's personal and professional life. Sports A study of Major League Baseball players indicated that a key component that separates major league players from the minor leagues and all other levels is their ability to develop mental characteristics and mental skills. Among them were mental toughness, confidence, maintaining a positive attitude, dealing with failure, expectations, and positive self-talk. Health Well-meaning friends in the US and similar cultures routinely encourage people with Disease to maintain a positive attitude. However, although a positive attitude confers some immediate advantages and is more comfortable for other people, it does not result in a greater chance of cure or longer survival times. A study done with HIV-positive individuals found that a high health self-efficacy, a task-oriented coping style, and a positive mental attitude were strong predictors for a health-promoting lifestyle which has a significant effect on overall health (coping and surviving). See also Creative thinking Creative Visualization (New Age) Law of attraction New Thought Self-fulfilling prophecy Self-help Toxic positivity Unconditional positive regard References 1937 introductions New Thought beliefs Personality