MENTAL DISORDERS (see also diseases of the central nervous system)

Table of contents :

  • developmental disorders
  • delirium, dementia, and amnestic disorders
  • substance-related disorders
  • psychoses
  • neuroses
  • factitious disorders
  • sleep disorders
  • impulse control disorders
  • adjustement disorders
  • personality disorders

  • Epidemiology : a national survey of US citizens has found that 6% of them have a debilitating mental illness. More startling, almost 50% of those surveyed were found to have had a mental disorder at some point during their lives; > 25% had had 1 in the year before the interview. Treatment is hard to get, and often not sufficient when available. Only about 33% of those in care receive "minimally adequate treatment", such as the appropriate drugs or a few hours of therapy over a period of several monthsref1, ref2, ref3, ref4. The statistics are nearly impossible to compare with previous studies, thanks to constantly changing definitions of mental illness, but in general things don't seem to have changed much over the past decade. > 9,000 US adults, chosen randomly, were visited in their homes as part of the National Comorbidity Survey, which looks at the incidence of multiple mental disorders. An interview then probed to see whether they had mental difficulties as determined by the latest Diagnostic and Statistical Manual of Mental Disorders. The study also classified the severity of disorders, separating them into severe, moderate or mild conditions. The definition of disorders used by the study was quite broad. A few instances of road rage, for example, might qualify as an intermittent explosive disorder. Such a wide net may not be any use in determining who needs medication or treatment, but the survey does provide some useful information. It reveals, for example, that 50% of those with a mental disorder encountered problems before their 14th birthday. This indicates that watching for signs of mental distress in early years could help to avert larger problems in the future. Progress will be made in finding biological markers that can help distinguish children who are simply shy or have a quick temper from those whose difficulties are likely to degenerate into illness, perhaps through an analysis of genes or brain scans. Meanwhile, the first order of business is to improve the quality of treatment. The prevalence of mental disorders did not change during the decade (29.4% between 1990 and 1992 and 30.5% between 2001 and 2003), but the rate of treatment increased. Among patients with a disorder, 20.3% received treatment between 1990 and 1992 and 32.9% received treatment between 2001 and 2003. Overall, 12.2% of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1% between 2001 and 2003. Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0% between 1990 and 1992 and 49.9% between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents. Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatmentsref.
    Web resources : Do I Need Therapy online test

  • psyche : the human faculty for thought, judgment, and emotion; the mental life, including both conscious and unconscious processes; the mind in its totality, as distinguished from the body.
  • situation : the combination of factors with which an individual is confronted. In psychology, the total sum of physical, psychological, and sociocultural factors that act on a person and influence his behavior
  • ego-syntonic : denoting aspects of a person's thoughts, impulses, attitudes, and behavior that are felt to be acceptable and consistent with the rest of their personality.
  • ego-dystonic : denoting aspects of a person's thoughts, impulses, attitudes, and behavior that are felt to be repugnant, distressing, unacceptable, or inconsistent with the rest of their personality.
  • psychiatry : that branch of medicine which deals with the study, treatment, and prevention of mental disorders.
  • psychobiology / biopsychology : a field of study examining the relationship between brain and mind, studying the effect of biological influences, including biochemical, neurological, and pharmacological factors, on psychological functioning or mental processes. Adolf Meyer's school of psychiatric thought, in which the human being is viewed as an integrated unit, incorporating psychological, social, and biological functions, with behavior a function of the total organism.
  • mental disorder : any clinically significant behavioral or psychological syndrome characterized by the presence of distressing symptoms, impairment of functioning, or significantly increased risk of suffering death, pain, disability, or loss of freedom. Mental disorders are assumed to be the manifestation of a behavioral, psychological, or biological dysfunction in the individual. The concept does not include deviant behavior, disturbances that are essentially conflicts between the individual and society, or expected and culturally sanctioned responses to particular events
  • disorders usually diagnosed for the first time in infancy, childhood, or adolescence / developmental disorders : a former classification of chronic disorders of mental development with onset in childhood; such disorders are now classified as ...
  • delirium, dementia, amnestic disorders, and other cognitive disorders
  • mental disorders due to general medical condition-not otherwise classified
  • toxicomanias / drug abuse / chemical substance dependence : a state of periodic or chronic intoxication, detrimental to the individual and to society, produced by the repeated administration of a drug.
  • Drugs of abuse can be classified according to ... Multiple simultaneous variables affecting onset and continuation of drug abuse and addiction
    drug of abuse
    acquired (nonspontaneous) tolerance / assuefaction
    reverse tolerance / sensitization
    dependence (depending on drug of abuse, consumer, and social environment)
    toxic psychoses from dose-dependent
    acute tolerance
    chronic tolerance
    physical dependence : continued administration of the drug is required to maintain normal function => temporarywithdrawal syndrome when administration is terminated (symptoms tend to be opposite to the original effects produced by the drug before tolerance developed)  => DA in the "shell" of nucleus accumbens => positive reinforcing effect (e.g. conditioned place preference) => psychological dependence : psychic abstinence syndrome
  • crash (hours/days : craving, compulsion, depression, anxiety)
  • withdrawal (weeks: dysphoric syndrome, apathy,..) 
  • extintion (months/years)
  • social substance dependence
    amphetamines (neurotoxicity : autooxidation of DA to 6-hydroxyDA or hyperactivity of Glu-ergic circuits => DA-ergic neurons)
    + (hypermotility, stereotypia, psychoses)
  • paranoideal psychosis 
  • chorea-like syndrome 
  • dysautonomic syndrome (anxiety, collapse, seizures) 
  • LSD
    may involve conditioning after long-term exposure, has been linked to paranoid, psychotic manifestations
     dysphoria, depression, sleepiness, fatigue, bradycardia
    cannabinoids seen clinically only in persons who use marijuana on a daily basis and then suddenly stop
    nicotine irritability, impatience, hostility, anxiety, dysphoric or depressed mood, difficulty concentrating, restlessness, bradycardia, hyperphagy or weight gain
    with 10 puffs per cigarette, the one-pack-per-day smoker reinforces the habit 200 times daily
    although > 80% of smokers express a desire to quit, only 35% try to stop each year, and < 5% are successful in unaided attempts to quit
    caffeine / teine fatigue, sedation, headache, nausea and vomiting
    PCP somnolence, tremor, seizures, diarrhea, piloerection, bruxism, and vocalizations schizophrenia
    opioids regular withdrawal : mydriasis, restlessness, irritability, hyperalgesia, sweating, piloerection, tachycardia, nausea and vomiting, gastritis, colic, diarrhea, myalgia, systemic arterial hypertension, dysphoria, yawning, insomnia, anxiety, fever, strabismus, rhinorrhoea, crying, cough ; 
    protracted withdrawal (up to 6 months): anxiety, insomnia, cyclic changes in weight, pupil size, respiratory center sensitivity
    chloral hydrate
    moderate doses : anxiety, paresthesias (photophobia, increased sensitivity to sound), muscle cramps, myloclonic jerks, sleep disturbance, dizziness; high-doses
    seizures, delirium
    tremor, irritability, nausea and vomiting, sleep disturbance, tachycardia, systemic arterial hypertension, sweating, perceptual distortion, seizures (12-48 hrs after last drink); in conjunction with infection, trauma, malnutrition, or electrolyte imbalance => delirium tremens
  •  substance-related disorders : any of the mental disorders associated with excessive use of or exposure to psychoactive substances, including drugs of abuse, medications, and toxins. DSM-IV includes specific disorders for the classes
  • The group is divided into substance use disorders and substance-induced disorders, each of which is specified on the basis of etiology, e.g., alcohol use disorders. Differential diagnosis : Laboratory examinations : Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS)
    Web resources :
  • psychotic disorders / psychoses : a mental disorder characterized by gross impairment in reality testing as evidenced by delusions, hallucinations, markedly incoherent speech, or disorganized and agitated behavior, usually without apparent awareness on the part of the patient of the incomprehensibility of his behavior (anosognosia); called psychotic disorder in DSM-IV. The term is also used in a more general sense to refer to mental disorders in which mental functioning is sufficiently impaired as to interfere grossly with the patient's capacity to meet the ordinary demands of life. Historically, the term has been applied to many conditions, e.g., manic-depressive psychosis, that were first described in psychotic patients, although many patients with the disorder are not judged psychotic.
  • Pathogenesis : increased activity of mesolimbic tract => alterations in perceptions of time, place, sounds and colors. Symptoms : Therapy :
  • neuroses :  former name for a category of mental disorders characterized by anxiety and avoidance behavior. In general, the term refers to disorders in which the symptoms are distressing to the person (ego-dystonic), reality testing is intact (conscious disorder), behavior does not violate gross social norms, and there is no apparent organic etiology (no fever, no anatomical injuries). Classified in DSM-IV under anxiety disorders, dissociative disorders, mood disorders, sexual disorders, and somatoform disorders.
  • malingering : the willful, deliberate, and fraudulent feigning or exaggeration of the symptoms of illness or injury, done for the purpose of a consciously desired end.
  • factitious disorder : a mental disorder characterized by repeated, intentional simulation of physical or psychological signs and symptoms of illness for no apparent purpose other than obtaining treatment. It differs from malingering in that there is no recognizable motive for feigning illness. It is subtyped on the basis of whether the predominant signs and symptoms are
  • Differential diagnosis :
  • eating disorders : any of several disorders in which abnormal feeding habits are associated with psychological factors. Often the consequences of eating disorders worsen them (e.g. mucositis)

  • Epidemiology : mostly females aged 12-25 years Laboratory examinations : sleep disorders : chronic disorders involving sleep During sleep, noise signals which are associated with danger (i.e. lorry noise) have the potential to trigger stress reactions even if the noise level is low and increases of cortisol in the first half of the night, which increases significantly with increasing traffic load, increases relative risks of asthma, chronic bronchitis and neurodermitisref
    Adolescents and young adults are often excessively sleepy. This excessive sleepiness can have a profound negative effect on school performance, cognitive function, and mood and has been associated with other serious consequences such as increased incidence of automobile crashesref. Sleep research data indicate that adolescents and even young adults under 21 still require 9-10 hours' sleep a night. But since the 1980s, the average sack time for both college and high school students has diminished to 6-7 hours nightly. Youngsters who are aged 9-10 years tend to sleep, on average, for about 10 hours on school nights and usually not more (and many times a lot less!) on weekends. But teenagers typically begin to enjoy sleeping in on the weekends. This trend increases during the high school years. As teens also develop a yen for late-night activities, their sleep debt increases daily. Developmental changes in circadian rhythms, endocrine and neurobehavioral systems, not to mention busier schedules, earlier start times for school, and parental supervision, also contribute to the problem of a teenager's getting less sleep. Regardless of the causes, however, this scenario often proves far more serious than a mere yawn or a brief encounter in slumber land. Current high school start times contribute to sleep deprivation among adolescents. Consistent with a delay in circadian sleep phase, students performed better later in the day than in the early morning. However, exposure to bright light in the morning did not change the sleep/wake cycle or improve daytime performance during weekdays. Both short-term and long-term strategies that address the epidemic of sleep deprivation among adolescents will be necessary to improve health and maximize school performanceref.
    In USA the percentage of people who typically sleep < 6 hours was : 12% in 1998; 13% in 2001; 15% in 2002; 16% in 2005. People who sleep > 10 hours per night have an average BMI = 26.4 kg/mBSA2, while people sleeping 2-4 hours per night have a BMI = 30.1 kg/mBSA2ref
    Therapy : chronotherapy : treatment of certain sleep disorders by capitalizing on the natural phase delay in adults; the bedtime is successively advanced by one to several hours each day until the individual can retire, sleep, and arise at appropriate times.
  • impulse control disorders : a group of mental disorders characterized by repeated failure to resist an impulse to perform some act harmful to oneself or to others. The person feels tension or an irresistible urge to perform the act which, even though ego-dystonic, gives pleasure or emotional release upon performance.
  • adjustment disorder : a maladaptive reaction to identifiable stressful life events, such as divorce, loss of job, physical illness, or natural disaster; this diagnosis assumes that the condition will remit when the stress ceases or when the patient adapts to the situation
  • Differential diagnosis :
  • personality disorders : a category of mental disorders characterized by enduring, inflexible, and maladaptive personality traits that deviate markedly from cultural expectations, are self-perpetuating, pervade a broad range of situations, and either generate subjective distress or result in significant impairments in social, occupational, or other functioning. Onset is by adolescence or early adulthood.
  • other factors that influence a medical condition
  • additive codes
  • reaction : the mental and/or emotional state elicited in response to any particular situation.
  • nyctophilia : a preference for darkness or for night.
  • Erickson's 8 psychosexual stages of man
  • complex : a group of interrelated ideas, mainly unconscious, that have a common emotional tone and strongly influence a person's attitudes and behavior
  • conflict : in psychiatry, a psychic struggle, often unconscious, arising from the clash of incompatible or opposing impulses, wishes, drives, or external demands.
  • euphoria : an exaggerated feeling of physical and mental well-being, especially when not justified by external reality. Euphoria may be induced by drugs such as opioids, amphetamines, and alcohol and is also a feature of mania
  • homicide : the taking of the life of one person by another
  • suicide : the taking of one's own life. Only a small minority has a rational base.
  • Epidemiology :
    failed suicide
    age mature/advanced < 35
    female-to-male ratio 3:1 1:3
    suicide way violent drugs (> 80%)
    diagnosis major depression 
    somatic disease
    psychogenous reaction
    personality disorder 
    depressive reaction
    psychogenous reaction 
    stressors no yes
    premeditation yes no
    aid possibility accidental yes
    aid request no  yes
    aim self-repression manipulatory
    Suicide rates for the elderly > 65 years continue to be the highest for any age group Aetiology : Most frequently used method for committing suicide : Prevention :
  • oedipism [from Oedipus, King of Thebes, who blinded himself after unknowingly killing his father and marrying his mother] : intentional injury of one's own eyes
  • borderline state :a diagnostic term used when it is difficult to determine which of two states are indicated by the presenting symptoms, generally for a state that has some characteristics of psychosis but in which the patient has some contact with reality.
  • Epstein's symptom : a symptom seen in nervous infants, consisting of failure of the upper lid to move downward, giving the child a frightened expression
  • chronotaraxis : disorientation for time; observed as a transient symptom following thalamic or frontal lobe lesions.
  • formal thought disorder : disturbance in the form, rather than the content, of thought; disruption in the flow of ideas or speech; inability to follow the normal semantic or syntactic rules in someone with adequate intelligence and education and the cultural background to do so.
  • asceticism : a way of life or character trait described by the elimination of pleasurable effects associated with experiences and characterized by renunciation, self-denial, withdrawal from society, and sometimes dedication to an unattainable ideal or to eradication of some specific evil.
  • psychataxia : a disordered mental condition marked by confusion and inability to concentrate
  • psycholepsy : a sudden, intense lowering of mood level, usually of short duration, in individuals with unstable psychic tension
  • hallucination : abnormal sensation
  • illusion : a false or misinterpreted sensory impression; a false interpretation of a real sensory image
  • delusion : a false belief that is firmly maintained in spite of incontrovertible and obvious proof or evidence to the contrary and in spite of the fact that other members of the culture do not share the belief.
  • misidentification : failure to identify correctly persons or objects known to the subject, caused by confusion or memory loss.
  • culture-specific syndrome : a form of disturbed behavior highly specific to certain cultural systems and that does not conform to Western nosologic entities; examples are amok, koro, piblokto, falling-out, and windigo.
  • windigo / witigo [Ojibwa a cannibalistic monster of the mythology of Eskimos and certain Native Americans] : a culture-specific syndrome characterized by delusions of being possessed by the windigo, with fears of becoming cannibalistic and agitated depression
  • Kleine-Levin syndrome : episodic periods of excessive sleep and overeating lasting for several weeks, with amnesia for the attacks; it usually occurs in adolescent boys.
  • maternal deprivation syndrome : failure to thrive with severe growth retardation, unresponsiveness to the environment, depression, retarded mental and emotional development, and behavioral problems resulting from loss, absence, or neglect of the mother or other primary caregiver.
  • organic personality syndrome : a term used in a former system of classification, denoting an organic mental syndrome characterized by a marked change in behavior or personality, caused by a specific organic factor and not associated with delirium or dementia. The most common causes are space-occupying lesions of the brain, head trauma, and cerebrovascular disease.
  • social breakdown syndrome : deterioration of social and interpersonal skills, work habits, and behavior seen in chronically hospitalized psychiatric patients; due to the effects of long-term institutionalization rather than the primary illness. Symptoms include excessive passivity, assumption of the chronic sick role, withdrawal, and apathy. Such effects are also seen in long-term inmates of prisons or concentration camps.
  • acathexis : a lack of the emotional charge (cathexis) with which an object or idea would normally be invested; detachment of feelings from thoughts and ideas.
  • taboo [Tongan tabu forbidden, set apart] : any of the negative traditions, objects, or behaviors that are generally regarded as harmful to social welfare and are therefore prohibited
  • mores : the traditions and habits which are generally regarded as conducive to social welfare.
  • psychic determinism : the concept, originated by Freud, that mental events do not occur by chance but have their antecedent mental causes, that even accidents, slips of the tongue, or whims commonly felt to be inexplicable result from unconscious mental processes.
  • stigma : a distinguishing personal trait that is perceived as or actually is physically, socially, or psychologically disadvantageous
  • psychic overtone : the consciousness of a fringe or halo of associated relations that surrounds every image presented to the mind
  • organic drivenness : hyperactivity seen in brain-damaged individuals as a result of injury to and disorganization of cerebellar structures.



    Laboratory examinations :

    Therapy : psychotherapy
    Glossary : In UK 23% of current and recent mental health patients had been in mixed-sex accommodation, despite Government reassurances in 2002 that such wards would be eliminated : those patients in mixed-sex wards had greater concerns about their safety and said it compromised their privacy and dignity. 27% rarely felt safe while in hospital, and only 20% felt they were treated with respect and dignity by staff. 23% had been physically or verbally threatened during their stay in hospital, with 20% reporting a physical assault. And 7% of patients had been harassed or assaulted by staff. > 50% of patients said the hospital surroundings had not helped them recover, and 33% thought they had made their health worse.

    Among elderly people hospitalization of a spouse is associated with an increased risk of death, and the effect of the illness of a spouse varies among diagnoses. Such interpersonal health effects have clinical and policy implications for the care of patients and their families. Overall, 383,480 husbands (74%) and 347,269 wives (67%) were hospitalized at least once, and 252,557 husbands (49%) and 156,004 wives (30%) died. Mortality after the hospitalization of a spouse varied according to the spouse's diagnosis. Among men, 6.4% died within 1 year after a spouse's hospitalization for colon cancer, 6.9% after a spouse's hospitalization for stroke, 7.5% after a spouse's hospitalization for psychiatric disease, and 8.6% after a spouse's hospitalization for dementia. Among women, 3.0% died within 1 year after a spouse's hospitalization for colon cancer, 3.7% after a spouse's hospitalization for stroke, 5.7% after a spouse's hospitalization for psychiatric disease, and 5.0% after a spouse's hospitalization for dementia. After adjustment for measured covariates, the risk of death for men was not significantly higher after a spouse's hospitalization for colon cancer (hazard ratio, 1.02; 95% confidence interval, 0.95 to 1.09) but was higher after hospitalization for stroke (hazard ratio, 1.06; 95% confidence interval, 1.03 to 1.09), congestive heart failure (hazard ratio, 1.12; 95% confidence interval, 1.07 to 1.16), hip fracture (hazard ratio, 1.15; 95% confidence interval, 1.11 to 1.18), psychiatric disease (hazard ratio, 1.19; 95% confidence interval, 1.12 to 1.26), or dementia (hazard ratio, 1.22; 95% confidence interval, 1.12 to 1.32). For women, the various risks of death after a spouse's hospitalization were similar. Overall, for men, the risk of death associated with a spouse's hospitalization was 22% of that associated with a spouse's death (95% confidence interval, 17 to 27%); for women, the risk was 16% of that associated with death (95% confidence interval, 8 to 24%)ref.
    According to the National Crime Victimization Survey for 1993 to 1999, conducted by the Department of Justice, the annual rate of nonfatal, job-related, violent crime was 12.6 per 1000 workers in all occupations. Among physicians, the rate was 16.2 per 1000, and among nurses, 21.9 per 1000. But for psychiatrists and mental health professionals, the rate was 68.2 per 1000, and for mental health custodial workers, 69.0 per 1000. For Tim Exworthy, a forensic psychiatrist at Redford Lodge Hospital in London who was recently assaulted by a patient, the risk of job-related violence is no longer a dry statistic. He was beaten unconscious by a 19-year-old psychotic man whom he had been treating in the hospital for 5 months. I was talking with him in a room and telling him why he couldn't leave, when I was suddenly aware of a few blows to my head. The next thing I knew, I was at the nursing station wiping the blood off my face. I never saw this coming and hadn't anticipated that he would react like that. Such attacks by psychotic patients highlight a larger question: Are people with mental illness really more likely than others to engage in violent behavior? If so, which psychiatric illnesses are associated with violence, and what is the magnitude of the increase in risk? Posing these questions is itself not without risk: being perceived as dangerous can have a devastating effect on a person's prospects for relationships, employment, housing, and social functioning. People with mental illness already bear the burden of much social stigma, and I am loath to add to it. But without a realistic understanding of this risk, medical practitioners can neither provide the best care for their patients nor ensure their own safety when the clinical situation warrants it. Until recently, most studies have focused on the rates of violence among inpatients with mental illness or, conversely, the rates of mental illness among people who have been arrested, convicted, or incarcerated for violent crimesref. For example, one national survey showed that the lifetime risk of schizophrenia was 5% among people convicted of homicide — a prevalence that is much higher than any published rate of schizophrenia in the general population — suggesting an association between schizophrenia and homicide convictionref.2 These studies, however, tend to be limited by selection bias: subjects who are arrested, incarcerated, or hospitalized are by definition more likely to be violent or very ill and thus are not representative of psychiatric patients in the general population. A more accurate and less biased assessment of the risk of violence perpetrated by the mentally ill comes from epidemiologic studies of community samples. The best known is the NIMH's Epidemiologic Catchment Area (ECA) study, which examined the rates of various psychiatric disorders in a representative sample of 17,803 subjects in five U.S. communities. Although this study was not initially designed to assess the prevalence of violent behavior, data on violence were collected for about 7000 of the subjects. "Violence" was defined as having used a weapon such as a knife or gun in a fight and having become involved, with a person other than a partner or spouse, in more than one fight that came to blows — behavior that is likely to frighten most people.

    Lifetime Prevalence of Violent Behavior among Persons with or without Major Psychiatric Disorders and Substance Abuse.
    The criteria for violent behavior were use of a weapon in a fight and engaging, with someone other than one's partner or spouse, in a fight that came to blows. Persons were considered to have a relevant psychiatric disorder if they met the lifetime criteria delineated in the Diagnostic and Statistical Manual of Mental Disorders (third edition) for schizophrenia, bipolar disorder, or major depression and had had active symptoms of that disorder within the previous 12 months (Swanson JW. Mental disorder, substance abuse, and community violence: an epidemiological approach. In: Monahan J, Steadman HJ, eds. Violence and mental disorder: developments in risk assessment. Chicago: University of Chicago Press, 1994:101-36)
    The study showed that patients with serious mental illness — those with schizophrenia, major depression, or bipolar disorder — were two to three times as likely as people without such an illness to be assaultive. In absolute terms, the lifetime prevalence of violence among people with serious mental illness was 16%, as compared with 7% among people without mental illness. Although not all types of psychiatric illness are associated with violence — anxiety disorders, for example, do not seem to increase the risk — and although most people with schizophrenia, major depression, or bipolar disorder do not commit assaultive acts, the presence of such a disorder is significantly associated with an increased risk of violence. Of course, because serious mental illness is quite rare, it actually contributes very little to the overall rate of violence in the general population; the attributable risk has been estimated to be 3 to 5% — much lower than that associated with substance abuse, for example. (People with no mental disorder who abuse alcohol or drugs are nearly seven times as likely as those without substance abuse to report violent behavior.) But substance abuse among the mentally ill compounds the increased risk of violence: one study involving 802 adults with a psychotic or major mood disorder showed that violence was independently correlated with several risk factors, including substance abuse, a history of having been a victim of violence, homelessness, and poor medical healthref. The 1-year rate of violent behavior for subjects with none or only one of these risk factors was 2% — a prevalence close to the ECA study's estimate for the general population. Thus, violence in people with serious mental illness probably results from multiple risk factors in several domains. Much can be done to diminish the risk of violence among the mentally ill. A study that compared the prevalence of violence in a group of psychiatric patients during the year after hospital discharge with the rate in the community in which the patients lived showed no difference in the risk of violence between treated patients and people without a psychiatric disorderref. Thus, symptoms of psychiatric illness, rather than the diagnosis itself, appear to confer the risk of violent behavior. So patients with schizophrenia who are free of the acute psychotic symptoms that increase this risk, such as having paranoid thoughts or hearing voices that command them to hurt others (called command auditory hallucinations), may be no more likely to be violent than people without a mental disorder. The study did not specifically monitor the treatments, but it seems possible that treating psychiatric illness does not just make patients feel better; it may also drastically reduce the risk of violent behavior. In the wake of Fenton's killing, there may be renewed efforts to expand the criteria or lower the clinical threshold for mandatory treatment of patients with psychosis — a movement that is sure to be controversial. We know that most such patients are not violent, but we also know that a patient with acute psychosis who is paranoid and has command auditory hallucinations or a history of being violent, being a victim of violence, or abusing alcohol or drugs is at high risk for violent behavior. Currently, in order to protect civil liberties, most states mandate treatment (whether hospitalization or medication) only if there is unambiguous evidence of an immediate danger to others, which is generally interpreted as overt threats or violent actions. Perhaps it makes sense to reset the threshold at the presence of known clinical risk factors — psychotic thoughts that are influencing behavior, a history of violence, and significant concurrent substance abuse. But expanding the criteria would require further substantiation that these factors can be accurately identified by clinicians and that their use in mandating treatment is warranted. The possibility that expanding the criteria might also discourage people with psychotic illnesses and substance abuse problems from voluntarily seeking treatment would also need to be considered. It is natural for psychiatrists and other medical professionals who treat psychiatric patients to deny, to some extent, the possible danger. After all, it is hard to have a therapeutic relationship with a patient we fear. Still, we need to remind ourselves that the risk of violence, though small, is real, and we must take necessary precautions. As Exworthy put it, "I guess I let down my guard and paid for it." Keeping up our guard means paying attention to our fear and anxiety about a patient; no physician should ever treat a patient whom he or she fears. It also means seeing patients with acute psychosis in locations where there is adequate assistance and security, such as hospitals and clinics, rather than in a private office setting. The challenge for medical practitioners is to remain aware that some of their psychiatric patients do in fact pose a small risk of violence, while not losing sight of the larger perspective — that most people who are violent are not mentally ill, and most people who are mentally ill are not violent.

    Web resources :

    Bibliography :
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