The purpose of this chapter is to review exciting new directions in anxiety disorders research, and to look ahead to areas that remain to be studied in depth. Although the diagnostic criteria for many of the anxiety disorders have been revised and updated over time, the list of basic anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders DSM has mostly remained unchanged since the publication of DSM-III American Psychiatric Association, The development of DSM-V is now moving forward, with a tentative publication date of see www.
In the context of the initial planning of DSM-V , a number of questions and issues are being raised Rounsaville et al. What is the most appropriate definition of the term mental disorder? What is the best way to establish the validity of psychiatric diagnoses? To what extent should the classification of psychopathology rely on a dimensional approach that describes the severity of symptoms along continuous dimensions, as opposed to the current categorical approach that describes symptoms and syndromes as either present or absent?
How can DSM-V be improved to be more relevant across a wider range of socioeconomic strata and cultures? Is it possible to develop strategies for reducing our reliance on clinical judgment, in favor of increased use of laboratory tests, psychological testing, and standardized self-report rating scales? Such an approach would make it easier to use DSM-V in a wider range of nonpsychiatric settings, perhaps for early detection of mental disorders. Another important question that researchers are now asking concerns the extent to which etiology should be considered in the classification of mental disorders, as it is in many medical conditions Charney et al.
Starting with the publication of DSM-III in , the last few editions of the DSM have taken a descriptive and atheoretical approach to classification, purposely avoiding issues of etiology. Are we now at a stage in our understanding of the etiology of anxiety disorders that etiological factors should be considered in classification? Although it may be decades before our knowledge of etiology and pathophysiology is complete enough to adequately inform our classification of mental disorders, some have raised the question of whether our current state of knowledge is advanced enough to have at least some of our nomenclature based on what we know about etiology.
In fact, Charney et al. Axis I: Genotype e. Axis II: Neurobiological phenotype e. Axis III: Behavioral phenotype e. Axis IV: Environmental modifiers or precipitants e. Although important decisions remain to be made by those developing DSM-V , the outcome of these general discussions could have a considerable impact on how anxiety disorders and other psychological problems are classified. In addition to these general issues, there have also been preliminary discussions about issues that are more specifically relevant to the anxiety disorders.
Disorders typically included in the OC spectrum include body dysmorphic disorder, hypochondriasis, tic disorders, and others, though there is not complete agreement about which conditions belong. The proposal to group OCD with other OC spectrum disorders is based on the fact that these conditions are associated with OC features and are often similar to OCD with respect to patient characteristics, course, comorbidity, neurobiology, and response to treatment.
In addition to removing OCD from the anxiety disorders, some researchers have argued that generalized anxiety disorder GAD and posttraumatic stress disorder PTSD have more in common with depression than they do with other anxiety disorders. For example, Gamez, Watson, and Doebbeling found that the personality features associated with GAD and PTSD were more similar to those associated with depression than to those associated with other anxiety disorders.
Using data from a large epidemiological sample, Slade and Watson used confirmatory factor analysis to examine the relationships among various mental disorders. A separate p. Based on these and other findings, some have argued that GAD and PTSD might be better grouped with depressive disorders, perhaps under the general heading of distress disorders. It is still too early to know how anxiety disorders will be classified in DSM-V. Calls will likely be made for all kinds of changes in the ways in which anxiety disorders are organized, as well as for changes in the diagnostic criteria for particular anxiety disorders in the next edition of the DSM.
Despite the potential benefits of making such changes, revisions to the DSM also come with important costs e. Although the literature on the epidemiology and descriptive psychopathology of anxiety disorders is quite advanced, many questions remain to be answered. Some examples are provided in the following sections. Many studies have reported on the age of onset for anxiety disorders. An exception is a study on specific phobias by Antony, Brown, and Barlow that asked about the age of onset for participants' excessive fear, as well as the age at which the fears began to cause significant distress and impairment i.
This study found that the age of onset for the full disorder was on average 9 years later than the age of onset for the initial symptoms i. Future studies will need to distinguish between the onset of anxiety symptoms and the onset of the anxiety disorder. It is well established that anxiety disorders occur more frequently in women than in men, although sex differences are considerably smaller in some anxiety disorders e.
Although possible reasons for sex differences across anxiety disorders have been identified e. In addition to variations in the presence of anxiety disorders across the sexes, there may also be differences in the ways in which these disorders are expressed e. There are some studies on the effects of culture, religion, and related factors on the prevalence and expression of anxiety disorders, but much of the existing research has simply measured the frequency of anxiety symptoms across different groups.
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Very little is known about reasons for cultural differences in the expression of anxiety. Nor are there adequate data addressing the expression of anxiety symptoms and syndromes that are different from those described in the DSM-IV anxiety disorders section. Better understanding the nature of anxiety disorders across ethnic groups may lead to the development of more culturally appropriate treatments, an issue to which we will return later in this chapter. Patterns of comorbidity between particular anxiety disorders and other conditions e.
However, much less is known about the reasons for comorbidity. For example, are the OCD-like behaviors seen in people with autism, eating disorders, and certain impulse control disorders etiologically related to those observed in people with OCD? Furthermore, what accounts for the high rates of co-occurrence between anxiety disorders and depression? Although researchers have begun to address questions such as these, there is still much more work to be done in this area.
Because comorbidity is very common among people with anxiety disorders, and certain types of comorbidity have been found to affect the outcome of treatment, improved outcomes may result from gaining a better understanding of the nature and causes of comorbidity. It is generally accepted that anxiety disorders are heterogeneous conditions.
DSM-IV American Psychiatric Association, acknowledges heterogeneity within several anxiety disorders, though only to a limited extent. Examples include requiring that a clinician specify which of five types i. Some investigators have questioned whether these are the best ways to describe the variability that occurs within anxiety disorders. Others have developed alternative ways of describing heterogeneity. For example, Heimberg, Holt, Schneier, Spitzer, and Liebowitz proposed three subtypes generalized, nongeneralized, discrete of social phobia.
Similarly, investigators have proposed various ways of capturing heterogeneity in OCD—for example, taking into account the presence versus absence of tics, the specific symptom content e. More research is needed to better understand heterogeneity within anxiety disorders and whether different symptom profiles are associated with different responses to treatment. Investigators are increasingly recognizing that anxiety disorders share various basic core features, and that effective psychological treatments can be developed to target these core dimensions, regardless of the specific diagnosis see Chapter Transdiagnostic approaches to understanding anxiety disorders can also help to conceptualize patterns of comorbidity that are often observed in patients.
Antony observed a number of dimensions that appear to be relevant to all anxiety disorders. These include the presence of fear, anticipatory anxiety, and worry, situational avoidance, avoidance of thoughts and feelings, interoceptive anxiety i. In addition, it was proposed that these symptoms may be moderated by other factors such as skills deficits, family issues, life stress, and medical complications. Antony and Rowa refined this list, suggesting a number of core features that are important to assess and treat: anxiety cues and triggers including situational cues, interoceptive cues, and cognitive cues , avoidance behaviors including situational avoidance and experiential avoidance , compulsions and overprotective behaviors i.
They suggested that by understanding symptoms associated with these dimensions, individualized treatment protocols can be developed to target these core features, particularly when additional relevant information has been assessed e. Although the value of considering these core dimensions may be evident when thinking about anxiety disorders from a cognitive behavioral perspective, it is quite possible that clinicians working from a different perspective might identify very different core features.
It remains to be determined whether these are in fact the most important dimensions for understanding anxiety disorders, and whether administering individualized treatments based on these assessment data will in fact lead to better outcomes than standardized treatments designed to target particular disorders. The definitions and boundaries for basic constructs e. For example, whereas some investigators argue that fear and anxiety are distinct emotional states e.
Similarly, whereas some researchers e. The definition of worry is also in need of refinement, and it needs to be differentiated from other cognitive processes that occur in people with anxiety disorders. Some investigators have proposed that p. Beck and others e. What remains unclear is the relationship between worry and negative automatic thoughts, and what is actually happening in people's minds when they worry. Similarly, the relationships among experiences such as worries, obsessions, intrusive memories, depressive ruminations, and other types of distressing cognitive activity are poorly understood, as are the relationships between relevant traits, such as impulsivity and compulsivity.
Advances in research on information processing and the pathophysiological underpinnings of these constructs may help to answer questions about the nature of these states, and the boundaries among them. As reviewed throughout this book, there have been many advances in our understanding of the factors that contribute to the onset and maintenance of anxiety disorders. It is now well established that anxiety disorders stem from a complex interaction between our experiences e. It appears that our genes influence the types of experiences we have, as well as the ways in which we process information.
Formally disparate avenues of research are increasingly converging, as investigators try to understand the relationship between biological and psychological processes. Research is ongoing in these areas, and it is almost certain that our understanding of the etiology of anxiety disorders will continue to improve in the future.
Because anxiety disorders often begin early in life, research on children and adolescents will be key to discovering the most important risk factors for developing anxiety disorders. In addition, prospective and longitudinal studies on the development and course of anxiety disorders are greatly needed; retrospective studies have dominated the literature thus far. Effective treatments now exist for all of the anxiety disorders.
Nevertheless, some people do not benefit from existing treatments, and those who do respond to treatment often experience only partial improvement. Examples of the types of questions addressed in recent studies include:.
In addition, there have been several new directions in anxiety disorders treatment research that have generated considerable interest. First, a number of recent studies have found that D-cycloserine a partial glutamatergic agonist that enhances memory and learning , leads to better treatment outcomes during exposure therapy, relative to exposure alone Hofmann, This line of research opens new possibilities for a mechanistically informed combining of pharmacological and psychological treatments.
Finally, there p. Despite the volume of research devoted to developing new treatments and improving upon existing treatments, there is still much that remains unknown. First, there are many issues for which evidence regarding the best ways to administer treatment is contradictory. More research is needed to better understand the source of these discrepancies. There are many treatment approaches for which research is lacking. For example, studies that have investigated the effects of combining medications and CBT for anxiety disorders have almost always studied the effects of concurrent treatments, rather than sequential treatments.
Therefore, little is know about the effects of combining treatments sequentially e. Little is known about the best ways to combine psychological treatment strategies as well. For example, should cognitive strategies be taught before exposure strategies? Should interoceptive exposure be taught before or after situational exposure when treating panic disorder? Should patients use cognitive strategies during their exposure practices? When should mindfulness-acceptance based approaches be used? In addition, there are many popular anxiety treatments for which there is very little research, including insight-oriented psychotherapy, hypnosis, biofeedback, herbal treatments, and various complementary and alternative interventions e.
Similarly, very little is known about the effects of lifestyle changes e. Given the interest of the public in these types of treatments Roy-Byrne et al. Most evidence-based psychological treatments include groups of strategies e. However, dismantling studies have often found that some of the strategies used in standard protocols are more important than others. For example, breathing retraining seems to add little to the treatment of panic disorder Schmidt et al.
Finally, among the interoceptive exposure exercises used in the treatment of panic disorder, some e. There are still many questions about the most important components of standard treatments that remain to be answered. For example, which cognitive strategies e. Is imaginal exposure useful, and if so, under what conditions? What is the most effective way to administer imaginal exposure?
How much time should be devoted to various treatment components? Which methods of relaxation e. What is the best way to assess whether a particular patient with social phobia is likely to benefit from social skills training in addition to exposure and cognitive restructuring? Although much is known about how effective various treatments are, less is known about the mechanisms through which treatments have their effects.
Even for well-established strategies such as exposure, cognitive restructuring, and antidepressant medications, there is much work to be done to fully understand why these treatments work. One general approach that may help to uncover the mechanisms underlying effective treatments is p. Straube et al. In this study, increased activation in the insula and anterior cingulate cortex was associated with specific phobia symptoms, whereas an attenuation of these brain responses was correlated with successful treatment.
Further research on the relationships between cognitive behavioral and biological processes during treatment may lead to exciting new advances in our understanding of the processes through which treatments have their effects. A number of effective treatments exist for people with anxiety disorders, and in many cases, it has been difficult to show consistent advantages of one approach over another across large groups of individuals.
For example, there are few differences in outcomes across various effective antidepressants e. In addition, there are few differences in the acute effects of medications, CBT, and combined treatments for most anxiety disorders. Group and individual treatments are often equally effective, and various combinations of CBT strategies often work about equally well. Nevertheless, it is important to recognize that, although various treatments may be equivalent across large groups of patients, that does not meant that they are equally likely to be effective for any one patient.
For example, patients with panic disorder who do not respond to medication alone often respond to CBT Heldt et al. Although we understand the relative effects of various treatments, much less is known about which treatments work for whom, and under what conditions. A number of studies have investigated various predictors of outcome e. Future studies may help to identify symptom profiles, genetic polymorphisms, or other factors that can help clinicians to select treatments with a high likelihood of success and fewer adverse events for a particular individual.
There has been increased recognition in recent years in the limitations of evidence-based psychological and pharmacological treatments. Investigator psycho s have begun to explore strategies for improving outcomes and for preventing the recurrence of symptoms e. For example, in the pharmacological literature, investigators have begun to study the effects of augmenting standard pharmacological treatments with other treatments.
In recent years, a number of studies have shown that combining atypical antipsychotic medications with antidepressants may lead to improved outcomes for some patients Pollack et al. Similarly, combining a benzodiazepine with antidepressant treatment for the first month of treatment may lead to earlier improvements in patients with panic disorder, compared to treatment with an antidepressant alone Goddard et al.
An exciting new development in the psychological treatment of anxiety disorders has been recent research on motivational interviewing. Much of the work in this area has been in the fields of addictions and health psychology. Despite these preliminary findings, more research is needed to establish whether motivational interviewing is useful for resolving ambivalence about treatment, enhancing compliance, and improving outcomes.
In addition to developing ways of improving outcomes, there is a great need for research on prevention of relapse and recurrence following treatment of anxiety disorders. For example, little is known about the ideal duration of pharmacological treatment for anxiety disorders, and what the best ways are of dealing with recurrence of symptoms following discontinuation of treatment. In the s 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. Other kinds of psychiatric medication gradually came into use, such as "psychic energizers" later antidepressants and lithium. Benzodiazepines gained widespread use in the s 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 s, new SSRI -type antidepressants became some of the most widely prescribed drugs in the world, as later did antipsychotics. Also during the s, a recovery approach developed. 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. 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.
Religious , spiritual , or transpersonal experiences and beliefs meet many criteria of delusional or psychotic disorders. Those with schizophrenia commonly report some type of religious delusion,    and religion itself may be a trigger for schizophrenia.
Controversy has often surrounded psychiatry, and the term anti-psychiatry was coined by psychiatrist David Cooper in 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. 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. Laing who wrote a series of best-selling books, including The Divided Self.
Some ex-patient groups have become militantly anti-psychiatric, often referring to themselves as " survivors ". Activists campaign for improved mental health services and for more involvement and empowerment within mental health services, policies and wider society. 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'.
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. 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.
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.
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.
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.
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 utilized 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.
In order 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. 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 future. 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 , 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 psychosocial 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. The social stigma associated with mental disorders is a widespread problem.
The US Surgeon General stated in that: "Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others. Employment discrimination is reported to play a significant part in the high rate of unemployment among those with a diagnosis of mental illness. Efforts are being undertaken worldwide to eliminate the stigma of mental illness,  although the methods and outcomes used have sometimes been criticized. 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.
The general public have been found to hold a strong stereotype of dangerousness and desire for social distance from individuals described as mentally ill. Recent depictions in media have included leading characters successfully living with and managing a mental illness, including in bipolar disorder in Homeland and posttraumatic stress disorder in Iron Man 3 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 abuse and various personal, social and economic factors. 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. 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 abuse including alcoholism 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. 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. Psychopathology in non-human primates has been studied since the midth 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 with regard to 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. 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.
From Wikipedia, the free encyclopedia. For the album, see Mental Illness album. Distressing thought or behavior pattern. Main article: Classification of mental disorders. Main article: Causes of mental disorders. Main article: Psychiatric genetics. Main article: Prevention of mental disorders. Main articles: Treatment of mental disorders , Services for mental disorders , and Mental health professional.
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National Institute of Mental Health. Department of Health and Human Services. Archived from the original on 7 April Retrieved 28 April Medline Plus. National Library of Medicine. Archived from the original on 8 May Retrieved 10 June What is Mental Disorder? OUP Oxford. World Health Organization. Archived from the original on 18 May Retrieved 2 February Archived from the original on 29 March Retrieved 9 April October Retrieved 13 May Diagnostic and Statistical Manual of Mental Disorders 5th ed.
EBioMedicine Review. December A perspective from cognitive-affective science". Canadian Journal of Psychiatry. Archived from the original PDF on 4 March A; Bolton, D; Fulford, K. M; Sadler, J. Z; Kendler, K. S November Psychological Medicine. In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress e.
In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual.
Neither deviant behavior e. All medical conditions are defined on various levels of abstraction—for example, structural pathology e. Mental disorders have also been defined by a variety of concepts e. Each is a useful indicator for a mental disorder, but none is equivalent to the concept, and different situations call for different definitions. American Psychiatric Publishing. The Metaphor of Mental Illness. Oxford University Press. J Pers Assess.
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American Journal of Psychiatry. Archives of General Psychiatry. A sociology of mental health and illness 3rd ed. Milton Keynes: Open University Press. The Lancet. Understanding suicidal behaviour. Leicester: BPS Books. The Lancet Psychiatry. Royal College of Psychiatrists. Retrieved 23 April John March Advances in Psychiatric Treatment. Expert Review of Neurotherapeutics. M; Murray, R. July Clinical Psychology Review. Joseph; Ginsburg, Golda S. International Review of Psychiatry. Comprehensive Psychiatry. Dialogues in Clinical Neuroscience.
Insel Journal of Clinical Investigation. JAMA Psychiatry. The Schizophrenia Commission. Archived from the original on 5 April Schizophrenia Bulletin. National Academies Press. Journal of Health and Social Behavior. Lancet Psychiatry Review. Mol Psychiatry. Behavioural and Cognitive Psychotherapy. Supporting this perspective is the rapidly expanding evidence illustrating excessive stress reactivity as a main contributor to many common 21st century ailments Juster et al. Crucially, it is important to note that the magnitude of the stress response is not solely dependent upon the magnitude of the stressor, but is heavily modulated by the individual's sensitivity to the particular stress Nabi et al.
Furthermore, the health and behavioural consequences of accumulating stress are dependent on individual stress resilience. Individual sensitivity, in turn, is shaped by a broad coalition of innate genetic and pre-dispositional factors, and is similarly heavily influenced by cultural and attitudinal factors forged by individual life history.
Accordingly, our stress reactivity is shaped by a blend of genetic, behavioural coping and health habits , historical developmental experiences, prior stress exposures factors, early life experiences and cultural attitudes Juster et al. Although high levels of stress, especially in early life, can serve to increase an individual's stress-resilience, if this stress is excessive or over-whelming, then early life stress can predispose the individual to a life-long vulnerability to future stressors Juster et al.
In simple terms, a lack of perceived self-efficacy in ability to cope with an imposed stressor entails that the negative impacts of that stressor are magnified. As a consequence, many of those exposed to high levels of trauma in early life, exhibit a lifelong predisposition to disproportionately excessive reactivity to imposed stress Appleton et al. This reactivity exposes individuals to an increased likelihood of future stress-induced wear and tear, increased susceptibility to stress-related illnesses, and subsequently accelerating health decline.
The health consequences of exposure to an excessively activated stress response are manifest in the increasing incidence of a host of 21st-century ailments such as obesity, cardiovascular disease and psychiatric disorders Juster et al. It seems apparent that low socio-economic status is an inherent pre-disposing factor to stress, accounting for a large proportion of the stress burden imposed on individuals.
Nevertheless, there remain certain enigmatic stress modulating characteristics of life in Scotland, and specifically in Glasgow, which further add to the health-reducing toll of accumulative stress. Certainly there appears a cultural disinclination, particularly amongst males, to discuss, or engage in, positive health behaviours Courtenay, In particular, many men considered discussion, or practice of good health behaviours, such as healthy dietary and exercise habits as feminine; whilst negative health behaviours, such as binge drinking were perceived as manly Courtenay, , O'Brien et al.
The suggestion that health inequalities in Scotland and more specifically Glasgow, are directly dependent upon deprivation offers a partial truth, but not explanatory closure. After controlling for deprivation, it seems apparent that the mortality disadvantage embedded within this phenomenon is worsening. Furthermore, many health-related indicators, such as psychological morbidity, death from all cancers, chronic liver disease, and inadequate dietary intake of fruit and vegetables seems pervasive across socio-economic Glaswegian groups Whyte and Ajetunmobi, Apart from socio-economic status, deprivation and social inequality, other biopsychosocial stress-inducing factors have also been suggested as adding to the overall stress burden potentially driving the Glasgow effect: such as, for example, the physical and the climatic environment McCartney et al.
Accordingly it seems clear there is no simple, single causative factor ultimately responsible for the Scottish, and nested Glasgow effects Reid, Our suggestion that apparently separate influencing factors can be understood within a unifying explanatory rubric of cumulative multi-source life stress, unites these factors within a single conceptual model. The biopsychosocial impact of multi-source stressors results in greater accumulative life stress, heightening the risk of stress-related negative health outcomes. The burden of this chronic stress is accompanied by culturally promoted changes in personal behaviours: such as increased incidence of smoking, disordered eating and drinking.
Stress-inducing lifestyle behaviours, in turn, drive other stress-elevating conditions, such as poor quality sleep, increasing body mass index, reducing energy levels and reduced tendencies to engage in health-promoting physical activity behaviours McEwen, In short, these factors interact in a downward spiral, adding momentum to an insidious vicious cycle of self-perpetuating stress whilst, simultaneously, over-activation of the stress response erodes stress resilience.
Contextualising the Scottish effect as the insidious accumulation of relatively minor, but pervasive and persistent, stressors provides a conceptual model illuminating a previously incompletely explained phenomenon. Further, a shift in how we conceptualise the problem re-emphasises the remedial potential value of a certain simple, straight-forward and cost-effective strategies: physical activity PA. The rationale for promoting vigorous PA has traditionally focussed upon the well-established benefits to physical health Cooper and Hancock, However, in recent years, multiple strands of research have emerged demonstrating a positive relationship between PA and a range of emotional, cognitive and mental health capacities Martikainen et al.
For example, PA has been shown to exert large to moderate positive effects on depression, anxiety-related disorders, and ADHD Dinas et al. Similarly, vigorous exercise has been demonstrated to enhance various dimensions of emotional regulation such as mood, self-esteem, and impulse control Chaddock et al. In addition, and perhaps critically, physical exercise serves to increase emotional resilience against stressors yet to be experienced Smith, These potential benefits are well supported by available research.
Cross-sectional studies illustrate that regular exercise is associated with enhanced wellbeing, exerting positive effects on mood and anxiety symptoms Goodwin, Further, growing evidence reveals positive relationships between PA, physical fitness, selected measures of cognitive function and academic performance Biddle et al.
Initiatives elsewhere, focusing on positively influencing lifestyle change, have demonstrated significant improvements in health factors. By way of example, the Finnish North Karelia project —a community outreach programme emphasising lifestyle, PA and dietary factors— demonstrated significant reductions in cardiovascular disease Puska, Furthermore self-reported levels of PA demonstrated a positive independent dose relationship with lowered mortality rates Hu et al.
In the Appalachian areas of the USA, physical inactivity as a result of deindustrialisation has been evidenced as a driving factor in the poor health status of the region Hortz et al. Epidemiological evidence has similarly highlighted the importance of promoting PA. Of additional relevance, PA undertaken within natural environments —parks, woodlands, trails has been evidenced to provide an extra stress-reducing effect: potentially hinting at the benefits of exposure to natural scenery and context more aligned with our shared evolutionary heritage Aspinall et al.
There is a profound mismatch between the historical contexts, within which we evolved, and 21st century life as experienced in first World countries. The stress response, which originally evolved to protect us from immediate short-term physical danger, is now habitually activated in response to commonplace, everyday events —such as financial worries, work-related pressure or perceived low social status.
Thereby placing a heavy burden on human neuro-physiological defense mechanisms.
Stress and Mental Health: Contemporary Issues and Prospects for the Future - Google книги
In essence, it is not the magnitude of applied stressors driving many health problems, but the negative consequences of persistent exposure to toxic levels of elevated stress hormones Ganzel et al. Negative health behaviours are a key driver of poor health. These behaviours may be culturally embedded as deep rooted beliefs, attitudes and perceptions, but ultimately all factors conspire to add to the cumulative stress burden to which individuals within that culture are exposed Sheridan et al.
Within this paper we have employed the Scottish effect as a lens through which to contextualize the root cause of many 21st century health problems: accumulating and un-remediated multi-source life stress. However, this problem is certainly not exclusive to Scotland, and in fact is a pervasively growing first World problem. Nevertheless, the Scottish population, for the range of reasons highlighted here, does seem particularly vulnerable to the spectrum of modern stress-related health issues. Given that Scotland has a deep rooted culture of obesity and low PA levels, it is evident that these issues need to be addressed in order to become a more active and healthy population.
Furthermore, it seems warranted that the deep rooted cultural attitudes and beliefs, which contribute to shaping behavioural influences, be tackled within the context of health promotion initiatives. Future research directions could profitably investigate cultural aspects of machismo, such as poor attitude towards exercise and PA, and perceived increases in male stature that accompanies bouts of heavy drinking, and other risky behaviours.
Given that the cultural embodiment of these factors may be important when analyzing the paradoxical Scotland effect, future research should address the issue of why so many males continue to engage in pseudo-rituals of masculinity that are likely to be harmful to health O'Brien et al. The promotion of healthy behaviours, such as a rejection of binge drinking together with implementation of minimum alcohol pricing, has been a recent focus of the Scottish Government. However males, particularly those already drinking at higher risk levels, appear less likely to support this policy ScotCen Social Research, Despite the entwined social, cultural, geographical, genetic and personal history underpinning our vulnerabilities and resilience's to accumulating life stress, and despite the expansive range of commonly suggested stress-remediating strategies, PA offers perhaps the most flexible, cheapest, readily accessible and logistically feasible evidence-led means of countering the negative stress-related consequences of our otherwise privileged position as citizens of first World 21st century life.
The bi-directional relationship between PA and stress resilience further underscores the criticality of embedding early, life-long PA habits, especially in populations at heightened risk of stress-related health impediments. Physical Education philosophy and the appropriate training of Physical Educators may subsequently play a crucial role in fostering the positive culture change, associated with ensuring sustainable PA during the important transitional phases of adolescence.
National Center for Biotechnology Information , U. Journal List Prev Med Rep v. Prev Med Rep. Published online Aug 3. Author information Article notes Copyright and License information Disclaimer. Joe Cowley: ku. Abstract To date, multiple hypotheses have been proposed for the Scottish effect and, more specifically, Glasgow's high mortality rate and the associated Glasgow effect. Keywords: Scottish effect, Glasgow effect, Biopsychosocial stress, Physical activity.
Methodology The electronic databases: Medline, Embase, Cochrane reviews, Omnifile, ABI inform and Google scholar , were searched for UK and worldwide academic literature published between and , using the key search terms: Scotland effect; Glasgow effect; stress; health inequalities; Scottish and Glasgow health.
Scottish, Glasgow and East Glasgow effects: Nested health effects illustrating the consequences of accumulative multi-source stress In the late 's a UK-wide report highlighted that premature mortality in Scotland was more severe than in England or Wales Carstairs and Morris, , Walsh et al. The search for an explanation To date multiple hypotheses have been offered explaining the Scottish and Glasgow effects.
A recent report identified seventeen possible hypotheses —ranging from socio-economic; cultural; political; genetic and climatic factors— before concluding: There was clearly a large number of outstanding deductive hypotheses which could be investigated for their potential causal role in generating the mortality pattern in Scotland Glasgow in particular.
What is stress; what causes stress? Biopsychosocial stress and the Scottish effect: A storm of Scottish stressors It seems apparent that low socio-economic status is an inherent pre-disposing factor to stress, accounting for a large proportion of the stress burden imposed on individuals. Unrelenting biopsychosocial stress and social health Our suggestion that apparently separate influencing factors can be understood within a unifying explanatory rubric of cumulative multi-source life stress, unites these factors within a single conceptual model.
Simple solutions alleviating a complex problem?