• DSM4r--symptoms (which are what); Degrees/shades of gray not like other diseases: Psychosis---Neurosis
• Intervention==>troublesomeness (schizophrenia)
• Hard: Biophysical
• Soft: disease metaphor-variety of causes
• Although some helped, not all. Often treatment is maintenance

• Behavior violates social norms
• No specific category to fit
• Leads to label (act weird==> crazy)
• Many sources/causes
• Most normalized, denied, transitory
• Many violate, few labeled
• Some persist==> Career
• Learn norms and stereotypes--childhood, constantly reinforced in EDL (D. Phillips and help seeking behavior
• When labeled; Rewards and Punishments for conforming to label or not
• Suggestibility: may not fight label, convenience, relieves anxiety, safety (looking-glass-self)
• Career: Goffman: Diverse individuals processed through institutional structures end up as uniform in social status and self-concept.

• Yes, there is a problem, but labeling and stigma are a part of it.
• Anticipation of negativity can lead to behavior
• More distant the relationship--more likely the label: Intimacy- H/W and resistance
• Access to other resources
  • Etiology and/or Social Reaction
    • Good reason for objective definitions, and treatments often work
    • Yet, this doesn't negate the extra-psychiatric factors
    • Troublesomeness
    • Voluntary and involuntary admission and discharge

• EPIDEMIOLOGY - the study of the distribution of diseases in the population.
• The field of psychiatric epidemiology is based on the idea that there is, or can be, a "true" rate or prevalence of mental disorder, just as there is a "true" rate of cancer or AIDS.
• Essentialist assumption - mental disorder is a concrete entity on whose reality all reasonable and informed observers can agree.
• Constructionist - mental disorder is a socially determined judgment,  the "true" rate or prevalence of mental illness can not be determined. They are interested in how mental disorder is conceptualized and defined, how certain categories in the population come to be designated as having higher, or lower, rates of mental disorder and what extra psychiatric factors influence rates of institutionalization.

"All epidemiologists agree that measuring mental disorder in the population, or in certain segments of the population is problematic. There is a huge non-institutionalized segment of the population who would be diagnosed as mentally disordered were they to be evaluated by a psychiatrist."

GENDER: Women v Men

• Women have somewhat higher rates of mental disorder than men.
• One nationally representative study of households across the United States conducted jointly by the National Institutes of Health and the National Center for Health Statistics identified 1.94 million females and 1.32 million males as having serious mental illness; rates of mental disorder were 20.6 for females and 15.5 for males.
• The Epidemiological Catchment Area Project study, which focused on five urban centers, found rates of mental disorder of 16.6 for females and 14.0 for males
• A later study using the same research instrument, based on a more nationally representative sample in 1994 reached the same conclusion.

Males are significantly more likely to be admitted to mental hospitals than females, and the ratio of males to females is increasing over time.

• In 1900, there were 110 males admitted to state mental hospitals for every 100 females; by 1975, this had risen to 183, and it remained between 172 and 186 between the late 1970s and the 1990s. In 1990, there were 146.6 male admissions per 100,000 males in the population and 80.3 female admissions per 100,000 females in the population.

Experts believe that this disparity is due to the conjunction of the specific type of mental disorder males are more likely to suffer from (an essentialistic phenomenon) and professional stereotyping (a constructionist phenomenon).

• Men are strikingly more likely to fall victim to antisocial personality disorders. Antisocial personality is highly likely to cause havoc in the lives of others- for instance, in the form of aggressiveness and violence. Thus, someone who causes disruptive social and interpersonal trouble is more likely to be institutionalized.
• Women are far more likely to suffer from a mood disorder, especially depression. Depressive mood disorders are more likely to result in withdrawal and isolation. Thus, women are less likely to be institutionalized.
• The mental disorder of men, holding severity of disorder constant, is regarded as more disabling, threatening, and dangerous to the society than is that of women. Women are regarded as more cooperative and compliant and more readily influenced by the hospital staff and, therefore, are more likely to be released.

There is a  "double standard" among clinicians in the diagnosis, hospitalization, and release of mental patients with respect to gender.  

• Psychiatrists and clinical psychologists seem to have a lower standard of mental health for women than for men. They are more likely to diagnose mental disorder for men. A woman's condition would have to be more severe to warrant hospitalization, and a man's less severe to warrant release.
• In a sexist or patriarchal society, males are expected to perform in a society to more exacting standards. Being a man in a very achievement-oriented society is incompatible with being mentally disordered; the penalties for stepping out of line are swift and strong.
• Where women are relegated to an inferior and dependent role, their performance in that role is met with more indulgence and leeway. A mildly psychiatrically impaired woman can perform in an imperfect fashion and still "get by".
• These sexist values result in a higher rate of mental illness labeling for men, supposedly the more powerful social category, and less for women, who are generally powerless.

MARTIAL STATUS

• Single, never married men are strikingly more likely to score high on every available measure of mental disorder than are married men; separated and divorced men rank somewhere in-between.

WHY?

• Men who are married and stay married are more stable, psychologically healthy, and conventional than men who never marry and therefore, they are less mentally disordered. The kind of man who marries is also the kind of man who exhibits relatively few personality problems, while the man who does not marry is far more likely to exhibit those same problems. Men with severe mental problems are not considered desirable partners and thus, will be socially avoided by women.
• Being married is conducive to a man's mental health, security, and well being. "Marriage does not prevent economic and social problems from invading life, but apparently can help fend off the psychological assaults that such problems otherwise create"

The special protection that supposedly extends to men seems to offer no special protection for women. Women suffer as a result of being married, because marriage is more demanding on women.  

• A man who is mentally ill is seen by all women as an undesirable partner, while a woman who displays certain mental disorders may still be considered marriageable. The evidence seems to favor few differences in the impact of marriage between men and women should strike the observer forcefully.

• SES is the most frequently studied: indicators measuring socioeconomic status are income, occupational prestige, and education.
• Mental disorder is very closely related to socioeconomic status: the higher the SES, the lower the rate of mental disorder; the lower the SES, the higher the rate of mental disorder.
• People at the bottom of the class ladder are far more likely to suffer from psychiatric distress, especially schizophrenia, than those at the top.
• There are a few mental disorders that are more common toward the top of the class structure, such as obsessive-compulsive neuroses and some mood disorders, but the most serious illnesses, especially schizophrenia, are most common toward the bottom of the class structure.

WHY?

• The kinds of disorder exhibited by lower-status persons are more likely to come to the attention of the authorities than the kinds of disorders exhibited by middle and upper status persons.
• Lower-status persons are less likely to attribute their problems to a psychiatric condition, since they are more likely to feel that some stigma adheres to consultation with a "shrink" or being committed to a mental hospital. Hence, they are less likely to seek out psychiatric assistance voluntarily.
• Lower-status persons are most likely to come to the attention of psychiatric authorities as a result of referral by the police or a social worker.

This explanation does not say that lower-SES persons are more mentally disordered than middle and upper SES persons overall so much as it focuses on how certain conditions, differentially distributed by social class, intersect with the social structure.

Constructionist Explanation

• This strong inverse relationship between SES and mental disorder may be due to class bias and the labeling process.
• Middle-class psychiatrists find lower-class behavior troublesome and are more likely to label it disordered than the behavior of middle-class persons.
• Mental health is judged by a middle-class yardstick.

Much of the behavior of the psychiatrically disordered is deemed undesirable by members of all social classes.

Stress

• Economic deprivation, poverty, occupational instability and unemployment are strongly related to psychological impairment.

• Social class is a consequence rather than a cause of mental illness.
• The mentally disordered are incapable of achieving a higher position on the SES hierarchy because they are mentally disordered.
• Members of the lower class who are mentally disordered are either stuck there or have drifted there because their mental disorder prevents them form achieving a higher position. Their disorder retards their social mobility.

It is likely that social class contributes more to mental disorder than mental disorder contributes to social class.

"If sanity and insanity exist, how shall we know them?"

CHEMICAL TREATMENT OF MENTAL DISORDER

• In 1952 in France, and in the United States in 1954 the first anti-psychotic drug was introduced. Chlorpromazine, or Thorazine, was the first anti-psychotic that helped reduce  the most blatant, florid, and troublesome symptoms of institutionalized schizophrenic mental patients.
• Anti-psychotics induced a more "normal" psychological condition in patients; thus it was possible to release patients into the community as outpatients, with only minimal treatment and care in aftercare facilities.
• Deinstitutionalization - releasing the mentally ill from large hospitals into the community.
• In 1955, there were nearly 560,000 patients in residence in public mental hospitals; this figure dropped almost every year until, by the 1990s, it was 80,000.
• Maintenance vs. cure
• Most not "normalized"
• BUT, costs reduced and psycho-surgery down