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A young girl is snatched from her bike as she rides to her elementary school and is later found sexually assaulted and killed by a recently released convicted sex offender.
A distraught, angry, and isolated adolescent comes to his high school with an automatic rifle and randomly shoots classmates and teachers—until he is confronted by a police sniper and ends his life by shooting himself. A conservative and seemingly religious congressman is discovered to have attempted to solicit a teenage congressional page for sexual encounters and used an office computer for accessing child pornography Web sites. News stories like this indicate how frequently Americans are forced to confront severe psychopathology, mental illness, or disordered behavior.
Then, thanks to the culture of celebrity obsession, we are all familiar with the highly narcissistic style of Donald Trump, the accusations of pedophilia and body dysmorphic disorder associated with Michael Jackson, as well as the anorexia nervosa struggles apparently experienced by young female celebs such as Mary-Kate Olsen, Nicole Richie, and Lindsay Lohan. We hear about the alcohol and substance abuse problems of Mel Gibson, Charlie Sheen, Whitney Houston, and even Miss USA, Tara Conner. Sometimes it seems like a rehabilitation stay at the Betty Ford Clinic is a requirement or rite of passage for the rich and famous.
Yet psychopathology, mental illness, addictions, and disordered behavior are not only experienced by Hollywood celebrities and the rich and famous. Perhaps all of us have had periods of our lives where we felt highly anxious, depressed, or developed patterns of behavior that were fairly destructive to ourselves or to others.
What is going on? Are people more disturbed now than in the past? Is so much remarkable and crazy behavior a sign that people are getting crazier?
Do the numbersA few statistics offer some sense of the scope of mental disorders we confront today:
- About 1 million people will die by suicide every year. The worldwide mortality rate of suicide is 16 per l00,000—or one suicide every 40 seconds. Fifty-five percent of the suicides occur before age 44. It is the third leading cause of death for both sexes.
- In one recent calendar year, 1,247 women and 440 men were killed by their intimate partners in the United States.
- Between 3 percent and 5 percent of older adults over the age of 65 are or will be victims of abuse and/or neglect. That's 1 million each year.
- The prevalence of child and adolescent depressive disorders ranges from 2 percent to 9 percent.
- More than 18 million Americans suffer from some type of depression each year, and about 20 percent of the U.S. population will experience a significant depressive episode in their lifetime.
- The number of pathological gamblers varies between 1 percent and 2 percent in the United States.
- About 20 percent of all American women and 15 percent of all American men report having been sexually abused by an adult while they were still children.
- Regardless of religious tradition, about 4 percent of clergy and 5 percent of schoolteachers have had a sexual encounter with a child in their care.
- Best estimates suggest that 7.4 percent of all American adults suffer from a serious mental illness, with 20 percent of these individuals also experiencing an alcohol or substance-abuse problem.
Terrorism, murder, suicide, drunken driving, addictive gambling, pornography, and religiously inspired violence all provide plenty of evidence that behavioral and emotional problems that are ultimately destructive to self and others are often at the root of so many global, national, and local crises. All these troubles in the world prompt several basic and fundamental questions.
What is a "mental disorder"?
There are a variety of ways to define mental illness and disorders. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published and frequently updated by the American Psychiatric Association, lists hundreds of psychiatric disorders that include a checklist of symptoms for each diagnosis. The 943-page "psychiatric bible" defines what is and isn't a mental illness or disorder. It is not a perfect text, and it is often viewed as controversial. The list of disorders grows substantially with each updated version (the most recent published in 2000) as various committees of psychiatrists along with a small number of other mental health professionals discuss and vote on the diagnostic criteria for both new and old disorders. So, the manual is not really informed by empirically based science as much as it is a collaborative effort of many psychiatrists.
Insurance companies generally won't reimburse for mental health services unless a problem meets the diagnostic criteria outlined in the DSM, so it is important to try and include many types of emotional, behavioral, and psychiatric problems or concerns in order to justify treatment services. Changing contemporary values and perspectives also affect inclusion in new editions of the manual. For example, homosexuality used to be considered a mental disorder according to the DSM. Then, an updated version only considered "ego-dystonic" homosexuality as a disorder. Ego-dystonic homosexuality is defined as someone who is homosexual but unhappy and distressed about that sexual orientation. Now, homosexuality in and of itself is not considered a disorder at all.
Regardless of what the DSM says, a reasonable and appropriate way to define a mental disorder is a pattern of thought, emotion, or behavior that causes significant distress in someone or in others and interferes with a person's personal, social, or occupational functioning. Some disorders can be life threatening or very disabling. Schizophrenia, bipolar illness (historically called "manic depression"), anorexia nervosa, and major depression are good examples. Other disorders can be stressful but generally pretty manageable and rarely life threatening for most people-such as some simple phobias (e.g., snakes, spiders, public speaking) or trichotillomania (chronic hair pulling). Some emerge among young children, such as autism and attention deficit hyperactivity disorder (ADHD)—while others usually don’t appear until late in life, such as most dementias. Some disorders such as post-traumatic stress disorder (PTSD) appear primarily because of the experience of particular and highly stressful situations, such as warfare or physical and sexual victimization. Other disorders are more likely the result of genetic or biological etiologies, such as autism. Therefore, while there is a wide number and range of mental disorders, the common denominator in all of them is patterns of emotion, thought, or behavior that negatively affects quality of life and functioning.
We don't always know why people act as they do when they experience a mental disorder—whether it is because of genetic background; hormonal or other biological contributions; psychological reasons, such as low self-esteem; or environmental influences, such as bad child rearing or abusive home lives. Most problems and disorders in thoughts, feelings, and behavior are influenced by combinations of biological, psychological, and social factors. While some disorders (e.g., autism and schizophrenia) may be more likely to be driven by biological factors than others (e.g., PTSD, excessive gambling), most mental disorders include some combination of influences that not only cause these problems to develop but also sustain them. Therefore, what we call a "biopsychosocial model" is typically used to examine the causes and potential treatments of the vast majority of mental illnesses and disorders.
Is the world going to hell in a handbasket?
It sure feels that way sometimes. But as far as we can tell, people have experienced psychopathology, abnormal behavior, and mental disorders since the dawn of time. Murder, suicide, depression, psychotic thinking, addictions, sexual abuse, and so forth are not new phenomena at all. Even disorders that appear to be more contemporary such as anorexia nervosa can be found in writings dating back to the 1600s.
Yet some disorders are somewhat more common or appear new because of changes in culture and technology. For example, many people are now addicted to Internet pornography or Internet gambling. The technology obviously didn't exist earlier, but the ease of use and availability of these products and services have allowed these disorders to develop and thrive among some vulnerable people, especially those who otherwise would have been too embarrassed or uncomfortable to purchase pornography from a store clerk or attend a craps or poker game in a seedy part of town.
Other disorders that have been with us for years, such as autism and a related milder form called Asperger's syndrome, may appear more common today but may actually just be more commonly diagnosed than in previous decades. Eating disorders, such as anorexia and bulimia, may both be at least partially a by-product of cultural and social expectations about body shape and form among young females. ADHD may partially be a by-product of the demand for children to spend most of their day in a confined classroom environment, along with high expectations for homework and other confining activities both during and after school. Recent efforts by parents and schools to offer extended-day kindergartens may result in the unforeseen consequence of more ADHD diagnoses among these confined young children.
Feeding the media
In terms of context for mental disorders, what is especially new today is a 24/7 news cycle with media coverage seemingly everywhere. Stories of people performing horrific acts to themselves or others-suicide, murder, abuse-are often caught on video. John Hinckley's assassination attempt on former President Ronald Reagan in order to "impress" his love object, the actress Jodie Foster, was "caught on tape" and his delusions and apparent schizophrenic behavior received enormous media attention. Many popular television shows such as "Cops" and "America’s Most Wanted" highlight the chase and apprehension of those who suffer from significant mental health problems such as alcoholism and other substance abuse as well as personality, mood, and thought disorders of various sorts. Popular news shows such as "Dateline NBC" lure sex offenders to a home expecting a sexual encounter with a minor child, only to be exposed by a news crew, with police waiting to arrest them after their television interview.
Security cameras, which now seem to be located everywhere, show child abuse, abductions, and other crimes that are then shown hundreds of times on television and the Internet, adding to our perception of a society that’s out of whack. Some criminals such as suicide bombers and adolescents who shoot their high school classmates dictate message tapes to contact friends, enemies, and the general public alike. It has been reported that the timing of the Sept. 11, 2001, plane hijackings were specifically timed to maximize media coverage. Digital photos and videos of Abu Ghraib prison abuse, Michael Richards’ racist rage during a comedy show in Los Angeles, and the beating death of the Florida teenager while a nurse watched—all these were caught on tape and were shown repeatedly in a variety of media outlets. In fact, the two teens who were involved in the infamous Columbine High School shootings even had decided who should play them in a movie based on their killing spree.
The constant bombardment of media stories about the crazy behavior of others becomes entertainment in and of itself, as the craze of reality shows use mental disorders and psychopathology as fodder for television programming. Therefore, media clearly plays a role in our perception of the world going to hell in a handbasket, for the more bizarre and crazy the behavior, the more likely it will appear over and over again on the news and entertainment shows as well as the Internet (e.g., YouTube).
An additional and often unforeseen consequence of media attention to psychopathology and disordered behavior is that it often contributes to copycat crimes as vulnerable others imitate the behavior seen on television or the Internet. This seems particularly evident with school shootings that appear to occur frequently and in clusters. There is a social contagion of these behaviors that has been well documented in the professional literature. Furthermore, in our contemporary tendency to worship fame and media attention, many act badly in order to receive the attention they desire. Even negative or humiliating attention can be experienced as better than no attention at all. I often wonder what people who choose to participate in shows like “Dr. Phil” might be thinking when they voluntarily share intimate and often highly embarrassing personal and family troubles on national television. Sadly, after a terrible tragedy often associated with disordered behavior, a rite of passage appears to be an immediate interview on the “Today” show or similar programs for victims and relatives associated with the story. Even 12 years following the tragic deaths of Nicole Brown Simpson and Ron Goldman, O.J.'s television interview and book project titled If I Did It created a media storm.
How do we treat mental disorders?
Different diagnoses or disorders require different treatment approaches, such as biological, psychological, and social interventions. Schizophrenia may serve as a useful example. Research suggests that state-of–the-art antipsychotic medications can greatly help most people who suffer from the delusions, hallucinations, and other problematic symptoms of schizophrenia. Medication alone is rarely adequate as a treatment intervention. Psychological counseling, social and group support, job training and consultation, among other psychological and social interventions, can greatly enhance the overall treatment package to maximize the chances of a successful recovery or at least improved odds of coping with this serious and often highly stressful mental disorder.
The integrative biopsychosocial approach is generally more effective for many other mental and behavioral disorders as well. For example, I treat a patient, Lucy, who suffers from frightening panic attacks among several other emotional and behavioral problems. She is in her 60s and has never worked, has never left the state of California, or traveled on a train or plane. She and her family have a longstanding history of panic and other anxiety disorders. She likely has a biological basis for her disorder and perhaps a genetic predisposition for these symptoms. While she has used biological interventions such as anti-anxiety medications, she has also tried breathing and relaxation techniques as well as hypnosis and biofeedback to reduce her physiological reactivity. She has also eliminated caffeine from her diet. In addition to these biologically based interventions, psychological and social interventions are used successfully, too. Discussing her feelings and conflicts with family members helps to give her more tools to cope better with the problems in her life, and getting involved in her church and other spiritual and social activities has also been effective. The combination of biological, psychological, and social interventions has been very productive for her recovery, and her quality of life has improved tremendously.
What can be done to minimize, eliminate, cope with, or better prevent mental disorders from occurring? There is no simple answer to this question. There are a variety of reasons why abnormal behavior emerges, develops, and sometimes thrives. Some are as a result of biological or physiological factors such as genetics, hormonal and biochemical influences, and the exposure to both legal and illegal substances. Others stem from internal psychological conflicts associated with personality, mood, and stress mechanisms. Still others are because of the interactions of many social and interpersonal relationships with loved ones, work or school associates, neighbors, and the community. Finally, many come from cultural and social expectations and influences. There are many different roads that lead to abnormal and problematic behavior and disorders. But this does not mean that we can't do much more to improve the odds that abnormal behavior won't develop among ourselves and others. We clearly can make a better world for ourselves and for society if we can follow some key principles of prevention.
Several principles have emerged as being especially important in preventing abnormal behavior from either developing or getting worse. While we cannot do justice to each prevention strategy articulated, we can at least introduce these seven principles to the reader. This list is not meant to be exhaustive or inclusive. They are merely some very brief reflections and observations on prevention and coping principles.
Seven principles of prevention:
Abused and neglected children are more likely to develop certain troubles with depression, anxiety, violence, substance abuse, interpersonal difficulties, and a host of other problem behaviors. Once developed, these problems affect others around them and can be passed on from generation to generation. Efforts must be increased to minimize child abuse and neglect. Public policy experts, child protection professionals, family attorneys, politicians, mental health professionals, parents, school officials, and others must work closely to help ensure that those entrusted with the welfare of children provide the competent and effective care that they need.
Those who are poor are less likely to have access to professional mental and physical health care services and are much more likely to be affected by the stresses associated with unemployment, poor housing, and exposure to community violence. Efforts to reduce poverty will likely minimize the worsening of a variety of abnormal psychology problems.
Wars and street crime are sources of violence, but partner abuse, date rape, and other kinds of violence are all too common. Furthermore, research performed during the past decade at a variety of universities and highlighted in position and policy papers by the American Psychological Association and other professional groups has clearly indicated that exposure to violence through entertainment sources such as movies and video games increases the risk of both violence and other mental health-related problems among vulnerable viewers. We all must somehow work together in order to minimize such exposure in entertainment, media in general, and in both public communities and private homes.
Effective, quality intervention strategies, including pharmaceutical agents, have the potential to greatly reduce the impact of abnormal behavior, assuming they are available to all those in need. For example, medications such as Prozac and other selective serotonin reuptake inhibitors have revolutionized the treatment of depressive disorders during the past decade and a half. These medications, while not perfect or right for everyone with depression, have greatly improved the odds of effectively dealing with a number of psychiatric troubles including obsessive compulsive disorder, depression, bulimia, and more. Recent quality research using empirically supported psychological interventions has also demonstrated remarkable results for a wide variety of abnormal behavior problems.
No medication, however, can fully treat so many of the psychological and behavioral problems caused by abuse and neglect, unhappy marriages, traumas, and so forth. Also, in the United States in particular, medications can be extremely expensive. Efforts to make appropriate medications available to those who can truly benefit from them will likely help minimize the severity of abnormal behavior, not only for identified patients but for all those connected to them via family, work, or other relationships.
Cultural expectations about how we ought to live our lives, or what is acceptable and what is not, can be applied to abnormal behavior risk factors as well. Maintaining zero tolerance for child abuse, alcohol and other substance abuse, and for abject poverty may help to create a society in which abnormal behavior cannot flourish. Public policy can be used to help decrease the odds that abnormal behavior risks are tolerated or nurtured. It is too often a social taboo to request help from mental health professionals. Tragically, resistance and avoidance allow potential problems to become more serious.
Compelling contemporary examples of the importance of cultural expectations on behavior are acts of terrorism-suicide bombings in particular. Research and forensic assessment clearly indicate that the perpetrators often do not suffer from mental disorders. Psychological evaluations of captured terrorists, as well as others who have engaged in heinous crimes such as torture, have found a remarkable level of normal psychological and personality functioning. Cultural expectations often account for much of their behavior.
While Americans demand individual freedoms, exposure to particular risks increases the chance of mental disorders developing. For example, legalized gambling such as Indian gaming, lotteries, or Internet gambling is now allowed in just about all states. Bars and liquor stores are convenient in just about every city across the land. On-line gambling and pornography sites allow nearly everyone with access to a computer to potentially be exposed to these influences. These trends increase the odds that those who are susceptible to disorders like alcoholism, pornography addiction, or addictive gambling will succumb to them. Controlling the environment so temptations are not available as easily would go a long way toward minimizing the development of many problems.
Somehow we all must find a way to live together, sharing the planet and its limited resources. In order to have a humane and just world where mental disorders and behavioral problems are managed better and minimized, we need to maximize our social responsibility and concern for others. This is very much consistent with Jesuit education and ideals. A global effort to support ethical interactions among all may help us better live with social responsibility and concern: being “men and women for others.”
While mental disorders are likely to be with us forever, there is much that we can do as a society to minimize the possibility of their development in at-risk individuals and to help those who experience these troubles. Working together, mental health professionals, public policy leaders, pharmaceutical companies, and experts in many other fields can help a great deal. Can our culture and society make the commitment to do this? Let us hope so.
Photo: Charles Barry
—Professor Thomas G. Plante is chair of the Department of Psychology at SCU.
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They're people first
Students learn about mental disorders at a homeless shelter.